UC-NRLF 
 
 B 3 135 b?E 
 
THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 PRESENTED BY 
 
 PROF. CHARLES A. KOFOID AND 
 MRS. PRUDENCE W. KOFOID 
 
ELEMENTS 
 
 OF 
 
 GENERAL PATHOLOGY 
 
ELEMENTS 
 
 OF 
 
 GENEKAL PATHOLOGY 
 
 BY A. F. CHOMEL, 
 
 PROFESSOR OF CLINICAL MEDICINE TO THE FACULTY OF PARIS J CONSULTING PHYSICIAN 
 
 TO THE KING J PHYSICIAN IN ORDINARY TO THE PRINCESS ROYAL J OFFICER OF 
 
 THE LEGION OF HONOR ; HONORARY PHYSICIAN OF THE HOSPITALS } 
 
 MEMBER OF THE ROYAL ACADEMY OF MEDICINE J AND 
 
 OF MANY OTHER ACADEMIES AND LEARNED 
 
 SOCIETIES, NATIONAL AND FOREIGN. 
 
 Melius est sistere gradum quam progredi per tenebras. GAUBIUS. 
 
 THIRD EDITION, CONSIDERABLY ENLARGED. 
 
 TRANSLATED FROM THE FRENCH 
 
 BY F. E OLIVER, M. D., AND W. W. MORLAND. M. D., 
 
 Members of the Massachusetts Medical Society. 
 
 BOSTON: 
 WILLIAM D. TICKNOR AND COMPANY. 
 
 CORNER OF WASHINGTON AND SCHOOL STREETS. 
 
 M DCCC XLVIII. 
 
Entered according to act of Congress, in the year 1847, by 
 
 F. E. OLIVER, AND W. W. MORLAND. 
 in the Clerk's Office of the District Court of the District of Massachusetts. 
 
 BOSTON: 
 
 PRINTED BY THURSTON, TORR Y AND CO. 
 31 Devonshire Street. 
 
k-RBl) 
 
 Bio 
 
 TO 
 
 JAMES JACKSON, M. D. 
 
 PROFESSOR EMERITUS OP THEORY AND PRACTICE OP PHYSIC IN HARVARD UNIVERSITY, 
 HONORARY MEMBER OP THE ROYAL MEDICAL AND CHIRURGICAL SOCIETY, ETC. ETC., 
 
 DISTINGUISHED ALIKE FOR HIS PRIVATE VIRTUES, PROFESSIONAL EMINENCE, 
 
 AND HIS UNWEARIED AND INVALUABLE LABORS IN THE 
 
 CAUSE OF MEDICAL SCIENCE, 
 
 THIS TRANSLATION 
 
 IS, BY PERMISSION, 
 MOST RESPECTFULLY DEDICATED. 
 
 
TRANSLATORS' PREFACE. 
 
 THE classical work now first presented to the medical public 
 in the form of a translation, can need no other recommendation 
 to secure its cordial reception, than the name and reputation of 
 its celebrated author. We may hazard an expression of surprise 
 that it has so long remained unclothed with a garb, which 
 would have introduced it more universally to the profession in 
 this country. With precepts of inestimable value to the student, 
 it combines a vast collection of details interesting to the practi- 
 tioner. Whoever has followed the author in his clinical practice, 
 and remarked his admirable qualities as a diagnostician of dis- 
 ease, his unfailing detection of the most obscure symptoms, his 
 accurate prognosis, and remarkable skill in exhibiting and ex- 
 plaining cadaveric lesions, will readily discover, in the present 
 work, the reflection of his practical labors. 
 
 We trust that our task, by no means a light one, has been, at 
 least, faithfully performed. The few additions, in the form 
 of notes, relate chiefly to new discoveries in medical science, 
 announced since the appearance of the last French edition, or 
 to questions still undecided, and consequently open to remark. 
 
 BOSTON, NOVEMBER 12, 1847. 
 
AUTHOR'S PREFACE. 
 
 GENERAL PATHOLOGY treats of diseases considered abstractly, 
 or in regard to that which is common to them all. It serves at 
 once as introduction and sequel to special or descriptive pathol- 
 ogy, whose end is the knowledge of each particular malady to 
 which man is subject. It comprehends all that is most simple, 
 and likewise what is most elevated in science ; on the one hand, 
 the definition of terms and the description of the phenomena of 
 disease ; on the other, the discussion of all those fundamental 
 questions and the exposition of those general principles, which 
 are to guide the physician in the arduous practice of a pro- 
 fession closely connected with the dearest interests of humanity. 
 General Pathology, consequently, comprises within itself the 
 most unpretending elements and the most exalted philosophy of 
 medicine. 
 
 In this new edition we have not departed from the plan and 
 rules which were adopted in those preceding it. We have 
 treated of disease in general, as we should of any one malady 
 in particular, when intending to give the most complete account 
 of it possible. 
 
 The definition of disease in general, and the mode of defining 
 each one in particular ; the nomenclature, seat, causes, and 
 precursory phenomena of diseases; their symptoms, progress, 
 duration, and varied terminations; convalescence, consecutive 
 phenomena, relapse, and recurrence ; the distinction of genus, 
 
x AUTHOR'S PREFACE. 
 
 of species, and of pathological varieties ; complications, diag- 
 nosis, prognosis, anatomical changes, and treatment ; the inti- 
 mate nature of diseases, their classification, and the examination 
 of the principal works upon general pathology, are each the 
 subject of a special chapter. 
 
 We resolved, in the first edition of this work, to abstain from 
 any systematic idea, and to adhere strictly to the narration of 
 facts, and the consequences rigorously deduced from them. We 
 dare not flatter ourselves that we have completely accomplished 
 this, but perhaps may be permitted to think that a near ap~ 
 proach to it has been made. In fact, in the midst of the 
 immense progress which medicine has made in its positive 
 truths, and the great revolutions which it has undergone in its 
 theories, we have not erased, in this new edition, anything 
 essential of what the first contained, which was published in 
 1817, twenty-three years ago. If, however, but little of the 
 former has been suppressed, we have been obliged to make, 
 in this, the third edition, numerous and important additions. 
 Wilhin the lapse of twenty-three years, auscultation has been 
 discovered; percussion, perfected in its manoeuvres, has been 
 extended in its applications; the observation of pathological 
 phenomena during life, and the study of anatomical lesions after 
 death, have been brought to a degree of precision, which, previ- 
 ously, they did not possess, and have furnished us with many 
 new facts ; chemistry and the microscope have lent their aid 
 to pathology; most positive consequences have been deduced 
 from the comparison and enumeration of better observed facts ; 
 diagnosis has become more exact, and experiment more rigor- 
 ous. We have sought, in this new edition, to omit nothing of 
 whatever important conquests have been made by science : this 
 has been a long and difficult task, in the midst of the duties of 
 medical teaching and the demands of practice. Thus, even 
 with the assistance of two young and highly distinguished 
 physicians, MM. Dalmas and Grisolle, who have kindly made, 
 in the works recently published, the necessary researches for the 
 
XI 
 
 present volume, six years have elapsed, from the time when the 
 preceding edition was exhausted, to the publication of the 
 present one. 
 
 This new edition is far more extended than the second. The 
 chapters devoted to the causes, the symptoms, and the progress 
 of diseases, have been subjected to important modifications, and 
 have received considerable additions. We have given to the 
 chapter on Diagnosis a new form and very great development : 
 the part relating to therapeutics has been greatly augmented ; 
 and we would particularly mention two articles, one, devoted 
 to the exposition of the rules of experiment in medicine ; and 
 the other, to the examination of a question sharply contested, 
 the application of the numerical method to pathological facts. 
 
 PARIS, OCTOBER 21, 1840. 
 
CONTENTS. 
 
 CHAPTER I. 
 
 PATHOLOGY, ITS IMPORTANCE, EXTENT, AND DIVISIONS. GENERAL PATHOL- 
 OGY, ITS EXTENT AND LIMITS ; THE ADVANTAGES AND DANGERS ATTEND- 
 ING ITS STUDY J MODE OF ITS EXPLICATION ...'.. 
 
 CHAPTER II. 
 
 GENERAL AND SPECIAL DEFINITIONS OF DISEASE 
 
 CHAPTER III. 
 
 NOMENCLATURE OF DISEASES. SYNONYMY. ETYMOLOGY 
 
 . 13 
 
 CHAPTER IV. 
 
 SEAT OF DISEASES 
 
 16 
 
 CHAPTER V. 
 
 ETIOLOGY, OR THE CAUSES OF DISEASE 
 
 ARTICLE I. 
 
 Determining causes . . 21 
 
 Common determining causes 21 
 
 Circumfusa ... 22 
 
 Applicata .... 23 
 
 Excreta, gesta, percepta . 24 
 
 Specific determining causes 25 
 
 Common specific causes . 25 
 
 Metallic emanations . . 25 
 
 Miasmatic exhalations . 25 
 
 Poisons . ... 26 
 Contagious specific causes or virus 26 
 
 ARTICLE II. 
 
 Predisposing causes 
 
 SECTION I. 
 
 General predisposing causes 
 Atmosphere 
 Winds . 
 Atmospheric pressure 
 Light .... 
 Electricity 
 
 Seasons .... 
 b 
 
 31 
 
 32 
 32 
 32 
 33 
 33 
 33 
 33 
 
 19 
 
 Planetary influences . . 34 
 
 Localities . . . .34 
 
 Garments . . . .36 
 
 Food 36 
 
 Moral affections . . .36 
 Political institutions . . 36 
 
 SECTION II. 
 
 Individual predisposing causes . 36 
 
 1. Aptitudes . . . .37 
 
 A. Origin .... 37 
 
 B. Age 39 
 
 C. Climacteric years . .40 
 
 D. Sex 41 
 
 E. Temperament . . .41 
 
 F. Constitution . . . 42 
 
 G. Habits . . . .42 
 H. Occupation . . .43 
 I. Affluence and poverty . 43 
 J. Healthy, convalescent or dis- 
 eased condition . . .43 
 
 K. Pregnancy . . .44 
 
 2. Individual predisposing causes 
 
 proper 44 
 
XIV 
 
 CONTENTS. 
 
 A. Circumfusa (dissect'g rooms, 
 hospitals, change of climate) 44 
 
 B. Applicata (clothing, various 
 causes of compression, beds, 
 baths) 45 
 
 C. Ingesta (food, drinks, spices, 
 condiments, medicaments) . 48 
 
 D. Excreta (evacuations) . 50 
 
 E. Gesta (exercise, repose, fa- 
 tigue, want of exercise, watch- 
 ing, sleep) . . . .51 
 
 F. Percepta (sensations, pas- 
 sions, mental exertion, ante- 
 cedent diseases) . . .52 
 
 ARTICLE III. 
 Occasional or exciting causes . 53 
 
 ARTICLE IV. 
 
 Mode of action of the different mor- 
 bific causes . 55 
 
 Determining causes . . 55 
 
 Aptitudes . . . .57 
 
 Predisposing causes proper . 58 
 
 Occasional causes . . .63 
 
 ARTICLE V. 
 
 Division of diseases relatively to 
 
 their productive causes . . 64 
 
 Innate or congenital diseases . 64 
 
 Acquired diseases . . .64 
 
 Sporadic diseases . . .64 
 
 Pandemic diseases . . .64 
 
 Endemic diseases . . .64 
 
 Epidemic diseases . . .65 
 
 Essential diseases . . .69 
 
 Symptomatic diseases . . 69 
 
 ARTICLE VI. 
 
 Lapse of time between the applica- 
 tion of the causes and the de- 
 velopment of diseases . . 69 
 
 CHAPTER VI. 
 
 PRECURSORY PHENOMENA, PRELUDES, ANTECEDENT SIGNS, PRODROMES, 
 IMMINENCE OF DISEASES 
 
 OR 
 
 70 
 
 CHAPTER VII. 
 
 SYMPTOMS OR SYMPTOMATOLOGY 
 
 ARTICLE I. 
 
 Symptoms furnished by the func- 
 tions of relation . . .75 
 
 SECTION I. 
 
 Symptoms furnished by the exter- 
 
 na appearance . . .75 
 
 A. Attitude . . . .75 
 
 B. Volume of the body . . 76 
 
 C. Growth of the body . . 77 
 
 D. Firmness of the flesh . 78 
 
 E. Color of the skin . . 78 
 
 F. Eruptions . . . .80 
 
 G. Plicatures . . . .80 
 H. Tumors, excoriations, fis- 
 sures, ulcers, fistula . . 80 
 
 Symptoms furnished by the head . 81 
 Symptoms furnished by the neck . 90 
 Symptoms furnished by the chest . 91 
 Symptoms furnished by the shoul- 
 ders 91 
 
 Symptoms furnished by the abdo- 
 men 92 
 
 Symptoms furnished by the organs 
 
 of generation . . .94 
 
 Symptoms furnished by the limbs 95 
 
 SECTION II. 
 
 Symptoms furnished by the organs 
 
 of locomotion . .97 
 Bones .... ,97 
 
 Muscles, (paralysis, tremor, ri- 
 gidity, subsultus, carphology, 
 convulsions, contraction, etc.) 
 
 SECTION III. 
 
 98 
 
 Symptoms furnished by the voice 
 
 and speech .... 102 
 
 SECTION IV. 
 
 Derangements of sensibility and of 
 sensation considered as symp- 
 toms 104 
 
 Internal sensations (pain) . 105 
 
 External sensations . . .108 
 
 A. Sight . . . .108 
 
 B. Hearing . . . .109 
 
 C. Smell . . . .109 
 
 D. Taste . . . .109 
 
 E. Touch . . . .109 
 
 SECTION V. 
 
 Symptoms furnished by the affec- 
 tive functions . 110 
 
 SECTION VI. 
 
 Symptoms furnished by the intel- 
 lectual functions (delirium) . 
 
 Ill 
 
 SECTION VII. 
 
 Symptoms furnished by sleep 
 (sleeplessness, dreams, som- 
 nolency, coma, etc.) . .113 
 
CONTENTS. 
 
 XV 
 
 SECTION VIII. 
 
 Lipothymia, syncope, vertigo . 115 
 
 ARTICLE II. 
 
 Symptoms furnished by the inter- 
 nal or assimilative functions 116 
 
 SECTION I. 
 
 Symptoms furnished by digestion 117 
 
 A. Hunger .... 117 
 
 B. Thirst . . . .118 
 
 C. Examination of the various 
 parts of the mouth . .118 
 
 The teeth . . . .118 
 
 The gums . . .119 
 
 The tongue . . .119 
 
 D. Mastication . . .123 
 
 E. Deglutition . . . 123 
 
 F. Stomachal digestion . . 125 
 
 1. Nausea .... 125 
 
 2. Subsultus praecordiorum . 125 
 
 3. Regurgitation . . .125 
 
 4. Vomiting .... 126 
 
 5. Pain . . . .127 
 Symptoms furnished by the intes- 
 tinal canal . . . 128 
 
 1. Borborygmi . . . 128 
 
 2. Gurgling . . . .128 
 
 3. Passage of alimentary sub- 
 stances .... 129 
 
 4. Alvine excretion or defeca- 
 tion 129 
 
 5. Excreted substances or ex- 
 crements . . . '131 
 
 SECTION II. 
 
 Symptoms furnished by the respi- 
 ration . . . .134 
 1. Frequency . . .134 
 2 Quickness . . .135 
 
 3. Quantity of air inspired and 
 expired . . . .135 
 
 4. Difficulty of respiration . 135 
 
 5. Inequalities of respiration 136 
 
 6. Concomitant sounds . . 136 
 
 7. Qualities of the expired air 137 
 
 8. Auscultation . . . 137 
 Modifications of the respira- 
 tory murmur . . 140 
 
 Rales . . . .140 
 
 Metallic tinkling . . 145 
 
 Thoracic succussion . . 146 
 
 Pleuritic friction sound . 147 
 
 Auscultation of the voice . 148 
 
 Bronchophony . . . 148 
 
 .i'Egophony . . . 149 
 
 Pectoriloquy . . . 150 
 
 Percussion of the chest . 151 
 
 11. Respiratory phenomena . 152 
 
 1. Laughter .... 152 
 
 2. Yawning . . . .152 
 
 3. Sneezing .... 152 
 
 4. Hiccough . 
 
 5. Cough 
 Exspuition 
 Expectoration 
 Sputa 
 
 152 
 152 
 154 
 154 
 155 
 
 SECTION III. 
 
 Symptoms derived from the circu- 
 lation 162 
 
 & I. Circulation of the blood . 163 
 
 A. The heart . . . .163 
 
 1. Extent of the heart's pul- 
 sations .... 164 
 
 2. Shock or impulse . . 165 
 
 3. Nature and intensity of the 
 sound . . . .166 
 
 4. Rhythm . . . .169 
 
 B. The Pulse . . . . 170 
 Auscultation of the arteries 179 
 
 C. Symptoms furnished by the 
 capillary circulation . . 180 
 
 D. Symptoms furnished by the 
 venous circulation . . 181 
 
 E. Symptoms furnished by the 
 examination of the blood . 182 
 
 II. Symptoms furnished by the 
 
 lymphatic system . . 189 
 
 SECTION IV. 
 
 Symptoms furnished by the heat . 192 
 SECTION v. 
 
 Symptoms furnished by the ex- 
 halations and secretions . 195 
 1. Exhalations . . . .196 
 
 A. Natural exhalations . . 196 
 
 1. Cutaneous exhalation, or 
 perspiration . . .196 
 
 2. Mucous exhalation . . 198 
 
 3. Serous exhalation . . 199 
 
 4. Exhalations upon the artic- 
 ular surfaces . . . 199 
 
 5. Exhalations within the eye, 
 the ear, the adipose cells, 
 the lymphatic and sanguine- 
 ous system, etc. . . 200 
 
 7. Gaseous exhalation . . 200 
 
 8. Sanguineous exhalation . 200 
 
 B. Morbid exhalations . . 200 
 
 1. Haemorrhage . . . 200 
 
 2. Pyogenia .... 201 
 Pus considered in regard to 
 
 its chemical properties 
 and its action upon the 
 animal economy . . 204 
 
 C. Artificial exhalations . . 206 
 II. Secretions, properly so called 206 
 
 1. Secretion of tears and the 
 fluid of the meibomian folli- 
 cles 207 
 
 2. Secretion of the saliva . 207 
 
 3. Secretion of the bile . 208 
 
XVI 
 
 CONTENTS. 
 
 4. Secretion of the pancreatic 
 juice . . .210 
 
 5. Secretion of the urine . 210 
 Physical and chemical prop- 
 erties of the urine .212 
 
 III. Excretions . . .219 
 
 SECTION VI. 
 
 Symptoms furnished by absorption 220 
 
 SECTION VII. 
 
 Symptoms furnished by nutrition . 
 Augmentation (hypertrophy) 
 Diminution (atrophy) . 
 
 222 
 222 
 222 
 
 ARTICLE III. 
 
 Symptoms furnished by the gen- 
 erative functions . . .223 
 
 A. In the male . . .224 
 
 B. In the female . . .224 
 
 ARTICLE IV. 
 
 Symptoms considered in disease . 226 
 Local and general symptoms . 227 
 Sympathetic phenomena ; sym- 
 pathies .... 227 
 Principal and accessory symp- 
 toms 228 
 
 Active and passive symptoms . 229 
 Epiphenomena . . . 229 
 
 CHAPTER VIII. 
 
 THE PROGRESS OR COURSE OP DISEASES 
 
 Types 231 
 
 Acute and chronic course . 233 
 Periods in diseases . . . 233 
 
 Invasion 234 
 
 Period of stasis or violence . 235 
 Period of decline . . 235 
 
 . 230 
 
 Circumstances which modify the 
 course of diseases (ages, tem- 
 perament diurnal revolutions, 
 temperature, planetary influ- 
 ences, climate, etc.) 
 
 236 
 
 DURATION OF DISEASES 
 
 CHAPTER IX. 
 
 . 240 
 
 TERMINATION OF DISEASES 
 
 CHAPTER X. 
 
 ARTICLE I. 
 
 Different modes of termination . 242 
 In the return to health . . 242 
 
 In death 244 
 
 In another disease . . . 245 
 Doctrine of crises . . . 246 
 Seat of critical phenomena . 247 
 Precursory signs of critical phe- 
 nomena . . . 249 
 
 242 
 
 Circumstances which favor or 
 
 oppose critical phenomena . 252 
 Duration of critical phenomena 252 
 Influence of critical phenomena 
 upon the termination of dis- 
 eases , . 253 
 
 ARTICLE II. 
 Doctrine of critical days 
 
 256 
 
 CHAPTER XI. 
 
 CONVALESCENCE 
 
 259 
 
 CHAPTER XII, 
 
 CONSECUTIVE PHENOMENA 
 
 262 
 
COiNTENTS. 
 
 XV11 
 
 CHAPTER XITI. 
 
 RELAPSE AND RECURRENCE 
 
 . 264 
 
 CHAPTER XIV. 
 
 THE DIFFERENT GENERA, SPECIES AND VARIETIES OF DISEASES . 
 
 . 266 
 
 CHAPTER XV. 
 
 COMPLICATIONS 
 
 270 
 
 CHAPTER XVI. 
 
 DIAGNOSIS 
 
 273 
 
 I. Diagnostic signs . . . 273 
 
 II. Necessary conditions on the 
 part of the patient and the 
 physician in forming a diag- 
 nosis 275 
 
 Different modes of exploration 
 
 for forming diagnosis . 276 
 
 1. Pressure .... 276 
 
 2. Palpation . . 278 
 
 3. Touch . . .280 
 
 4. Succussion . . 282 
 
 5. Mensuration . . 283 
 
 6. Percussion . . 286 
 
 7. Auscultation . . . 290 
 
 8. Exploration by sounds and 
 probes .... 293 
 
 9. Exploration by specula . 294 
 
 10. Examinations with the mi- 
 croscope and the magnify- 
 ing glass .... 297 
 
 11. Employment of chemical 
 agents in the diagnosis of 
 disease .... 297 
 
 III. Mode of examination and 
 interrogation of patients for 
 the purpose of forming a diag- 
 nosis 298 
 
 Order to be observed in ques- 
 tioning patients . . . 301 
 Examination of the existing 
 
 symptoms .... 302 
 Exploration of the head . . 303 
 Exploration of the spine . . 303 
 Exploration of the auditory canal 304 
 Exploration of the nasal fossae . 304 
 Exploration of the isthmus of 
 the fauces, the larynx and the 
 ffisophagus .... 305 
 Exploration of the chest . . 306 
 Exploration of the abdomen . 308 
 Exploration of the genital organs 309 
 
 Exploration of the rectum .310 
 Exploration of the limbs . .310 
 IV. Principal component ele- 
 ments of diagnosis . .311 
 
 A. Determination of the seat of 
 
 diseases . . . .312 
 
 1. Which is the affected organ? 312 
 
 2. The seat of disease being 
 known, what is its extent? 314 
 
 3. Which of the elementary 
 tissues is primarily affected ? 3 1 5 
 
 B. Determination of the lesion 316 
 1. Nature of the lesion . 
 
 317 
 318 
 
 2. Degree attained by the le- 
 sion 
 
 C. Symptomatic phenomena con- 
 sidered in regard to diag- 
 nosis . . . .319 
 V. Circumstances which may 
 render diagnosis difficult and 
 even uncertain . . . 321 
 
 1. Difficult diagnosis on ac- 
 count of the period at which 
 the physician is summoned 321 
 
 2. Difficulties in diagnosis de- 
 pending upon the predomi- 
 nance of general phenom- 
 ena, or the obscurity or 
 absence of local phenomena 323 
 
 The febrile state in relation 
 to diagnosis . . . 330 
 
 3. Difficulties in diagnosis re- 
 sulting from the infrequency 
 
 of the disease . . .336 
 
 4. Difficulties resulting from 
 complications . . . 337 
 
 5. Difficulties resulting from 
 
 deception . . . 338 
 Feigned and concealed dis- 
 
 . 338 
 
XV111 
 
 CONTENTS. 
 
 CHAPTER XVII. 
 
 PROGNOSIS 
 
 I. Conditions on the part of the 
 patient and the physician for the 
 formation of the prognosis . 341 
 
 II. Prognostic signs . . 342 
 
 1. Diagnosis the original basis 
 
 of prognosis . . . 343 
 
 2. Power of nature and of art 344 
 
 3. Age, previous health, phys- 
 
 ical and moral causes . 344 
 Hereditary condition . 345 
 Menstruation, pregnancy, 
 
 the puerperal state . 345 
 Habitual intemperance . 345 
 Excessive evacuations fa- 
 
 tigue . . . .346 
 Climate seasons . . 346 
 
 4. Precursory phenomena . 346 
 
 341 
 
 5. Commencement of diseases 346 
 
 6. Progress of diseases . . 347 
 
 7. Duration of diseases . 347 
 
 8. Influence of remedies pre- 
 
 viously employed . . 347 
 
 9. Complications . . . 347 
 Prognostic value of certain 
 
 symptoms considered sep- 
 arately (external appear- 
 ance, aphonia, pain, sen- 
 sorial disturbance, deli- 
 rium, sleep, dysphagia, 
 hunger, thirst, meteor- 
 ism, involuntary evacua- 
 tions, stertorous respira- 
 tion, syncope, sweats, 
 haemorrhage, parotiditis) 348 
 
 CHAPTER XVIII. 
 
 THE DIFFERENT ALTERATIONS PRESENTED BY THE ORGANS AFTER DEATH 
 
 ARTICLE I. 
 Mode of conducting post-mortem 
 
 examinations . . . 358 
 
 Examination of the exterior of 
 the body . . . .358 
 
 Inspection of the internal organs 359 
 
 Mode of opening the great 
 splanchnic cavities . . 360 
 
 Order in which visceral inspec- 
 tion should be conducted . 361 
 
 ARTICLE II. 
 The principal lesions presented by 
 
 the organs after death . .365 
 
 FIRST SERIES. 
 
 Lesions of the solids . . . 365 
 Inflammation of the various tis- 
 sues 366 
 
 Ulcers 367 
 
 Fistula 368 
 
 Gangrene .... 368 
 Tubercle .... 368 
 
 Granulations . . . .369 
 Cancer . . . 370 
 
 357 
 
 Scirrhus 370 
 
 Melanosis .... 371 
 
 Cutaneous transformation . 372 
 
 Mucous transformation . * . 372 
 
 Serous transformation . . 372 
 
 Fatty transformation . . 372 
 
 Fibrous transformation . . 373 
 
 Oseous transformation . . 373 
 
 Cartilaginous transformation . 373 
 
 Corneous transformation . . 373 
 
 Alterations of form . . , 373 
 
 Alterations of volume . . 373 
 
 Alterations of color . . . 373 
 
 SECOND SERIES. 
 
 Alterations of the fluids . . 374 
 Alterations of the liquids . . 374 
 Alterations of the gases . . 377 
 
 THIRD SERIES. 
 
 Foreign bodies, inanimate and liv- 
 ing 378 
 
 Different importance of cadaveric 
 changes ..... 379 
 
 CHAPTER XIX. 
 
 THERAPEUTICS 
 
 Observation and experience the 
 only guides in the study of 
 therapeutics . . . 381 
 Experimentation, its difficulties, 
 the requisite rules in its pur- 
 suit 383 
 
 380 
 
 The numerical method applied 
 to the study of diseases . 393 
 
 Refutation of the principal ob- 
 jections to the numerical sys- 
 tem . . . . .395 
 
 Experience in medicine . . 403 
 
CONTENTS. 
 
 XIX 
 
 Physical and chemical theories 
 applied to therapeutics . . 405 
 
 ARTICLE I. 
 
 Indications 406 
 
 Conditions productive of indica- 
 tions 406 
 
 A. Genus of the disease . 406 
 
 B. Character of the disease . 407 
 
 C. Type of the disease . . 407 
 
 D. State of the vital forces . 408 
 
 E. Intensity of the disease .412 
 
 F. Different periods of the dis- 
 ease 412 
 
 G. Particular symptoms .413 
 H. Seat of diseases . .414 
 I. Complications . . .414 
 J. Causes . . . .414 
 
 Temperament, constitution, 
 age, sex, profession, hab- 
 itual regimen . . .415 
 
 K. Commemorative circumstan- 
 ces 416 
 
 L. Means previously employed 418 
 
 M. Epidemic constitution . 419 
 N. Tendency of the disease .419 
 O. Influence exercised by the 
 disease upon the constitu- 
 tion 420 
 
 Possibility of the occurrence 
 of several indications in one 
 and the same disease . 420 
 Preservative indications . 422 
 Principal indications in con- 
 valescence . . . 423 
 Indications furnished by the 
 consecutive phenomena . 423 
 
 ARTICLE II. 
 
 Therapeutical means . . . 423 
 Therapeutical means, properly 
 
 so termed . . .424 
 
 Surgical means . . . 424 
 
 Medical means . . . 425 
 
 General or hygienic means . 428 
 
 Means in acute diseases . 429 
 
 Means in chronic diseases . 434 
 
 CHAPTER XX. 
 
 NATURE OR ESSENCE OF DISEASES 
 
 Ideas of the humoral pathologists 
 Ideas of the Solidists 
 
 435 
 
 437 
 
 438 
 
 CHAPTER XXI. 
 
 CLASSIFICATION OF DISEASES 
 
 442 
 
 CHAPTER XXII. 
 
 PRINCIPAL WORKS UPON GENERAL PATHOLOGY 
 
 444 
 
 INDEX 
 
 451 
 
ERRATA. 
 
 Page 80, lines 19 and 23, for " vesicula," read vesiculce. 
 
 " 10J, line 16, insert a comma after "attacks." 
 
 " 115, lines 11 and 32, for " Topor," read Sopor. 
 
 " 117, line 21, for "boulimus," read boulimia. 
 
 " 117, lines 24 and 26, dele the parentheses. 
 
 " 128, line 25, for " sound," read sounds. 
 
 " 136, note, for ntvw, read nvt<a. 
 
 " 182, line 35, for " Nosographic," read Nosographie. 
 
 " 186, line 13 from bottom, for "secretions," read secretion. 
 
 " 189, line 20, for " Seltzar," read Seltzer. 
 
 " 189, line 4 from bottom, for I. read II. 
 
 " 197, line 30, for " mouldiness," read mould. 
 
 " 200, line 5 from bottom, for " haemorrhages consist," read haemorrhage consists. 
 
 " 208, line 7 from bottom, for " after," read of the. 
 
 11 213, line 30, for " a thousandth," read of a thousandth. 
 
 " 226, line 14, for " venereus," read venereus. 
 
 " 229, last line, for " epigenometa," read epigenemeta. 
 
 " 231, note, for i//voe, read 7ivQ(ig. 
 
 " 300, line 3 from bottom, for " diagnosing," read diagnosticating. 
 
ELEMENTS 
 
 OF 
 
 GENERAL PATHOLOGY 
 
 CHAPTER I. 
 
 PATHOLOGY, ITS IMPORTANCE, ITS EXTENT, AND ITS DIVISIONS. 
 
 GENERAL PATHOLOGY, ITS EXTENT, ITS LIMITS. ADVANTAGES AND 
 
 DANGERS ARISING FROM ITS STUDY. ORDER ADOPTED IN ITS EXPO- 
 SITION. 
 
 PATHOLOGY has been defined to be that branch of medicine 
 which treats of the classification, causes, symptoms and signs of 
 disease. This definition is far from accurate. As it is the pecu- 
 liar province of physiology to treat of whatever relates to the 
 human body in its normal condition, so pathology includes within 
 its limits whatever relates to the same in a state of disease. The 
 seat of diseases, the phenomena which precede and follow them, 
 their progress, duration and different modes of termination, their 
 reappearance, various forms and complications, the changes they 
 produce in the texture of organs, their prophylactic and curative 
 treatment, &c. &c., are but so many essential points in their his- 
 tory, which necessarily fall within the cognizance of pathology,* 
 or that branch of medical science, the object of which is the know- 
 ledge of disease. 
 
 Of the various branches of the healing art, none to the physician 
 is so attractive as a study, none so important in its results, as 
 pathology. He views it as a centre, around which are disposed at 
 unequal distances the other natural sciences. The study of anat- 
 omy and physiology, of chemistry and physics, of botany and 
 
 * n6og, disease; loyog, discourse. 
 1 
 
2 GENERAL PATHOLOGY. 
 
 materia medica, afford him but an introduction to that of pathol- 
 ogy ; he regarding those sciences of far less importance, so soon as 
 the latter shall become the object of his special study, viewing 
 them rather as accessory sciences, and among the numerous facts 
 presented by them, noting only those which are nearly connected 
 with the knowledge of disease, and its appropriate methods of 
 treatment. 
 
 We would not however exalt the science of pathology at the 
 expense of the other branches of natural history ; whatever be its 
 importance, and the dignity of its aim, we claim for it no supe- 
 riority over the other sciences. Physiology, physics, zoology, &c., 
 it will not be denied, are entitled to equal consideration. Inti- 
 mately connected as are all these sciences, they reciprocally aid in 
 the elucidation of each other, and none among them should be 
 allowed the preeminence, although in his estimation who makes it 
 his particular study, either will appear of paramount importance. 
 
 Pathology, like the other natural sciences, is without limit ; while 
 botany, zoology, physics, chemistry and mineralogy are daily ex- 
 tending their domain, the science of disease, also, to the observer, 
 appears to be rapidly advancing. Without here referring to the 
 ever new and infinite varieties of disease, this must be evident, 
 whether we consider the more careful study of causes, the more 
 accurate description of symptoms, the more critical examination 
 of the circumstances which exert a favorable or unfavorable in- 
 fluence upon the progress of diseases, the discovery of affections 
 previously unknown or imperfectly described, or lastly, the appli- 
 cation of new methods of exploration to the phenomena of disease. 
 To cite a recent example, has not the discovery of auscultation, in 
 our own time, added to the history of thoracic disease, a multitude 
 of phenomena and valuable diagnostic signs, of which we were 
 previously ignorant ? Pathology presents for consideration, a mass 
 of facts, all the details of which it is beyond the power of the 
 human mind to comprehend ; it may even be asserted that, throw- 
 ing aside its theories and its systems, no one is possessed of all the 
 knowledge contained in the records of pathological science. 
 
 This want of correspondence between the extent of the science 
 and the capacity of the human mind, has led to results which were 
 not unforeseen. It being impossible to increase the mental powers, 
 it was attempted to make a division of the science into several 
 parts which should be within the reach of our intellectual capacity. 
 Hence the numerous divisions of pathology. Of these the most 
 important is that distinctive of internal or medical, and external 
 or surgical pathology. The diseases of women, of children, of the 
 aged, those seated, whether in any of the splanchnic cavities, in 
 any of the great anatomical systems, in an apparatus, or single 
 organ, &c., have severally undergone subdivision; and eminent 
 professional men have deigned to devote themselves exclusively to 
 the study of a single class of these affections. But it should be 
 recollected that, in no instance, has the investigation of a special 
 group of diseases been of profit to the science, except so far as 
 
GENERAL PATHOLOGY. 3 
 
 those, who have devoted themselves to these studies, have been 
 well versed in the other branches of pathology. Diseases are not 
 confined in their effects to single organs, nor can they be discon- 
 nectedly studied. 
 
 There is another division, which has had the effect to enlarge 
 rather than diminish the range of the science, and which, like that 
 adopted by Bichat in the study of anatomy, has extended its lim- 
 its. We refer to the division into general and descriptive patholo- 
 gy. The object of this is not to divide the science into several 
 parts, nor to separate a particular class of diseases from all others. 
 General pathology, whose object it is to treat of diseases in the 
 abstract, and of whatever is common to them, includes all under 
 the same head, studies their general characteristics, causes and 
 development, the succession and connection of their phenomena 
 observed during life, the appearances after death, and the circum- 
 stances which modify their progress, and by which we are enabled 
 to prognosticate the changes which will take place in their course. 
 Descriptive pathology includes alike all diseases, but presents 
 them in a series of groups, in which each affection is described, 
 with the appearances peculiar to it, and which serve to distinguish 
 it from all others. Hence, it is evident that there is no analogy 
 between this division of the subject, and those before mentioned. 
 The latter shorten the study, by presenting fewer objects for in- 
 vestigation ; the former leads to the same result without narrowing 
 the limits of the science ; and not only does it preserve it entire, 
 but by presenting, under different aspects, the objects to which the 
 attention should be successively directed, we obtain a more accu- 
 rate knowledge and a more just appreciation of them. 
 
 This division differs also from the first in other respects. It is 
 possible to devote ourselves exclusively to the study of internal, and 
 neglect to a certain extent that of external pathology : so special 
 study may be made of those diseases which occur during child- 
 hood or old age, while those peculiar to other periods of life are 
 neglected. General and special pathology, on the contrary, cannot 
 be exclusively studied ; one is but an introduction to the other ; 
 both are indispensable to the physician. 
 
 This division of pathology is one, the limits of which are the 
 most clearly defined. The consideration of all the phenomena 
 common to diseases belongs to general pathology, while whatever 
 relates to the history of particular diseases falls within the prov- 
 ince of descriptive pathology. Between these two branches of 
 pathology, there are however numeroiis points of contact ; but it 
 is not a little singular that most authors who have treated upon 
 general pathology, should have introduced, among considerations 
 legitimately within the province of that subject, the history of 
 particular diseases. Thus the description of plethora is found in 
 almost all treatises upon general pathology. Sprengel, in his 
 valuable work * upon this subject, goes still farther, and treats 
 
 * Pathologia Generalis. Amstelodami, 1813. 
 
GENERAL PATHOLOGY. 
 
 successively (in the article, Etiology,) of the signs of the various 
 fractures, dislocations, and hernise, and describes the various kinds 
 of worms which infest the human body, with the signs indicative 
 of their presence. While subjects are thus considered in connec- 
 tion with general pathology, which are not within its scope, others 
 strictly belonging to it are neglected. The nomenclature of dis- 
 eases, the circumstances which influence their course, the treat- 
 ment, convalescence, and appearances after death, the mode of 
 examination and interrogation of patients, are all important points 
 in the general history of diseases, which authors have hitherto 
 omitted to mention, although as essential to it as the classification, 
 causes, symptoms and signs. 
 
 If the division of pathology into general and descriptive, appear 
 to some rather to prolong than to abridge the study of diseases, it 
 will be an easy task to bring them to a more just conclusion. We 
 readily grant that the knowledge of particular diseases is of the 
 highest importance, and that the study of general pathology is not 
 of equal utility to the practical physician. But admitting for a 
 moment, that the latter be wholly valueless to him who is already 
 versed in science, it would not be therefore just to conclude that it 
 is without profit to the student. Without here referring to the ab- 
 solute necessity of his first becoming familiar with a new language, 
 the study of general pathology is to him in other respects of man- 
 ifest utility ; all is as yet new to him, he should leave no point 
 unattained. Diseases possess certain forms in common, they have 
 also features which are peculiar to them. Were it not better, we 
 would then ask, to present to the beginner, once for all, the vari- 
 ous points of doctrine, and the phenomena common to most dis- 
 eases, and thereby avoid the necessity of afterward pointing out 
 those peculiar to each, than to weary him with tedious and unpro- 
 fitable repetitions, which, in the description of each particular dis- 
 ease, must necessarily lead to an incomplete examination of the 
 same questions ? In short, should he be made acquainted at once 
 with the characteristics common to all diseases, or be under the 
 necessity of reviewing the same, as often as he should be led to 
 the investigation of a particular disease ? The answer is evident. 
 
 There are still numerous other advantages attending the study 
 of general pathology. It gives scope to considerations, favorable to 
 the development of the understanding, and an enlargement of the 
 views of the student. It briefly points out to him, at the com- 
 mencement of his career, the path he should pursue, the objects 
 which claim his attention, and the dangers to be avoided ; it also 
 indicates the course which should be adopted in the investigation 
 of particular diseases ; and lastly, by grouping together these va- 
 rious affections, it aids in the elucidation of their history. 
 
 But aside from the advantages, there are dangers connected 
 with the study of general pathology. A cursory examination of 
 the treatises, upon this subject will alone suffice, to show us the 
 systems and hypotheses, which have been either substituted for, or 
 mingled with, the results of observation or experience. The same 
 
GENERAL PATHOLOGY. 5 
 
 may be said, it is true, of most medical treatises, whatever be 
 their object, as descriptions of particular diseases, and even records 
 of observations. But systems properly so called, those great 
 hypotheses, by which the universality of facts is understood and 
 explained, necessarily proceed from general pathology. The com- 
 parison of diseases, the study and comparison of their various 
 phenomena, necessarily lead to those general conclusions so 
 seductive to the mind, which receives them with dangerous 
 facility, proudly proclaiming them as secrets wrested from nature, 
 as laws without exception ; and should they afterward be shown 
 by facts to be inaccurate or false, to nature rather than to the 
 theory is the error ascribed ; the freaks and caprices of nature 
 excite astonishment, while the theory is still regarded with admi- 
 ration, until some other takes its place, which ultimately shares 
 the same fate. When it is considered that general pathology treats 
 of subjects abstractly, and that hence it becomes easy to wander 
 from the truth, the tendency of this science to the formation of 
 those theories by which the progress of medicine has been so 
 long impeded, becomes manifest. 
 
 If the knowledge of the dangers be sufficient in order to avoid 
 them, we hope that we ourselves have escaped from those to 
 which we have just alluded ; but whatever may have been our 
 efforts to attain this end, we dare not flatter ourselves that we have 
 succeeded. Those most averse to theories and hypotheses, have 
 not in all cases been able to guard against them ; they have over- 
 thrown the hypotheses of others, by substituting those of their 
 own invention, and which appeared to them but the legitimate 
 results of observation and experience. It was a remark of Gaubius, 
 that it is better to pause, than go blindly forward ; and yet, in 
 the same work, he himself becomes enveloped in the mists of 
 humorism, and gravely descants upon the chemical and mechani- 
 cal acrimonies of the humors. 
 
 If, as we have seen, the province of general .pathology has not 
 been with certainty determined, and it be necessary to strip it of 
 the erroneous and dangerous theories which have till now rendered 
 it obscure, it is no less important that a far different course be 
 adopted in its exposition, from that hitherto pursued. By refer- 
 ring, as has been the case, to nosology or the classification of dis- 
 eases, their definition, seat, course, duration and complications, 
 subjects are considered under the same head, which should be 
 separately studied, and which are as widely different as signs and 
 symptoms, from which two distinct branches have arisen ; if, in 
 connection with the nosology, the seat, progress and duration of 
 diseases, which have but a vague affinity to their classifications, 
 be considered, it is not clear why on this, all other branches of 
 general pathology should not depend. 
 
 Is the method to be pursued in the study of general pathology 
 an important consideration ? Is it absolutely necessary, for exam- 
 ple, in our inquiries, that prognosis be considered before diagnosis, 
 or the causes before the seat of disease ? We think not ; but are 
 1* 
 
6 DEFINITION OF DISEASE. 
 
 yet of the opinion that there are certain points in the history of 
 diseases, which, before others, naturally claim our first attention. 
 The definition of disease, is the first subject which presents itself; 
 the study of the progress of diseases should not precede the 
 exposition of the symptoms, and the causes more properly come 
 before than after the latter ; the diagnostic and prognostic signs 
 should follow the symptoms, and the consideration of the treat- 
 ment come after the signs. Thus among the various subjects em- 
 braced by general pathology, there are those whose relative posi- 
 tion is to a certain extent defined, while there are others which 
 may be considered with equal propriety at different periods during 
 the investigation. 
 
 In the arrangement of the subjects which constitute general 
 pathology, it seems to us important that some method be adopted, 
 which shall be equally applicable to the study of particular dis- 
 eases. This method would thus become more strongly impressed 
 upon the mind. It is moreover well known that a uniform method 
 powerfully assists the memory, accustoming the mind to a proper 
 arrangement of its ideas, and the classification of the new truths 
 which are daily presented. 
 
 The following is the order we have adopted in the exposition 
 of general pathology. 
 
 We shall first consider the definition of disease in general, and 
 point out the rules which should guide us in the definition of dis- 
 eases respectively. After some considerations on the nomenclature, 
 etymology and synonomy, we shall speak of the seat of diseases, 
 their cames, precursory phenomena, symptoms, progress, dura- 
 tion and various terminations. We shall thus be led to the ex- 
 amination of the doctrine of crises and critical days. Convales- 
 cence, the consecutive phenomena, relapse, kinds, varieties and com- 
 plications of diseases, diagnosis and prognosis, will be generally 
 considered. We shall also devote a chapter to the examination" and 
 appearances of bodies after death ; and having touched upon the 
 fundamental rules of treatment, we shall conclude by offering a 
 few remarks on the nature and classification of diseases. O. 
 
 CHAPTER II. 
 
 DEFINITION OF DISEASE IN GENERAL, AND OF DISEASES RESPECTIVELY. 
 
 THERE are two kinds of definition, one being an accurate state- 
 ment of the nature of a thing, the other a rapid enumeration of 
 its principal characteristics. In either case, the definition to be 
 correct, should present so clear an idea of the object defined, as 
 to render it always recognizable, and easily distinguishable from 
 all others. 
 
DEFINITION OF DISEASE. 7 
 
 Of these two kinds of definition, the first, which acquaints us 
 with the nature of things, would be preferable to the second, were 
 it as certain and general in its application ; but there is a vast 
 number of objects whose nature is unknown to us ; and though 
 there be those in which it seems to be understood, this knowledge 
 is rarely so well established, as to serve as a basis whereon to 
 found a correct definition. The second mode of definition con- 
 sists rather in a brief description, than a definition of the object. 
 It rests on phenomena appreciable to our senses, without reference 
 to the nature of the object itself, which is beyond their reach, and 
 the knowledge of which can only be attained by abstract reason- 
 ing. It has been justly remarked by M. Dumas that abstractions 
 mislead the mind, while truth is conveyed to us through the medi- 
 um of our senses. The history of all sciences, and particularly 
 that of medicine, proves the truth of this assertion. During the 
 period when the first mode of definition was employed, the pro- 
 gress of science was retrograde ; when, on the contrary, the 
 description came to be substituted for the definition, its advance 
 was constant. 
 
 I. Disease, as is well known, is that state opposed to health, a 
 word the significance of which is familiar to every one. But to 
 render an accurate definition is still no less difficult, as is evident 
 from the number and variety of those which have been already 
 proposed. Many physicians have attempted its definition by 
 referring to its nature, or its ultimate cause. Alcmoeon de Crotone 
 made it to consist in a derangement of the forces, the concurrence 
 and harmonious action of which result in health ; Plato, in his 
 definition, for forces, substituted elements, and Asdepiades replaced 
 the elements of Plato by indivisible corpnscules ; Sylvius viewed 
 disease as a reaction of salts ; Broivn, a lesion of excitability ; 
 Ritter, a galvanic change ; Baumes, a change in the proportion of 
 caloric, oxygen, hydrogen, nitrogen and phosphorus; and Broussais, 
 an effect of irritation, &c. Most of the other definitions of dis- 
 ease, founded upon its nature, are either comprised in those above 
 cited, or are so obscure, as to require a long explanation to render 
 them intelligible ; they have consequently been omitted in a work 
 strictly elementary, and in which such a display of erudition 
 would be out of place. Before taking leave of this subject, how- 
 ever, due consideration should be given to the definition of disease 
 proposed by Sydenham. 
 
 This writer, with all his natural sagacity and soundness of 
 judgment, attempted to define disease, according to its peculiar 
 nature. " Dictat ratio, si quid ego hie judico"* modestly says 
 this eminent physician, "morbum quantum libet ejus causce humano 
 corpori adversantur, nihil esse aliud quam naturce conamen 
 matericB morbificce exterminationem, in ccgri salutem, omni ope 
 molientis." This definition, although approximating in some 
 respects to the present language of the science, is nearly as defec- 
 
 * Sydenham, de morbis acutis in genere, page 19. 
 
8 DEFINITION OF DISEASE. 
 
 live as those which preceded it, presenting but a vagne idea of 
 an indeterminate effort of nature, a power of which we are totally 
 ignorant. Besides, the effort exerted by nature to destroy the 
 morbific cause, would rather constitute the remedy, than the dis- 
 ease. Finally, this reaction against the morbific cause does not 
 always exist, and consequently Sydenham's definition, were it 
 correct in other respects, would fail in this, since a definition 
 should apply to all cases. 
 
 The nature of disease being unknown, it becomes necessary to 
 seek other grounds upon which to found its definition. This 
 necessity has been recognized by pathologists of every age. 
 " Disease has by some authors been defined to be a derangement 
 of the functions. To this it has been objected that mere function- 
 al disturbance is insufficient to constitute disease, and that there 
 are certain phenomena, which are capable of giving rise to the 
 former, without producing the latter. A state of general disturb- 
 ance ordinarily accompanies the catamenial flow in females, not 
 however, amounting to disease. Parturition is attended with 
 violent pains, is folio-wed by a flow of blood, together with a 
 feeling of weariness and debility, yet without the existence of 
 disease. A violent passion, as anger or fright, may give rise to 
 extreme functional disturbance, without however inducing disease. 
 In old age, the exercise of the functions no longer takes place with 
 the same regularity ; the organs of generation become gradually 
 unfitted for reproduction, the functions of relation become by de- 
 grees enfeebled, the intellectual faculties become clouded, the sen- 
 sations blunted, and the step unsteady. The organs of individual * 
 life themselves become subsequently affected, yet without the 
 existence of disease. In the person who has been deprived in any- 
 way of an eye or an arm, there is not a regular exercise of all 
 the functions, yet it is manifest that disease does not exist. A 
 sensation of uneasiness in any part, an acute but momentary pain, 
 a transient spasm, or involuntary movement, are instances of 
 functional derangement, but cannot be considered as diseases. 
 
 Disturbance of the functions alone is then insufficient to constitute 
 disease, since even a considerable irregularity in their performance 
 is not necessarily incompatible with health. To define health 
 therefore to be that state in which all the functions are performed 
 with harmony and regularity, is incorrect. There is, as has been 
 said, an individual health which is influenced by a variety of cir- 
 cumstances. This has been remarked by many physicians, and 
 has led them to modify the definition under consideration. Some 
 have said, that functional derangement to constitute disease must 
 be the result of morbific causes.* By others, the epithet preter- 
 natural has been prefixed to signify that such functional disturbance 
 must be a deviation from the ordinary course of nature, f This defi- 
 
 * Ludwig, Patholog. Instil., page 6. 
 
 f The Latin adjective prtzternaturalis has commonly been construed by the 
 word unnatural; this is far from its true sense : it expresses a deviation from, 
 not an opposition to, the ordinary course of nature. 
 
DEFINITION OF DISEASE. 9 
 
 nition thus modified, is more accurate, but is still susceptible of 
 improvement. Every species of functional derangement, in which 
 there is a greater or less deviation from the usual order of nature, 
 constitutes a disease; but disease may exist independent of func- 
 tional disorder. Hernia, for example, is a disease, but not always 
 accompanied by disturbance of the functions. Tubercular degen- 
 eration, a very serious disease, may occur in several glands, and 
 even in a portion of an important viscus, as the lungs, without 
 giving rise to apparent disturbance of the health. It has been 
 maintained by some authors, that an anatomical lesion, which 
 is not followed by apparent functional disorder should not be 
 considered as a disease ; that the disease can only be said to exist 
 from the moment when certain phenomena of reaction render 
 it evident. Disease, according to them, and M. Littre adopts this 
 definition, f is u a vital reaction, either local or general, immediate 
 or mediate, against some obstruction, disorder or lesion." According 
 to this definition, a change of structure, however considerable, 
 in those cases of aneurism at the root of the aorta, which some- 
 times become far advanced without causing apparent disturbance 
 of the health, would not become a disease till complete perforation 
 of the vessel should take place ; while the same lesion, occurring 
 in another part of the same vessel, and causing either compression 
 upon a neighboring organ, or giving rise to perceptible pulsations 
 through the thoracic walls, would constitute a disease almost from 
 its commencement. In a fracture, the disease would consist rather 
 in the reaction against the lesion, that is, in the pain, difficulty of 
 movement, and inflammation which is developed at the surface 
 of the fragments and in the contiguous parts, than in the ana- 
 tomical lesion itself. These two examples taken from the most 
 familiar diseases, show the incorrectness of this definition, which 
 has been before pointed out, in considering that proposed by Syden- 
 ham, within which it is comprised. 
 
 It follows from these considerations, that it is impossible to 
 render a satisfactory definition of disease, without including 
 changes of structure, whether accompanied or not by functional 
 disturbance. 
 
 Structural changes being in most diseases the principal, and 
 functional disorders occurring, as secondary phenomena, it has 
 been thought by some physicians that all diseases are necessarily 
 connected with a material organic lesion, and that disease, con- 
 sidered abstractly, should be defined an alteration occurring in the 
 structure of the body. 
 
 It should be recollected that in a great number of diseases, the 
 existence of such an alteration is manifest, and is of the highest 
 value in the appreciation, as well as in the definition of disease. 
 It may be also remarked, that the number of affections, in which 
 these changes are found to exist, is becoming more considerable 
 in proportion to the advance of medical science, and will ultimate- 
 
 f Dictionnaire de Medecine, ou Repertoire general, vol. xviii , article, Maladie. 
 
10 DEFINITION OF DISEASE. 
 
 ly become indefinitely increased; in addition to the discoveries 
 daily made by pathological anatomists of lesion in the solid parts, 
 previously unnoticed, chemistry is leading to similar results, by 
 bringing to light important alterations in the fluids which enter 
 into the composition of the human body, as the bile, blood, urine, 
 &c. The changes observed in the quantity and consistence of 
 certain fluids, and particularly the blood (plethora, anemia) ; the 
 excessive accumulation of gas, in parts which naturally contain 
 it, its formation in parts to which it is foreign, have added to the 
 list of diseases, in which a material alteration exists. These 
 lesions of the liquid and gaseous fluids, which form a part of the 
 human body, deserve to be placed with those of the solid parts ; 
 and should, in the absence of lesions occurring in the latter, 
 be comprehended, at least by inference in the definition of the 
 disease. 
 
 By thus observing the progress of the science, it may be very 
 naturally inferred that, in proportion as our means of chemical 
 analysis and observation become more perfect, those diseases in 
 which hitherto no material lesion has been discoverable, will be 
 gradually added to those whose primitive lesion is already known, 
 and disease may then be defined to be an alteration occurring in 
 the structure of organs. But in medicine, more perhaps than in 
 any other science, we must be guided by facts ; and as it often 
 happens that this alteration escapes all our means of investigation, 
 and the functional disturbance is alone appreciable, and conse- 
 quently that alone which, in the present state of our knowledge, 
 indicates and constitutes the disease, it becomes necessary, in at- 
 tempting its definition, to characterize it by reference both to mate- 
 rial lesions and to functional derangement. 
 
 In the former editions of this work, we defined disease to be a 
 perceptible change in the position or structure of parts, or in the 
 exercise of one or many functions, relatively to the habitual health 
 of the individual. 
 
 We have thought proper, for the sake of brevity, to strike out 
 the clause relating to the changes of position of organs, since such 
 a change cannot be effected, unless there be also structural altera- 
 tion of the parts : a hernia can only follow a structural change in 
 the parietes of the splanchnic cavities ; dislocation can only take 
 place after rupture, or some other alteration in the parts, of which 
 the articulation is composed. We would likewise omit the last 
 clause of the definition, relatively to the habitual health of the in- 
 dividual, as good sense alone indicates this condition, which more- 
 over would be more appropriately placed among the considera- 
 tions which precede the definition, where it is presented with its 
 necessary developments. We have also employed another expres- 
 sion in place of the word structure, which does not so well apply, 
 in common phraseology, to the changes which occur in the com- 
 position and quantity of the fluids, or to alterations in the volume 
 of the solid parts, when at the same time unaccompanied by 
 manifest alteration of the tissues. It being impossible to define 
 
DEFINITION OF DISEASE. 11 
 
 I 
 
 disease according to its nature, and to obtain a clear idea of it 
 except from what is revealed to us by its phenomena, we give the 
 following definition : a perceptible disorder occurring, either in the 
 material disposition of the parts composing the living body, or in 
 the exercise of its functions.* 
 
 Some authors have endeavored to create a distinction between 
 affection and disease, expressions generally employed as synony- 
 mous. It has been thought by some that the word affection is 
 more appropriately applied to surgical cases, while those strictly 
 medical, would be better indicated by the word disease. Others 
 have maintained that disease consists in structural lesion, and af- 
 fection in the sensible phenomena arising from such lesion. 
 
 Sprengel, who presents this distinction, thinks it should serve as 
 a base for the division of pathology into general and special; the 
 former treating of diseases, the latter of affections. In the sense in 
 which Sprengel employs these two expressions, both belong equally 
 to general, and descriptive or special pathology. This distinction 
 between affection and disease ought then to be rejected, as con- 
 trary to common acceptation, and as rendering the language 
 obscure without elucidating the subject. The words affection and 
 disease therefore, in medical phraseology, are used synonymously, 
 although the latter, considered in its most general sense, admits of 
 a different signification. 
 
 II. Having defined disease in general according to the principles 
 previously established, we shall proceed to consider the mode of 
 defining diseases respectively. These considerations belong to 
 general pathology, inasmuch as they apply to all diseases. 
 
 To obtain a correct definition of each particular disease is of far 
 more importance, than the attainment of a clear idea of disease in 
 general. 
 
 Being ignorant of the nature of diseases respectively, as well as 
 of disease in general, it is necessary that we define them also ac- 
 cording to their sensible phenomena. 
 
 It has been recently advanced, that a disease can only be defined 
 by determining which is the organ affected and the character of 
 that affection ; but this kind of definition which can only apply to 
 a limited number of diseases, is not strictly a definition. To say 
 that pleurisy is an inflammation of the pleura ; tabes mesenterica, 
 a tubercular degeneration of the mesenteric glands ; ascites, an ef- 
 fusion of serum into the peritoneum ; epistaxis, a haemorrhage from 
 the pituitary membrane ; is to give a signification of the word, and 
 not a definition of the disease. Another and more serious inconve- 
 nience connected with this kind of definition, is the uncertainty in 
 respect to the seat of certain diseases, and the conflicting opinions 
 among physicians on this point. How various, for example, 
 
 * This definition appears to us more accurate than any other, although defec- 
 tive in some respects ; this imperfection is, perhaps, inherent in the subject un- 
 der consideration. Health and disease are often confounded. How is it possible 
 to define with strict accuracy things not always distinct ? 
 
12 DEFINITION OF DISEASE. 
 
 would have been the definitions of intermittent fever, whose seat 
 has been placed in the liver, spleen, stomach, intestines, nervous 
 system, skin, vena porta, lymphatic vessels of the mesentery, and 
 to what confusion would these contradictory statements have given 
 rise ! It is necessary then, in order that the definition be always 
 intelligible, to define these affections according to their phenomena. 
 There are also cases, in which the manifest cause of diseases be- 
 comes an accessory element in their definition : contusions, wounds, 
 lead colic, asphyxia, syphilis, variola, &c., cannot be accurately de- 
 fined, unless the cause which produced them be indicated. 
 
 In general, in order to the correct definition of a disease, it is 
 necessary to collect the greatest possible number of detailed cases, 
 relating to it ; to compare them with each other, so as to isolate 
 those phenomena which are constant, from those which are simply 
 accidental. 
 
 The phenomena which are found to occur in all the cases, or at 
 least in the majority, form the characteristic features of the dis- 
 ease ; their brief enumeration will present an outline of the latter, 
 constituting its definition. 
 
 Some diseases appear with such different degrees of intensity, 
 that it would be impossible to include in a common description 
 these various forms of the same affection : cerebral haemorrhage, 
 for example, gives rise to phenomena so various, according to the 
 size of the coagulum, that it is indispensable, in order to give a cor- 
 rect idea of this disease, to present a descriptive definition of its 
 principal forms, as in natural history, in which the representation 
 of a plant or animal is given, in its principal phases of existence, 
 and in its various proportions. The remark of Grimaud, that the 
 thorough knowledge of a disease is only to be obtained, by study- 
 ing it at the age, and in the sex, temperament and climate, which 
 observation has shown to be congenial with it, is incorrect; "for," 
 says he, " every disease,* like every natural being, appears in its 
 true light, and enjoys the whole plenitude of its existence, only when 
 formed and developed under a concurrence of circumstances, which 
 are analogous to it, and equally tend to favor its production." The 
 physician, whose knowledge of a disease only extends to its se- 
 verest form, can have but an imperfect idea of it, being acquainted 
 only with its exceptional form. It should be studied, on the 
 contrary, in all its varieties, and if there be any which deserve 
 particular attention, it should first be those of most frequent oc- 
 currence, and afterwards those whose characteristics are least ap- 
 parent, the former on account of their greater utility, the latter, 
 because of their more difficult diagnosis. But, we repeat it, the 
 definition of a disease is only correct, so far as it comprehends all 
 the forms which the latter is capable of presenting. O. 
 
 * Grimaud. Cours de Fttvres, vol. i., p. 2. 
 
NOMENCLATURE, SYNONOMY, ETYMOLOGY, OF DISEASES. 13 
 
 CHAPTER III. 
 
 NOMENCLATURE OF DISEASES. SYNONOMY. ETYMOLOGY. 
 
 I. Nomenclature. There is perhaps no science, the nomencla- 
 ture of which is so defective, as that of pathology. This is doubt- 
 less, in part, attributable to the very gradual progress made in the 
 knowledge of diseases. If, like chemistry, the science of pathology 
 had made a sudden and rapid advance, the old terms would have 
 been replaced by others formed on more regular bases. But the 
 case has been far otherwise, and nothing can be more preposterous 
 than the collection of names by which diseases have been desig- 
 nated. Some have been named from their known or supposed 
 seat, as pleuritis and hypochondriasis ; or from their causes, as 
 colds, &c. ; others from the places and seasons in which they ap- 
 pear, as the camp, harvest and autumnal, fevers, ( Grant ;) from 
 the country where they originated, as the typhus of America ; from 
 the people who transmitted them, as the French disease, (a term 
 applied by the Italians to syphilis ;) from the animal which com- 
 municates it, as vaccinia ; others, from one of the principal symp- 
 toms, as hydrophobia, chorea, &c. In eruptive diseases, the color 
 of the skin has, in many instances, suggested the name by which 
 they are designated ; rubcola and scarlatina are examples. The 
 word variola seems to have had the same origin, and to signify 
 that diversity of color which the skin presents, when its surface is 
 covered with white pustules, or yellowish or brownish crusts, sur- 
 rounded by a red and sometimes brown areola, and separated by 
 spaces in which the natural color remains unchanged. The par- 
 ticular form of certain eruptions, the manner in which they are 
 disposed upon the skin, their appearance during the night, have led 
 to the adoption of names indicating these different circumstances, 
 as miliaria, herpes zoster, epinyctis ; other affections have received 
 names relating to their progress or duration, as intermittent, con- 
 tinued, and remittent fevers. The insidious form of some diseases 
 has caused the term malignant to be applied to them. There are 
 others which have been designated, from a sort of resemblance to 
 certain products of human industry, or some object of natural his- 
 tory, as tympanitis, clavus, cancer, polypus, talpa, and elephantia- 
 sis. Others have received names indicative of their supposed na- 
 ture, as putrid and bilious fevers ; and again, indicative of the 
 kind of organic alteration which constitutes the disease, as tubercle, 
 melanosis, eneephaloid disease ; others have been named from the 
 physician who first described them, as Potts' disease, Bright's 
 disease. Besides these principal terms, some epithet indicating its 
 degree of severity, form, termination or mobility, has been added 
 to the name of the disease. Examples of this, are the variola benig- 
 
14 NOMENCLATURE, SYNONOMY, ETYMOLOGY, OF DISEASES. 
 
 na, apoplexia fulminans, tinea favosa, angina gangrccnosa, febris 
 ephemera, erysipelas erraticum. 
 
 It is evident from this brief survey, that no rule has been ob- 
 served in the selection of the names under which diseases have been 
 described, and that incongruity prevails thoughout pathological 
 nomenclature. But another and more serious inconvenience which 
 it presents, is, that many terms are false, and consequently liable 
 to lead to error ; such are those based on the supposed seat of the 
 disease, and upon its intimate nature. In some cases, the error is 
 still more palpable, affecting some point relative to the origin of the 
 disease, or some one of its more apparent phenomena. Thus, the 
 disease of Siam, originated in America ; the hepatic flux does not 
 generally come from the liver, and the fluor albus may be of other 
 colors, &c. 
 
 The defects of such a nomenclature are too striking, not to have 
 led many physicians to attempt their correction ; but it should be 
 remarked, that these corrections have in nearly every case been 
 partial, and that M. Piorry has been the first to propose a complete 
 system of nomenclature for all diseases, established on uniform 
 bases. These partial corrections, failing to produce a proper regu- 
 larity, have proved rather injurious than useful. In some cases, 
 more appropriate names have -been substituted for those which 
 were vague or erroneous, but the latter have not been totally aban- 
 doned ; so that many diseases have received a variety of names, 
 with which it is necessary to become familiar ; no less than twenty 
 have been applied to yellow fever. The effect of these numerous 
 pathological terms, has been to increase the number of words, 
 without aiding in the elicitation of truth. 
 
 Another, and still more serious, inconvenience results from these 
 partial corrections ; some authors, not content with adding new 
 names to the old, have transferred the same term from one disease 
 to another, under the pretext that it was less appropriate to that to 
 which it had been previously applied, than to the one which it was 
 henceforth to represent. The troublesome results of these pretend- 
 ed improvements are easily discernible ; confusion in pathological 
 language has been the necessary consequence. 
 
 It will be perhaps asked, if, in the present state of the science, a 
 new nomenclature could with advantage be established, and on 
 what basis. When we consider tjie imperfections and incongruity 
 of nomenclature, as it now exists, we become convinced of the im- 
 portance of substituting a methodical nomenclature, which shall in- 
 dicate the characteristic features of each disease, and by which we 
 shall be enabled to establish their relations with each other. But 
 if it be also considered, how much the difficulties connected with 
 the study of the science become increased by such a multiplicity of 
 names, and that, in the present state of our knowledge, it is impos- 
 sible to present any system of nomenclature, which shall be satis- 
 factory to all, as the attempts of M. Piorry sufficiently prove ; and, 
 lastly, if we regard the apparent contradictions to which new terms 
 give rise, and the unfavorable inferences of the public with respect 
 
NOMENCLATURE, SYNONOMY, ETYMOLOGY, OF DISEASES. 15 
 
 to the certainty of medicine, we shall be led to conclude that the 
 advantages of a new nomenclature would be more than counter- 
 balanced by the inseparable inconveniences connected with it. " Si 
 nunc imponenda essent nomina" says Morgagni,* " non dubito 
 quin plura excogitari possint meliora et cum vero magis congru- 
 entia ; sed proestat, opinor, verum postea animadverswn docere, 
 vetera autem et usitata nomina retincre" 
 
 There are some circumstances, however, in which it becomes 
 necessary to add to pathological nomenclature ; as upon the dis- 
 covery of an affection not before described, and also when different 
 diseases have been confounded under the same name. In both 
 cases, it is indispensably necessary, even the enemies of neologism 
 will admit, to seek a new name for the disease just discovered or 
 pointed out. 
 
 II. Synonomy. The same disease having, in some instances, 
 received a variety of names, and the same name having been 
 applied to many diseases by different authors, the study of the 
 various names of diseases, with their different significations, has 
 become also indispensable. This is, as it were, an artificial 
 branch which man has added to pathology, without any real pro- 
 fit, though not without necessity. Synonomy of diseases has con- 
 sequently become a highly important point in their history, render- 
 ing their study more complicated, an irremediable inconvenience, 
 but enabling us to avoid much confusion. 
 
 III. The Etymology of diseases is one of the least interesting 
 points in pathology. It is, however, like many other things, a 
 knowledge of which is of little utility, but ignorance of which 
 would be attended with inconvenience. No one doubts that a 
 physician may skilfully treat a disease, without being acquainted 
 with the origin of its name ; but it is equally certain, that it would 
 be embarrassing, and even injurious for him to appear ignorant in 
 the r presence of some persons, of the etymology of a word which 
 he daily employs. An acquaintance with the exact value of the 
 terms in common use, is moreover convenient to the physican; 
 medical phraseology would, otherwise, be to him unintelligible. 
 Most of the names which have been applied to diseases, are of 
 Greek and Latin origin ; and as the study of these two languages 
 should always precede that of medicine, it is rarely necessary 
 for the physician to seek the etymology of the terms of which he 
 makes use. 
 
 The etymology of the various terms used in pathology but im- 
 perfectly indicates the meaning which should be attached to them. 
 It rarely gives an accurate, and often presents a totally incorrect 
 idea of the disease. Thus the words phlegmon, and phlegmasice, 
 from yJeycflj { I burn,' merely give the idea of heat, which is but one 
 of the symptoms of the disease ; the word peripneumony, from n^i, 
 ' around,' and nvevuonj, l lung,' indicates an affection seated around 
 the lungs, whereas it consists in inflammation of this viscus itself. 
 
 * Morgagni, Epist xvi. 14. 
 
16 SEAT OF DISEASES. 
 
 and not of the surrounding parts. Thus, etymology, in the former 
 case, presents an imperfect, in the latter, an erroneous, idea of the 
 disease.^ O. 
 
 CHAPTER IV. 
 
 4 
 
 SEAT OF DISEASES. 
 
 IT may be remarked generally, that all the constituent parts of 
 the human body are susceptible of some change, and consequently 
 may become affected with diseases of greater or less severity. The 
 susceptibility to the influence of the various morbific causes, varies 
 in different organs ; the skin and mucous membranes are of all 
 tissues, those in which diseases are most frequently observed. The 
 organs which are deeply seated, and which have no direct commu- 
 nication with external objects, are less prone than all others to the 
 action of disease. 
 
 It is not always easy to determine the seat of diseases, and the 
 history of medicine shows how great has been the diversity of 
 opinion on this point. During the reign of humorism, the primi- 
 tive seat of most diseases was supposed to be in some one of the 
 fluids which enter into the organization of the human body. The 
 Solidists, who came afterwards, supposed the humors to be purely 
 passive in the phenomena of life, and considered the solids to be 
 the seat of all diseases. Time has dealt justly with these erroneous 
 opinions, and observation has shown that the exclusive claims of 
 both these systems are alike inadmissible. 
 
 It should be recollected that many diseases have a complex seat, 
 primarily affecting the solid parts, and afterwards extending to the 
 fluids of the body, or vice versa. The first stage of phlebitis pre- 
 sents an example of a disease at first confined to a single tissue, 
 but soon followed by a secretion of pus from the suffering part ; 
 this morbid product being carried along by the circulatory move- 
 ment, is mixed with the blood, which becomes altered, and, by its 
 effect upon other organs, produces phlegmasiae and suppurations. 
 In variola, on the contrary, and in the other contagious eruptive 
 
 * Although the etymology of diseases is generally of slight importance, it is not 
 in many cases devoid of interest. The names which have been given to diseases 
 are often connected with the history of medicine, and the theories to which it has 
 given rise ; such are the terms humoral fever , nervous fever. Etymology may also 
 give rise to conjectures upon some of the circumstances relating to the particular 
 history of a disease, &c. The term morbtlli, for example, by which rubeolahas 
 been designated, would lead us to suppose that there appeared, simultaneously 
 with it, another and more severe affection, bearing resemblance to it, which was 
 called morbus, a name always given to epidemic diseases. This circumstance 
 would add weight to the opinion generally entertained, that rubeola, which origi- 
 nated in the same country with variola, first appeared at about the same period. 
 
SEAT OF DISEASES. 17 
 
 fevers, in which the blood appears to be the primary seat of the 
 disease, the eruption makes its appearance upon the skin and mu- 
 cous membranes, a few days after this alteration has taken place. 
 
 There are some diseases which affect nearly all the tissues of 
 the economy, as, inflammation, cancer, tubercles, and syphilis. 
 Others are observed in but a few ; dropsy, for example, is peculiar 
 to the membranes which line the interior of cavities, and to the 
 cellular tissue ; spontaneous haemorrhage rarely occurs except from 
 the mucous membranes. Haemorrhage may, however, take place 
 in other parts, and dropsy may be formed, by means of accidental 
 cysts, in parts naturally protected from it by their structure. 
 There are also other diseases, which appear to be constantly and 
 exclusively confined to the same anatomical element, wherever 
 this be ; this is probably the case in rheumatism and gout, which 
 are peculiar to the muscular and fibrous tissues. 
 
 Many diseases have a fixed seat, that is, they become developed 
 and terminate in the same part where they originally appeared : 
 others, on the contrary, successively invade the neighboring parts, 
 as certain phagedenic ulcers, cancer, erysipelas, and perhaps most 
 of the phlegmasiae, called spontaneous. There are others whose 
 seat, which is essentially vague and moveable, is constantly vary- 
 ing, as is observed in rheumatism and gout, the mobility of which 
 affections constitutes one of their most essential characteristics. 
 There are also certain nervous affections, which successively ap- 
 pear in parts remote from each other, and haemorrhages are equal- 
 ly liable to change their seat. 
 
 There are many diseases which affect but a portion of the 
 economy ; there are others, which appear simultaneously in parts 
 more or less remote from each other, exhibiting the same form and 
 characteristics. The former have but a single seat, the latter are 
 disseminated, or have a multiple seat. To the first belong the 
 visceral and membranous phlegmasiae, as pneumonia or pericar- 
 ditis ; to the second, urticaria, variola, rubeola, the syphilitic 
 eruptions, morbus macidosus, &c. These latter affections, to 
 which we have applied the term disseminated, deserve particular 
 attention, from the conditions under which they are developed. 
 These multiple lesions are indeed almost always secondary, and 
 the physician may in most cases recognize the affection which 
 gave rise to them, and to which the treatment should be directed. 
 
 The organs which exist in pairs are often simultaneously affect- 
 ed with the same disease. It is rare to see spontaneous ophthalmia 
 confined to one of the conjunctivae, or bronchitis or emphysema 
 affecting but one lung. There are certain chronic exanthemata 
 which appear simultaneously in both armpits, in the two groins, 
 and in corresponding parts of the same limbs. In rheumatism, 
 corresponding articulations become generally successively affected. 
 The same law is observed in regard to the deep seated organs. It 
 has been clearly shown by M. Bizot, that the numerous changes 
 which take place in the arteries, are almost always affected si- 
 multaneously in the symmetrical vessels, and at corresponding 
 2* 
 
18 SEAT OF DISEASES. 
 
 points.* There are, however, some exceptions to this law ; the 
 two testicles, or the mammae, for example, which often become 
 singly affected with inflammation or carcinomatous disease, are 
 rarely the seat of either of these affections simultaneously. 
 
 It has heen long observed that the age has a marked influence 
 upon the seat of diseases. During infancy the head is the seat of 
 numerous affections; hydrocephalus, tubercular meningitis, the 
 various eruptions of the hairy scalp, excoriations of the lips, nose 
 and ears, apthre, grangrene of the mouth, and epistaxis are pecu- 
 liar to 'this period ; the lightest affections are accompanied with 
 delirium, the submaxillary glands are often engorged, and the 
 larynx is the seat of very serious diseases; it is at this period 
 that croup is most commonly observed. At puberty and during 
 the period of youth, affections of the chest, as inflammations of 
 the pleura and lungs, hemoptysis, and bronchitis, become more 
 frequent ; it is then that the first signs of cardiac disease often 
 manifest themselves, and so common is the occurrence of phthisis 
 pulmonalis at this period, that it was for a long time supposed 
 never to appear except between the ages of fifteen and thirty. 
 While thoracic disease is more frequent during the period of 
 youth, that of adult age is more prone to diseases of the abdomen ; 
 it is at this period that most organic affections of the abdominal 
 viscera become developed; diseases of the stomach, intestines, 
 ovaries, testicles, liver, bladder and uterus rarely occur before this 
 time. The haemoptysis of youth, which succeeds the epistaxis of 
 childhood, is followed in adult age by the hgemorrhoidal flux, which 
 is as peculiar to this period, as the others to the preceding. Lastly, 
 in old age, while the abdomen continues the seat of various diseases, 
 those of the urinary organs become more frequent, and the head 
 again becomes prone to morbific action ; dementia, paralysis, effu- 
 sion of blood into the brain, softening of its substance, deafness, 
 cataract, &c., are diseases as common during this, as they are rare 
 at other periods of life. 
 
 To this observation respecting the frequency of diseases of the 
 head, chest and abdomen at particular periods of life, although 
 generally true, there are numerous exceptions. Without referring 
 to the diseases produced by mechanical causes, whose seat is 
 determined by external circumstances, we often see children 
 affected with pulmonary catarrh, phthisis, and various forms of 
 enteritis. Scrofulous enlargement of the mesenteric glands, and 
 intestinal worms, are of more frequent occurrence during child- 
 hood than at other periods ; mania, whose seat appears to be in the 
 brain, is more common in youth and adult age ; simple meningitis 
 occurs at all periods of life, and pneumonia is one of the acute 
 diseases most frequently observed in old age. But however nu- 
 merous the exceptions, they are insufficient to invalidate the gen- 
 eral rule. 
 
 It has been stated that the seasons, as well as the age, exert 
 
 * Memoires de la Soc. Med. d'Observation. Paris, 1836, t. 1, p. 399. 
 
ETIOLOGY. 19 
 
 a marked influence upon the seat of diseases ; that in winter, 
 cerebral diseases prevail ; in spring, those of the chest ; while ab- 
 dominal affections are more prevalent in summer and autumn. 
 This assertion does not so generally apply as the preceding, 
 although not without foundation, particularly if it be considered 
 with exclusive reference to acute diseases. 
 
 Such are the general points of view, in which the seat of dis- 
 eases may be considered, the difficulties and modes of deter- 
 mining which, will be particularly considered in the chapter on 
 diagnosis. O. 
 
 CHAPTER V. 
 
 ETIOLOGY, OR THE CAUSES OF DISEASE.* 
 
 THE most general signification of Etiology in all the sciences, 
 is the study of causes ; in medicine, its object is the knowledge 
 of morbific causes. 
 
 Under the title morbific causes, is included every thing which 
 produces disease, and all that contributes to its development. 
 
 The causes of disease are everywhere present, both around and 
 within us. The things most necessary to our existence, as the 
 air we breathe, the food and fluids which restore our daily loss of 
 substance, the products of human industry by which life is 
 rendered more comfortable and happy, themselves give rise to the 
 ills with which we are afflicted. 
 
 The different organs, which united, constitute tfye economy, and 
 which are designed for the preservation of the entire system, of 
 which they form part, may also, in certain circumstances, disturb 
 its harmony ; the muscles, whose use is to transport us from one 
 place to another, may cause displacement and even fracture of 
 the bones ; the teeth, the eye-lashes, the nails, by their irregular 
 development, sometimes occasion diseases of a more or less seri- 
 ous nature ; gestation, and especially the expulsion of the fostus, 
 become under certain conditions the sources of danger and death. 
 When we thus behold, within the system and without, the things 
 most indispensable to human life and to the preservation of the 
 species, become in some circumstances the causes of the maladies 
 by which we are afflicted, we are tempted to admit with Testa, 
 that there is not, properly speaking, any morbific cause, nothing 
 in itself injurious : " Nikil proprie morbificum, nihil noxium 
 natura/sua" But this assertion, although true in respect to the 
 greater number of causes which disturb the health, becomes the 
 opposite, when, reviewing all the causes of disease, we come to 
 
 *Ali(a, cause ; Aoyo?, narration. 
 
20 ETIOLOGY. 
 
 the contagious principles, which are certainly, in themselves and 
 despite the abuse that may be made of them, morbific agents. 
 
 The causes of disease being very numerous and varied, the 
 necessity for a division of them has always been experienced : 
 they have been divided into external, or those which surround 
 the individual; internal, existing within him; jjrificipal, or 
 those which act an important part in developing diseases ; accesso- 
 ry, which exert but little influence in their production ; remote, 
 which prepare or determine the hidden alteration constituting 
 the essence or proximate cause of the disease ; predisposing, 
 which gradually modify the economy and dispose to various affec- 
 tions ; occasional, which provoke the development of such 
 affections. 
 
 The terms physical and chemical, have been applied to those 
 causes which act in accordance with the laws of physics and 
 chemistry, and which would affect the dead equally with the liv- 
 ing body : such are instruments capable of inflicting wounds, 
 caustic substances, etc. ; the term ^physiological is applied to those 
 which need the co-operation of a vital reaction in the organ 
 which receives their impressions ; local, to those whose action 
 affects but a portion of the economy ; general, to those which ex- 
 tend their influence over all ; negative, to those which consist in 
 the abstraction of conditions necessary to health ; and the oppo- 
 site, positive, to those which act by their own power in the pro- 
 duction of diseases. Material and immaterial causes have been 
 admitted, according as they are or are not recognized by our senses. 
 Finally, as there is a certain number of diseases which occur 
 without appreciable cause, concealed or occult causes have 
 necessarily been admitted, and these have been ascribed by 
 many authors to certain inappreciable qualities of the atmosphere, 
 to which the .development of epidemics may be attributed. 
 There are serious inconveniences attending each of these divis- 
 ions. The proximate cause, which is nothing else than the very 
 essence of the disease and the peculiar modification of the organism 
 which constitutes it, cannot be reckoned among the causes which 
 produce it. Among the occasional causes, circumstances entirely 
 dissimilar are enumerated : the impression of cold, for instance, 
 which at one time developes pneumonia, at another, occasions 
 anasarca, and which most frequently is productive of nothing 
 morbid, is placed in the same category with wounding instru- 
 ments and poisons, which always produce definite effects upon 
 the system. It is unnecessary to insist upon the imperfection of 
 each of these divisions ; neither of them possesses the advantage 
 of uniting those causes which have an analogous action ; and yet 
 it is this very circumstance which should serve as a foundation 
 for the most natural division of morbific causes. 
 
 Among these causes there are those which are constantly fol- 
 lowed by the same diseases ; for them we reserve the name deter- 
 mining. Others, whose action is often uncertain and always ob- 
 scure, may be subdivided into two series. In the first, we place 
 
ETIOLOGY. 
 
 21 
 
 whatever serves, by gradually modifying the economy, to pre- 
 pare it for any particular affection, and everything constituting 
 the aptitude for being so affected : these are predisposing causes. 
 
 In the second series we rank those whose action, usually tran- 
 sient, only hastens the development of a disease, to which the 
 patient was predisposed : to the latter we give the name occasion- 
 al or exciting causes. 
 
 Thus we admit three orders of morbific causes, which we dis- 
 tinguish by the appellations determining, predisposing and occa- 
 sional. We shall rapidly review the chief causes which belong 
 to each of these three divisions, and shall afterwards offer some 
 general considerations upon their mode of action in the production 
 of disease. 
 
 ARTICLE FIRST. 
 Determining Causes. 
 
 DETERMINING causes, which constantly give rise to the same af- 
 fection, if we except certain conditions more or less well known, 
 exhibit in almost every instance, either in themselves or in the dis- 
 ease which they produce, some peculiarity. The hot body which 
 burns, the cold which freezes, the gases which poison or cause 
 asphyxia, the body which inflicts a wound, the poison which nar- 
 cotizes or causes convulsions, are certainly special causes, in like 
 manner as the diseases which they induce are themselves unlike 
 all others. This it is which led us in the former editions of this 
 work, to class these morbific agents among the specific causes, and 
 to use synonymously the terms specific and determining causes. 
 
 Notwithstanding, we now think that a more strict signification 
 should be given to these words, and one more in accordance with 
 general usage : by specific causes, then, will be understood those 
 which produce specific diseases, and by specific diseases, those 
 which cannot be developed except by one and the same cause, as 
 syphilis, rabies, variola. Those causes whose action is equally di- 
 rect and constant, but which give rise to diseases which other 
 causes may also produce, will be designated common determining 
 causes ; burns and wounds, for instance, may be produced by vari- 
 ous agents. We may add, that the greater part of the common 
 determining causes act by virtue of physical or chemical laws, 
 and that their action can be explained by these laws. Specific 
 causes, on the contrary, in their mode of action, are inexplicable, 
 either by means of physics or chemistry. Such are the motives 
 which have induced us to divide these two classes of causes and 
 to study them separately. 
 
 $ I. Common determining Causes. These may be diffused in 
 the atmosphere (tircumftisa), brought in contact with our bodies, 
 (applicata), or introduced into our organs (ingesta) ; they may 
 exist within us and depend upon derangement of the evacuations 
 
22 ETIOLOGY. 
 
 (excreta), of the movements (acta) or of the perceptions (percep- 
 ta) ; they will be pointed out in this order, which is the one most 
 commonly followed in the explanation of hygiene, and which is 
 equally well adapted to the study of morbific causes. 
 
 A. Circumfusa* In certain circumstances gases unfit for re- 
 spiration are introduced into the air passages ; nitrogen, the pro- 
 toxide of nitrogen and hydrogen have been inhaled by chemists 
 in order to ascertain their effects on the animal economy. They 
 produced a mild asphyxia very different from that caused by the 
 deleterious gases. These last are sometimes found accumulated 
 accidentally in certain places where the external air penetrates with 
 difficulty ; as in drains, sewers, mines, certain work-shops, facto- 
 ries, and in some thermal establishments. Carbonic acid gas and 
 carburetted hydrogen, which are disengaged by the combustion of 
 charcoal, may become mixed with the air in sufficient quantity to 
 asphyxiate the persons who breathe them. The same is true of 
 the gases which escape from animal matters, particularly excrement 
 in a state of putrefaction, in a closed vault, by which asphyxia is 
 quickly produced. This accident, to which the workmen, who 
 are employed in clearing privies are exposed, is occasioned by a 
 gas long known as sulphuretted hydrogen, and which seems most 
 commonly composed of hydro-sulphuric acid, hydro-sulphate of 
 ammonia and nitrogen. Carbonic acid gas accumulated in the 
 lowest part of certain caverns, (as in the Grotto del Cane, for in- 
 stance) is in that situation several feet in depth ; if a man enter, 
 he is above the level of the deleterious gas, but a child would be 
 asphyxiated, like the animals which are introduced for experiment. 
 
 Putrid and malignant fevers have at times raged epidemically 
 during the disinterment of a large number of bodies : the town of 
 Saulieu, in 1773, presented a sad example ;f and long previously, 
 an epidemic, gangrenous fever had been observed, J produced by 
 tainted air after contagious disease among animals, where great 
 numbers of their bodies remained unburied and infected the at-- 
 mosphere. 
 
 Vegetable emanations are occasionally the determining causes of 
 disease. Air charged with the odorous principle of the hyacinth, 
 the lily, the orange blossom, the narcissus, causes headache, nau- 
 sea, dizziness, and sometimes even fainting, especially in small and 
 warm apartments. 
 
 A very high, or exceedingly low temperature of the atmosphere 
 is a determining cause of many affections. Individuals exposed to 
 severe cold have often been observed to die with symptoms which 
 might be ascribed to asphyxia or to strong cerebral congestion; 
 
 * Properly speaking, morbific agents, diffused in the atmosphere, act only by 
 their introduction into our organs, and, thus considered, should, perhaps, be ranked 
 with the ingesta ; but it has not been deemed proper to depart from the classifica- 
 tion generally adopted. 
 
 Maret, Usage cTenterrer les morts dans les eglises. Dijon, 1775. 
 
 | De recondita febrium rcmitt. ac mtermitt. natura. 
 
ETIOLOGY. 23 
 
 freezing of a portion of the body is at such a time a yet more fre- 
 quent occurrence. The grave symptoms caused by a very elevat- 
 ed temperature have also been referred by most physicians to apo- 
 plexy or asphyxia ; but, from the researches of some authors, and 
 those of J. J. Russel in particular, it seems that the special action 
 of heat is a determination towards the thoracic organs, causing vi- 
 olent congestion, frequently terminating in death.* 
 
 A very brilliant light suddenly flashing upon the eye, or an ex- 
 ceedingly loud noise, may produce blindness, or deafness. 
 
 A violent discharge of electricity diffused through the air, or col- 
 lected by apparatus, has caused in some persons sudden death, in 
 others, incurable tremor, stupor, or partial paralysis. 
 
 B. Among the applicata a great number of determining causes 
 exist. Those bodies which inflict bruises, and pointed and cutting 
 instruments, are the most common causes of all the wounds to 
 which man is exposed. Falls, in which the human body strikes with 
 the impetus it has received, against surfaces more or less resistant, 
 give rise to diseases, Analogous to those produced by vulnerary 
 agents. 
 
 In the same class with these latter must be placed ligatures, 
 which, in addition to their hindrance of free circulation, may pene- 
 trate into the tissues when strongly drawn, and asphyxiate when 
 applied over the course of the trachea. 
 
 Immersion in a liquid has a similar eifect by preventing the 
 ingress of air. Incandescent bodies, and boiling liquids placed 
 in contact with our flesh either inflame or cause gangrene, ac- 
 cording to their degree of power. Solid or liquid caustics, acids, 
 alkalies and salts, act in an analogous manner ; some of these sub- 
 stances, as corrosive sublimate and arsenical preparations, may be 
 absorbed at the surface of the body at the same time that they act 
 locally as caustics ; they may likewise be conveyed into the in- 
 ternal organs and give rise to the phenomena of poisoning. In the 
 same series may also be placed the acrid topical agents, whether 
 rubefacient or vesicant, as the flower of mustard, the powder of 
 cantharides, the bark of the Daphne Mezereum, etc., etc. 
 
 C. Ingesta. Substances introduced into the interior of the 
 body, become frequently the determining causes of disease. The 
 poisons belong almost wholly to this class. By poisons are under- 
 stood, according to Mead, all those substances which, in minute 
 doses, are capable of producing great changes in living bodies. 
 We prefer, with Mahon, to give the name to those only which are 
 destructive of life. 
 
 Formerly, poisons were divided into mineral, vegetable and ani- 
 mal. M. Orfila has, with reason, considered it more convenient to 
 class them according to their mode of action upon the economy, 
 rather than after the particular natural kingdom to which they 
 
 * Encycl. des. Sciences Medicales p. 235. 
 
24 ETIOLOGY. 
 
 belong. Consequently, he has divided them into four classes, 
 according to their properties, viz., irritating, narcotic, narcotico- 
 acrid and septic. Irritating, corrosive, escharotic or acrid poisons, 
 according to their strength, simply inflame or completely disorgan- 
 ize the part to which they are applied. Narcotic poisons, such 
 as opium, the solanacese, etc., act in an entirely different manner : 
 their operation is particularly upon the brain, whose functions 
 they disorder or suspend, and they have but little effect upon the 
 organs with which they are in immediate contact. Narcotico- 
 acrid poisons, such as the poisonous mushrooms, present the above 
 two modes of action united. Finally, septic poisons, as the flesh 
 of animals who have died of pestilential diseases, putrifying animal 
 matters, and certain products of morbid secretion, bring on grave 
 disease of an adynamic or ataxic form, often complicated with 
 gangrene, and most usually terminating fatally. Ergot, which 
 produces gangrene of the tissues, must be classed, for this reason, 
 with the septic, rather than with the narcotico-acrid poisons. 
 
 D. There are but few determining causts among the excreta, 
 the gesta or the percepta. A very abundant natural haemor- 
 rhage, particularly if menstrual, may bring on anaemia. A strong 
 muscular contraction may rupture a tendon, or break a bone : it 
 is often the determining cause of hernia, and sometimes of dislo- 
 cation. Very powerful moral affections, as disappointed love, or 
 nostalgia in adults, and chagrin in children, are sometimes the de- 
 termining causes of a species of hectic fever. A deep-seated pas- 
 sion is commonly the determining cause of melancholy. Despair, 
 terror, and immoderate joy, have, in some cases, caused sudden 
 death. There are some diseases which may become the deter- 
 mining cause of certain others. Thus, severe parotiditis has 
 sometimes produced asphyxia ; a fracture or a dislocation, the 
 formation of enormous abscesses in the cellular tissue ; perforation 
 of the stomach, rupture of the galf-bladder, the urinary bladder, 
 the uterus, the erosion of the intestines by ulceration, and of the 
 pleura by softened tubercle, are so many direct causes of peritonitis 
 or of pleurisy almost inevitably fatal. 
 
 Retention of frecal matter in the rectum, has sometimes occa- 
 sioned all the phenomena of intestinal occlusion, and in some rare 
 cases has caused death, especially in aged patients. 
 
 Finally, the presence of certain parasitic animals in the human 
 body, may be added to the above determining causes, as tsenia, 
 the oxyuris, the ascaris lumbricoides, hydatids, etc. Their exist- 
 ence does not always produce morbid phenomena, but is, in itself, 
 something abnormal as regards the material disposition of the 
 parts. Consequently, it constitutes a disease which will always 
 be the same in its essence, however varied may be its form. It is 
 the same with inanimate foreign bodies, introduced into our organs 
 by the natural passages, or by the medium of a wound; although 
 their presence may occasion no disturbance of the health, we 
 must, nevertheless, class them with the determining causes, be- 
 
ETIOLOGY. 25 
 
 because they act in a uniform manner ; the point of an instrument 
 or a ball remaining in a wound, or a foreign body in the trachea, 
 evidently belong to this class of causes. 
 
 Specific determining Causes. The peculiar character of these, 
 as was mentioned, is the production of diseases, which they 
 alone can cause, and the impossibility of explaining them by 
 physical or chemical laws. 
 
 They are subdivided into two distinct series, according to their 
 mode of action : to the first, belong those whose effects are confined 
 to the individual who is exposed to their influence; to the second, 
 those morbific agents, which, like seeds, reproduce themselves in 
 the course of diseases to which they give rise ; so that the indi- 
 vidual affected by them, propagates them in turn, and may trans- 
 mit them to other persons ; hence arises the necessity of sub- 
 dividing specific causes into common and contagious. 
 
 Common specific Causes. This series consists of certain me- 
 tallic emanations, some of the poisons, miasmatic exhalations, 
 and the venomous secretions of animals. 
 
 Those who work in lead, painters, smelters of metals, those 
 who grind colors or prepare the carbonate and red oxide of lead, 
 etc., are subject to a disease known as lead colic, an affection, 
 which differs sufficiently from all others to which the digestive 
 tube is subject, to be ranked among the specific diseases. The 
 colic caused by copper, on -the contrary, closely resembles the 
 inflammation resulting from external causes. Therefore, notwith- 
 standing the similarity between these two kinds of colic, we must 
 refer the action of copper upon the economy, to common determining 
 causes, while the preparations of lead will come under the head 
 of specific causes ; in like manner mercury and its compounds 
 belong to this second series, in consequence of their entirely 
 specific influence upon the mucous membrane of the mouth, 
 (stomatitis, or mercurial salivation.) Strychnine and brucine, 
 which cause tetanic convulsions, such as no other known sub- 
 stance can produce, may with propriety be classed with the 
 specific morbid agents. 
 
 Miasmatic exhalations constitute another group of morbific 
 causes, which reason would induce us to admit, but whose exist- 
 ence even, has not, as yet, been confirmed by physics and chem- 
 istry, much less their nature and effects determined. We shall 
 refer them to two classes, according to their origin. 
 
 The first spring from the decomposition of dead vegetable 
 and animal matter, in moist or marshy places, and in stagnant 
 water. These are styled marsh miasmata, the effluvia of 
 marshy grounds : if it is borne in mind that intermittent fevers 
 prevail habitually throughout the regions where the conditions 
 which cause such decomposition exist; that these fevers make 
 their appearance towards the end of summer, when the receding 
 water has exposed its basin, formed chiefly by the remains of de- 
 caying substances; if it be remembered that these affections have 
 3 
 
26 ETIOLOGY. 
 
 always disappeared upon the drying up of the marshes ; that they 
 show themselves only momentarily in most of those places where 
 pools of water are accidently formed ; if we notice that they are 
 very frequent and exceedingly grave in the localities nearest to 
 standing water, and become more rare and less severe in propor- 
 tion as we remove farther from such places ; finally, if we regard 
 the influence which the winds in the neighborhood of marshes 
 have upon their development,* we cannot but admit the existence 
 of these miasmata, and the part which they play in the produc- 
 tion of intermittent fevers. Our authority for ranking the marsh 
 miasmata among the specific causes, becomes the higher, from the 
 fact that the specific character of the diseases which they produce, 
 is demonstrated by the specific character of their remedy. There 
 cannot be a specific remedy, except for those diseases which recog- 
 nize one and the same cause. 
 
 The other species of miasmatic exhalations is derived from liv- 
 ing beings, healthy or otherwise, but chiefly from those diseased, 
 when collected in too large numbers in confined places. 
 
 The peculiar developing causes of infectious disease most often 
 exist united, on board vessels, in prisons, camps, hospitals, and be- 
 sieged cities, and these are the conditions which cause a great 
 number of diseases to rage with the most intensity ; they have 
 been described as putrid, malignant and pestilential affections. 
 Almost all of them belong to the different kinds of typhus and to 
 dysentery. 
 
 By general agreement, they are deemed to be owing to the alter- 
 ation of the air by the miasmata, and to the infection of the 
 economy by it when thus vitiated ; by infection is understood the 
 action exercised by these causes, and the resulting diseases are 
 termed infectious. 
 
 Venomous secretions must also be classed among the specific 
 causes of disease. These are peculiar to certain species of ani- 
 mals, and serve as their natural means of attack and defence : 
 when deposited by the animal secreting them, in the wounds 
 which it inflicts, they occasion the same sort of affection in every 
 instance. The viper, the wasp, and the bee, in our climate, are 
 the only creatures provided with apparatus fitted for the secretion 
 and deposition of these poisons. In warmer climates, the scor- 
 pion and various kinds of serpents possess far more deleterious 
 qualities. Venom differs from virus in many respects. The latter, 
 as we shall hereafter see, is only produced accidentally, by diseased 
 individuals; the formation of venom, on the contrary, is continual, 
 and is not connected with any functional disturbance : virus acts 
 slowly, and reproduces itself in those affections to which it gives 
 rise ; the effects of venomous secretion are prompt, and not trans- 
 mitted from the one who suffers by them, to others. 
 
 $ II. Contagious Principles. There is a certain number of 
 diseases which may be transmitted from the affected individual 
 
 * Lancisi, Senac, Alibert. 
 
ETIOLOGY. 
 
 27 
 
 to healthy persons, who are in communication with him. This 
 transmission of disease arising usually from direct or indirect 
 contact, has been called contagion; and the epithet contagions 
 is applied to diseases thus transmitted. 
 
 We are ignorant of the modus operandi of contagion ; neverthe- 
 less it is probable that it takes place by means of a material agent 
 whose existence cannot be called in question, although it escapes 
 our perceptions : this agent is called the contagious principle or 
 virus. 
 
 Although not recognized by our senses, the contagious princi- 
 ples have been made the object of special research by some phy- 
 sicians. The following is the opinion of most pathologists upon 
 this point. 
 
 The invisible principle which causes contagion, is usually 
 enveloped in a visible substance, as mucus, serous fluid, pus, 
 (either liquid or dried into crusts.) and the matter of cutaneous 
 transpiration. These different substances not being contagious in 
 themselves, it is supposed that they do not become so, in certain 
 cases, except by mixture with this subtle and unattainable matter, 
 which is the agent of the contagion. At all events, it is not 
 impossible that the pus and mucus may become contagious in 
 themselves, by reason of the alteration effected in their essential 
 nature. 
 
 However this may be, the following are the chief characteristics 
 of contagious principles : 
 
 By means of a constant series of morbid phenomena, they all 
 reproduce principles similar to themselves, and capable of causing 
 the same effects. They maybe multiplied ad infinitum, by means 
 of this secondary development, so long as they meet with bodies 
 capable of fully receiving their action. Indeed, we doubt the ex- 
 istence of any virus whose contagious properties become extinct 
 after the second transmission, as some have endeavored to prove 
 in regard to rabies ; nevertheless, we do not hesitate to admit that 
 some kinds of virus, by continual reproduction, appear to become 
 enfeebled in their action ; for example, the syphilitic virus and 
 that of the plague. 
 
 Some of these contagious principles destroy, either temporarily 
 or entirely, in the individual who experiences their effects, the 
 susceptibility of being again affected ; such are those productive 
 
 * Hufeland defines contagion, or the contagious principle, to be a subtle mat- 
 ter which insinuates itself into the living body, and which may there excite a 
 definite form of disease. The marsh miasmata are, according to him, and by the 
 above definition, contagious principles, as well as the variolous and syphilitic 
 virus. He admits two sorts of contagion, the living and the dead. " The 
 first is produced by a living body ; it may occur in all those diseases where 
 the humors have acquired a high degree of putridity, and when there is a 
 specific change in the state of the secreting organs, as also in that of the 
 humors which they secrete, as in measles, scarlatina, dysentery, etc. The 
 other sort of contagion, is that derived from the exhalations of inanimate 
 bodies ; such are the marsh miasmata, the foul air which causes catarrhal 
 fevers, etc. 
 
28 ETIOLOGY. 
 
 of typhus, small-pox, scarlatina and measles : others have seemed 
 to increase rather than diminish this liability to renewed attacks : 
 the syphilitic virus is one of these. In other words, some conta- 
 gions diseases attack the same person only once during life ; others, 
 which are the exception, reappear at the end of some years; 
 finally, others occur in those who have before been affected by 
 them, more readily than in those who had previously escaped their 
 effects. 
 
 It is supposed that a certain proportion of the contagious princi- 
 ples are produced without cessation during the entire course of the 
 disease, while others only arise during a certain part of it ; but this 
 opinion is not yet sufficiently proved. 
 
 The different modes of contagion have been likewise the object 
 of particular research ; it may be immediate, or communicated by 
 an intermediate body. 
 
 Contagion is immediate when its principle is directly transmit- 
 ted from the person who originates it to the one who receives it 
 and experiences its effects ; this immediate transmission may occur 
 in many ways : 1st, by remaining in the sick room when the air 
 is charged with contagiou's principles, as appears to be the case in 
 the transmission of typhus and perhaps of variola. 2d. By actual 
 contact, as is observed in most diseases of this character. 3d. By 
 still closer contact, as in the transmission of pestilential, vaccine 
 and syphilitic virus, which are inert upon the sound skin, and 
 cannot be communicated except the epidermis has been previously 
 removed or destroyed, or the virus deposited upon a mucous mem- 
 brane. 4th. Immediate communication, also, may be effected by 
 means of the remains of animals destroyed by the disease which 
 engenders the contagion : it is in this way that the malignant 
 pustule is communicated to those. who dress the skins, or handle 
 the wool of such animals, &c. 
 
 Mediate contagion arises through the agency of substances 
 which have been in contact with the patient's body, as his clothes, 
 and the various utensils employed about him. It has been remarked 
 that among the substances which most readily receive and transmit 
 contagion, woollen, silk, cotton and linen, hold the first rank; a 
 strong affinity for these materials has been ascribed to the conta- 
 gious principles, which are retained by them a long while, espe- 
 cially when kept from the air. Those holding communication 
 with the sick may transmit contagion without being themselves af- 
 fected ; and flying insects, alighting in turn upon the patients and 
 upon healthy individuals, have been supposed to carry to the latter 
 the virus which they had drawn from the former. 
 
 The circumstances favoring contagion, or the action of contagious 
 principles, have been carefully examined. It is considered highly 
 important that the contagious principle be of recent origin ; its 
 power diminishes gradually in the course of time ; for instance, it 
 has been proved by numerous experiments, that the pus of variola, 
 after the lapse of a year, becomes less energetic, and at the end 
 of three, is no longer contagious. Hildenbrand supposed that the 
 
ETIOLOGY. 29 
 
 contagious principle of typhus did not exist beyond three months, 
 because, according to him, no epidemic typhus is reproduced after 
 that lapse of time, without the concurrence of new causes. 
 
 Temperature also has a great influence in facilitating the trans- 
 mission of contagious diseases ; the degree of heat peculiar to the 
 human body seems most favorable to contagion, and the nearer the 
 atmospheric temperature approaches this standard, the more easily 
 are contagious diseases propagated. The sudden disappearance 
 of pestilential disease when the temperature is below freezing, 
 has led to the supposition that the contagious principle was 
 susceptible of congelation. It has also been thought that these 
 principles might be destroyed or burned, as it were, by extremely 
 elevated temperature ; arid those physicians who enumerate yellow 
 fever among the contagious diseases, have supported the theory of 
 the decomposition of virus by heat, by the fact of the sudden cessa- 
 tion of that disease in the torrid zone, when the atmospheric heat 
 attains an unusual degree of intensity. M. Bulard has observed 
 the same in regard to the plague of the East. The frequency of 
 typhus in winter and its greater violence at that season, seem to 
 invalidate the assertion that we have lately made, viz., that a tem- 
 perature approaching that of the human body would be the most 
 favorable for the transmission of contagious diseases. But if we 
 reflect that the number of sick soldiers is much greater during 
 winter campaigns, and that the cold weather renders it indispensa- 
 ble to quarter them in places partially or entirely closed, where in 
 a short time they become crowded, we shall understand that if epi- 
 demic typhus is more frequent and destructive in cold and wet 
 seasons, it is not owing to the cold, but to the concurrence of those 
 injurious circumstances which have just been mentioned. Still 
 farther, it has been remarked that dampness, absence of light, and 
 animal emanations favor the transmission of contagious disease. 
 
 Besides these general circumstances which assist the action of 
 contagious principles, there is a certain number which are peculiar, 
 and which exercise the same influence ; such are youth and adult 
 age, an impressible and delicate constitution, want of food, absti- 
 nence from alcoholic drinks in persons who have habitually used 
 them ; the weakness accompanying convalescence, fear, discour- 
 agement, terror, errors in diet, excessive evacuations, and the state 
 of sleep. 
 
 Man is. almost constantly, the source which begets and perpetu- 
 ates the greater part of the contagious principles with which we 
 are acquainted. There are, however, some which seem not to be 
 spontaneously developed in him, but to be always transmitted by 
 animals ; such are rabies, glanders, and the vaccine disease. 
 
 Among contagious diseases, or those considered as such, there 
 
 are several which originated upon this continent, typhus fever and 
 
 the itch are examples ; there are others which have been imported ; 
 
 variola, scarlatina and measles originated apparently in Asia ; the 
 
 3* 
 
30 ETIOLOGY. 
 
 plague, in Asia or Africa ; syphilis and yellow fever were proba- 
 bly brought among us from America.* 
 
 The primitive formation or generation of contagious principles 
 is shrouded in great obscurity. Some physicians think that having 
 been generated at one particular time, they have ever since been 
 reproduced by means of transmission only. This opinion is, 
 however, inadmissible. It is true that the conditions under which 
 many of these principles are developed, are unknown ; but still 
 we must allow that they can, and must be, reproduced by a con- 
 currence of causes resembling those which first brought them into 
 being. The history of European typhus, and its reproduction 
 under the action of well known circumstances, exemplify this 
 opinion, and lead us to suppose that there must be some analogy 
 in the development of exotic poisons, as those of the plague, 
 variola and syphilis. 
 
 But if, as everything would induce us to think, these different 
 sorts of virus did not originate in Europe, if they were first 
 
 * Were not the incompatibility of this assertion with the date of the first appear- 
 ance of syphilis, in Europe, sufficient to prevent its incorporation into the present 
 work, even in the slightly qualified terms used by the author, it would seem that 
 the concurrent testimony of the best authorities of more remote times as well as of 
 our own, would have rendered its insertion impossible. Jourdan, long since, suf- 
 ficiently disproved the opinion of the American origin of syphilis, and by an elabo- 
 rate comparison of dates showed the utter impossibility of its having been imported 
 into Europe, according to our author's supposition. But it is unnecessary to re- 
 peat his widely known observations, or even the apparently well-founded opinions 
 of many others who date the origin of the disease as far back as the days of Old 
 Testament narration ; among these are B. Bell andM. Cazenave, cited by Grisolle 
 in his late work upon Internal Pathology, 1 who himself also, although he considers 
 the question undecided, evidently leans toward the ancient origin of the disease, 
 and mentions a statute of Jeanne the First, Queen of the Sicilies, relative to medi- 
 cal inspection of prostitutes diseased in their genital organs ; this was in 1347, 
 and no author has pretended that the disease was imported before the arrival of 
 Columbus and his companions from America in 1493. Oviedo, one of the cham- 
 pions of the importation doctrine, mentions its appearance in America in 1498, 
 which is after its manifestation at the siege of Naples, by Charles VIII. , the con- 
 quest of which city was effected in 1495. Some have asserted its existence at 
 Paris, in 1494. It is likewise stated to have been "raging" at Rome, and in 
 other parts of Italy in June, 1493, and even supposing the possibility of its having 
 been carried to that country by the followers of Columbus, who arrived from 
 America only two months previously to the latter date, is it reasonable to suppose 
 that it could have been raging in various parts of the country so soon ? Besides, 
 the importation by these men in that space of time, is not proved. Hunter, Spren- 
 gel, Pearson and Bacot, among others, have lent the powerful influence of their 
 names and arguments against this doctrine. M. Cazenave, of all modern writers, 
 perhaps, uses the strongest language, and furnishes the most irresistible proof in re- 
 gard to what he considers the "fable " of the American origin of syphilis. Some 
 account of his views may be found in the British and Foreign Medical Review, for 
 April, 1847, pp. 346, 347. Why is it not reasonable to suppose that promiscuous 
 copulation in any country and amongthe most cleanly people, might engender disease 
 of the genital organs ? But was it less likely to occur among the dirty and depraved 
 soldiers of a European army, and the luxurious profligates of the higher classes, 
 than among the inhabitants of America, simple in their habits, and, as it were, only 
 on the borders of civilization ? TRANS. 
 
 1 Path. Int., vol. ii. p. 23. De La Syphilis ou Maladie Venerienne. 
 
ETIOLOGY. 31 
 
 generated in other countries and with an assemblage of conditions 
 nonexistent among us, we must suppose, whenever we observe 
 them, that they are owing to contagion, even when we cannot point 
 out the individual from whom it emanated. 
 
 Among exotic poisons, many are acclimated on our con- 
 tinent; they appear there without interruption, and produce at 
 intervals, (doubtless with the concurrence of favorable atmospheric 
 conditions,) epidemics of greater or less severity : variolic virus 
 and that of scarlatina and measles, are examples. Other conta- 
 gious diseases, or those so reputed, as the plague and yellow fever, 
 manifest themselves, as it were, only momentarily : they usually 
 disappear, after having committed their ravages for some seasons. 
 
 Linnceus published, in the Amenites Academiques, a dissertation 
 wherein he endeavors to establish that all contagious diseases are 
 owing to animalcules, which, by being transported from the infect- 
 ed to the healthy, transmit the disease, which is but the effect of 
 their presence. The foundation of this theory may be seen in the 
 work above mentioned ; some very curious details, especially, will 
 be found, relative to the form and habits of the acarus dysen- 
 terice, but these are foreign to our purpose. The interesting 
 researches which have since been made, have firmly established 
 this opinion, as regards the itch; the existence of the acarus scabiei, 
 is now demonstrated ; but there is no reason for supposing any- 
 thing analogous in other contagious diseases. 
 
 Such are the chief morbific causes, which, brought into action 
 upon the economy, invariably produce the same effects. Their 
 mode of action will be hereafter considered. 
 
 ARTICLE SECOND. 
 Predisposing Causes. 
 
 ACCORDING to the course generally agreed upon in the methodical 
 study of all sciences, we have thought proper to speak first of the 
 most apparent causes of disease ; at present, we intend to examine 
 those which are the least so, commencing with those called pre- 
 disposing, which, as we have said, act by degrees upon the econ- 
 omy and prepare it for various affections. Their action is almost 
 always obscure and often questionable. All that we shall say 
 therefore, upon this action, must be considered as a collection of 
 generally admitted opinions on the subject, rather than the con- 
 sequence of facts rigorously observed, or the expression of our 
 own conviction. 
 
 Some of the predisposing causes extend their action to a great 
 number of individuals at once, as to the entire population of 
 a city, a province or an empire; sometimes to large collections 
 of men encamped, or in navies, hospitals and prisons ; they favor 
 the development of similar, or analogous affections in all who are 
 
32 ETIOLOGY. 
 
 exposed to their influence : we shall style these, general predis- 
 posing causes. Others act only upon isolated individuals: these 
 may be called individual predisposing causes. The principal 
 morbific causes belonging to these two series, will now be briefly 
 enumerated. 
 
 SECTION FIRST. 
 
 General Predisposing Causes. 
 
 The general predisposing causes are, for the most part, diffused 
 in the atmosphere, or arise from certain local conditions. 
 
 Atmosphere. The air has a very decided influence upon the 
 human body: this is, however, limited, and it does not at all follow 
 that the state of the economy should be entirely subordinate to 
 that of the atmosphere, as some physicians have pretended.* 
 
 The frequent changes of the atmosphere are occasional rather 
 than predisposing causes of disease. It is more particularly, when 
 for a long time in the same state, that the air seems to produce modi- 
 fications in the human body, from which result various predispo- 
 sitions to disease. A cold and dry air predisposes to deep-seated 
 inflammations, and active haemorrhage, and gives to the greater 
 part of acute affections which may be developed, their character, or 
 what has been called inflammatory nature. A warm and dry air 
 hastens the development of superficial inflammations, as erysipe- 
 las, and the exanthemata, and often gives to acute disease the 
 form termed bilious. Aifections of the mucous membranes and 
 those called adynamic, prevail under the influence of a warm and 
 moist air : catarrh, scurvy and rheumatism occur more particularly 
 when the atmosphere has for a long while been moist and cold. 
 
 In our climate,t the north and east winds are almost always 
 dry and cold; the south-east dry and warm; the south-west is 
 of a warm and moist temperature ; the north- west is cold and 
 moist. The influence of these winds in the production of dis- 
 eases is the same as that of the different qualities to which they 
 correspond. 
 
 Air which is riot renewed, quickly becomes vitiated, as may be 
 remarked in confined apartments, especially in dungeons and 
 subterranean passages. Man cannot remain long in such places 
 without experiencing injurious effects ; his functions languish, his 
 
 * Tails est sanguinis dispositio, quails est aer quern inspiramus. RAMAZZINI, 
 de Constitutione, anni 1691. 
 
 f The reader will of course perceive the necessity of adapting the above 
 remarks in regard to the influence of the winds, to " our climate ;" our differ- 
 ent position, as respects the ocean, changing wholly the nature of that influence : 
 as for instance, the north and east winds with us, are almost uniformly moist 
 and cold ; the term " dry " is almost never applicable to our south-east wind, 
 although it may, sometimes, be " warm ; " our south-west winds are warm and 
 dry, and our north-west, cold and dry. TRANS. 
 
ETIOLOGY. 33 
 
 constitution becomes enfeebled, and chronic affections of different 
 kinds are developed. The stagnation of the air in the ravines 
 of the Valais, appears (from the researches of Fodere) to be the 
 principal cause of the frequency of goitre in that country. 
 
 Considerable variations in atmospheric pressure may also be 
 considered as causes of disease. Examples are cited of ocular 
 haemorrhage, of epistaxis and haemoptysis determined by a dimi- 
 nution of the weight of the air, produced either by a change 
 supervening in the atmosphere, or because the individual, being 
 elevated into a higher region, was submitted to the pressure of a 
 smaller column of air. The diminution and increase of atmos- 
 pheric pressure have also been declared equally powerful causes 
 of cerebral congestion and apoplexy. 
 
 Deprivation of light disposes to anasarca, to scurvy and scrofu- 
 la, and always gives rise to a sort of etiolation, similar to that 
 produced by the same cause in vegetables. 
 
 The researches of M. Edwards also go to prove that the action 
 of light is necessary for the development of the body, and that 
 its withdrawal may be considered one of the external causes 
 productive of deformity in scrofulous children.* This agrees also 
 with the generally admitted opinions upon the etiology of these 
 affections. Hildenbrand has likewise remarked that absence of 
 light greatly favored the contagion of typhus, f 
 
 Does electricity diffused in the atmosphere, aid in developing 
 disease, as some modern physiologists have asserted? Can we 
 admit the existence of a nervous fluid analogous to galvanism ? 
 Does it follow that vital power is increased when positive elec- 
 tricity is in excess ; that it diminishes when negative electricity 
 is most abundant, in low and moist localities, before storms, in 
 warm seasons, and with a west wind ? These purely hypotheti- 
 cal opinions are not suitable for present discussion. 
 
 As Hippocrates remarks, all diseases may manifest themselves 
 at any time of the year ; nevertheless, the natural changes which 
 supervene in the atmosphere, by reason of the succession of sea- 
 sons, influence very powerfully the development of many among 
 them. This influence, which has been recognized from the 
 earliest days of the science, has been confirmed by physicians of 
 every age. Hippocrates remarked a uniform character among 
 summer diseases ; he likewise noticed some analogy among those 
 of winter,^ and he comprised among the former, the complaints 
 common in the latter half of spring and the first half of autumn ; 
 and in the second class, those of the last of autumn and of the 
 early spring. In our climate, more resemblance exists between 
 the diseases of spring and of the months preceding and following 
 that season, than between those of summer and the neighboring 
 
 * Influence des Agens Physiques, pp. 401 et 402. 
 f Typh. conta. 
 J Aphor. lib. iii. 
 
34 ETIOLOGY. 
 
 months ; the same observation applies to the complaints of 
 autumn and winter, and those of spring and autumn form sepa- 
 rate groups. The progress of the former is more rapid, their ter- 
 mination more complete, their duration less ; in them, relapse is 
 not so common, and remedies are more efficacious. The develop- 
 ment of the other class is more gradual, their continuance far 
 longer, and sequelae of a bad and obstinate nature often succeed 
 them ; they do not yield as readily to treatment, and are more 
 easily reproduced after momentary suspension. This difference 
 has been particularly observed in intermittent fevers, vernal or 
 autumnal ; but it is by no means a rule of constant application. 
 In our climate, the number of grave diseases is uniformly more 
 considerable, and the mortality greater, in spring than in au- 
 tumn. 
 
 In addition to the above marked differences which these two 
 opposite periods of the year cause in disease, it has been observed 
 that each season has, in like manner, a less noticeable, but still an 
 incontestible influence.* 
 
 Winter, with a dry atmosphere, usually predisposes to inflam- 
 matory complaints, active haemorrhages and cerebral congestions ; 
 when wet, to affections of the mucous membranes and chronic 
 discharges. In summer, bilious diseases, cutaneous exanthemata, 
 cholera morbus, mental alienation and various other neuroses, 
 prevail. Autumn apparently contributes to the development of 
 mucous and rheumatic affections, dysentery and intermittent fe- 
 vers, which are more frequent at this season than at any other. 
 Spring almost always abounds in inflammations of the throat and 
 chest, and in haemorrhages, etc. 
 
 The influence of the moon, and fixed stars, upon the develop- 
 ment of disease has often furnished physicians with matter for dis- 
 cussion. If these bodies exert no action upon the temperature and 
 moisture of the air, it is very likely that they have none upon the 
 animal economy. But if, as many natural philosophers have as- 
 serted, tides, storms and the course of the winds are subject to the 
 influence of lunar changes, the moon might possibly have a direct 
 action upon the economy ; an indirect effect might, at least, be 
 demonstrated. 
 
 Localities. There is no part of the earth which is not habitable 
 by man. But although capable of inhabiting every place, he can- 
 not escape the influence which is thus exerted upon his constitution 
 or the morbid modifications communicated. In southern climates, 
 
 * Some physicians, supposing they had observed that the principal changes 
 caused by the seasons in prevailing diseases, did not correspond exactly to 
 the divisions of the common year, proposed to form a mtdical year, in which 
 spring should commence on the twelfth of February ; summer on the twelfth 
 of May ; autumn in August, and winter in November ; but, as there is no regu- 
 larity in the period when the so-called vernal or autumnal diseases appear, 
 as their manifestation even, is not constant, it is more reasonable to continue 
 the usual limits to each great division of the year, and to the words in common 
 use their general acceptation. 
 
ETIOLOGY. 35 
 
 tetanus, yellow fever, and many diseases wholly unknown at the 
 north, prevail ; in the opposite latitudes, inflammatory affections 
 are very frequent : in temperate climes a greater variety of disease 
 exists. In dry and elevated districts, men are exceedingly subject 
 to all the acute affections ; chronic complaints, on the contrary, pre- 
 vail in low and wet countries. This influence of elevated position 
 may be easily verified in cities built both on high and low ground ; 
 in the upper portion, diseases are rare and of very rapid progress ; 
 in the lower, they are more frequent and tend to the chronic type. 
 
 A northern or eastern exposure, or a southern or western one 
 have the same influence in the development of disease, as the 
 winds blowing from either of these directions. (Page 32.) 
 
 City and country life dispose to very different affections. The 
 neuroses, scrofula, rachitis and pulmonary phthisis are far more 
 frequent among the inhabitants of cities than among those residing 
 in the country ; a country population is more exposed to acute dis- 
 ease, and chronic affections are rare. A residence in hospitals, 
 prisons, vessels, and barracks apparently predisposes to dysentery, 
 scurvy and different kinds of dropsy. 
 
 Change of abode likewise becomes a general predisposing cause 
 for sailors and soldiers transported far from their country. Lind 
 compares men who have left the land of their birth to vegetables 
 transplanted into a strange soil ; they cannot experience the new 
 conditions in which they are placed, without injury to their health 
 or a loss of vigor, at least for a time. The masses of men which 
 are transported far from their country, the European troops which 
 go to another continent, are often smitten by more or less severe 
 disease, evidently owing to this cause ; for these diseases not being 
 known in the country where the men were born, they would have 
 escaped them if they had remained there ; of such is the yellow 
 fever which destroys Europeans in some parts of America, and 
 which has never been observed in the north of Europe, above the 
 mouth of the Gironde ; and abscess of the liver, so rare among us 
 and so common in some parts of India. 
 
 An almost constant fact, to which the attention of physicians 
 has not, perhaps, been sufficiently directed, is the good health on 
 board fleets which traverse the seas without making any port, and 
 which is singularly in contrast with the diseases that afflict 
 them under opposite circumstances. The constant change of 
 place seems useful to man upon the ocean, as well as on land ; 
 voyages generally preserve and strengthen the health; if pas- 
 sengers become diseased, it is almost always when they have been 
 stationary for a certain time in the same place. 
 
 The changes brought about in certain situations through the 
 agency of man, as the clearing of forests, or the cutting of canals, 
 have sometimes produced a marked effect upon the sanatory con- 
 dition of the population. 
 
 There are still some predisposing causes of disease, which may 
 act simultaneously upon a great number of individuals, and which 
 at present we shall only mention, because they act most com- 
 
36 ETIOLOGY. 
 
 monly upon isolated individuals, and thus appertain more naturally 
 to the individual predisposing causes. Such are clothing, food 
 and the moral affections. 
 
 Wet garments suffered to remain upon the body, are one of the 
 chief causes of rheumatism and dysentery in land armies, and of 
 scurvy on board ship. If it surprise us that a cause, to all appear- 
 ance the same, should produce different effects on land, and at sea, 
 the reason of this difference may be discovered in the opposite 
 qualities of rain and sea-water, the latter of which contains deli- 
 quescent salts, which prevent the complete drying of the sailor's 
 garments and keep him constantly wet. 
 
 Food which has become putrid, salted meat, want of flour, or 
 of fresh vegetables, and bad water, are all general causes of disease 
 for the inhabitants of a besieged city } or for men in large num- 
 bers on board a fleet or in camp. 
 
 The moral affections, which are the same for the whole of an 
 army, and sometimes for all the inhabitants of a city, or an empire, 
 may be considered in some cases general predisposing causes. The 
 influence of these affections upon the health of our soldiers, in the 
 disastrous campaigns of 1813 and 1814, was very evident; the 
 number of diseases increased in a frightful degree, as fortune for- 
 sook our banners. 
 
 Political institutions, and the more or less advanced state 
 of civilization of different nations, must also be ranked in the 
 number of the general predisposing causes of many diseases ; it is 
 for this reason that in free countries, among enlightened people, 
 where the intellectual faculties are most active, where man de- 
 votes himself to the study of the sciences and arts, to commercial 
 speculations and to labor, and among nations often distracted by 
 violent political commotions, mental alienation and hypochondria- 
 sis are far more frequent than where the people live in idleness, 
 ignorance or slavery. 
 
 SECTION SECOND. 
 
 Individual Predisposing Causes. 
 
 Individual predisposing causes are much more numerous than 
 those termed general, because there are many circumstances 
 which may act upon isolated individuals and cannot be common 
 to a great number ; while all the general predisposing causes, as 
 situation, dwelling, etc., are also individual predisposing causes. 
 
 These causes being very numerous, and their influence in pro- 
 ducing disease not being the same, we shall divide them into two 
 series. In the first, will be classed the various conditions peculiar 
 to each individual, as birth, age, sex, temperament, constitution, 
 habits, profession, degree of comfort or privation, illness, conva- 
 lescence, health, and pregnancy ; and we shall designate these 
 
ETIOLOGY. 37 
 
 different conditions by the term aptitudes, since they dispose the 
 individuals to various diseases, rather than take an active part in 
 their production. 
 
 In the second series will be enumerated those various external 
 circumstances, which predispose with more or less energy to the 
 development of disease. 
 
 I. APTITUDES. 
 
 A. A descent from parents affected with certain diseases, is a 
 condition which should lead us to fear the development of similar 
 affections. " The ailments of our parents," said Baillou, " are 
 inherited as well as their goods, and this sad inheritance is far 
 more certainly transmitted than the other." Diseases which thus 
 pass from father to child, are called hereditary ; sometimes, so to 
 speak, they skip one generation and manifest themselves in the 
 grandchildren. They may appear in every child ; but usually, only 
 in a limited number. They may be transmitted by either father 
 or mother. Cullen has observed that children are most subject to 
 the diseases of the parent whom they most resemble. 
 
 The diseases of the mother are perhaps more commonly trans- 
 mitted than those of the father, not only because there is certainty 
 in regard to the maternity, but also because the female, whose 
 part in the act of conception is equal to that of the male, supplies 
 from herself alone, what is required for the development of the 
 foetus during its entire intra-uterine existence, and also nourishes 
 it from her own substance through the whole period of nursing. 
 It is, therefore, natural to suppose that the mother has a greater 
 influence than the father upon the child's constitution, and upon 
 its predisposition to disease. In support of this opinion, let 
 it be remembered that in the crossing of animals, the relative 
 influence of the two sexes is quite manifest : the mule, which is 
 the issue of the mare and the ass, is incomparably larger and 
 stronger than the product of an opposite cross. 
 
 There is no longer any dispute in regard to the transmission of 
 diseases from parents to children, considered in an abstract manner ; 
 but admitting this first point, discussions arise with regard to the 
 question of the hereditary nature of particular diseases. There 
 could be no doubt on this point, if the affections were such as show 
 themselves only in the offspring of those who had suffered by 
 them, and if all the children of parents so affected were attacked 
 without exception ; but this is not the case. On the one hand, 
 every disease susceptible of transmission from parents to children 
 may occur from other causes, and on the other, there is no cause 
 which uniformly affects all the children who become diseased: 
 it is only by aid of exact and numerous observations, which sci- 
 ence does not yet possess, and which it can only slowly acquire, 
 that we shall be able to appreciate the relative frequency of a dis- 
 ease in individuals born of affected parents, and in those whose 
 4 
 
38 ETIOLOGY. 
 
 parents have been exempt from it, and thus determine how far 
 a disease is hereditary. r 
 
 When we wish thus to study any disease, phthisis, for in- 
 stance, we must seek the solution of the problem more by follow- 
 ing the course of the children's lives, who are born of parents 
 destroyed by this disease, than by going back to the complaints 
 of which the parents died. It is, indeed, needless to examine 
 whether the disease may be developed or not by the aid of 
 hereditary predisposition and occasional causes. This is not the 
 question: no author has asserted that a disease susceptible of 
 transmission from father to child could not be developed likewise 
 by other causes. The real question is, to "determine at first, if such 
 a disease is transmitted from parents to children, and afterwards, 
 how frequently this happens. It is then, by following the gener- 
 ations, rather than by tracing them back, (if we may be allowed 
 the expression,) that the question of hereditary disease must be 
 studied and definitely decided. We are convinced that by follow- 
 ing this course in regard to pulmonary phthisis, results will be 
 obtained, proving that children born of phthisical parents, die, in 
 a great proportion of cases, of the same disease. It is not so easy 
 to say what would be the result of similar research with the 
 intention of ascertaining whether cancer is hereditary. In the 
 present state of science, it appears to us reasonable to allow, 
 without however affirming it, that individuals born of cancerous 
 parents, are, other things being equal, more often affected with 
 like complaints than those who are not thus connected. 
 
 In general, diseases which are developed under the influence 
 of hereditary predisposition, are manifested at an earlier age than 
 when not thus transmitted. It has been remarked, that children 
 born of consumptive parents, died at a less advanced age than 
 their parents, and often before they were old enough to transmit 
 this unfortunate predisposition. 
 
 Reputed hereditary affections are exceedingly various. Some 
 consist in an evidently vicious conformation, for instance, a 
 diminution or increase in the number of organs ; others, in simple 
 functional disturbance without any appreciable lesion of the 
 tissues, as blindness or deafness. Some are congenital, as is 
 occasionally the case with syphilis, etc. ; others, and by far the 
 greater number, are latent for a longer or shorter time after birth ; 
 rachitis until the second or third year ; scrofula and epilepsy 
 appear in infancy ; pulmonary consumption and mental alienation 
 in youth ; gout and haemorrhoids in adult age ; apoplexy still 
 later. In some families hereditary disease is developed and ter- 
 minated, uniformly at the same period of life. Montaigne, whose 
 ancestors were affected with gravel, was attacked by it at the 
 same age as his father. Some practitioners have thought that 
 chronic affections only, could be transmitted from parents to chil- 
 dren; and it should be remembered that phthisis, mania and 
 epilepsy occupy the first rank among hereditary diseases. Gout 
 and rheumatism, however, are usually, acute diseases, at any rate 
 
ETIOLOGY. 39 
 
 in their first attacks, and by common consent, are hereditary. In 
 some families it has also been observed that there exists a 
 tendency to plethora and to certain inflammations. 
 
 The diseases which infants exhibit at birth, (maladies de 
 naissance, ) are not always hereditary ; those affected with hydro- 
 cephalus or spina bifida, die soon; they cannot, consequently, 
 transmit these diseases, and for the same reason they cannot have 
 inherited them. Still farther, it has been remarked in certain 
 cases, that all the children, or most of them, have been attacked 
 by disease with which their parents never had been or could be 
 affected; among other instances is sterility, noticed in all the 
 daughters born of the same parents. Squamous disease of the 
 skin and scrofula appear sometimes in all the children born of the 
 same parents, although they may never have had those diseases. 
 We must then, with Portal, admit family diseases, which although 
 never observed in father or mother, but declaring themselves in all 
 their children, are evidently ascribable to the influence exercised 
 in generation by the concurrence of two determinate organizations, 
 which give rise to one differing from each of the others, the 
 same thing happening in all the offspring of such connection. 
 
 We shall not give a detailed account of the different theories 
 which relate to the hereditary transmission of disease. Like ex- 
 ternal characteristics, this transmission is a well marked phenom- 
 enon, but quite as inexplicable. The various hypotheses on this 
 subject may be seen in the little work of Meara. * The Consider- 
 ations of Portal upon hereditary and family diseases will be read 
 with much greater interest by those who prefer facts to explana- 
 tions: in this work the learned author has collected all that is 
 useful and curious upon this point in pathology, f 
 
 B. Age. This is not, properly speaking, a morbific cause. 
 No perioid of life plays an active part in the production of disease, 
 but there is greater liability to certain affections at some ages than 
 at others. Some complaints never appear previous to or after a 
 certain period; on this account, those aptitudes for contracting 
 disease which belong to the different ages, possess a peculiar 
 interest for the student. 
 
 Many affections may be developed at all periods of our existence, 
 from intra-uterine life to the most advanced age. Children have 
 been born with intermittent fever and with variolic eruption, both 
 of which may occur at any other age. There are, however, 
 diseases peculiar to every age, or at any rate of more frequent 
 occurrence during such periods. Hydrocephalus and spina bifida 
 are developed while the foetus is yet in utero. The diseases 
 most frequently noticed at birth are the asphyxia of the new-born, 
 
 * Palhologia hereditaria generalis, sive de morbis hereditariis tractatus, spa- 
 gyricodogmaticus. (Authore, Derm. Meara; Dublin. 1619.) 
 
 f Considerations sur la Nature et le Traitement des Maladies de Famille et des 
 Maladies hereditaires, par Antoine Portal. 1814. Paris. 
 
40 ETIOLOGY. 
 
 icterus and hardening of the cellular tissue. From the first to 
 the seventh year, the child is chiefly exposed to the eruptive 
 fevers, to the accidents of dentition, epistaxis, croup, whooping- 
 cough, tinea, rachitis, scrofulous complaints, acute hydrocephalus, 
 tubercular meningitis and verminous affections. The period of 
 puberty in females is fraught with various diseases. In both 
 sexes, rapidity of growth sometimes disposes the system to 
 serious affections. Plethora, inflammatory disease, haemoptysis, 
 angina and pulmonary consumption are more frequent in youth 
 than at any other age. In middle life, hypochondriasis, haemor- 
 rhoids, cancer and the greater portion of organic diseases occur, 
 scrofula excepted. In old age, softening and haemorrhage of the 
 brain, idiocy, deafness, cataract, affections of the urinary passages, 
 etc., are more common than in earlier life. 
 
 The etiological study of the different ages offers still another 
 consideration, viz. the inaptitude of certain ages for developing 
 certain diseases. Thus cerebral haemorrhage is hardly ever ob- 
 served before middle life; nor scirrhus and arterial aneurism 
 previous to the thirtieth year ; typhoid fever has perhaps never 
 been observed after the age of fifty -five. These data are occasion- 
 ally very useful in diagnosis. 
 
 C. The ancients supposed there were certain fixed years in 
 human life, when diseases were more frequently developed and 
 attended with greater mortality. They called them climacteric 
 years, from the word *;u>a, tendency, or from xAi>a$, signifying a 
 scale or degrees. They compared these years to knots, which 
 might be said to unite the different periods of life, and to give a 
 new direction to the economy. This doctrine, which is said to have 
 been derived by Pythagoras from the Chaldean institutions, was for 
 a long time in great favor in the schools. Nearly all who have ad- 
 mitted the climacteric years, have fixed them at intervals of seven 
 years ; they asserted the fourteenth and twenty-first years to be 
 replete with danger. Others have divided them into periods of nine 
 years. Some mingled the two, and the sixty-third year, composed 
 of the numbers seven and nine, was, in their estimation, the most 
 fruitful in diseases, especially those of fatal termination. Others 
 preferred a triennial interval. All of them supposed that the space 
 of time they thus allotted, was requisite for the complete renovation 
 of the constituent elements of the body ; so that at the end of three, 
 seven and nine years, there did not remain in the system any of 
 those parts which previously composed it; and, admitting this 
 entire change in the constitution, an analogous change in the 
 health seemed to them the almost unavoidable consequence. It is 
 very certain, that in an indefinite time, varying according to age 
 and many other circumstances, the body is renewed, and that 
 hardly any of its former constituent parts are then found in it ; 
 but this change is not a sudden one : it is continuous, and modifies 
 unceasingly the component parts of the body. It is no more per- 
 ceptible at the seventh or ninth year, than upon every day which 
 
ETIOLOGY. 41 
 
 goes to make up the climacteric periods. These useless specula- 
 tions have, with great reason, been rejected; they seem fitted 
 merely to torment the imagination of the sick. * 
 
 D. The sexes are nearly alike in their predisposition to most 
 diseases : fevers, inflammations, nervous and organic affections, 
 attack males and females without distinction. If there be any 
 difference between their diseases, it is rather to be attributed to 
 the mode of life, than to sex. If the male be more subject to 
 wounds, contusions, fractures, rheumatic affections and typhus, it 
 is because he is more exposed to the causes of such affections. In 
 like manner, in cities, women are more subject to nervous diseases 
 than men. But in the opposite case ; if we compare the female 
 who labors in the fields, to the man who leads a luxurious and 
 inactive life in the city, the former will be observed to be liable to 
 the same complaints as the man whose occupations are similar, 
 and the latter to all those nervous affections which have been con- 
 sidered as peculiar to females. There are, indeed, certain diseases 
 which attack one or other of the sexes most frequently ; of these, 
 tuberculous disease of the lungs is more common in females than 
 males ; and that this difference is observable in every period of life, 
 any one may be convinced by consulting the statistics of M. M. 
 Louis, Benoiston de Chateauneuf and Papavoine. 
 
 There are certain diseases which almost exclusively belong to 
 sex : not to mention those of the genital organs and their appen- 
 dages, as hydrocele and sarcocele in man, scirrhus and inflamma- 
 tion of the uterus and ovaries in the female, stone in the bladder 
 and retention of urine are almost exclusively confined to the male 
 sex, while crural hernia, hysteria and mammary cancer are pecu- 
 liar to women. 
 
 E. Temperament predisposes to various affections, and gives a 
 peculiar character to any that may be developed. In the san- 
 guine temperament, there is a tendency to plethora, to deep-seated 
 inflammation, haemorrhages, etc. ; and almost all the acute dis- 
 eases occurring in persons thus constituted, are accompanied 
 with general symptoms of inflammatory fever. The bilious tem- 
 perament is conducive of bilious diarrhoea, the exanthemata, 
 inflammations of the membranes and organic disease, especially 
 cancerous degeneration. Those of a lymphatic temperament are 
 peculiarly liable to catarrh, chronic discharges, dropsy, scrofula, 
 and scurvy ; and nearly all the acute diseases which affect them are 
 of an adynamic character, and slow in their progress. Those of a 
 nervous temperament are particularly subject to hysteria, hypochon- 
 
 * Some authors have given a different signification to the word climacteric : 
 they understand by it the periods of life at which great changes occur, indepen- 
 dently of the numerical order of the years ; such is the epoch of puberty in both 
 sexes and the suspension of the menstrual discharge, or critical season, in females. 
 Every one allows the influence of these climacteric epochs upon the constitution 
 and health. 
 
 4* 
 
42 ETIOLOGY. 
 
 driasis, convulsions, disturbance of the sensations and intellectual 
 faculties, melancholy, mania, etc. ; and in addition to the ordinary 
 symptoms of acute disease, various disorders of innervation, which 
 alter the character of the affection, make its course irregular and 
 its termination less certain. The mixed temperaments predispose, 
 though less energetically, to the affections peculiar to each of the 
 temperaments united in the same individual. 
 
 F. A very strong constitution seems rather a preservative 
 against all disease than a predisposant to any. Nevertheless, it 
 has been observed that such constitutions are more subject than 
 others to acute and violent inflammatory affections. Those of 
 feeble constitution, on the contrary, are liable to frequent and slight 
 attacks of disease, and to habitual indisposition, and nearly all of 
 them die of chronic disease. It has also been remarked, but with- 
 out sufficiently accurate data, that very corpulent persons are 
 subject to apoplexy, and are almost entirely exempt from inflam- 
 mations of the thoracic organs. * 
 
 The disposition of each part of the body seems also to have an 
 influence in hastening the development of disease. Considerable 
 volume of the head should lead us to apprehend hydrocephalus in 
 children and apoplexy in the aged. A remarkably broad chest 
 excites suspicion that the contained organs have a size dispropor- 
 tioned to that of the other viscera, and this disposition is like the 
 first stage of cardiac aneurism. Those in whom all the cavities 
 are large, or to use the expression of Hippocrates, who have volumi- 
 nous viscera, are, according to this prince of medicine, liable to 
 arthritis. The weakness of the aponeuroses which correspond to 
 the natural apertures of the abdomen, is the chief predisposing 
 cause of hernia. The structure of the bones in children, favors 
 the detachment of their epiphyses and their abnormal curvature ; 
 in the adult, the angles which the neck of the femur forms with 
 its supporting bone, and the ramus of the lower jaw with its 
 body, favor the fracture of the one and the dislocation of the 
 other. Finally, in the aged subject, the diminished thickness of 
 the compact part of the bones, the predominance of their inorganic 
 element, and the increased size of the medullary cavity of the 
 long bones, are each circumstances explanatory of the frequency 
 of fracture in old age. 
 
 G. Habits, which arise from the frequent repetition of the same 
 acts in a given time, are usually injurious to those who become 
 enslaved by them, and they are very properly numbered among 
 
 * Obesa corpora minus pleuritidi el peripneumonia, sunt obnoxia, ut animad- 
 vertit aequb diligens ac eruditus medicus Trillerus. Quod cum omnes peripneu- 
 monicos a me visos aut curatos memoria repeto, verum esse intelligo ; et ipse 
 poteris, perlectis eorum qui a Valsalva itemque a me dissecti fuerunt historiis 
 cunctis, duobus exceptis, facile cognoscere. (MORGAGNI de Sed. et Caus. morb., 
 Epist. XX. art. 10.) 
 
ETIOLOGY. 43 
 
 the predisposing causes of disease. The power of habit and the 
 danger of its discontinuance are in proportion to its duration and 
 the number of actions committed under its influence in a given 
 time. So great is this power that, as Cabanis has remarked, it 
 would be dangerous to change from the worst regimen to the 
 wisest and best. Now as there is no habit which we can be sure 
 of satisfying through life, it is prudent not be bound by any, unless 
 absolutely compelled. Many habits are injurious to the health 
 from the moment they are contracted; all may become so if 
 interrupted. 
 
 H. The professions may predispose to different diseases, by the 
 concurrence of circumstances in which those practising them are 
 placed. Literary men are subject to headaches, wakefulness, and 
 haemorrhoids ; many die of apoplexy. Faggot-bearers are subject 
 to hernia ; watermen, to a peculiar alteration of the dermis, charac- 
 terized by softening, fissures, and frequently absorption of the parts 
 in contact with the water; * while, contrary to the common opin- 
 ion, they are rarely affected with ulcers of the legs ; f varicocele 
 is of frequent occurrence in horsemen. 
 
 I. Statistics collected by numerous distinguished physicians, 
 demonstrate satisfactorily the sad influence of poverty upon mor- 
 tality. Dr. Villerme has proved by very interesting researches, 
 that in Paris and many other large cities, the proportion of deaths 
 to the number of inhabitants in the different quarters, is in an 
 inverse ratio to their degree of comfort. J M. Benoiston of Cha- 
 teauneuf has arrived at similar conclusions ; he has observed that, 
 at the same periods of life, the mortality among the poor is almost 
 double that of the rich. || The diseases most usually observed 
 under these circumstances among the poor are scurvy, scrofula, 
 tinea and some other exanthematous diseases; in the higher 
 classes, inflammatory and nervous diseases are most frequent. 
 
 It nevertheless sometimes happens that similar affections, not 
 contagious, such as catarrh and erysipelas, prevail simultaneously 
 in both classes. 
 
 J. The state of health, of convalescence or of disease, has like- 
 wise an influence upon the facility of development of various 
 affections. 
 
 It would be absurd to rank health among the preparatory causes 
 of disease. There are, however, certain affections which are 
 observed only in those who previously enjoyed perfect health; 
 such is the ephemeral fever produced by an evident external cause ; 
 
 * This affection, peculiar to the skin, has received the name, grenouilles. See 
 the Memoir of Parent-Duchatelet upon porters employed to unload boats. An- 
 nales de hyg. publ. t. iii. p. 245. 
 
 f Of 670 boat porters examined by Parent-Duchatelet, one only had an ulcer. 
 
 \Annal. d'hyg. et de med leg. t. iii. p. 294. 
 
 || Annal. d'hyg. et de mid. Mg. t. iii. p. 5. 
 
44 ETIOLOGY. 
 
 the same cause would have excited in another person a more 
 serious malady, etc. Descriptions of epidemics also exist, in which 
 the prevailing disease attacked healthy individuals by preference, 
 as it were, while feeble and infirm persons escaped. But the 
 opposite of this has been almost constantly observed, and a dis- 
 eased condition must always be considered as favorable to the 
 development of prevailing complaints, and as a predisposing cause 
 of various affections. Diemerbroeck states, that in the plague of 
 Nimegue, all those who were attacked by any complaint whatever, 
 were soon afterwards affected with the contagious malady ; the 
 same was remarked in the epidemic cholera of Paris in 1832, and 
 has been noticed in many other epidemics. Oedema of the glottis 
 scarcely ever occurs except among patients already seriously ill. 
 Convalescence is accompanied by a debility and susceptibility, 
 which greatly accelerate the action of morbific causes. 
 
 K. Pregnancy, likewise, renders the system liable to different 
 diseases. Many women experience some nervous affection during 
 gestation, as vomiting, depraved appetite, cramp and convulsive 
 movements; or plethoric accidents, as headache, ringing of the 
 ears, oppression, or palpitations, which yield to venesection, etc. ; 
 during the period immediately succeeding delivery, the suscepti- 
 bility of women to attacks of acute disease, to which the epithet 
 puerperal is given, is singularly augmented ; every one knows 
 how frequent these affections are ; the uterus with its appendages 
 is most usually the origin of disease; acute metritis supervenes 
 more often under these circumstances, than in any others. The 
 same is true in inflammation of the mammae during lactation. 
 Nursing women, and those who have lately weaned their children, 
 are very easily affected by the action of the productive causes of 
 rheumatism : they often experience its attacks, and it then receives 
 the popular name of milk pains. 
 
 2. INDIVIDUAL PREDISPOSING CAUSES, PROPERLY so CALLED. 
 
 Having pointed out the various conditions which we have 
 styled aptitudes, and which may predispose to disease, we shall 
 briefly examine the individual predisposing causes, properly so 
 called, which belong to the second series. 
 
 A. General causes prevail in the class of the circumfusa ; still 
 there are some that act upon isolated individuals, as the fre- 
 quenting of dissection rooms and hospitals, which disposes to dis- 
 ease of an adynamic character ; also an habitual residence in con- 
 fined, ill-aired, and overheated apartments, which renders the 
 body more sensible to external cold, and more likely to be affected 
 by it. 
 
 Change of climate, which is a general predisposing cause for 
 troops transported to the colonies, is more frequently an individual 
 
ETIOLOGY. 45 
 
 predisposing cause. The inhabitants of the country when they 
 come to reside in cities, almost always experience some disorder ; 
 within the first few days, diarrhoea, or severe fever after some 
 months' residence. The greater number of those who retire to the 
 country, after having spent the first part of their lives in cities, 
 as for instance, merchants who have become independent, or pub- 
 lic functionaries who have lost their situations through political 
 vicissitudes, soon experience more or less disturbance of health, 
 which often results in death. But we should observe, that, in all 
 such cases, many other alterations assist the mere change of dwell- 
 ing-place in causing the result thus observed. 
 
 B. Some individual predisposing causes are found among the 
 applicata. Clothing, when too thin, favors the action of causes 
 productive of catarrh and rheumatism. That which is too 
 warm, determines indirectly a similar effect by increasing the 
 susceptibility. The form of the dress, which changes according 
 to the fashion and tastes of the various classes of society, is not 
 without its influence upon the health. Many physicians think 
 that the costume adopted since the French Revolution, has con- 
 tributed very much to render pulmonary consumption more com- 
 mon among females, and croup among children ; the exposure of 
 the neck, the arms, and the upper part of the chest, accounts 
 apparently for the frequency of these diseases. It has been said 
 also, that the Greeks and Romans, whose legs were habitually 
 bare, were more subject than we are, to erysipelas of those parts. 
 
 Among the morbific agents belonging to the applicata, those 
 acting through the medium of winpression probably produce the 
 most remarkable effects. 
 
 The immediate effect of all compression is to diminish the vol- 
 ume of the parts subjected to it, and almost constantly to inter- 
 fere with the action of the organs, to retard the circulation of 
 the fluids, and particularly of the venous, and even the arterial 
 blood. In this case, compression may have a rapid and manifest 
 effect, like the specific causes ; the gangrene which occurs in a 
 tumor, whose base is surrounded by a ligature, and asphyxia 
 caused by compression upon the trachea, are examples ; but in the 
 great proportion of cases, the effects of compression manifest 
 themselves slowly, like those resulting from the action of predis- 
 posing causes. 
 
 These effects, which are exceedingly various, might belong to 
 either predisposing or determining causes ; still we have included 
 them under one head, so as not to separate them from those phe- 
 nomena which are more interesting when studied collectively; 
 they depend on the nature of the compressing agents, the struc- 
 ture of the parts compressed, the time during which the compres- 
 sion is continued, the extent of surface compressed, and the 
 force with which it is applied. 
 
 I. The agents capable of producing compression are very nu- 
 merous : some are applied to the surface of the body, as the cloth- 
 
46 ETIOLOGY. 
 
 ing, particularly corsets, garters, and girdles; others, whose 
 action is internal, are either foreign bodies or morbid growths, as 
 tumors, effused liquids, or gases, which become an actual cause of 
 various secondary disorders by means of the compression they 
 maintain upon the neighboring organs. 
 
 The elastic corsets used by most females, are, probably, one of the 
 causes which lead to the development of organic disease of the 
 lungs and heart, particularly during the period of growth and 
 that of pregnancy, when the chest should rather be increased in 
 volume. In this latter case, there are many other inconveniences : 
 the pressure upon the abdomen prevents the development of the 
 uterus, tends to give it an abnormal position, and may excite 
 abortion. Their action upon the mammae is not less marked : it 
 prevents their attaining the increased volume which they should 
 acquire, flattens the nipple, and renders nursing difficult or im- 
 possible. The stomach and intestines thus compressed, some- 
 times assume a faulty position, the exercise of their functions 
 is always impaired; the inconvenient and noisy borborygmi, so 
 frequent in females, are probably owing to the compression of the 
 intestines by corsets ; this is scarcely ever observed in men. 
 
 Compression, however slight, if long continued, caused by sur- 
 gical apparatus, or by a simple bandage intended to support the 
 dressing of an issue, may sensibly diminish the volume of the 
 part compressed, and sometimes may occasion oedema of that por- 
 tion of the limb in which the venous circulation is obstructed. 
 Garters, when very tightly drawn, may cause varicose dilatation 
 of the veins. Very narrow socks worn in childhood, change the 
 conformation of the toes, and at any age produce a thickening of 
 the skin and the development of those hard and painful tumors 
 called corns ; but friction contributes to this result. The synovial 
 cyst called hygroma, which is formed in the neighborhood of the 
 knee and elbow, in workmen whose employment forces them to 
 press continually upon these parts, either with the instrument they 
 use or against the table at which they work, is an analogous for- 
 mation. Compression of the neck, by a tight cravat, excites 
 or increases the distension of the cerebral vessels, and favors 
 haemorrhage and inflammations of the brain. 
 
 Internal compression, caused by a tumor, affects the organs in 
 various ways. It attracts but little notice when the tumor is be- 
 neath the skin or between the muscles, because the resistance is 
 slight and the compression consequently less. The case is nearly 
 the same when the tumor occupies the superficial portion of the 
 abdomen, whose anterior parietes are susceptible of considerable 
 extension. But it is otherwise within the skull, the thorax, the 
 nasal fossae, and even the inferior parietes of the mouth. 
 
 The primary effect of tumors developed within the skull is to 
 compress the corresponding cerebral hemisphere, and to induce 
 more or less complete paralysis of the muscles of the opposite 
 side. If the tumor be near the bony arch of the skull it often hap- 
 pens that it gradually reduces the thickness of the bone, even to 
 
ETIOLOGY. 47 
 
 the tenuity of parchment, and in some cases completely perforates 
 it, making its appearance through the aperture ; fungous tumors 
 of the dura mater often present this series of phenomena. Analo- 
 gous effects occur in the chest : such as functional disturbance, 
 and absorption of the parietes. If the tumor be in the vicinity of 
 one of the axillary regions, it sometimes causes, by compression 
 of the arfery, a progressive decrease in the force of the pulse 
 upon that side, and by compression of the veins and lymphatics, 
 oedema of the corresponding limb. 
 
 If the compressing agent be a fluid, its effect is only distension 
 of the natural or adventitious cavity which encloses it, and inter- 
 ference with the action of neighboring organs, as is uniformly 
 noticed in the abdomen, often in the thorax, and occasionally in the 
 skull, where ossification is incomplete ; but absorption of the 
 bony walls never occurs, as it does from solid tumors. 
 
 2. The structure of compressed parts has great influence upon 
 the phenomena of compression. This may be easily appreciated 
 in the chest, where the organs differ very much from each other 
 in texture, and whose parietes are composed of both hard and 
 soft parts. It is observed that the softer and more flexible the 
 tissues, the less change occurs in their texture, in consequence 
 of the tumors which compress them ; on the other hand, the harder 
 they are, the greater effect is produced. Thus an aneurismal tu- 
 mor of the arch of the aorta causes absorption of the sternum, 
 cartilages of the ribs in front, and of the vertebras behind, while, 
 for a long time, it simply displaces the heart, and diminishes the 
 volume of the lungs. 
 
 If the trachea be compressed, the cartilaginous rings are first de- 
 stroyed ; their uniting membrane resists for a long time, as do the 
 intercostal muscles when the ribs and their cartilages are already 
 absorbed. In the case where the tumor opens into the bronchial 
 tubes, the oesophagus, pleurae or pericardium, and causes death, 
 the comparative examination of the different parts shows that 
 the lesion of those which are hard and resistant is greater and of 
 earlier date than that of the soft parts. We should notice that there 
 is here something special in the nature of the compression, on ac- 
 count of the pulsation occurring in aneurismal tumors ; both per- 
 cussion and compression exist. The application of this principle 
 and the proof of its truth is found in the tumor known as ranula, 
 which causes absorption and deformity of the lower maxillary 
 bone and of the teeth therein inserted, and only occasions simple 
 displacement of the soft parts. But in all these cases the latter 
 resist only by reason of their elasticity under the force of the 
 compressing agent. If compression be so applied as that they 
 cannot thus escape it, they feel its effects, and indeed much 
 sooner than the firmer tissues ; as is observed by the formation of 
 eschars on those portions of integument compressed between super- 
 ficial and projecting bones, as the sacrum, the great trochanters, 
 and the bed on which the patient lies. 
 
 3. The effect of compression is proportionate in great measure to 
 
48 ETIOLOGY. 
 
 the time during which it is exercised. When short, even though 
 very violent, provided it be not carried far enough to cause altera- 
 tion in the tissue of the organs, the latter immediately regain their 
 size and the full exercise of their functions. After longer com- 
 pression, for some days, or weeks, for instance, the natural condi- 
 tion is slowly, but maybe completely regained. It is far otherwise 
 when compression has been continued for a considerable time, as 
 for years ; it then most usually happens that the suffering organ 
 does not regain its primitive volume ; this is particularly the case 
 with the lungs after pleuritic effusions. There is, moreover, this 
 difference between compression of short and long duration, that in 
 the former, the diminution in volume seems alone owing to the 
 liquid contents being discharged and the solid parts brought more 
 closely together, while in the latter there is a real decrease in the 
 solids themselves, partial emaciation or atrophy. 
 
 4. The extent of surface over which compression is applied, also 
 modifies its effects. A very narrow bandage may penetrate the 
 tissues; a broader one wpuld not. When compression is main- 
 tained upon one particular portion of a limb, the circulation be- 
 comes arrested below the point of application. This does not 
 happen if the compression extend to the extremity of the limb. 
 Such are the chief effects of compression in the development of 
 disease either primitive or secondary, whatever be the agent or the 
 recipient organ. 
 
 Beds also deserve some attention. The habit of sleeping upon 
 feathers, by increasing cutaneous transpiration, favors the forma- 
 tion of urinary calculi and disposes to nephritis. A hard bed does 
 not seem a predisposing cause of any complaint. Seats, which 
 are very soft, and particularly those furnished with feather cush- 
 ions (bergeres), are conducive of sanguineous congestion in the 
 uterine and hsemorrhoidal vessels. 
 
 The daily use of cold baths is thought to predisp'ose to inflamma- 
 tory disease by their tonic action upon most of the organs. Warm 
 baths, often repeated, produce an opposite effect ; they weaken the 
 constitution, and predispose to chronic discharges and diseases of 
 debility. Want of cleanliness generally favors the development 
 of all contagious and cutaneous diseases. Excess of cleanliness, 
 combined with the use of perfumes and the various resorts of lux- 
 ury, seems to aid in the production of nervous diseases. 
 
 C. Ingesta. Food, liquids and remedies may dispose to various 
 diseases when improper use is made of them. 
 
 In health, the quantity of food and liquid should vary according 
 to age, strength, occupation, habits, etc. Their moderate and 
 temporary increase or diminution does not usually produce func- 
 tional disturbance, but beyond certain limits the health becomes 
 deranged. 
 
 A decided and long continued diminution in the ordinary quan- 
 tity of food causes analogous loss of strength and flesh ; its increase 
 produces plethora. Habitual excess in food seems to dispose to 
 
ETIOLOGY. 49 
 
 organic disease of the stomach and intestines, which is not 
 always avoided by extreme abstinence. The daily abuse of fer- 
 mented liquors, of wine or alcoholic drinks, gives to acute diseases 
 so grave a character as to render them generally fatal. 
 
 Wine and alcoholic liquors are more pernicious in their effects 
 when drunk between meals than when taken into the stomach 
 mixed with solid food. The disease known as delirium >tremens 
 is often owing to the abuse of these drinks, or to their sudden ab- 
 straction from the intemperate.* According to some physicians, 
 sudden death and spontaneous combustion are not rare in persons 
 who use habitually a large quantity of alcohol. The immoderate 
 use of coffee disposes to cerebral congestion and inflammation of 
 the stomach ; tea, on the contrary, weakens this viscus gradually, 
 and seems to predispose to chronic discharges. Some authors 
 have attributed the frequent occurrence of leucorrhea in women re- 
 siding in cities to this cause, and others have seen the use of 
 beer produce blennorrhagia in both sexes. It has been said that 
 the use of cider and beer in England and Normandy, is the chief 
 cause of the rheumatism so common in those countries ; but is not 
 this rather to be attributed to the conditions which prevent the cul- 
 tivation of the vine, and to the moisture of the soil ? 
 
 The bad quality of food containing in itself but little nutriment, 
 or altered by putrefaction, fermentation or mouldiness, disposes 
 to disease of more or less severity, as inflammations of the diges- 
 tive canal, adynamic fevers, scurvy, etc. The use of bad water, like 
 that drunk on shipboard during long voyages, of sour wine, or 
 badly prepared cider, produces analogous effects. 
 
 Variety in food is necessary to man. The satiety experienced 
 after having for a long time used the same alimentary substances 
 and the satisfaction experienced by a change, prove the truth of this 
 assertion. The exclusive use of any one article of food, in those 
 whose unrestrained habits would have been opposed to such a 
 course, almost always terminates in disease ; farinaceous food dis- 
 poses to plethora, fat and oily articles induce chronic discharges, 
 and animal substances give rise to inflammatory complaints of 
 every description ; salted food, in conjunction with want of vegeta- 
 bles and the fruits of the season, produces scurvy; the prolonged 
 use of a scanty regimen is a frequent cause of obstinate constipa- 
 tion and various digestive troubles, in those who fast throughout 
 Lent. 
 
 Spices and powerful condiments, as pepper, mustard, pimento, etc., 
 increase, at first, the energy of the stomach ; but this viscus becomes 
 accustomed to the action of such excitants, which soon cease to 
 stimulate it, and inactivity frequently succeeds the temporary ex- 
 citement. The abuse of these substances may cause inflammation 
 of a part or the whole of the digestive canal, of the mouth, the 
 pharynx, stomach and intestines. 
 
 Medicines, considered by most persons as means of preserving 
 
 * BLAKE, Edinb. Med. and Surg. Jour., t. xix. 
 5 
 
50 ETIOLOGY. 
 
 and re-establishing the health, may sometimes disturb it. Reme- 
 dies styled precautionary, far from strengthening, often injure the 
 health. Repeated emetics have finally caused weakness or even 
 inflammation of the stomach, and purgatives thus used have had 
 the same effect on the bowels. The use of medicine not indicated 
 in the course of a disease, may instantly cause a new affection or 
 aggravate the existing complaint. 
 
 D. Excreta. The evacuations may vary considerably without 
 derangement of the health ; usually, one being augmented, another 
 is diminished, so that the balance of the system is preserved. 
 Slight changes in the quantity of the evacuated matters, either 
 more or less, do not suffice for the production of disease ; but when 
 the disproportion between the excreted matter and the reparatory 
 means becomes very considerable, it acts upon the constitution and 
 so modifies it, as to predispose it to various affections. If the quan- 
 tity of food daily assimilated be greater than the portion excreted, 
 a tendency to plethora and inflammations of every kind is the con- 
 sequence ; if, on the contrary, absorption is not sufficient for the 
 reparation of the daily losses of the economy, the body gradually 
 diminishes and is liable to complaints resulting from debility. 
 Profuse sweating, copious salivation, too great secretion of milk in 
 nurses, etc., cause the latter effect. In man, venereal excess and 
 masturbation act in a similar manner, with this peculiarity, that 
 nervous phenomena almost always accompany the debility arising 
 from repeated evacuations of semen. 
 
 The debility induced by excessive evacuations, brings into ac- 
 tion the occasional and determining causes of disease. Thus a 
 man who, during his whole life, has exposed himself with impu- 
 nity to the inclemencies of weather, is attacked with rheumatism, 
 when exposed after excess in venereal indulgence.* The same 
 circumstance disposes to attacks of yellow fever at St. Domingo ;f 
 and Diemerbroeck J observed at Nimegue, that all who married 
 during the continuance of the plague, were attacked by the con- 
 tagion a few days after their nuptials. Abundant hemorrhage, 
 bleeding, and repeated purgatives, have had the same effect during 
 many other epidemics. 
 
 Natural or artificial evacuations, when reproduced at nearly 
 equal intervals, have a very different effect, especially when they 
 are confined within certain limits ; the system repairs and sup- 
 ports these losses, either by the diminution of other evacuations, 
 or by the" assimilation of a greater proportion of food ; from this, 
 plethora results. Periodical evacuations, natural or artificial, cause 
 this to yield, but at the same time they increase the tendency to 
 its reproduction, so that nothing more strongly predisposes to ple- 
 thora, or at any rate, to strengthen the predisposition to it when 
 
 * Essai sur la Rhumatisme, 1813. 
 
 f Traite de la Fievre jaune, par BALLY. 
 
 j DIEMERBROECK, de la Peste de Nimegue. 
 
ETIOLOGY. 51 
 
 existing, than these evacuations. The menstrual discharge in 
 females, periodical haemorrhoids in males, and habitual bleeding 
 in both sexes, often produce this effect. 
 
 The suppression of habitual evacuations, the omission of cus- 
 tomary bleeding and purging, may tend to produce various com- 
 plaints ; but they act generally as occasional, rather than predis- 
 posing causes. 
 
 E. Gesta. The precise degree of action and rest, of sleep and 
 waking, to which man should restrict himself in order to preserve 
 his health, cannot be determined ; nevertheless there are certain 
 bounds which he can rarely pass without deranging the harmony 
 of the functions. 
 
 Any marked disproportion between exercise and repose always 
 injures the health ; too great fatigue induces a kind of debility, and 
 gives an adynamic character to acute affections developed under 
 such conditions. It has been said of country people, that usually 
 they have but one disease in their lives, and that fatal to them . 
 Partial exercise may also predispose to certain affections ; the con- 
 tinual and repeated movements of the arms, for instance, seem 
 calculated, in a greater degree than those of the lower limbs, to 
 bring on haemoptysis in those subject to it, and to hasten the 
 progress of cardiac aneurism. 
 
 The want of exercise is far more replete with danger than the 
 opposite extreme ; this is more decidedly the case in proportion as 
 the individual has need of exercise, on account of his age, habits, 
 and strength. Thus it is most injurious to children, to robust per- 
 sons, and to those who have always led an active life. It is ob- 
 served that a sedentary life is less prejudicial to the female than 
 to the male, either because, from youth, habit has lessened in her 
 case the troubles arising from it, or because such a life is more 
 conformable to her peculiar destination, and consequently to her' 
 constitution. Want of exercise is the source of many disorders. 
 One of its first effects, is loss of appetite and slow digestion ; dys- 
 pepsia frequently recognizes this as its sole cause, and yields only 
 to regular exercise. Prolonged inaction causes debility of the lo- 
 comotive organs, favors sanguineous congestion towards certain 
 parts, and vitiates nutrition ; the body increases in size and loses 
 strength ; adipose polysarcia, mucous discharges, scrofula, and 
 oedema, are the different results of this inaction when carried to a 
 great extent, the effects varying according to the constitution of the 
 individual. The same cause, in a less degree, exercise not being 
 quite sufficient, disposes to plethora, especially in high livers. In- 
 action of a single limb usually produces mere local effects, such as 
 weakness, diminution of size, and atrophy of the part which is kept 
 motionless. 
 
 That change, which is necessary in all the acts of life, is espe- 
 cially so in regard to the positions of the body. The restraint 
 arising from too long retention of one position, the need of chang- 
 ing it at intervals, even during sleep, had already established the 
 
52 ETIOLOGY. ( 
 
 truth of the above assertion, even prior to its adoption as a hygi- 
 enic precept. The upright posture, when habitual, disposes to 
 varicose affections, oedema of the legs in both sexes, varicocele in 
 man and prolapsus uteri in women ; the sitting posture, to haemor- 
 rhoids and engorgement of the abdominal viscera; the kneeling pos- 
 ture induces lumbago and early curvature of the spine ; horizontal 
 .posture favors cerebral congestion, epistaxis and apoplexy. This 
 latter position, when maintained for many months, on account of 
 fractures of the lower limbs, has often seemed to be the main 
 cause of calculous formations in patients who had never previ- 
 ously been so affected. 
 
 A proper division of our sleeping and waking hours is useful 
 in maintaining health. From six to eight hours' sleep are neces- 
 sary for adults ; less is requisite for old persons, and more for chil- 
 dren. But here, as elsewhere, general rules admit of exceptions ; 
 some persons need nine or ten hours' sleep; four or five are suf- 
 ficient for others. Prolonged sleep induces general sluggishness, 
 and predisposes to plethora and cerebral affections. Those who 
 retire and rise very late, who sleep in the daytime and remain 
 awake at night, hardly ever attain to an advanced age. After 
 long watchings, nervous affections are frequently developed, and 
 particularly great irritability of the nervous system. 
 
 F. Percepta. The sensations, passions, and intellectual efforts, 
 when they exceed certain limits, become predisposing causes of 
 disease. 
 
 Sensations, habitually very feeble, augment by degrees the sen- 
 sibility of the organs which are their seat, to such extent that they 
 become unfit to bear those which are moderately powerful : this 
 is observed in individuals who remain for a long time in a dark 
 abode, and among those who live upon very unstimulating food. 
 Sensations habitually very lively, on the contrary, exhaust the 
 sensibility of the organs, and render them unfit to fulfil their func- 
 tions. 
 
 The passions have a very remarkable influence upon the de- 
 velopment of disease. While the mild and varied, favor the har- 
 mony of the functions, the strong and exclusive, are injurious in 
 the same degree. They not only may affect the system in a sud- 
 den and marked manner, as in the instances of derangement, 
 instant death and hectic fever from moral causes, as we have seen 
 in the enumeration of determining causes ; but they also, and far 
 more frequently, give rise to an exaggerated sensibility which 
 peculiarly predisposes to nervous affections. Prolonged grief seems 
 to have a powerful influence in developing organic diseases, es- 
 pecially cancer. 
 
 Mental labor, when excessive, predisposes to nervous affections ; 
 but it does not hence follow, as has been supposed, that study is 
 contrary to nature. It is a law of nature, that the greatest pos- 
 sible intellectual and physical development should be simultane- 
 ously attained. The exercise of the mind, meditation and study, 
 
ETIOLOGY 53 
 
 are necessary to the development of the intellect, as motion is to 
 that of the body. When the object of study suits the taste of the 
 student, when it alternates with some manual occupation or with 
 suitable exercise, it rather benefits than injures the health. Many 
 literary men, physicians and mathematicians, have attained to 
 very advanced age ; and if there have been those who have died 
 from excessive application, the number is very small. When, 
 however, studies are continued daily for many hours, and relate 
 to subjects in themselves uninteresting and irksome to the one 
 employed in them, when they are not varied and interrupted from 
 time to time by exercise, the body is injured in its development ; 
 the energy of the mental powers may be blunted, and in early 
 youth the germ of the most brilliant faculties blighted. 
 
 Antecedent diseases may be added to these different individual 
 predisposing causes ; they strongly favor the action of those spe- 
 cific or occasional causes which are likely to excite anew the 
 above named diseases. A first attack of hysteria or rheumatism 
 not only indicates the aptitude of the patient to be thus affected, 
 but seems to increase the tendency to repeated attacks. It has 
 often been noticed in ulterior attacks of hysteria and rheumatism, 
 that very slight occasional causes sufficed for the development of 
 these affections, while the first attack required the influence of 
 very powerful agency. 
 
 ARTICLE THIRD. 
 Occasional or exciting Causes. 
 
 OCCASIONAL causes, as we have stated, are those which excite 
 disease without determining its nature or situation, and which act 
 only with the concurrence of the predisposition. 
 
 These have not the importance which attaches to those of the 
 first two orders ; but because they do not belong to the particular 
 history of any one disease, they are, more than the others, within 
 the domain of general pathology : their enumeration is therefore 
 necessary. 
 
 The impression made by very cold or very hot air, by the 
 north or south wind ; the action of a current of air upon the 
 whole body, or of a smaller draught (vent coulis) upon one part in 
 particular ; the sudden passing from a very warm to a very cold 
 apartment, and vice versa ; a short stay in a damp house, newly 
 built ; a temporary change in the thickness or form of the gar- 
 ments ; immersion in a very hot or very cold bath, exposure to 
 rain ; wet clothes retained upon the body ; errors in diet, as the 
 excessive ingestion of food, otherwise of good quality ; the use 
 of inferior or badly prepared food, difficult of digestion, taken 
 at an unaccustomed hour or hastily eaten ; very hot or very cold 
 drinks, or those injurious by their quality; the suppression of 
 
54 ETIOLOGY. 
 
 certain natural evacuations, as the perspiration, lochia, milk, 
 and menstrual discharge ; or of a morbid or artificial discharge, 
 as that of leucorrhea, chronic ulcers, long established setons or 
 blisters; an habitual hsemorrhagic discharge which has become 
 necessary ; a natural evacuation considerably increased ; untimely 
 venesection ; emetics and purgatives administered without indica- 
 tion ; excessive fatigue ; an unusual amount of rest ; cries ; singing ; 
 shouts of laughter ; running against the wind ; prolonged watch- 
 ing ; physical or moral shocks ; lively emotion, as joy or terror ; 
 necessary mental strife ; retrocession of gout ; disappearance of 
 exanthematous affections ; sudden cessation of some other com- 
 plaint; such are the chief occasional causes of disease. 
 
 These differ from special and predisposing causes by not being 
 connected with the history of any affection in particular. One 
 occasional cause may excite any disease, and the same disease 
 may be induced by every kind of occasional cause. If there 
 were any doubt as to the correctness of this proposition, the ex- 
 amination of any treatise on pathology would suffice for its re- 
 moval ; in the portion devoted to the etiology of each disease, the 
 acute in particular, all the occasional causes we have just named 
 would be almost literally enumerated. It is quite otherwise with 
 the determining causes ; they differ either in themselves or as re- 
 gards the parts upon which their action is exerted in each kind of 
 disease. Notwithstanding this great difference between them, 
 there are many points of contact, where the occasional, are, as it 
 were, mingled with the determining and predisposing causes. For 
 instance, is cold a determining or an occasional cause of rheuma- 
 tism ? The different opinions of physicians prove that this is a 
 point not easily decided. On the other hand, if we compare 
 occasional and predisposing causes, it will be seen that the same 
 circumstances may belong to each. There is, it is true, this differ- 
 ence, that in the one case, the cause is momentary in its action, 
 while in the other, that action has been of long duration; an error 
 in diet is an occasional cause ; habitual intemperance, on the 
 contrary, is predisposing ; the distinction is very marked when 
 our examples are extreme cases, but becomes more obscure in 
 proportion as they are less so ; excesses which are prolonged for 
 many days, for one or several weeks, can hardly be said to belong 
 decidedly to either class. There are some circumstances where a 
 simple error in diet, usually considered one of the occasional 
 causes of disease, becomes a predisposing cause. During epidemic 
 variola or prevailing plague, excessive drinking or venereal indul- 
 gence often repeated in the space of a few hours, have frequently 
 been observed to favor the action of the pestilential or variolic 
 virus, and the individual who for months had braved contagion 
 with impunity, has been attacked immediately after being debili- 
 tated by these causes, which, in these cases, evidently acted as 
 predisposants. 
 
 This division of morbific causes presents some defects ; nature 
 does not submit herself to our divisions in this instance any more 
 
ETIOLOGY. 55 
 
 than in others ; she cannot be rigorously bound by any. The 
 proposed arrangement seems more methodical and practical than 
 others ; above alt, it is particularly suitable as our guide in the 
 study of morbific causes, considered in regard to their mode of 
 action. 
 
 ARTICLE FOURTH. 
 Mode of Action of Morbific Causes. 
 
 ALL the organs of the human body are not equally exposed to 
 the action of morbific causes ; the alimentary canal, the lungs and 
 the skin are more apt to receive from them an injurious impres- 
 sion on acccount of their more intimate relations with external 
 objects. Huf eland in his Pathogeny* has for this reason denomi- 
 nated them atria morborum, the gates of disease. To them should 
 be added the brain and nerves, which especially in civilized man, 
 are directly exposed to the action of a large class of morbific 
 causes. 
 
 Among the agents which disturb the health, there are those 
 which, impelled by a greater or less force communicated to them, 
 or by means of their chemical qualities, penetrate into the substance 
 of the organs ; their action is purely physical or chemical ; their 
 effects would be the same upon the dead body. Among these are 
 bodies which cause wounds, caustic substances and fire. Others 
 influence only the living tissues, and can act only by the power of 
 vital laws. Such are acrid plants and rubefacients. whose action 
 is confined to the skin and mucous membranes with which they 
 are in immediate contact ; food and drink, and perhaps poisons, 
 and certain miasmata which penetrate the system through the ab- 
 sorbent vessels, and whose morbific effects may be felt very far 
 from the spot where they were first deposited ; the passions, sensa- 
 tions and intellectual efforts which manifest themselves through 
 the nervous system, are also of the same class. 
 
 We shall not extend farther our remarks upon the mode of ad- 
 mission of these causes into the system ; but will proceed to point 
 out the modus operandi of the three classes of causes which we 
 have proposed. 
 
 I. The action of specific causes is usually evident, although 
 not always easy, and often impossible to explain. 
 
 When a wounding instrument penetrates any part, fractures a 
 bone, injures a tendon or an artery, we suppose the force which 
 divided these organs to have been superior to that which preserved 
 their continuity ; we can likewise account for the disordered mo- 
 tions, and the flow of blood which result from such injuries. A 
 foreign body in the trachea or bladder causes symptoms easy of 
 
 , disease ; ytroi/at, to exist. 
 
56 ETIOLOGY. 
 
 explanation, because its action is wholly mechanical. The case is 
 similar when the passage of alimentary matter is intercepted, 
 where the intestines are compressed by a tumor, or strangulated 
 by a peritoneal, or hernial stricture. We can understand likewise 
 how a violent contraction of the muscles may cause hernia, dislo- 
 cation, fracture of the patella, or rupture of a tendon ; but most of 
 the causes we have enumerated, while they exert a mechanical 
 action upon living organs, produce other effects subordinate to the 
 vital laws. Thus, divided or displaced parts become red, hot, 
 painful and swollen ; a new secretion is established in them, etc. 
 There is nothing surprising to us in these phenomena, because we 
 are accustomed to observe them. But if we desire to examine 
 them thoroughly and to know the mechanism of their production, 
 we are compelled to acknowledge our ignorance, unless we are 
 willing to substitute error in its place, or veil it by language which 
 imposes even upon ourselves. Notwithstanding the progress of 
 modern chemistry, we are constrained to say the same thing in re- 
 gard to the action of the gases which produce asphyxia. We 
 know that some suspend gradually, and others immediately the 
 phenomena of life; we are acquainted also with the changes 
 caused by some of these agents in the color and consistence of the 
 blood ; but asphyxia still remains unexplained. The action of the 
 poisons upon the economy is equally well demonstrated, but quite 
 as inexplicable. Why is a species of coma caused by the narcotic 
 poisons ; inflammation of the stomach and intestines by the acrid, 
 and gangrene of various parts by the septic 1 These are questions 
 which do not admit of reply. We can more easily understand the 
 effects of fire and caustics, because they are partially the same 
 upon all organized bodies; but their peculiar action is quite as 
 much beyond our penetration. 
 
 The action of contagious principles is yet more obscure. To a 
 certain extent we are acquainted with the agents of which we have 
 just spoken ; we appreciate the physical and chemical properties 
 of the irrespirable and the deleterious gases, caustics and some poi- 
 sons. This is not the case with contagious principles, for they 
 escape our senses, and those whose action is most easily appreciated, 
 as vaccine and variolic virus, cannot be separated from the vehicle 
 which contains them, and studied in regard to their properties. 
 Thus it is only by a process of reasoning that we admit their ex- 
 istence. 
 
 Many authors have compared the development of contagious 
 diseases to that of vegetables, and likened the contagious principles 
 to their seeds. If we bear in mind what has previously been said 
 of contagion, it will be easy to see the principal points of analogy 
 between them; but the resemblance is far from complete. The 
 existence of plants and the seeds from which they spring, is mani- 
 fest and does not admit of doubt. The existence of contagious 
 principles, on the contrary, is only admitted as a consequence of a 
 series of facts which are thus clearly explained, and which other- 
 wise would remain inexplicable. Certain diseases being capable 
 
ETIOLOGY. 57 
 
 of transmission from affected to healthy individuals, this mode of 
 transmission has been called contagion, and the inappreciable 
 agent is called a contagious principle. 
 
 The action of contagious principles is obscure for many other 
 reasons. Do they act directly upon the nerves of the part with 
 which they are brought in contact, or are they absorbed into the 
 rest of the system ? These two opinions have been supported by 
 quite plausible arguments ; and each might be true as regards cer- 
 tain poisons, for it is possible that all may not obey the same laws 
 in their manner of entering the system. 
 
 The efficacy of cauterization practised fifteen or twenty days 
 after the bite of a rabid animal, has led some practitioners to the 
 conclusion that the poison of rabies is not absorbed, and that being 
 simply deposited in the soft parts which received the wound, its 
 action is at first confined to the nervous extremities which there 
 exist, from whence, in time, it extends to the rest of the nervous 
 system. But in other contagions diseases, the pain, swelling, 
 and redness which occur in the track of the lymphatic vessels and 
 glands, seem to prove the absorption of certain poisons, although 
 some authors have attributed these phenomena to sympathy. 
 Admitting absorption, what is the absorbing surface, if these poi- 
 sons are volatile ? Is it the skin, or the mucous membrane of the air 
 passages, into which they are carried with the air ? or that of the 
 alimentary canal where they enter mingled with the food or sali- 
 va? Some authors have supposed that contagious principles 
 cannot act upon the membrane of the stomach, because all the 
 substances introduced into this viscus are there digested and conse- 
 quently become changed. This is an ingenious supposition ; but 
 if we remember that variola has been inoculated by mingling some 
 of the dried scabs with the food and drink, it will be allowed that 
 this supposed decomposition of the virus by the action of the 
 stomach or by the gastric juice is still very doubtful. Others have 
 asserted that contagious principles could be absorbed by those or- 
 gans only in which their symptoms appeared ; that variola and 
 scarlatina were contracted by the skin, syphilis by the mucous 
 membranes, etc. ; but in the existing state of our knowledge, it is 
 more reasonable to admit that nearly all the contagious agents may 
 be absorbed by every surface with which they come in contact ; 
 and that being once introduced into the economy they act specially 
 upon those organs which seem most congenial to each of them. 
 
 After having studied the action of the evident causes of disease, 
 we shall examine in like manner the predisposing causes, com- 
 mencing with aptitudes. 
 
 $ II. Aptitudes. 
 
 The age, sex, temperament, constitution, the degree of comfort, 
 the healthy or diseased condition, and pregnancy, seem neither 
 actively to concur in, nor to oppose, the production of disease. 
 Their influence is appreciated with difficulty, but their action 
 
58 ETIOLOGY. 
 
 cannot be doubted when general conclusions are drawn from a 
 large number of facts. If, for instance, we collect all the obser- 
 vations which relate to any particular affection, and observe that, 
 in every case, or at least in the greatest number, the disease 
 declares itself at a certain age, and in persons of certain tempera- 
 ment, we must admit that these circumstances constitute favorable, 
 perhaps necessary conditions for the development of such disease. 
 Thus, croup is incontestably more frequent during infancy than at 
 other periods of life, phthisis in youth, arterial aneurism and 
 cancer in adult years, haemorrhage and softening of the brain in 
 old age. Females are more disposed to hysterical affections; 
 males, to hypochondriasis ; some epimedics prevail among the 
 poor, others among the opulent, etc. In fact, the influence of 
 aptitudes grows more obscure, as we descend from general conclu- 
 sions to individual applications ; for instance, it does not absolutely 
 follow because scrofula affects children more frequently than 
 adults, and shows a preference for the lymphatic temperament, 
 that these two conditions have always concurred in its production, 
 when observed in such circumstances ; but this does not invalidate 
 the fact that, generally, this age and temperament favor the affec- 
 tion. It is no reason because typhoid fever occurs chiefly in 
 youth, rarely in the adult, and never after the age of fifty-five, 
 that the season of youth has an active agency in its production, 
 but it shows that the liability to contract it, is bounded by certain 
 limits in regard to age, beyond which it does not pass. 
 
 The influence of age in the development of disease, is far more 
 evident, than that of either temperament, constitution, sex, or 
 degree of comfort. There is no disease incompatible with any 
 temperament or constitution, or with either sex ; while certain ages 
 are exempt from some affections, and others are peculiarly exposed 
 to them. 
 
 It is universally conceded, that of all the conditions comprised 
 under the name of aptitudes, hereditary transmission has the 
 greatest influence in producing disease. In some affections, in- 
 deed, it is an active predisposing cause, rather than a mere 
 aptitude. Children of phthisical origin are in imminent peril of 
 this fearful disease, by reason of that origin alone; and the larger 
 proportion of them are attacked by it, however they may be cir- 
 cumstanced. The influence of birth is less powerful in some other 
 diseases, as rheumatism, stone, apoplexy. Children of parents 
 thus afflicted are, other things being equal, more liable to be 
 affected; but other causes must often concur in order to their 
 production, and even then they are not all attacked. 
 
 $ III. Predisposing Causes, properly so called. 
 
 Although usually obscure, the action of predisposing causes can 
 often be explained in a satisfactory manner. It is easy to conceive 
 how certain diseases, as indigestion and abortion, may be caused 
 by too tight clothing or corsets. The disposition to plethora, 
 
ETIOLOGY. 59 
 
 when it follows the use of very nutritious food, and anaemia, which 
 is the effect of abstinence and poor diet, may be easily accounted 
 for. The debilitating influence of excessive evacuations of every 
 sort, and the tendency to inflammation which results from the 
 suppression of habitual evacuations, is quite as clearly explained. 
 So it is with regard to the effect of habitual repose or excessive 
 fatigue upon the health. Nervous disease in anxious or melan- 
 choly persons, or in those who devote themselves exclusively to 
 mental labor, is naturally connected with the causes productive of 
 these affections. The influence of the air and the dwelling is 
 commonly more obscure, although plausible explanations have 
 been given in regard to it. 
 
 Predisposing causes must not be confounded with predisposi- 
 tions ; the latter depend, but not constantly, upon the former. All 
 persons are not uniformly affected by the same predisposing causes, 
 and a predisposition to disease cannot be accurately determined 
 by the apparent power of the causes which produced it. In one 
 case, a slight predisposing cause will establish a very decided 
 predisposition; in another, a number of such causes, of greater 
 power and longer continued action, will have far less effect, or 
 perhaps none whatever. In many instances we are compelled to 
 acknowledge a decided predisposition to certain diseases in those 
 who have not been exposed to any of their developing causes. 
 
 Whenever a disease appears without apparent cause, a frequent 
 occurrence in internal pathology, we must have recourse to a 
 latent predisposition to explain its production ; and this doubtless 
 consists in a peculiar modification (whose essence is wholly un- 
 known) either of the whole system, or of one or many of its 
 constituent parts. Thus in pneumonia, erysipelas, or articular 
 rheumatism, it is in almost every case impossible to point out, 
 from a consideration of the antecedent circumstances, the causes 
 which have produced either of these affections. Great obscurity 
 also surrounds the origin of organic diseases. 
 
 Observation shows us that, in some persons, one organ is much 
 more frequently affected than the rest, or is even the exclusive 
 seat of almost all the diseases which manifest themselves during 
 an entire life, or at any rate, during one or more of its great divis- 
 ions, as infancy, youth, or adult age : in one individual the lungs, 
 in another, the stomach or intestines, in a third the brain, are, in 
 popular terms the feeble organs, that is, the most liable to the 
 action of morbific causes. The advocates of the theory of irrita- 
 tion proposed to call this tendency of an organ to become diseased 
 diathesis, * and they admit pulmonary, gastric, cerebral and 
 uterine varieties ; but with most authors and in the usual language 
 of science, this word has a different acceptation. Diathesis is a 
 disposition through whose influence many portions of thfe body, 
 either simultaneously or in succession, become the seats of spon- 
 taneously developed affections, identical in their nature, although 
 
 , disposition. 
 
60 ETIOLOGY. 
 
 variable in external appearance. Consequently, as many sorts of 
 diathesis must be admitted, as there are diseases which show 
 themselves in various organs simultaneously or otherwise, by the 
 agency of a common internal cause : this latter condition is barely 
 admissible. If various forms of inflammation, as peritonitis, 
 pneumonia and ophthalmia, should occur simultaneously in the 
 same patient, each arising from evident external causes, there is no 
 existent diathesis; but if these affections are developed without 
 distinct cause, they are then attributed to a common predisposition, 
 styled inflammatory diathesis. Rheumatic, gouty, tuberculous, 
 cancerous, gangrenous, herpetic, scorbutic, osseous and aneurismal 
 diatheses, have been admitted ; to these, the varicose, melanic, 
 ulcerative and hsemorrhagic should be added. 
 
 The simultaneous development in many parts of the system, of 
 rheumatic or gouty affections, of tubercle, cancer, gangrenous 
 disease, herpetic eruptions, scorbutic symptoms, osseous and 
 aneurismal tumors, varix, melanotic deposits, ulcers, granulations 
 and haemorrhage declares the existence of the corresponding 
 diatheses. We admit also a granular diathesis which most physi- 
 cians regard as a variety of the tubercular. Some authors mention 
 a dropsical diathesis, which is incorrect, since dropsy is in general 
 merely a symptom. The mucous and bilious diatheses are too ill 
 defined for retention among scientific terms. Finally, we do not 
 allow the purulent diathesis of some writers, because it is most 
 frequently a mere infection ; nor a syphilitic or variolous diathesis, 
 because these diseases do not recognise an internal cause, but are 
 owing to the evident absorption of a virus whose mode of action 
 is wholly unlike that of diathesis. 
 
 A peculiar disposition exists in a few instances, which, either in 
 the exercise of some function, or in the impression made upon it 
 by external agents, produces phenomena wholly different from 
 those which are observed in most persons in similar circumstances ; 
 such are the syncope caused by the sight of certain objects, or by a 
 kneeling posture maintained for some time ; and the urticaria noticed 
 in some individuals whenever they take certain food, as strawberries 
 and shellfish. There are persons upon whom exposure to the exter- 
 nal air has uniformly the same effect during the cold season. Bour- 
 dier saw at the Hotel Dieu of Paris, a man forty years of age, 
 become affected with intermittent fever whenever elastic bougies 
 were introduced into the urethra.* An exceptional predisposition 
 must universally be admitted, through whose agency, in certain 
 persons, like causes always produce remarkable effects. This is 
 called morbific idiosyncrasy. 
 
 Predisposing and individual causes may act in unison or singly. 
 Their energy is in proportion to their mutual action, or tendency 
 to modify the economy in a similar manner. 
 
 Among a large population, the individual rarely agree with the 
 general predispositions, from which it results that all the inhabi- 
 
 * Theses de la Faculte de Medecine de Paris, annte 1809, No. 17. 
 
ETIOLOGY. bl 
 
 tants of a district are very seldom simultaneously attacked by 
 disease, except it spring from a contagious principle, that is, a spe- 
 cific cause acting independently of predisposing causes. An affec- 
 tion uniformly developed by the latter, hardly ever attacks more 
 than one third or one quarter of a population ; most usually 
 only one tenth, one twentieth, or even a less proportion. We 
 can sometimes be certain, that those attacked by the prevailing 
 malady, are those in whom the influence of general predisposing 
 causes has rendered more active that of the individual pre- 
 disposing causes. When, for instance, bilious affections are very 
 common, persons of bilious temperament, who live chiefly on 
 animal food, etc., are more often attacked, while the sanguine or 
 lymphatic, being less impressible by general predisposing causes, 
 possess a resisting power in their very constitution. Thus, other 
 things being equal, the latter are more rarely and less severely 
 affected, while the former are more generally attacked and with 
 more violence and rapidity. There are, however, many excep- 
 tions to this rule. 
 
 t. Individual predisposing causes are sufficient of themselves to 
 produce most diseases. There is no affection which may not be 
 occasionally developed in isolated individuals, independently of 
 general predisposing causes. Angina and pneumonia, for instance, 
 although more frequent in certain seasons, may occur in all, through 
 the influence of individual predisposing causes only. Often, while 
 certain diseases prevail under the influence of general causes, indi- 
 vidual predisposing causes develope affections of a wholly different 
 nature. It is in this way that inflammatory diseases may appear 
 in certain persons inhabiting places where dropsy and scurvy *e 
 endemic. 
 
 2. On the other hand, general predisposing causes, when exceed- 
 ingly active, may exert an influence independently of the individ- 
 ual predisposants, and even notwithstanding the resistance they 
 offer. Thus it is that diseases developed during public calamities, 
 as famines, sieges, etc., fall upon all classes of society, almost 
 without distinction ; neither is any temperament or age exempted, 
 as has been observed in many epidemics, particularly at Modena* 
 and Naples, f 
 
 As regards their relative energy, then, we find that general pre- 
 disposing causes may neutralize the effect of individual causes, 
 and bring on diseases entirely in opposition to the latter, and vice 
 versa. 
 
 Before concluding what we have to say of predisposing causes, 
 we remark, that if there be certain conditions which dispose to 
 disease, there are likewise many which are preservative of health. 
 Without mentioning in this connection that unknown power called 
 vital force, which, as has been said, appears to struggle incessantly 
 against the destructive agents which surround us, there are condi- 
 
 * RAMAZZINI, 1690-93. 
 f SARCONE, 1764. 
 
62 ETIOLOGY. 
 
 tions which exempt us from certain affections ; habit, in particular, 
 is one of these. By it the most indigestible articles of food are par- 
 tially deprived of their injurious effects, and the pernicious energies 
 of the most subtle poisons destroyed ; the Turks use opium with 
 impunity, and Mithridates, according to historians, became insen- 
 sible to poisons. We must not suppose, however, that the daily 
 use of deleterious substances has no injurious effect upon the econ- 
 omy ; habit does not wholly free us from their action ; it merely 
 alters and strikingly enfeebles it. 
 
 The power of certain contagious principles seems to be exhaust- 
 ted in like manner by the force of habit. In places where yellow 
 fever is endemic, the inhabitants are not attacked by it, as at 
 Havana and Vera Cruz, for instance. The Turks resident at Con- 
 stantinople seem to be as much habituated to the principle of the 
 plague, which is in almost continual action in some parts of the city, 
 as they are to opium by daily use. We may with as much propriety 
 conclude that if the visiting physicians of hospitals are not more 
 frequently than others the victims of typhus when widely epidemic, 
 it is because they have become accustomed to the action of the 
 contagious principle before it has acquired its full power. 
 
 The force of habit goes yet farther, and deprives even chemical 
 agents of a portion of their influence over living tissues. There 
 are those who handle with impunity bodies at a very high temper- 
 ature, as burning coals, or iron bars whose opposite extremity is 
 incandescent ; others have accustomed themselves to swallow boil- 
 ing liquids without any sensible inconvenience. Tartra relates the 
 curious fact, that a woman given to intemperance, had passed 
 fifcm the immoderate use of wine to that of brandy, then of alco- 
 hol, and even of ether ; at last, unaffected by these liquids, she fin- 
 ished by drinking nitric acid, without experiencing from it any 
 remarkable injury.* 
 
 It is hardly necessary to add, that age, sex and temperament are 
 all conditions which should be considered preservative against cer- 
 tain affections. Primitive scirrhus or aneurism are never observed 
 in infancy ; one instance only of croup is recorded in old age. 
 
 We have already seen that some contagious diseases attack the 
 same person but once during life ; those who have been affected, 
 are consequently exempt. A very extraordinary, although very 
 well known phenomenon, is the reciprocally preservative property 
 of variola as regards vaccinia, and vice versa. This fact which 
 is unique in the history of contagious disease, naturally leads us to 
 suspect a similarity of origin in these affections. 
 
 Finally, there exists a fortunate disposition, whose nature is un- 
 known, but whose effects are appreciable, which protects from cer- 
 tain maladies. There are some individuals who appear to be 
 insusceptible of the contagion of variola, or vaccinia. Others ex- 
 pose themselves daily to syphilis with impunity. In all the 
 instances of epidemic typhus or yellow fever there are some who 
 
 * Empoison, par V acide nilr., p. 124. 
 
ETIOLOGY. 63 
 
 brave the contagion and escape the disease. When the plague 
 was at Marseilles, the venerable Belzunce, patriarch of the city, 
 was not affected by it, although almost constantly among the sick, 
 aiding them in every manner. In the black plague which deso- 
 lated the south of France, in 1347, another fact, no less remarka- 
 ble, was noticed ; of thirty-five monks who dwelt in the monastery 
 of Mont Rieux, one only escaped the contagion ; this was Gerard, 
 brother of the celebrated Petrarch, who took care of all the breth- 
 ren and also buried them. 
 
 $ IV. We have considered the mode of action exhibited by spe- 
 cific and predisposing causes in developing disease ; it remains for 
 us to notice that of the occasional causes. The influence of the 
 latter is not by any means so great ; they act only when there 
 exists a predisposition. Thus, of ten persons who may commit an 
 excess of the table, or who may be exposed to cold, etc., there 
 will be, at farthest, but one or two whose health will be disturbed, 
 and sometimes out of a larger number there will be none affected. 
 Moreover, these causes have no influence upon the sort of affection 
 which is developed ; the same occasional cause may, as we have 
 seen, excite any disease, and the same disease may result indiffer- 
 ently from any occasional cause. Such a cause is, as it were, a 
 shock given to the system ; it does not affect those in firm health ; 
 in others it may develope any affection whatever. 
 
 Such is the mode of action of each kind of morbific causes. 
 There is a certain number of diseases in whose production some of 
 these three classes of causes concur ; there are others where the 
 disease arises exclusively from a specific cause, or from one or 
 more predisposing causes. Asphyxia always depends on a specific 
 cause ; typhus requires the influence of some predisposing cause in 
 the majority of cases ; and sometimes an occasional cause, as ter- 
 ror, or too strict diet, may excite its attack ; plethora and inflam- 
 matory fevers are almost always exclusively produced by predis- 
 posing causes ; no affection arises solely from an occasional cause. 
 
 The knowledge of causes is not absolutely necessary in particu- 
 lar cases. When the disease is due to specific causes, they are 
 easily appreciated, but the predisposing causes, which are usually 
 obscure, frequently escape the physician's sagacity. The kind of 
 disease developed, may in some cases lead to the suspicion of the 
 causes which have produced it, and serve as a guide in the search 
 for them ; but in many other instances these causes remain uncer- 
 tain, or even unknown. In respect to occasional causes, as they 
 are immediately antecedent to the disease, they attract more par- 
 ticularly the patient's attention, which cannot fail to instruct the 
 physician ; but a knowledge of them is generally of slight impor- 
 tance, and many diseases make their appearance without their 
 influence. 
 
64 ETIOLOGY. 
 
 ARTICLE FIFTH. 
 Division of Diseases relatively to the Causes which produce them. 
 
 DISEASES arising under similar conditions, or which offer cer- 
 tain points of resemblance as respects their causes, have been 
 grouped together and possess certain interesting relations. The 
 principal groups to which this etiological division has given rise are 
 those of innate and acquired, sporadic, endemic and epidemic dis- 
 eases. 
 
 By innate or congenital diseases (morbi cognati, congeniti) is 
 understood those exhibited by the child at birth. They are not all 
 hereditary, neither do all hereditary diseases appear at the time of 
 birth. The latter have existed, or are still present in the parents, 
 and this does not necessarily occur in regard to the former. An 
 affection may be both hereditary and congenital. 
 
 Under the title acquired diseases (morbi acquisiti, adventitii) 
 are included those not commencing till after birth and independent 
 of hereditary disposition. All diseases may come under this head 
 except deformities. 
 
 Sporadic diseases (morbi sporadici*} are those which attack a 
 single individual, or a certain number of isolated persons. They 
 depend especially upon the predisposing causes ; for the epithet 
 sporadic is not given to affections induced by specific causes. We 
 do not say that wounds, fractures, and asphyxia are sporadic ; 
 this term is applicable only to those diseases whose development 
 is apparently spontaneous. Sporadic diseases are, of all, the most 
 common ; they appear at all seasons, at every age, and in all 
 climates, under the action of individual causes. 
 
 Diseases which attack a mass of individuals at once, have been 
 styled pandemic (morbi popular -es); these have been subdivided 
 into several series, according to the circumstances which accom- 
 pany their development. Those which appear every year at 
 nearly the same time, are called annual (morbi annui, anniversarii) ; 
 those which manifest themselves uninterruptedly for many seasons, 
 or one or more years, are known as stationary (morbi stationarii) ; 
 those occurring at various seasons, and modified only by prevalent 
 affections, are termed intercurrent (morbi inter currentes). At the 
 present time these names are generally abandoned, and two classes 
 only of popular diseases are admitted, endemic and epidemic. 
 
 Endemic f diseases (morbi endemici) are those produced by the 
 concurrence of causes constantly or periodically in operation in 
 certain situations, so that the diseases resulting from them are con- 
 stant, or at any rate, appear at fixed periods, affecting, in every 
 
 * SniiQta, to scatter here and there, 
 f Ev, in ; <*>;/>, the people. 
 
ETIOLOGY. 65 
 
 instance, a greater or less proportion of the population ; such are 
 goitre and cretinism in the Valley of the Rhone, and intermittent 
 fever in most marshy districts. 
 
 Epidemic* diseases, (morbi epidemici) which, like the former, 
 attack a large number of persons simultaneously, or become far 
 more frequent than they usually are, have a limited duration, and 
 do not appear at regular intervals. Their causes have ever been 
 the object of research to the observing physician. Nearly every 
 one is ready to acknowledge that most epidemics do not depend 
 solely upon the circumstances which surround the inhabitants of 
 an infected district ; and that the action of a succession of causes 
 for a variable space of time, has prepared the way for their mani- 
 festation, and produced a predisposition which the actual causes 
 have only developed or increased. It is also observed in many 
 epidemics, that those who have been resident for a short time 
 only in the region where they prevail, escape them, while the 
 older inhabitants are attacked. Some have sought for the causes 
 of all epidemics in the food and drinks, but especially in the sensible 
 qualities of the atmosphere. Others having noticed that the changes 
 sometimes occurring in the atmosphere during an epidemic, do not 
 always sensibly influence its course, have concluded from this, 
 that the exciting and continuing causes of prevalent, diseases do 
 not exist in the appreciable qualities of the air. They have thus 
 been led to admit hidden qualities in this fluid, to which they 
 attribute the diseases, whose occurrence cannot be explained by 
 the sensible changes of the atmosphere. From this arises the doc- 
 trine of occult causes, admitted under various titles, by very cele- 
 brated and highly judicious physicians, from Hippocrates to 
 Sydenham and Mertens. 
 
 Nothing was better suited to throw light upon this question, than 
 the numerous epidemic constitutions, published within two cen- 
 turies. It was thought that a constant relation would be recognised 
 between epidemics and the conditions under which they manifest 
 themselves, by means of a careful comparison, for a series of years, 
 on the one hand, of the various states of the atmosphere and the other 
 general morbific causes ; on the other, of the diseases developed 
 under their influence : this is the object of epidemic constitutions. 
 The result, however, has not answered the apparently well founded 
 expectations formed in regard to this undertaking, either because 
 the epidemic constitutions were not properly observed and de- 
 scribed, or because epidemics depend upon causes which have 
 hitherto escaped our means of investigation. 
 
 Without giving a decided opinion upon so obscure a question, 
 we shall remark, that among the hitherto described epidemics, 
 there are some which seem to have fixed appreciable causes : of 
 th isnumber are those of Lausanne, Modena, Gottingen and Genoa ; 
 but we must still remember that a concurrence of causes resem- 
 bling those already cited, would not necessarily produce like effects ; 
 
 * Enl, upon ; dftiog, the people. 
 6* 
 
66 ETIOLOGY. 
 
 and that by far the greater number of epidemics cannot be ascribed 
 to any known causes, notAvithstanding the great pains that many 
 physicians have taken to indicate every circumstance which pre- 
 ceded or accompanied their development. 
 
 Among widely prevalent diseases, there is a certain number 
 arising from contagion or infection, which must not be confounded 
 with the rest, although the majority of writers have included them 
 under the common denomination, epidemic diseases. 
 
 It is not always easy to determine whether a disease which 
 attacks many persons simultaneously, be owing to general predis- 
 posing causes, or to a contagious principle. It may happen * that 
 a disease is really contagious while it appears only epidemic, 
 because contagion does not affect all who are exposed to its in- 
 fluence, or because the vehicles of contagion and the contagious 
 principles being almost infinite, persons may be affected who 
 thought themselves removed from all communication with the 
 sick ; and again, some other affection, considered contagious, be- 
 cause it attacks individuals who are in communication, may be 
 dependent upon epidemic influence, which is common to all. 
 Thus when many persons occupying the same house, fall ill si- 
 multaneously or successively, contagion is nearly always suspected ; 
 yet, as Ramazzini-\ remarks, it is natural that a number of per- 
 sons exposed equally, and for the same length of time, to the 
 influence of the same causes, should be attacked, at a nearly 
 identical period, with the same disease. A sort of maturity, says 
 this distinguished physician, supervenes in the system when 
 exposed for a certain time to the action of similar morbific causes. 
 
 In certain instances, the difficulty of lulling all suspicion of 
 contagion, hinders us from wholly denying its action ; and in others 
 we cannot admit it, from not being sure whether the disease is 
 ascribable to the state of the atmosphere, or to some other general 
 cause. 
 
 The more volatile and easy of transmission the contagious prin- 
 ciple, the more obscurity surrounds it. 
 
 Another circumstance which renders the distinction more difficult 
 is, that the majority of contagious diseases attack a population only 
 while contagion is favored by a peculiar condition of the atmos- 
 phere, or by other general predisposing causes to which the 
 prevailing malady might be attributed. Finally, contagion some- 
 times loses its activity after a time, and from observations at such 
 periods, we are led to suppose that the affection is not contagious. 
 This has been remarked in most of the pestilential diseases, par- 
 ticularly in the typhus of Europe, and the plague of the East. 
 We should find it difficult to conceive of their gradual cessation, if 
 this principle be not admitted. 
 
 There are, nevertheless, certain circumstances which serve to 
 distinguish contagious from epidemic diseases : among these are 
 inoculation and importation. Whenever a disease is clearly capable 
 
 *TOMMASINI. Filvre jaune. f Epidem. Modlne. 
 
ETIOLOGY. 67 
 
 of transmission from the affected individual to the healthy, and 
 this transmission has been recognised in repeated instances, con- 
 tagion can no longer be doubted. It is in this manner that the 
 contagious nature of variola and vaccinia has been clearly proved. 
 
 The impossibility of transmitting a disease by inoculation, has 
 been considered a negative means of forming an opinion as to 
 contagion. During the prevalence of epidemic cholera, many 
 courageous and devoted physicians inoculated themselves with the 
 matters excreted by the sick, with the intention of throwing light 
 upon this question, whose solution was so important to society. 
 While we award to their zeal the praise due to the honorable 
 motive which directed them, it must be asserted that these experi- 
 ments were not sufficient to fully settle the question. All diseases 
 are not similarly contagious ; many have a peculiar mode of trans- 
 mission, out of whose limits contagion does not manifest itself. 
 Thus syphilis is rarely contracted except by coitus ; nor the 
 vaccine disease, except by the artificial insertion of the liquid 
 contained in the pustules. The same may be true of certain other 
 affections ; and the virus of Asiatic cholera, if it exist, might 
 require, in order to transmission, a different mode of inoculation 
 from those hitherto tried. In addition, as we have elsewhere 
 remarked, every individual is not prone to receive the contagion ; 
 many more cases, also, are needed, in order to solve the question, 
 and in trials of this kind, negative have far less influence than 
 positive results. Finally, it should be remarked, that the develop- 
 ment of a disease in those who have been subjected to inoculation, 
 cannot prove its contagious nature, except the inoculation be prac- 
 tised at a distance from the place where the affection prevails. 
 Thus, whatever may have been the results of inoculations which 
 took place during the epidemic cholera, and in the regions where 
 it raged ; they were, from the very first, of no value. 
 
 Importation, is, in this class of cases, the most suitable means 
 of explaining these questions. When a disease previously un- 
 known in a country, suddenly makes its appearance there ; if its 
 manifestation succeed the arrival of a number of strangers who 
 may be then affected with it, but recently cured, or who come 
 from a place where it prevails ; if those who receive these strangers 
 and provide for them, are the first to be attacked by the disease ; 
 and if it next appear among the individuals who live with those 
 first affected, it is evidently contagious. It is in this manner that 
 the appearance of variola at the Cape of Good Hope, in the Faroe 
 islands and in many parts of Russia, where it was previously 
 unknown, would prove, if it were necessary, the contagious nature 
 of this disease. The importation of scarlatina into Podolia,* as 
 
 * Hddenbrand thus speaks in regard to this subject : " A black coat which I 
 wore when visiting a patient affected with scarlet fever, and afterwards carried 
 with me from Vienna into Podolia, without having it on for the space of one year 
 and a half, communicated to me this contagious disease upon my first arrival ; 
 from me it spread in the province, where it haS until then been almost unknown." 
 (Du Typhus Contagieux.) 
 
68 ETIOLOGY. 
 
 related by Hildenbrand, establishes, in like manner, its contagious 
 qualities. Tf the importation of the plague, of yellow fever, or of 
 Asiatic cholera were absolutely proved, it would leave no doubt as 
 to the contagious nature of these diseases. But in the present 
 state of Our knowledge, these delicate questions are yet undecided. 
 Many good observers are convinced that these diseases, arising in 
 the first place from miasmata, are transmitted more particularly 
 by the accumulation of the sick ; and that consequently they are 
 infectious. It should be added, that any disease arising from a 
 crowding of patients, and infectious in its origin, may become 
 contagious in its future transmission. Camp fever and hospital 
 gangrene are striking examples. 
 
 Upon this subject we shall offer one final remark, viz. It is not 
 in large cities that the question of contagion can be advantageously 
 studied and thoroughly examined. In a place where six or eight 
 hundred thousand inhabitants are congregated, unknown to each 
 other, it is impossible to follow in its transmission, the most evi- 
 dently contagious disease. The course of variola at Paris may be 
 cited as an example, and the impossibility of arriving, in the ma- 
 jority of cases, at a knowledge of the period and source of its trans- 
 mission. On the other hand, in places where the inhabitants are 
 fewer and better acquainted, it is usually easy to follow the 
 propagation of a disease ; all know who were first attacked by it, 
 what other persons have been successively affected, and what com- 
 munication they held with those first diseased. On this account, 
 villages, and not populous cities, are the places where the mode 
 of propagation of diseases can be advantageously studied, and 
 their contagious, infectious, or merely epidemic character, most cor- 
 rectly appreciated. We do not, in this connection, speak of 
 syphilis or vaccinia, which cannot be confounded with epidemic 
 diseases, since they require close contact in order to their trans- 
 mission.* We shall conclude by calling to mind this ancient 
 precept, too often combatted in our day, that whenever there is 
 uncertainty in regard to contagion, it is the physician's duty, as 
 also that of the acting authorities, to proceed as if it were proved. 
 There is, doubtless, serious inconvenience in declaring contagion 
 to exist where it does not in reality, but there is still greater in 
 mistaking it when really present, f 
 
 i 
 
 * According to many authors, (and the opinion is supported by certain histo- 
 rical facts,) it would appear to be proved that syphilis, at the period of its first 
 appearance, presented as ready a contagion as the plague or variola, and that, in 
 course of time, it became less and less active. No other contagious affection 
 has presented analogous changes in its mode of transmission. 
 
 f This motive would have sufficed to induce us to rank yellow and typhus 
 fever among the contagious diseases, even if we had not been convinced, as we 
 are, of their contagious nature. [The author ranks himself with the very small 
 number of those in favor of the contagious nature of yellow fever : the best 
 observers of the present day are decidedly opposed to the doctrine of contagion. 
 Grisolle, in his work on Internal Pathology, 1 makes several assertions which 
 
 1 Path. Int., Vol. i, p. 77, Deuridme Edition. De La Fitvre Jaune. 
 
ETIOLOGY. 69 
 
 Diseases have likewise been divided, in respect to their causes, 
 into essential, primitive, or protopathic* and into symptomatic, 
 secondary, or deuteropatkic.\ The first are the immediate result 
 of morbific causes ; the second depend upon another affection, of 
 which they are, properly speaking, but a symptom. Haemorrhage 
 belongs occasionally to the latter, sometimes to the former. They 
 are essential, when not connected with perceptible lesion of the 
 organ where they are seated ; they are symptomatic in scorbutus, 
 and many organic affections. 
 
 It is sometimes easy to determine, whether a disease is primitive 
 or secondary : thus, when cancer of the uterus has attained a 
 certain stage, the sanious discharge cannot be mistaken for uterine 
 catarrh, and the haemorrhage, which comes on at intervals, can- 
 not be considered as primitive; but it is otherwise when the 
 same disease is only commencing, and the neck of the uterus 
 does not yet present the hardness and deformity which character- 
 ize the disease. 
 
 There is a certain number of affections which, however well 
 marked they may be, are essential according to some authors, and 
 are considered symptomatic by others ; among these are curva- 
 ture and softening of the bones, regarded by some physicians as 
 primitive diseases, while others look upon them as secondary, and 
 connected with scrofula. The intestinal ulcerations in typhoid 
 fever, and the enlargement of the spleen in intermittent fever, are 
 likewise of this class. Dropsy and the neuroses have been, and still 
 are, at least in some of their forms, subject to similar diversity 
 of opinion. Exact observation and thorough discussion have 
 decided some of these questions, and time will gradually lead to 
 the solution of many others. 
 
 ARTICLE SIXTH. 
 
 Lapse of Time between the Application of Causes and the Development 
 
 of Disease. 
 
 A CERTAIN number of diseases are produced at the moment 
 when the action of their determining cause takes place ; this is 
 
 seem sufficiently positive in regard to the truth of the opinion of the non-con- 
 tagionists ; he mentions the names of Chervin, Dalmas, Deveze, Valentin, and 
 Rush , as among the principal supporters of the latter doctrine. The work of Cher- 
 vin is pronounced by the accomplished editors of the American edition of Marshall 
 Hall's Theory and Practice of Medicine, to be the most elaborate investigation 
 of the point in dispute ; ' and certainly, if we consider the time devoted to his 
 undertaking, and his unwearied researches both in Europe and America, his 
 opinion is entitled to our very highest consideration. Five hundred Spanish 
 and American physicians out of six hundred, coincided with him in favor of 
 non- contagion. TRANS.] 
 
 * IIuQog, disease; idiog, proper; TT(>WTOC, first. 
 
 f jfufiog, disease ; devrtQog, secondary. 
 
 1 Prin. of the Theor. and Practice of Med. By M. Hall. American Edition, p. 275. 
 Yellow Fever. 
 
70 PRECURSORY PHENOMENA. 
 
 observed in contusions, wounds, fractures, and the inspiration of 
 certain deleterious gases. The inflammation resulting from the 
 application of rubefacients is usually manifested in a short time, 
 as an hour, for instance ; the action of vaccine virus commences 
 at the end of three days ; the first symptoms of variola are not 
 evident, generally speaking, till eight days from the period when 
 the contagion took place ; syphilis is not developed in some in- 
 stances for three or four weeks after connection, and usually the 
 first symptoms of rabies do not declare themselves in adults be- 
 fore the thirtieth or fortieth day after the bite. 
 
 The time which elapses between the application of contagious 
 principles and their first effects upon the economy, has by many 
 authors been called the period of incubation. 
 
 It is almost always impossible to ascertain accurately the time 
 since which the predisposing causes have acted : some of these 
 causes are inherent in the constitution of the individual, as age, 
 sex, temperament, etc. The development of disease follows im- 
 mediately, or at any rate, very closely, the application of occa- 
 sional causes. M. 
 
 CHAPTER VI. 
 
 PRECURSORY PHENOMENA. PRELUDES. ANTECEDENT SIGNS. PRO- 
 DROMES OR IMMINENCE OF DISEASES. 
 
 ALL those phenomena which are exhibited from the moment 
 when the healthy action of the functions begins to be disturbed, 
 up to the time when the disease commences, are styled precursory 
 or antecedent signs.* 
 
 Diseases are not invariably ushered in by precursory phenome- 
 na; the transition from perfect health to illness may be sudden. 
 Those affections which are produced by specific causes never have 
 any prodrome, even when they arise from contagion. The sneezing 
 which precedes the eruption of rubeola, the vomiting which occurs 
 previously to that of variola, cannot be considered as precursory 
 phenomena ; they are the first effects of the action of the peculiar 
 virus of these two affections, and the disease has already com- 
 menced, although the eruption be not apparent. Preludes do not 
 take place, except the affection be owing to predisposing causes ; 
 none are observed in chronic diseases. 
 
 The precursory phenomena have not, generally, any analogy 
 with the malady about to be developed, and cannot lead us to sus- 
 pect its nature. Those of almost all diseases strikingly resemble 
 
 * 17(36, before ; fyo.uos, course. 
 
PRECURSORY PHENOMENA. 71 
 
 each other, and those of the same affection are scarcely ever simi- 
 lar. When, however, an epidemic prevails, it may be announced 
 by phenomena which are uniform in a large majority of cases, and 
 from this the physician recognises, or at least suspects, the kind of 
 affection about to appear. But, in most instances, the prodrome 
 cannot lay the foundation of any decision, nor even of reasonable 
 conjecture. 
 
 The precursory phenomena of acute diseases are exceedingly 
 varied and numerous. We shall mention those most usually ob- 
 served. 
 
 The attitude indicates an unusual languor, the step loses its or- 
 dinary firmness, there is progressive loss of flesh, the expression of 
 the countenance is slightly altered, in a manner appreciable only 
 by those familiar with the individual ; the face is either pale, or 
 pale and flushed alternately; the least exercise causes fatigue; 
 slight flying pains, variable in their seat and nature, are experien- 
 ced in different parts of the body, particularly the head ; transient 
 disturbance of the senses of sight and hearing occurs, as dimness 
 of vision, and tinnitus aurium ; the moral impressions are either 
 increased or diminished ; presentiments of misfortune and inability 
 for mental exertion, disturbed sleep, its entire absence, or a slight 
 degree of somnolence, are frequent precursory phenomena of dis- 
 eases. The appetite is usually diminished, rarely heightened or per- 
 verted ; the mouth is often clammy or bitter, the thirst increased, the 
 breath fetid, digestion difficult and slow, and the bowels less regular. 
 The slightest exertion causes breathlessness ; at intervals, sighing, 
 groaning, yawning, stretching, and occasionally, repeated fits of 
 sneezing are noticed. Palpitation, syncope, sensitiveness to exter- 
 nal cold, the unequal distribution of heat, a dry skin or transient 
 perspiration, a paler or deeper color of the urine and inaction of the 
 genital organs, announce the approaching invasion of an acute af- 
 fection. 
 
 In other cases, illness is preceded by entirely opposite phe- 
 nomena; the functions, far from being enfeebled, seem exercised 
 with more than ordinary vigor ; the countenance is flushed, the 
 strength increased, the intellectual faculties more active, appetite 
 and digestion are more powerful; the individual congratulates 
 himself upon his increased health, which is but a precursor of 
 disease. 
 
 Certain other phenomena have been observed while disease was 
 still latent; one patient experiences a sensation which may be 
 compared to that caused by a breath of wind lightly fanning the 
 surface of the body; another, a sort of shock similar to that caused 
 by electricity. Finally, to these phenomena should be added the 
 changes supervening in the pre-existing diseases, in the secretion 
 from wounds or ulcers, cauteries, blisters, in the appearance of ex- 
 anthemata, etc. It is not uncommon to observe at such times a 
 more or less complete absorption of the serosity infiltrated into the 
 cellular tissue. 
 
 Such are the principal phenomena which precede acute diseases. 
 
72 SYMPTOMS. 
 
 They may be variously grouped and combined. Each of them 
 may exist separately. They are never all present in the same in- 
 dividual. 
 
 The duration of the precursory period is very variable : occa- 
 sionally a few minutes, sometimes a number of hours ; it may 
 continue many days or even weeks, but rarely longer. When it 
 has been long, a grave disease may be apprehended, there are, 
 however, numerous exceptions to this rule. 
 
 When the intensity of the precursory phenomena augments pro- 
 gressively, they may gradually become confounded with those of 
 the disease, and likewise with the occasional causes which excite 
 its appearance ; a chill, an attack of indigestion, the suppression 
 of an habitual evacuation, the desiccation of an issue, are at one 
 time the causes, at another the first effects of the disease. 
 
 The intensity of precursory phenomena cannot convey an accu- 
 rate idea of the gravity of the affection which they announce. 
 The prodrome of some very severe, and even fatal diseases, may be 
 hardly perceptible; while certain mild affections are sometimes 
 preceded by inexpressible anxiety and other very alarming signs. 
 
 The same phenomena which precede diseases may be manifested 
 without any subsequent illness ; they cease suddenly, or gradually 
 disappear, and the functions resume their usual regularity. M. 
 
 CHAPTER VII, 
 
 SYMPTOMS,* OR SYMPTOMATOLOGY. 
 
 A SYMPTOM is any change perceptible to the senses, occurring 
 in any organ or function, and connected with the existence of 
 disease. 
 
 Symptoms should not be confounded with phenomena or signs. 
 
 A phenomenon is any act or change effected in the healthy or 
 diseased body, whereas, a symptom is alone observable in the latter. 
 Where there is no disease, there can be no symptom. Galen 
 justly remarks, that the symptom follows the disease, as the 
 shadow follows the body. Hence, the impropriety of the terms 
 precursory and consecutive symptoms , employed by many authors ; 
 whatever is observable previous to the existence, or after the ter- 
 mination of a disease, is a phenomenon, not a symptom.f 
 
 It is equally important to distinguish between the symptom and 
 the sign. A sign, in the common acceptation of the word, is any 
 
 * Svr, with, at the same time ; ninrw, I fall, 
 f Joyo?, discourse ; ov^nru^ua, symptom. 
 
SYMPTOMS. 73 
 
 circumstance, by which we become acquainted with that of 
 which we were previously ignorant. In medicine, is understood 
 by this word, whatever reveals anything relating to the past, 
 present, or future state of a disease. The causes which preceded its 
 development, its mode of attack, its progress, and the effect of 
 therapeutical agents, all afford signs as well as symptoms. The 
 symptom is simply a sensation, which a special effort of the mind 
 is alone able to convert into a sign. While the latter, therefore, 
 relates to the judgment, the former is referable to the senses. The 
 symptom is recognizable by every one, the physician alone detects 
 the sign in the symptom. As there are no symptoms which may 
 not furnish some sign to the physician, and moreover, as signs occur 
 in health as well as disease, it has been said, that "every symptom 
 is a sign, but that all signs are not symptoms." By what means 
 symptoms are converted into signs will be seen hereafter : the 
 former claim our present attention. 
 
 Symptoms, or the appreciable changes effected by disease in the 
 various organs or functions, are very numerous. It is important 
 that some method be adopted in their exposition, by means of 
 which, those between which the greatest analogy exists, may, as far 
 as possible, be grouped together. Several methods have been pro- 
 posed, which offer this advantage to a greater or less extent. Among 
 these may be mentioned the division into those symptoms appre- 
 ciable to the physician, and those perceptible to the patient ; that 
 also of Boerhaave, who divided them into three series, according 
 as they depend upon disorder of the functions, excretions, or quali- 
 ties of the body ; and finally, that recently proposed by Bayle, our 
 former instructor and friend, who divided them into vital and 
 physical: the former, which are solely dependent upon functional 
 disturbance without any appreciable organic lesion, and which 
 disappear entirely at death; the latter, on the contrary, which con- 
 sist in an appreciable change in the parts themselves, and continue 
 after death. It will be at once evident, that this distinction had 
 special reference to pathological anatomy, and was entirely inap- 
 plicable to the methodical exposition of symptoms. That pro- 
 posed by Boerhaave, makes too wide a separation between things 
 which are nearly connected ; the secretions, for example, are 
 separated from secreted matters, and the qualities of the body from 
 the functions to which they belong. 
 
 Another equally important point, is the adoption of some order 
 which may be advantageously applied to the history of each 
 affection, and to the examination of each particular patient. 
 There are many highly commendable practitioners, who at the 
 bedside, examine in succession all the functions, the organs of 
 which are situated in the head, neck, chest, abdomen, and limbs ; 
 this method, which it woufd be difficult to employ in the general 
 exposition of symptoms, would not present in the examination of 
 individual patients, the same advantages, which might be obtained 
 from a different one. It approximates things the most unlike, and 
 widely separates those, between which, the greatest analogy exists. 
 
74 SYMPTOMS. 
 
 The various disorders of the digestive organs, for example, in- 
 stead of being successively and uninterruptedly examined, are 
 separated from each other by so many intermediate questions, 
 that it becomes difficult to discover the connection between them. 
 The same may be said of the circulation and locomotion, the or- 
 gans of which extend throughout the economy, and of many 
 other functions. 
 
 A more natural method is to examine successively all the de- 
 rangements which each function presents, in whatever part of the 
 body the organs which concur in its performance are situated. 
 This method, which is equally convenient in the examination of 
 the patient, and in making a record of the disease, is the only one 
 applicable to the particular description of each affection, and to a 
 general exposition of symptoms. 
 
 But what order should be pursued, in the examination of the 
 functions ? It would be desirable if that could be adopted, which 
 is generally followed in the study of physiology ; examining in 
 succession the functions of assimilation, those of relation, and 
 lastly, those of generation. As, however, this division does not 
 present the same advantages in the study of the diseased, as in 
 that of the healthy body, we think it unnecessary to confine our- 
 selves strictly to it. 
 
 That which strikes the physician, in first accosting a patient, 
 and from which he draws his first conclusions respecting the na- 
 ture of his disease, is the physiognomy, attitude, movements, and 
 voice : here, then, we should naturally commence our examination 
 of symptoms ; it is, moreover, at this time that the changes which 
 have taken place upon the exterior of the body, are more justly 
 appreciated. If this first sensation be neglected, the eye gradu- 
 ally becomes accustomed to whatever is unusual in the physi- 
 ognomy of the patient, and the physician is rarely able, after re- 
 maining with him for a time, to judge with the same accuracy as 
 he would have done at first. The same is true of the movements 
 and voice ; it is therefore better to commence the examination of 
 patients, and the general exposition of symptoms, with the functions 
 of relation, afterwards passing successively to those of assimila- 
 tion and generation. We shall pursue the following order, in the 
 exposition of the symptoms which belong to each of these three 
 great series. 
 
 1. Exterior of the body. 2. Digestion. 
 Locomotion. Respiration. 
 
 Voice and speech. Circulation. 
 
 Sensations. Heat. 
 
 Affective functions. Secretions. 
 
 Intellectual functions. 3. Generative functions in the male. 
 Sleep and the waking state. Generative functions in the female. 
 
SYMPTOMS. 75 
 
 ARTICLE FIRST. 
 Symptoms furnished by the Functions of Relation. 
 
 IN order to the just appreciation of the changes effected by dis- 
 ease in the various functions, and particularly those of relation, it 
 is important, if not indispensable, that the physician be familiar with 
 the physiognomy, attitude, gestures, and voice of persons in health. 
 Without this fixed point of comparison, he will be unable to 
 arrive at more than approximate results, in his appreciation of the 
 phenomena which fall under his observation. 
 
 SECTION FIRST. 
 Symptoms furnished by the Exterior of the Body. 
 
 THE symptoms which may be presented by the exterior of the 
 body, are of the highest importance. Having first considered 
 those presented by the body as a whole, we shall pass to the 
 consideration of those which may be furnished by each part re- 
 spectively. 
 
 $ I. The exterior of the body, considered generally, comprises the 
 attitude, volume of the body, firmness of the flesh, color of the 
 skin, eruptions, plicatures. tumors, and solutions of continuity of 
 every kind. To these might be added, the heat and moisture of 
 the skin, pulsations of superficial arteries, distension of veins, 
 &c. ; but these will be more naturally considered elsewhere. 
 
 A. In health, the attitude in the waking state is free and un- 
 constrained ; during sleep, the limbs are usually demiflexed, and 
 the body inclined to one side, commonly the right. In disease, 
 the attitude varies more or less from these conditions. 
 
 If the patient be up, an unusual degree of languor is observable 
 in his attitude; in some cases, as in maniacs, for example, an 
 unnatural degree of strength and assurance is noticed. There are 
 some diseases which are at once recognizable from the position 
 of the patient ; as catalepsy, for example, from the general immo- 
 bility ; St. Vitus' dance, from the irregularity and continual suc- 
 cession of motions ; hemiplegia, from distortion of the features, 
 and a change in the position and motions of the limbs, and 
 opisthotonos and emprosthotonos, from the convulsive flexion of 
 the body backward and forward. 
 
 When in bed, some patients assume various postures, and retain 
 them for a time ; others are constrained to remain in the same 
 position, a symptom not without importance. Thus some patients 
 lie constantly upon the back, (decubitus dorsal) either from debil- 
 ity, which occurs in adynamic fevers, or from difficulty or pain 
 
76 SYMPTOMS. 
 
 experienced when in any other posture, as is the case in general 
 rheumatism, and acute peritonitis. Others, from the nature and 
 violence of their pains, are compelled, at least for a time, to lie 
 upon the abdomen, as in saturnine, nephritic and hepatic colic, and 
 in some cases of delirium. At times the patient lies upon one and 
 the same side, (decubitus lateral) in consequence of effusion into 
 one of the pleurae, inflammation of one lung, or an acute pain on 
 either side; in cases of effusion or hepatization the patient lies 
 upon the affected side, and upon the opposite side when suffering 
 from acute pain. There are however numerous exceptions to these 
 rules, the dorsal decubitus being the posture most frequently 
 observed in cases of pleuritic effusion, and single pneumonia. 
 Lastly, in certain thoracic affections attended with difficulty of 
 respiration, and particularly in cardiac aneurism, in double hydro- 
 thorax, and in the paroxysm of dyspnoea occurring in pulmonary 
 emphysema, the patient is compelled to sit up in bed, it being 
 impossible for him to retain the horizontal position ; he is even in 
 some cases obliged to bend forward, in order to create a support, 
 allowing the legs to hang down. In some affections of the air 
 passages, the patient retains the sitting posture, with the head 
 thrown backward. In compression of the trachea by a tumor, 
 particularly if it be an aortic aneurism, the patient is constrained 
 to assume a fixed and often strange attitude, this position doubtless 
 partially relieving the pressure upon this organ, and thereby 
 rendering respiration less difficult. In other diseases, instead of 
 being constantly confined to one position, the patient is obliged to 
 change it continually. This state of restlessness (inquies) is par- 
 ticularly observable in inflammations of the abdomen, and at the 
 commencement of eruptive fevers. 
 
 B. The body becomes increased or diminished in volume in 
 many diseases. 
 
 A slight increase of volume occurs in febrile heat, and in the 
 second stage of intermittent fever ; while in the first or cold stage 
 diminution takes place. Plethora produces an analogous effect, 
 appreciable in the face, hands, and particularly the fingers, which 
 are with difficulty flexed. A more marked tumidity occurs at the 
 commencement of the exanthematous diseases. But where con- 
 siderable increase of volume exists, it is almost always owing to 
 an accumulation of fat or serous fluid in the cellular tissue, and 
 is sometimes caused by the passage of air between its lamellae. 
 
 The accumulation of fat, and the consequent increase in the 
 volume of the body, have been rarely observed in disease. They 
 may occur in certain local affections, which compel the patient to 
 abstain from exercise, and in which a subjection to regimen is 
 unnecessary. This accumulation, when considerable, is itself a 
 disease, which has been designated by the term adipose polysarcia. 
 
 Increase in the volume of the body when occurring in disease, 
 is almost always owing to infiltration of serum into the interstices 
 of the cellular texture. This infiltration, when general, is called 
 
SYMPTOMS. 77 
 
 anasarca # or leucophlegmasia, f and when partial, oedema. J It 
 is known by the paleness and semi-transparency of the skin, and 
 by its pitting on pressure of the finger. This depression however, 
 to be perceptible, often requires that the finger be passed lightly 
 over it, when it is at once felt. (Edematous swelling may be 
 more easily recognized, when the disposition of the skin allows us 
 to pinch it between the fingers. Incipient osdema may be often 
 thus distinguished in patients confined to their beds, on the inter- 
 nal surface of the thighs; in those who are up. oedema first shows 
 itself around the malleoli, particularly towards evening. 
 
 The infiltration of air into the cellular tissue, is called emphyse- 
 ma. || It occurs in penetrating wounds of the thorax, and in 
 diseases in which the continuity of the air passages is destroyed : it 
 is owing in both cases to the introduction of air into the interstices 
 of the cellular texture. That which occurs in gangrenous affec- 
 tions seems to depend upon the rapid decomposition of parts 
 already deprived of life. The insufflation of air into the cellular 
 tissue produces artificial emphysema. Can we admit with some 
 authors, the existence of spontaneous emphysema, produced by 
 exhalation of gas into the cellular tissue ? Without pretending to 
 assign a limit to possibilities, we are of opinion that in the present 
 state of the science, such exhalation cannot be certainly proved. 
 Emphysema, whatever be its origin, is easily recognized, particu- 
 larly in gangrenous diseases, by the crepitation produced by pres- 
 sure upon the tumified parts, by the softness and elasticity of the 
 distended integuments which readily yield under the finger with- 
 out preserving the impression, and by increased resonance. 
 
 Diminution in the volume of the body is a very frequent phe- 
 nomenon in disease. It may in the course of a few days, and 
 even a few hours, become considerable, as after one or two 
 paroxysms of malignant intermittent fever, or after excessive 
 alvine discharges, as was observed by Morgagni on his own person, 
 in an attack of serous diarrhoea, and as we have ourselves frequent- 
 ly remarked in Asiatic cholera ; but it usually takes place slowly, 
 constituting emaciation, which may exist in different degrees from 
 simple emaciation, to marasmus. $ In most acute diseases, there is 
 little diminution of volume, unless they be prolonged or accompa- 
 nied with abundant evacuations, or treated by artificial evacuants, 
 as bleeding, purgatives, &c. With these exceptions, emaciation 
 does not become very apparent in acute affections till the period of 
 convalescence. It is particularly in chronic diseases that it be- 
 comes considerable, and in such cases is always indicative of great 
 danger. 
 
 C. During the period of growth, in the course of acute and 
 
 *''Ava, in ; & - a , flesh. 
 
 f Jtvxo?, white ; y*y< <a, inflammation. 
 | Oi<Vi swelling. 
 || 'Eutpvaato, I inflate. 
 <S JUapau'w, I dry up. 
 
 7* 
 
78 SYMPTOMS. 
 
 chronic diseases, increase in height is sometimes observed to he far 
 more rapid than ordinarily takes place in health. This sudden 
 growth is generally a suspicious sign. 
 
 D. The firmness of the flesh demands attentive consideration 
 in diseases. Huxham, and many other distinguished physicians, 
 have attached due importance to this symptom, with reference to 
 the appreciation of the strength, in acute diseases. It is preserved 
 and even augmented in most inflammatory affections; and is sen- 
 sibly diminished in diseases of debility. Flaccidity of the flesh is 
 particularly noticed in the adynamic diseases. 
 
 E. The color of the skin varies according to the climate, sex, 
 age, 'habitual occupations, &c. ; there is however a tint peculiar to 
 health which is familiar to every one. There are some slight 
 affections in which the color of the skin remains unchanged ; but 
 in nearly all grave diseases, there is a perceptible change in the 
 natural color of this membrane. 
 
 The skin is pale in the cold stage of intermittent fevers ; and in 
 cases of scrofula, chlorosis, anemia and in certain species of dropsy, 
 it also has a semi-transparent appearance. It is sallow and en- 
 crusted, as it were, with an earthy substance in adynamic diseases, 
 particularly in the last stage of grave and epidemic dysenteries, 
 and often also in phthisis pulmonalis. It becomes of a livid hue 
 in persons of full habit when chilled, in scurvy, diseases of the 
 heart, and certain chronic inflammations of the intestinal canal. 
 In most of these affections the lividity is more apparent in some 
 parts than others, as about the lips, -eyes and fingers. The skin 
 is of a rosy hue in inflammatory fevers, and just previous to the 
 development of general ^eruptions, it is of a bright red color in 
 scarlatina. It presents a yellowish tint in certain bilious affec- 
 tions ; is of a dull yellow color in intermittent fevers when of a 
 certain duration, of a pale yellow or earthy appearance in cancer, 
 and of a citron or deep yellow color in jaundice ; it becomes of a 
 bluish tint in those suffering under the severest form of Asiatic 
 cholera. The same is observed in certain organic affections of the 
 heart; this singular discoloration is called cyanosis.* This has 
 generally been attributed to malformation of the heart, which 
 allows the blood, at least a portion of it, to pass from the right to 
 the left side of the heart, without first traversing the lungs. But 
 cyanosis is often independent of every such lesion, and even in the 
 cases in. which there is permanent patency of the foramen Botale, 
 it is evident that this affection cannot be referred to admixture of 
 the two fluids, as this phenomenon sometimes fails in cases where 
 the heart being unilocular, the pulmonary artery and aorta have a 
 common origin. Cyanosis seems to depend on a stagnation of 
 blood in the capillary vessels, produced by some obstacle to its 
 circulation through the lungs and heart; it is' observed in different 
 
 * Kvaiog, blue. 
 
SYMPTOMS. 79 
 
 degrees, in most organic diseases of this viscus, and particularly 
 in contraction of its orifices, in certain forms of pulmonary em- 
 physema, and general or capillary bronchitis, and lastly, in some 
 cases of rachitis, in which there is considerable deformity of the 
 thorax. In these different diseases, cyanosis is generally partial, 
 affecting usually the face, particularly the cheeks and lips, the 
 hands, principally about the nails and the pulp of the fingers, and 
 (in thejnale) the genital organs, becoming more marked in all these 
 parts when general. * We have observed a greenish tint in the 
 skin of an anemic patient who appeared to labor under an affec- 
 tion of the liver. The skin, in some individuals, accidentally 
 becomes, from the influence of some unknown cause, of a blackish 
 or brownish color. This was the case with a patient who spent 
 several months at the Hospital de la Charite, whose skin, naturally 
 white, became almost as black as that of a negro, f Several 
 similar cases have been observed and published by M. Rostan. J 
 
 In connection with these cases may be mentioned those, in 
 which the blackish or bluish color is owing to a coloring matter 
 which transudes through the skin, a very curious example of 
 which is given by Billard. || 
 
 Lastly, it is well known that the internal use of nitrate of silver, 
 when long continued, produces in the skin a bronze or slate color 
 which is indelible. It has been supposed that the light exerted a 
 great influence in its production ; but to us this does not appear a 
 satisfactory explanation. We believe that light has the prop- 
 erty of increasing the color, but is not the sole agent in its produc- 
 tion ; for this brown tint appears in parts of the body which are 
 shielded from it by clothing, as well as in those parts which are 
 exposed to its influence ; it is also found to exist in internal organs. 
 
 The skin presents, in some cases, red, black, bluish or yellow 
 spots called ecchymoses, which are caused by extravasation of 
 blood ; they are often produced by contusions, pressure and other 
 external causes ; and are sometimes owing to a cachectic state of 
 the system, as in scurvy and morbus maculosus. 
 
 Spots of a livid, brown or blackish tint, are sometimes observed 
 in the course of acute diseases, generally appearing upon the most 
 depending parts, and constituting an unfavorable sign. These 
 spots have been sometimes confounded with ecchymoses, but are 
 generally rather the result of stagnation than extravasation of 
 blood, as they momentarily disappear under pressure. Eschars 
 and excoriations are also formed upon various parts of the surface 
 of the body, and particularly those upon which the body rests, as 
 the region of the sacrum and trochanters. This phenomenon is 
 of more frequent occurrence in typhoid than in other acute affec- 
 tions, and its appearance in obscure cases is an important diag- 
 nostic sign. 
 
 * Dictionaire de Mrdecine t. ix. Cyanose, par FERRUS ; et Louis Memoires 
 anat-pathol., ou Archives de 1823. 
 
 f Bulletin de la Faculte,t. iv., p. 114. 
 
 j Idem. 
 
 || Archives de Medecine t. xxvi., p. 453. 
 
80 SYMPTOMS. 
 
 The skin may undergo modifications of more or less importance 
 in disease, which are appreciable to the touch. Instead of remain- 
 ing pliant and soft as in health, it often becomes dry and rough, 
 as in the first stages of acute affections, and in chronic diseases. 
 This roughness and dryness becomes still more marked during 
 convalescence from certain eruptive diseases, as rubeola and 
 variola. After scarlatina it is dry, smooth and shining, as if cov- 
 ered with goldbeater's skin ; this state of the skin which is more 
 apparent in the hands, enables the physician, even before otesqua- 
 mation has commenced, to decide upon the previous existence of 
 scarlatina. In Asiatic cholera, the skin in various parts of the 
 body, particularly upon the back of the hands and forearms, strik- 
 ingly resembles parchment. When pinched between the fingers 
 it forms a fold which retains its form for some minutes ; in this 
 affection also, the palmar surfaces of the fingers present inequal- 
 ities, similar to those which are produced in the same parts, after 
 their prolonged immersion in water. 
 
 F. The skin is the seat of various eruptions. These have 
 been distinguished by the terms exanthemata, vesicula, bullse 
 pustules, papulae, squamae, tubercula and maculae. Exanthemata 
 are reddish spots, with or without prominence, which vary in size, 
 form, and degree of color, and which disappear on pressure of the 
 finger. Vesicula are small elevations of the epidermis, formed by 
 a collection of serous and transparent fluid which sometimes 
 becomes opaque. Bullae differ from the latter only in their size, 
 which is not less than that of a pea, while vesicles do not 
 exceed that of a millet seed. Pustulae are small tumors filled 
 with pus, developed upon the surface of the inflamed corpus 
 mucosum. Papulae are small hard elevations which contain no 
 fluid, but are susceptible of ulceration. Squamae are small laminae 
 of epidermis generally thickened, dry, whitish and friable, which 
 surmount small elevations resembling papules. The name tuber- 
 cula has, in cutaneous pathology, been applied to small, hard, 
 circumscribed and permanent tumors, susceptible of ulceration or 
 partial suppuration. Maculae are colorations or permanent discol- 
 orations of certain portions of the skin, or of the whole cutaneous 
 envelope, unattended with general constitutional disturbance. * 
 
 G. Plicatures are impressions made upon the skin by the con- 
 tact of bedclothes, or clothing. When occurring in health, they 
 are superficial, of a rosy color, and readily disappear. In certain 
 diseases, they are deep, lasting, of a livid or bluish tint, and 
 sometimes excoriated. Vibices (vibices) are a species of plicature, 
 although in some cases they are but varieties of urticaria. 
 
 H. To these symptoms furnished by the exterior of the body, 
 
 * Abregt pratique des Maladies de la Peau, d 'apres les lemons du docteur Bietl 
 par Alph. Cazenave et Schedel. 3d edit. 
 
SYMPTOMS. 81 
 
 may be added tumors, excoriations, fissures, wounds, ulcers and 
 fistulge, which may appear on any part of the body. Tumors 
 (tumores) consist of a partial increase in the natural size of any 
 part ; they vary in form, mode of increase, consistence and in their 
 constituent parts. Some disappear under certain circumstances, and 
 particularly under the influence of pressure ; others convey to the 
 fingers a feeling of fluctuation owing to the presence of a fluid 
 which they contain ; others, as certain hsemorrhoidal tumors, are en- 
 dowed with a kind of erectility. An excoriation is the appearance 
 presented by the skin when deprived of its epidermis, and the most 
 superficial layers of the corion ; it occurs in grave diseases, and 
 commonly precedes the formation of eschars. 
 
 Fissures (fissura) is the name given to those solutions of con- 
 tinuity which occur in different parts of the body, and which 
 seem by their elongated and narrow form, to result from excessive 
 distension of the skin : they are generally owing to syphilitic virus 
 or certain eruptions ; they appear on the back of the hand, but 
 more frequently at the points of junction of the skin and mucous 
 membranes, as about the nose, lips, nipples and orifice of the 
 rectum. Ulcers (ulcera) are solutions of continuity depending 
 upon some constitutional or local disease. Of these, there are 
 numerous varieties according to the elevation of their edges, color 
 of the ulcerated surface, and phenomena which generally accom- 
 pany them. Fistulce. are accidental canals which convey away, 
 sometimes matters contained in natural canals, and sometimes the 
 product of a morbid exhalation. 
 
 $ II. The head, considered as a whole and with reference to po- 
 sition and size, furnishes some remarkable symptoms. 
 
 It is inclined laterally in convulsions, paralysis of the muscles 
 of one side, torticollis, dislocation of the vertebrae and certain 
 engorgements of the cervical glands ; it is strongly bent backward 
 in croup and in some diseases accompanied by dyspnoea ; it is in- 
 clined forward in cases of vertebral malformation. 
 
 The portion of the head corresponding to the cranium is the seat 
 of many important symptoms. Its volume is increased in congen- 
 ital hydrocephalus. The hairy scalp, when affected with erysipelas, 
 becomes aedematous, with extreme sensibility to pressure. These 
 two phenomena are particularly important, as the redness, which is 
 the principal sign of the disease in other parts of the body, is rarely 
 observed in this variety. 
 
 In idiots, the forehead is generally low. narrow and receding ; 
 or the occiput may be flattened and directed vertically towards the 
 summit of the head. In some cases the two sides of the cranium 
 are not symmetrical, one, generally in the parietal region, being 
 more or less depressed. The cranium may present tumors which 
 are developed either in one of its bones, in the surrounding integ- 
 uments, or in the substance contained within it. Its integuments 
 are the peculiar seat of certain eruptions, as crusta lactea and tinea. 
 
 The symptoms furnished by the face are extremely numerous, 
 of which the most important and difficult of exposition are those 
 
SYMPTOMS. 
 
 presented by the physiognomy. This in health is characterized, as 
 has been remarked by Chaussier, by vigor and alacrity, and its 
 expression is in harmony with surrounding objects. The various 
 shades of expression which the physiognomy is capable of present- 
 ing under morbific influence, it would be impossible to describe ; 
 it may appear sad, dejected, uneasy, terrified, indifferent or atten- 
 tive, sometimes smiling, at others menacing or wandering, without 
 there being any circumstance to account for these modifications of 
 the features, which consequently should be classed among the 
 morbid phenomena. 
 
 The natural symmetry of the two sides of the face is destroyed 
 in cases of complete hemiplegia. and in paralysis of the nerves of the 
 seventh pair. The paralyzed side loses all expression, while the 
 natural appearance of the sound side is retained ; there is manifest 
 deviation of the mouth, its commissures being drawn down and 
 towards the median line ; the cheek is flaccid, and the eyelids are 
 no longer capable of covering the eye ; the eyebrow is depressed, 
 and the forehead free from its natural wrinkles. All these differ- 
 ences become still more marked, when the muscles of the sound 
 side are strongly contracted, particularly in the effort of laughing. 
 If the disease be of long standing, the nose becomes affected. 
 
 Among the numerous alterations of the countenance effected by 
 disease, some have received distinctive appellations ; as stupor 
 (fades stupida), the injected, pinched, and hippocratic countenance. 
 It has also been observed that diseases of the brain, chest, and 
 abdomen so modify the countenance as to enable the physician, in 
 many instances, to determine from its inspection the seat of the 
 disease. 
 
 Stupor is distinguished by a want of expression of the features 
 generally, and particularly the eyes; the patient appears uncon- 
 scious of what is going on around him, and incapable of reflection, 
 as if in a state of intoxication. This expression of face is peculiar 
 to typhoid disease. 
 
 The fades vultuosa is characterized by fulness and redness of the 
 part, prominence of the eyes, injection of the conjunctives, disten- 
 sion of the eyelids and lips, and fulness of all the features. This 
 is particularly observed in hypertrophy of the heart, and in some 
 cases of cerebral congestion. 
 
 The pinched countenance, which belongs to acute peritonitis, pre- 
 sents the opposite characteristics ; the face appears diminished in 
 size, of a pale or livid hue, its muscles contracted, and the features 
 drawn upward or towards the median line. Exposure to severe 
 cold produces analogous effects in healthy persons. 
 
 The hippocratic countenance has been so called from Hippo- 
 crates, who first pointed out its peculiar characteristics. It is 
 observable in patients suffering from chronic disease, a few days 
 before death, and in some cases of prolonged acute disease. Its 
 principal features are the pinched nose, sunken eyes, hollow tem- 
 ples, cold and retracted ears, dryness and tensity of the skin of the 
 forehead, livid complexion, and cold and relaxed lips ; such are 
 
SYMPTOMS. 83 
 
 the sure harbingers of death, unless there be some manifest cause, 
 as excessive watchfulness, obstinate diarrhoea, or prolonged absti- 
 nence, to account for such an appearance. 
 
 Diseases of the head are far from impressing upon the physiogno- 
 my uniform characteristics ; the same is true of thoracic and ab- 
 dominal diseases. There are, however, numerous affections of the 
 organs contained within these cavities, in which the appearance of 
 the countenance is characteristic. The appearance of sleep, con- 
 vulsions of the facial muscles, lateral paralysis, an expression of 
 fury or joy, are indicative of a primary, or secondary lesion of the 
 brain ; fulness of the face or neck, together with a whistling 
 sound in the larynx, or convulsive efforts at deglutition or expec- 
 toration, clearly denote some form of angina. There is a peculiar 
 alteration in the face noticeable in diseases of the heart, and in 
 phthisis pulmonalis, though in the latter it is less apparent. The 
 pinched face, as has been remarked, is peculiar to peritonitis, and 
 most abdominal diseases of an organic nature are discoverable by 
 their effect upon the countenance of the patient. 
 
 M. Jadelot thought he observed in children, a constant corres- 
 pondence, between diseases of the head, chest, and abdomen, and 
 certain alterations in the physiognomy, differing from those just 
 mentioned. The following, appeared in a work published under 
 the supervision of this physician.* In the face of the child three 
 principal features are observable ; the first, extending from the 
 external angle of the orbit of the eye, to a little below the promi- 
 nence formed by the malar bone ; this may be called the ocitlo- 
 zygomatic ; the second commences at the superior part of the 
 ala nasi, and embraces in a semicircle, more or less complete, the 
 external line of the commissure of the lips ; this is the nasal feature 
 to which another sometimes extends, from the middle of the cheek 
 called genal ; the last commences at the angle of the lips, and 
 terminates at the lower part of the face, which may be called the 
 labial feature. The first indicates affections of the brain and ner- 
 vous system ; the second and its accessory point out those of the 
 abdominal viscera; the third appertains to diseases of the heart 
 and respiratory organs. f 
 
 The face furnishes still other symptoms relative to changes in 
 its motions, size, color, and the eruptions of which it is the seat. 
 
 Convulsive movements of the face are observed in incipient teta- 
 nus, permanent immobility in some nervous diseases, and transient 
 tremors in typhus fever ; in some cases of cerebral compression, the 
 paralysis is confined to the muscles of this region. 
 
 The face rarely becomes increased or diminished in volume, 
 without the occurrence of a similar change in other parts of the 
 
 * Maladies des Enfans cT Underwood, publiees par M. de Salles, avec des notes 
 de M Jadelot. 
 
 f We refrain from all conclusions upon the value of these signs ; first, because 
 our observations upon this point have been thus far too limited to enable us us to 
 form an opinion ; and second, because the result of these observations would not 
 conform to the opinion of M. Jadelot. 
 
84 SYMPTOMS. 
 
 body ; partial turgescence of this region, however, is common at 
 the commencement of eruptive fevers, and sometimes just previous 
 to nasal or cerebral haemorrhage. It may be also remarked that 
 in those cases in which increase or diminution in volume of the 
 whole body occurs, these changes are perceptible in the face before 
 becoming so in other parts. 
 
 In disease, the same changes occur in the color of the face as in 
 that of other parts; it also undergoes modifications which do not 
 extend to the rest of the cutaneous surface. Redness of the face is 
 a very frequent symptom ; it may affect its whole surface or be 
 confined to a particular part. The face is of a bright red color in 
 the paroxysms of acute diseases, of a deep and livid red in those 
 of hysteria and epilepsy, and the difficulty of distinguishing 
 between the two latter affections is partly owing to this circum- 
 stance ; in hysteria, however, the face does not present the same 
 hideous aspect as in epilepsy, and this, according to M. Landre 
 Beauvais, is perhaps the most important sign in the diagnoses of 
 these two affections. The face is occasionally the seat of a tran- 
 sient redness, commonly known as feux au visage ; this is partic- 
 ularly observable in females suffering from menstrual irregularity, 
 or at the critical age. The seat of the redness during the febrile 
 paroxysm and in chronic diseases, is the malar region. It is some- 
 times confined to one cheek, a phenomenon formerly considered as 
 connected with an acute or chronic affection of the corresponding 
 lung; but it generally depends upon the position of the patient 
 when in bed, the cheek which rests upon the pillow being redder 
 than that of the opposite side. A bright and circumscribed redness 
 in the malar regions, together with paleness of the rest of the face, 
 is a frequent symptom in tubercular affections. The yellowness 
 which characterizes jaundice is generally perceptible in the face, 
 and particularly in the sclerotics, before appearing elsewhere ; it 
 also remains apparent in these, after its entire disappearance in 
 other parts of the body. In some bilious affections, the yellow 
 tint is confined to the labial commissures and alae nasi. 
 
 There are certain eruptions which are peculiar to the face; 
 during the period of youth the forehead often becomes the seat of 
 a papular eruption which commonly disappears before the age of 
 twenty-five. In adults, towards the decline of ephemeral fevers 
 and slight acute inflammatory affections, the lips become affected 
 with an herpetic eruption. Every part of the face furnishes 
 numerous symptoms, which we shall briefly enumerate. 
 
 In health, the eyes are moderately prominent, moist, brilliant, 
 moving with facility, and both directed to the same object; the 
 white portion of the eye is smooth, unstriated, and of its natural 
 color ; the pupils of both, dilate and contract promptly and equally ; 
 the eyelids are thin, moveable, equally separated during the 
 waking state, and entirely cover the eye during sleep; the eye- 
 brows are slightly arched. Under the influence of disease, the 
 globe of the eye and the parts which protect it, present remarka- 
 ble changes. 
 
SYMPTOMS. 85 
 
 The expression of the eyes often corresponds with that of the rest 
 of the face: it may be mild, suppliant, threatening, haggard, orter-' 
 rifled ; but sometimes in the disturbance which accompanies malig- 
 nant fevers and the cerebral phlegmasise, their expression is in 
 contrast with that of the physiognomy. 
 
 The changes observed in the movements of the eye are generally 
 connected with some primary or secondary lesion of the brain. 
 The eyes are fixed in catalepsy, and in the ecstasy of melancho- 
 lies ; their motions are convulsive in the hydrocephalus of children : 
 strabismus or divergence of the optic axes, when occurring acci- 
 dentally, is almost always the effect of cerebral disease. 
 
 There is another very remarkable phenomenon, resembling 
 ordinary strabismus, but differing from it in some respects ; we 
 refer to the isolated movement of one eye, the other remaining 
 totally immovable ; we witnessed the repeated occurrence of this 
 phenomenon in a case of hemiplegia in a child from ten to twelve 
 years of age, succeeding epileptiform convulsions which were 
 probably connected with some organic lesion of the brain. This 
 symptom, together with a state nearly comatose, had excited fears 
 which were not however realized. 
 
 The volume of the eye appears increased in some inflammatory 
 fevers, and particularly in cases where an obstacle exists to the flow 
 of venous blood in the vessels of the neck, as in severe anginose 
 affections and apoplexy by strangulation ; the prominence of the 
 eye is lessened, on the contrary, when there is diminution of the 
 cellular substance at the bottom of the orbits. The unequal sepa- 
 ration of the eyelids may cause an apparent difference in the 
 prominence of the two eyes ; but in all these cases their real size 
 remains about the same. The size of this organ becomes actually 
 increased in internal ophthalmia and hydrophthalmia ; it is dimin- 
 ished in the atrophy which follows various diseases of this organ, 
 in wounds and after certain operations. It becomes very promi- 
 nent, without increase of size, when a tumor is developed at the 
 bottom of the orbit, or within the cranium, which presses it out 
 (exophthalmid). Inflammation of the cellular tissue of the orbit 
 produces a similar effect. The color of the eye corresponds with 
 that of the rest of the face ; but these alterations in color are almost 
 always confined to the sclerotic and its covering membrane, the 
 conjunctiva. Dulness of the cornea is not unfrequently observed 
 in acute and chronic diseases a few hours before death. 
 
 The cornea sometimes presents spots of different forms, phlyc- 
 taense, liberations, purulent collections, &c., in the diseases wnich 
 are peculiar to it. It may become prominent, the effect of which 
 is to increase the refraction of the luminous rays, producing what 
 is called myopia ; in other cases it becomes flattened, causing a 
 diminution in the refracting power of the eye, and constituting 
 presbyopia. 
 
 The motions of the pupil may become variously deranged. This 
 aperture is sometimes considerably dilated, although exposed to a 
 strong light ; or it may contract slightly and slowly, as in coma- 
 
86 SYMPTOMS. 
 
 tose affections. In other cases, it is contracted, as in internal 
 ophthalmia and meningitis; it is almost always immovable in 
 amaurosis, and sometimes becomes of unequal size in the two 
 eyes, either from a difference in their natural contractility, or from 
 compression of one side of the brain; its form becomes irregular 
 in diseases of the iris. According to M. Jadelot, this irregularity 
 also occurs in some verminous diseases. 
 
 The crystalline with its capsule become opaque in cataract ; the 
 aqueous and vitreous humors become changed in color in hypo- 
 pyon and glaucoma. 
 
 Professor Sanson has recently pointed out a phenomenon, which 
 will aid in the diagnosis of many diseases of the eye. If a light 
 be placed before this organ, no part of which has been rendered 
 opaque by disease, and the pupil of which is dilated either by 
 the action of belladonna or in consequence of amaurosis, three 
 images of the flame will be distinctly and constantly visible, 
 situated one behind the other ; of these, two are upright and the 
 other reversed. The most anterior, which is also the most appa- 
 rent, is upright ; that situated posteriorly, is the palest and is also 
 upright; the third, which is situated between the other two, is 
 reversed. The latter is the smallest of the three, being less appa- 
 rent than the anterior, but brighter than the posterior, image. 
 These three images fail to appear if the cornea be opaque. If the 
 opacity affect the anterior surface of the capsule only, the two 
 posterior images are not visible ; if confined to its posterior surface, 
 the reversed image will alone be wanting. The existence of the 
 three images is a certain sign that the crystalline and its capsule 
 are perfectly transparent. This new method of exploration in 
 diseases of the eye, enables us to distinguish with certainty, in 
 some obscure cases, between amaurosis and black cataract, glau- 
 coma and the ordinary form of cataract. * 
 
 The parts comprised by Haller in the term, tutamina oculi, 
 present in disease numerous alterations. 
 
 Rapid and repeated motions of the eyelids, or perpetual nicta- 
 tion (hippus) is observed in some cases of mania and idiocy; in 
 other cases, as in adynamic fevers, their motions are extremely 
 slow, and occur at long intervals. In cephalalgia they have a 
 feeling of weight, as some patients have expressed it ; they are con- 
 stantly closed in comatose affections, and in certain cases of 
 ophthalmia their closure is accompanied with a violent contraction 
 of the muscles ; they remain partially open during sleep, in some 
 persons ; in others, during the waking state, they are unequally 
 separated on the two sides, as is sometimes observed in hemicrania, 
 hemiplegia, and certain acute cerebral diseases. In partial paraly- 
 sis, produced by a lesion of the nerve of the seventh pair, closure 
 
 * L" 1 Experience, No. 1, 1837, t. 1, p. 1, M. M. Bardinot et Pigne, pupils of 
 Sanson, have shown by a series of careful experiments performed in the presence 
 of the professor, that the anterior image is produced by the cornea, the middle 
 one is reflected by the posterior segment of the capsule, and the posterior one 
 by its anterior segment. 
 
SYMPTOMS. 87 
 
 of the eyelids is impossible, in consequence of a partial loss of 
 contractility of the orbicularis muscle. The volume of the eyelids 
 with that of the neighboring parts, becomes increased in erysipelas 
 of the face and in oedema ; the swelling of this part is generally 
 more considerable on account of the laxity of the cellular tissue, of 
 which its structure is composed ; they sometimes become suddenly 
 emphysematous, from contusion at the root of the nose, or after 
 violent efforts to blow the nose. In both cases it is owing to a 
 rupture of the osseous parts which form the roof of the nose. The 
 color of the eyelids generally corresponds to that of the face. Their 
 free edges become red and swollen in chronic ophthalmia; they 
 become inverted and everted in some diseases of which they are 
 the seat. Their adherent borders, particularly of the lower lid, are 
 often marked by a bluish line : the eyes are then said to be cernes. 
 This phenomenon occurs in many females during menstruation. 
 It may however be produced in both sexes by watchfulness, fa- 
 tigue, excessive coitus, and excessive evacuations of any kind. 
 
 The conjunctiva becomes more moist and of a deeper red in erup- 
 tive fevers, typhus, and particularly in ophthalmia. It is more 
 or less swollen in inflammation, and often forms a sort of border 
 around the cornea (chemosis). Its natural humidity becomes some- 
 times diminished : the eyes are then said to be dry. In some cases 
 the mucus which it exhales, forms whitish striae on the globe of 
 the eye ; in grave diseases the patient becomes unconscious, and 
 neglects to clear it away. 
 
 The caruncula lachrymalis furnishes few important symptoms ; 
 it is of a bright red color in inflammatory diseases, and becomes 
 pale in chronic affections. Paleness of this little organ is by some 
 authors considered as a never failing symptom in dropsy ; but this 
 is incorrect. Hairs are sometimes developed on its surface, which 
 by contact irritate the eye, and produce obstinate ophthalmia. 
 
 The eyelashes become sometimes covered with dust, and more 
 often with scales, in affections of the eye and in severe acute dis- 
 eases. Their inversion produces obstinate ophthalmia, and their 
 fall is often the result of ulceration of the free edges of the eyelids. 
 Their length when considerable has, by some physicians, been 
 thought to belong to the tubercular constitution. 
 
 The lachrymal sac becomes swollen, red and ulcerated, when 
 any obstacle exists to the passage of the tears into the nasal canal. 
 A flowing of the tears over the cheek is often produced by the 
 same cause. This latter symptom, called epiphora, may also be 
 owing to closure of the puncta and lachrymal canals, and also to 
 paralysis of the lids or eversion of the lower lid. 
 
 The eyebrows are raised in the furious delirium of fevers and 
 paroxysms of mania, and depressed in cases of melancholy and 
 violent cephalalgia. They are alternately elevated and depressed 
 during inspiration and expiration, in certain diseases accompanied 
 with great difficulty of breathing. These alternate movements 
 are sometimes confined to one brow, the other remaining immov- 
 able. In paralysis of the facial nerve, the eyebrow of the same 
 
88 SYMPTOMS. 
 
 side is depressed, and can no longer be drawn towards that of the 
 opposite side. 
 
 The forehead in health is ordinarily smooth and serene. It be- 
 comes wrinkled in painful and convulsive, and is the seat of a 
 papular eruption and exostosis in syphilitic, aifections. 
 
 The temples in their natural state are full and smooth ; they 
 become concave towards the termination of acute and chronic dis- 
 eases. The pulsations of the superficial arteries of this region are 
 more manifest in diseases attended with an increased flow of blood 
 to the head. 
 
 The cheeks, firm and round in health, and exhibiting more color 
 in the malar regions, may become in disease agitated with convul- 
 sive motions, or paralyzed ; in the latter case, they are flabby and 
 become distended with food in mastication, and with air if the 
 patient attempt to blow out a light. One or both cheeks may be 
 increased in bulk in odontalgia and certain affections of the max- 
 illary sinus. They sometimes become the seat of red and obstinate 
 pustules known by the name of guff a rosea, which some physi- 
 cians have supposed to be connected with a peculiar affection of 
 the liver. 
 
 The nose, which contributes but little to the expression of the 
 face, furnishes few symptoms. It has been sometimes observed to 
 deviate to the right or left before a convulsive attack, and to 
 become red before epistaxis. It is swollen and shining at the com- 
 mencement of erysipelas which has not yet extended to the rest of 
 the face. It becomes thin towards the close of acute and chronic 
 diseases. Its extremity becomes livid and gangrenous in certain 
 adynamic fevers, or in consequence of severe cold. 
 
 The nares also deserve attention ; their dilation is rapid and 
 convulsive at the moment of respiration in affections accompanied 
 with considerable difficulty of breathing ; but in cases of extreme 
 debility and emaciation they are contracted, as is observed in the 
 hippocratic countenance. In paralysis of the facial nerve the naris 
 of the affected side is immovable ; and not only is it incapable of 
 dilatation during the act of inspiration, but is often depressed. The 
 nares are sometimes filled with a blackish mucus in the course 
 of grave fevers ; they become the seat of a scaly eruption towards 
 the close of some light diseases, and of fissures in scrofulous chil- 
 dren. Tumors developed in the nasal fossas may be seen in the 
 interior of the nares, and in some cases they protrude beyond these 
 openings. 
 
 The lips in healthy persons are free and supple in their motions ; 
 when at rest, they are closed, firm and sustained by the action of 
 their muscles ; their borders are smooth, rounded, and of a rose 
 color. In disease, they present important alterations in respect to 
 their position, motions, volume, color, state of dryness or humidity, 
 and the eruptions of which they are the seat. 
 
 They are pendent in adynamic fevers, and in the agony of vari- 
 ous diseases ; they are widely separated from each other in forward 
 dislocation of the lower jaw ; compressed and contracted in violent 
 
SYMPTOMS. 89 
 
 pain ; trembling, in some nervous affections : they are suddenly 
 thrust forward and separated at each expiration in certain cerebral 
 affections ; this is said to resemble a person in the act of smoking a 
 pipe. The lips are drawn to the right or left, when one side of 
 the face is affected with paralysis, or convulsion ; in the latter 
 case the symptom is called a cynic spasm (spasmus cynicus); * 
 when the two commissures are drawn away from each other, it is 
 called the risus sardonicus.-\ It has been said that the upper lip 
 is thick in scrofulous persons, but to this there are numerous ex- 
 ceptions. Swelling of both lips precedes and accompanies the 
 eruptions which sometimes appear at the decline of certain acute 
 affections. 
 
 Their color is of a vermilion red in inflammatory diseases, pale 
 in anemia and chlorosis, livid in the cold stage of intermittent fevers 
 and in organic lesions of the heart. 
 
 The lips are dry, ordinarily smooth, sometimes cracked, in grave 
 fevers ; they may also become covered with a dry and blackish 
 coat, similar to that which appears upon the teeth and tongue. 
 This dryness and these deposits of buccal mucus are sometimes 
 observed in the lightest affections, and even in healthy persons who 
 sleep with the mouth open. The necessity of sleeping with the 
 mouth open is connected with an anatomical disposition which we 
 do not recollect to have seen pointed out. It consists in a malfor- 
 mation of the roof of the mouth, which being too much arched 
 towards the nasal fossae and too narrow between the dental arches, 
 produces, as the inevitable result, narrowness and shortness of 
 the nasal fossae, or rather a drawing up of the upper lip. All 
 those persons, in whom the upper lip does not cover the teeth, 
 not extending below the alveoli, sleep necessarily with the mouth 
 open. 
 
 The chin participates in the changes which the face undergoes ; 
 there are few which are peculiar to it. It deviates from the 
 median line of the body in dislocation of one side of the jaw, and is 
 often deformed in fracture of this bone. It sometimes becomes the 
 seat of an herpetic eruption, known by the name mentagra. It 
 presents in the agony, at the moment of the last inspiration, a con- 
 vulsive falling which immediately precedes death. 
 
 The parotid regions become, in some affections, the seat of a 
 remarkable swelling, affecting the glands themselves or the cellu- 
 lar substance in which they are enveloped. This swelling, which 
 occurs in typhus and many other acute diseases, either at their 
 commencement or termination, demands the careful attention of the 
 physician. To this symptom the term parotis has been applied. 
 It may be confined to both sides, or extend to both at once, or suc- 
 cessively ; it may be hardly perceptible or very considerable, &c. 
 
 * JCvtav, xfroc, a dog. 
 
 f It has been said that this name was given to the convulsive laugh, from its 
 having been sometimes produced by the use of a plant [ranunculus] which grows 
 in Sardinia, ab herba Sardonia. 
 
 8* 
 
90 SYMPTOMS. 
 
 The ears are livid and cold during the first stage of intermittent 
 fevers ; red and burning in the paroxysm of nearly all febrile 
 affections, and particularly those accompanied with a determination 
 of blood to the head. The meatus externus may become the seat 
 of various discharges, as mucus, pus, blood, and in some cases frag- 
 ments of bone. In some affections, the air which penetrates into 
 the cavity of the tympanum through the eustachian tube, may 
 issue from the meatus with sufficient force to agitate a light placed 
 before it, or to produce a gurgling sound as it mixes with the pus 
 which may be contained in the part. This canal may be con- 
 tracted, or obliterated by vegetations or polypi, tumefaction of its 
 lining membrane, the accumulation and desiccation of the matters 
 it secretes, pressure exerted upon it by an abscess formed in its 
 substance, or tumor developed near it. The mastoid process may 
 become unusually prominent in consequence of disease of the bone ; 
 atrophy of this bone has been sometimes noticed, following caries. 
 
 The loss of the hair, which Hippocrates supposed to be a symp- 
 tom of phthisis, rarely accompanies this disease. It is of frequent 
 occurrence in syphilitic affections, affecting the beard and other por- 
 tions of the pilous system ; the hair is after a certain time partially 
 restored. Where this is not the case, the phenomenon is desig- 
 nated by the term alopecia,* a rare symptom, the causes of which 
 are unknown. The fall of hair is not unfrequently noticed during 
 convalescence from typhus and eruptive fevers. The hair turns 
 white in some instances, under the influence of a severe moral 
 shock. It becomes of a greenish hue in those who work in copper, 
 and red in those employed in the preparation of minium. 
 
 In tinea, the hair falls off, and is replaced by wooly tufts scat- 
 tered over the scalp. In plica polonica, the inextricable interlacing 
 of the hair is the principal symptom of this singular disease. 
 
 The neck becomes increased in bulk in some anginose affections, 
 and in goitre ; it is diminished in size, with other parts, in general 
 emaciation, when it appears lengthened. The distension of the 
 superficial veins of the neck and external jugulars, the undulatory 
 reflux of the blood in these vessels, from the clavicle where it is 
 very apparent, to the neighborhood of the jaw where it is no 
 longer perceptible, has been pointed out as alone existing in aneu- 
 rism of the right cavities of the heart ; but more accurate obser- 
 vations have shown that it occurs as well in affections of the left 
 as right side of the heart, and particularly in contraction of its 
 orifices. Pulsations of the carotids are frequently observed in 
 active aneurism of the left ventricle ; this symptom also sometimes 
 precedes delirium in acute diseases. Enlargement of the lymphatic 
 glands is one of the most important symptoms presented by the cer- 
 vical region. It accompanies or precedes acute and chronic 
 eruptions of the face and scalp. Sudden swelling of the glands, 
 accompanied by febrile symptoms, is an almost certain sign of ap- 
 
 * Alunrfe, a fox. This animal is said to be subject, in old age. to the loss of 
 its hair. 
 
SYMPTOMS. 91 
 
 preaching erysipelas of the face. That which comes on slowly is 
 often owing to an affection of one of the neighboring teeth. 
 
 The chest, which in the healthy man is of a size proportionate to 
 his stature and strength, is narrow and flat in pulmonary phthisis, 
 and prominent in pulmonary emphysema. In rachitis, it presents 
 various and numerous malformations to which we can here but 
 allude, as they belong rather to the history of that disease, than to 
 general pathology. The integuments covering the chest become 
 very thin in chronic diseases ; in the last stages of phthisis they 
 form over the whole, or but a part of its extent, deep depressions 
 between the ribs. In empyema, on the contrary, the intercostal 
 spaces are often more prominent than the ribs themselves ; this pe- 
 culiar disposition is only perceptible where the integuments are very 
 thin. There are certain cases in which one side of the chest is more 
 voluminous than the other; this morbid disposition may depend on 
 one of two opposite causes, either enlargement of one, or contraction 
 of the other side; so that the disease is sometimes seated in the 
 larger, and sometimes in the smaller side. Enlargement is owing 
 to dilatation of the pulmonary vesicles, or an accumulation of fluid, 
 and sometimes of air, in the cavity of the pleura. Contraction 
 always follows effusion, and consequently enlargement of the same 
 side of the chest : the lung which has been for a time compressed, 
 regains its dimensions, if at all, very slowly, and its parietes in ac- 
 commodating themselves to it, lose part of their fulness. A more 
 circumscribed portion of the chest may present a fulness or partial 
 depression : the former is sometimes observed, though often with 
 difficulty, in pleuritic effusion confined to the base of one side of 
 the chest, and more manifestly, in cases of arterial aneurism de- 
 veloped under the sternum or ribs, in pericarditis with effusion, in 
 hypertrophy of the heart and in some cases of pulmonary emphy- 
 sema. But to avoid error, it should be recollected that, according 
 to the researches of M. Woillez,* the right side of the chest is 
 normally larger than the left, the difference varying from one half 
 a centimetre to three centimetres [about one inch] ; that in left- 
 handed persons there is often observed a prominence upon the left 
 side anteriorly, which seems to depend upon increased thickness 
 of the soft parts ; that there are also persons whose chests are nat- 
 urally prominent on one side, while they are depressed upon the 
 other. The disposition is the reverse, in such cases, upon the 
 opposite side. Partial contraction is particularly observable beneath 
 the clavicles, in certain forms of tubercular phthisis, and more 
 rarely at the base of the thorax, after the absorption of pleuritic 
 effusions confined to that region. 
 
 The mammae, furnish certain symptoms which will be consid- 
 ered elsewhere. 
 
 The shoulders are raised and prominent in phthisical patients; 
 one is lower than the other in lateral curvature of the trunk, 
 pointed out by Laennec in those suffering or convalescent from 
 
 * Recherches sur I'insp. et la mensur. de la poitrine. 8vo. Paris, 1838. 
 
92 SYMPTOMS. 
 
 considerable and prolonged pleuritic effusion. Prominence of one 
 of the dorsal vertebrae is the most important symptom in Potts' 
 disease. In spina bifida, a soft, fluctuating, and often translucent 
 tumor in the vertebral region is distinguishable by the eye, and 
 the absence of one or more spinous processes can be felt. A depres- 
 sion at the lower extremity of the sternum, in some workmen, is 
 rather owing to habitual pressure on the part by the instruments 
 they employ, than to disease. This is most frequently observed in 
 shoemakers. 
 
 The exploration of the chest, by means of percussion and 
 auscultation, reveals many other very important phenomena, which 
 will be considered in the articles on the symptoms furnished by the 
 respiration and circulation, and in the chapter on diagnosis. 
 
 The abdomen, in health, varies in size in different individuals, 
 and is moderately resonant; it is firm without hardness, and 
 pliant without softness. 
 
 The skin of the abdomen is generally smooth and of a white color. 
 In women who have been once pregnant, and particularly those 
 who have borne many children, whitish or bluish wrinkles are ob- 
 served extending across the hypogastric region, to which the term 
 vergetures has been applied, and which are certain indices of pre- 
 vious pregnancy ; but it should be recollected that this sign fails in 
 some women who have borne children, and sometimes occurs in 
 persons of both sexes, in whom distension of the abdomen has 
 previously taken place, either from a considerable accumulation of 
 serum or fat. It is chiefly upon the surface of the abdomen that 
 the rose-colored lenticular spots, peculiar to typhoid and typhus 
 fevers, appear. The subcutaneous veins, in some cases of ascites, 
 become considerably enlarged, forming a true varicose network, 
 which will be hereafter considered (venous circulation). There 
 often exists in pregnant women, on the median line, extending 
 from the umbilicus to the pubis, a brownish coloration, owing to a 
 superabundant secretion of pigmentum. The lower half of the 
 linea alba sometimes presents below the umbilicus a very narrow 
 opening, not easily distinguished, in which a small portion of the 
 epiploon may become engaged. This affection has often given rise 
 to obstinate vomiting and considerable emaciation, which has led 
 to the belief in the existence of stomachal cancer, and which has 
 been cured by the application of a bandage. It is therefore of the 
 greatest importance in patients attacked with vomiting, to exam- 
 ine with particular care the whole extent of the linea alba, as well 
 as all other parts of the abdominal surface where hernia is liable 
 to occur. Lastly, after repeated parturition, the linea alba some- 
 times becomes thin and ruptured, allowing the intestines to form 
 considerable tumors; and in subsequent pregnancies, the womb 
 has been known to fall forward in front of the pubis, forming an 
 enormous protuberance. 
 
 The volume of the abdomen may be increased or diminished 
 under the influence of disease; its increase may be partial or 
 general. In the latter case, it is almost always owing to the 
 
SYMPTOMS. 93 
 
 presence of gas in the digestive canal, some fluid in the cavity 
 of the peritoneum, or an abundant exhalation of fat within the 
 cavity, and in the parietes of the abdomen. A moderate accumu- 
 lation of air in the intestines increases the bulk and resonance of 
 the abdomen : this is termed meteorism (meteorismus).* If the 
 accumulation be more abundant with distension of the abdomen, 
 it is called tympanites ;f these two words express nearly the same 
 thing : the latter is, however, more generally employed in chronic 
 diseases, and the former in acute affections, and particularly grave 
 fevers. J 
 
 The abdomen is frequently the seat of partial swellings. These 
 occur in the hypochondriac regions in diseases of the liver and 
 spleen, and in the epigastrium in hysteria. The bladder when 
 distended with urine, forms an ovoid tumor in the hypogastrium, 
 which sometimes extends to the umbilicus; the intestines, stomach, 
 uterus, ovaries, and mesentric glands, may also form, in the dif- 
 ferent regions of the abdomen, tumors more or less distinct to 
 the touch and sometimes to the eye : so with the cysts which are 
 occasionally developed within this cavity, &c. These various tu- 
 mors are, in some cases, very apparent, in others, they are alone 
 evident from an obscure and deep seated resistance which they 
 present. 
 
 Diminution in the volume of the abdomen may be general or 
 partial. 
 
 Its volume is diminished in many chronic diseases, in conse- 
 quence of the general emaciation. It becomes suddenly dimin- 
 ished also in some acute affections, as in violent colic, and par- 
 ticularly that produced by lead. In adynamic fevers and perito- 
 nitis, the abdomen often falls away a short time before death : a 
 similar phenomenon is sometimes observed in patients who die 
 dropsical. The abdomen becomes alternately diminished and 
 increased in size in some affections, and particularly in hysteria 
 and schirrus of the large intestines. The most important sign of 
 the latter affection is prolonged constipation with progressive 
 enlargement of the abdomen, alternating with abundant stools, 
 which are followed by immediate sinking of the abdominal pari- 
 etes. In hysteria, on the contrary, enlargement of the abdomen 
 comes on rapidly, in consequence of gaseous exhalation, often 
 disappearing as rapidly, without the appearance of any evacua- 
 tion. Partial diminution of the abdomen is more rarely observed 
 than circumscribed swelling: it is relative rather than absolute, 
 and commonly succeeds the latter : such is that observed in the 
 epigastrium, in some nervous affections, in the hypogastrium after 
 the excretion of urine which has been for a long time retained in 
 the hypochondriac regions, on a favorable termination of engorge- 
 ment of the liver or spleen, &c. A partial diminution may, how- 
 ever, take place in some very rare cases ; as depression ot the 
 
 , from utTEwQog, elevated. 
 , a drum. 
 FRANCE., t. vii., p. 55. 
 
94 SYMPTOMS. 
 
 epigastrium and left side from displacement of the spleen or 
 stomach. Many examples of this are cited by Morgagni. M. 
 Rayer has recently shown that displacement of a kidney may also 
 give rise to these phenomena. In a case, in which the kidneys 
 appeared placed transversely across the vertebral column, the lum- 
 bar region was depressed and flattened like the two sides of a 
 saddle.* It is necessary, in order to distinguish this appearance, 
 that the patient be placed on all fours. 
 
 The form of the abdomen is generally in relation to its 
 volume; both increasing and diminishing simultaneously. The 
 abdomen may, however, become very hard, although diminished 
 in volume, as in metallic colic. An unusual resistance felt over 
 the whole region is, in some cases, the only symptom of chronic 
 peritonitis. The abdomen is soft in some cases of dropsy, when 
 the quantity of fluid has been lessened by absorption or punc- 
 ture. 
 
 The form of the abdomen varies according to the disease that 
 produces its increase ; in ascites, its dilatation takes place particu- 
 larly from before backward, and the umbilicus, raised by the fluid 
 that distends it, sometimes forms a small, pellucid tumor, which 
 rests upon the enormous swelling presented by the abdomen. In 
 03dematous swelling of the abdominal parietes, on the contrary, 
 the transverse diameter is the greatest, and the flanks acquire an 
 extraordinary width. In both cases the abdomen, to use the 
 vulgar expression, falls to that side on which the patient lies ; its 
 form, in other respects, is regular. It is otherwise in the cases in 
 which the increased size is owing to an encysted tumor, or to an 
 organic affection of any viscus : in such cases, unless there be 
 accompanying ascites, the abdomen presents a remarkable irregu- 
 larity of form, particularly in the first stage of the disease. 
 
 The abdomen presents at various points, and particularly at the 
 umbilicus, inguinal ring, crural arch, and on a level with the 
 obturator foramina, tumors which appear and disappear, or at least 
 become increased and diminished under certain circumstances, 
 and which are formed of some one of the parts naturally contained 
 within the cavity of the abdomen, protruding through one of 
 the apertures alluded to. These tumors, which are called hernice, 
 may occur in the thorax and head ; but they are as rare in those 
 parts, as they are common in the abdomen. The inguinal regions 
 are also the seat of many important phenomena, such as the 
 buboes which occur in syphilis and the plague. The abscesses 
 formed in the iliac regions and in front of the vertebral column, 
 make their appearance in these regions. 
 
 The organs of generation furnish several important phenom- 
 ena : the primary symptoms of syphilis almost always occur in 
 these parts, and it is here that discharges, ulcers, vegetations fre- 
 quently manifest themselves. 
 
 The penis is increased beyond its natural size in children af- 
 
 * RAYER. Malad. des Reins. Obs. xxxiii., t. 1, p. 407. 
 
SYMPTOMS. 95 
 
 fected with stone, in those addicted to masturbation, and in adults 
 who have indulged immoderately in the pleasures of love. It is, 
 in most diseases, in a state of permanent flaccidity ; it disappears 
 beneath the integuments in some affections of the scrotum and 
 tunica vaginalis. In other diseases, as blenorrhagia and satyriasis, 
 it is, on the contrary, continually in a state of erection. The 
 testicles are retracted strongly against the inguinal ring in cases of 
 nephritic calculus, ilio-scrotal neuralgia, and violent colic; this 
 retraction is, in some cases, attended with very severe local pain. 
 The epidydimis and spermatic cord are the common seat of the 
 inflammation which is said to be the consequence of repelled go- 
 norrhoea, and which was for a long time supposed to be an affection 
 of the testicle itself, which is but rarely and secondarily affected. 
 The tunica vaginalis, distended with the fluid it exhales, is the 
 ordinary seat of hydrocele which sometimes also affects the sper- 
 matic cord. The scrotum is considerably swollen in anasarca, 
 voluminous inguinal hernise, urinal abscesses, &c. 
 
 The labia 'major a, in the female, often become enormously^ swol- 
 len in dropsy ; they are sometimes, as are the testicles in the male, 
 the seat of violent inflammation, succeeding and alternating with 
 parotiditis. The vulva is the seat of ulcerations and vegetations 
 of a syphilitic origin, and not unfrequently of lypomatous and 
 steatomatous tumors. The labia majora may also, together with 
 the clitoris, become hypertrophied ; the various malformations 
 which characterize the female hermaphrodite and the tumors which 
 take their rise in the uterus, here make their appearance. Lastly, 
 there is sometimes observed, during pregnancy, a varicose develop- 
 ment of veins, which is often but precursory to a much more 
 serious disease, the trombus or sanguineous tumor, an affection 
 which is peculiar to the period of labor. 
 
 The limbs also furnish to symptomatology numerous phenomena. 
 
 They are immovable and pliant in paralysis ; their immobility 
 is accompanied with stiffness, in softening of the brain, in various 
 organic diseases of this viscus, in rheumatic affections, cramps and 
 tonic convulsions ; their movements are disordered in some nervous 
 affections, as chorea and hysteria. 
 
 They become increased and diminished in size in those diseases 
 which produce like effects in other parts of the body. 
 
 One of the limbs may become cedematous and engorged, when 
 the vessels and nerves which are distributed to it, are compressed 
 by a tumor. A tumor in the side may produce these results in the 
 corresponding thigh ; the arm is similarly affected in aneurism of 
 the arch of the aorta. These phenomena principally depend upon 
 some obstruction to the venous circulation, which may also produce 
 a varicose development of the superficial veins. 
 
 The limbs often become swollen around the articulations, or in 
 the parts between; the first takes place in articular rheumatism, hy- 
 darthrosis, white swelling, &c. ; the second, which is much more 
 rare, sometimes occurs in scurvy, in which the muscles become the 
 seat of a sanguineous exhalation between their fibres ; phlegmon, 
 
96 SYMPTOMS. 
 
 abscesses and aneurisms may also produce partial swellings in 
 these as in other parts of the body. 
 
 The limbs become diminished in size, in paralysis; in such 
 cases the paralyzed limbs are those affected, in paraplegia both 
 thighs, in hemiplegia the leg and arm of one side. In the paralysis, 
 which occurs in children, increase in the length of the limb is 
 sometimes checked, the part remaining for several years shorter 
 by some inches than the other, and smaller in other respects. 
 This atrophy is often observed to follow spontaneous dislocations. 
 
 The extremities of the limbs also present remarkable changes, 
 in respect to size. Without noticing the diseases of which they 
 are the special seat, as gout and caries, the hands are swollen in 
 scarlatina and variola ; it has also been remarked, that in plethora, 
 the general intumescence is much more apparent in the hands 
 than elsewhere ; the fingers are sometimes so much swollen as to 
 be with difficulty flexed. Beclard having observed that, in many 
 children affected with cardiac aneurism, the last phalanx of the 
 fingers was so much enlarged as to give the finger the form of a 
 small club, was led to believe that a connection existed between 
 this peculiarity and lesions of the heart, and considered it a sign 
 of those diseases. This form of the fingers has been more recently 
 thought to be peculiar to tubercular disease of the lungs. This 
 phenomenon does not appear to us, in a semeiotic point of view, 
 to deserve the importance that has been attached to it. 
 
 The feet become swollen in some affections, and particularly in 
 incipient anasarca. 
 
 The alterations in color presented by the skin, are, in some af- 
 fections, more marked at the extremities than in other parts of the 
 limbs and trunk ; as the lividity which occurs in the cold stage of 
 febrile affections, the marbled appearance observed in some ady- 
 namic fevers, and the bluish tint which occurs in Asiatic cholera, 
 in diseases of the heart, and in all cases where there is any ob- 
 struction to the pulmonary or cardiac circulation. We have seen 
 the feet of a woman affected with elephantiasis, of a greyish slate 
 color, with deep and regular furrows, and a hard and swollen con- 
 dition of their tissue. 
 
 The nails deserve little attention, in relation to symptomatology ; 
 they are pale or livid in the cold stage of intermittent fevers, and 
 present a yellowish tint in icterus. Hippocrates observed that 
 they were curved in phthisical patients : this phenomenon, what- 
 ever be its cause, is here rarely well marked. 
 
 Such are the principal symptoms furnished by the exterior of 
 the body ; there are many others which we have not considered, 
 as their place is more naturally among those furnished by each 
 particular function. 
 
SYMPTOMS. 97 
 
 SECTION SECOND. 
 Symptoms furnished by the Organs of Locomotion. 
 
 The organs of locomotion consist of the bones with their appen- 
 dages, and of the muscles. The bones which serve as the base 
 and support of all the other parts, affording them strength and 
 stability, are the passive, while the muscles constitute the active, 
 organs of locomotion. 
 
 I. The symptoms furnished by the bones are generally connect- 
 ed with diseases which are confined to these organs. They may 
 however become the seat of syphilitic tumors, scurvy may effect 
 separation of the cartilages and apophyses, before complete bony 
 union has taken place, and tubercular disease may produce en- 
 largement and caries. 
 
 The two principal symptoms of diseases of the osseous system, 
 are deformity of the part and difficulty of motion. The former is 
 present in nearly all fractures and dislocations ; it is also apparent 
 in osteo sarcoma, and particularly in rachitis or softening of the 
 bones. In the latter affection, the limbs are not only incapable of 
 supporting the body in the upright position and of every kind of 
 regular motion, but they may be bent by the hand into any form. 
 Difficulty or complete loss of motion, accompanies nearly all the 
 affections of these organs ; in some cases, voluntary motion is 
 alone suspended, and the limb is capable of receiving the motion 
 communicated to it, as in case of fracture ; in other cases, every 
 kind of spontaneous or communicated motion is impossible, as in 
 anchylosis and some dislocations. 
 
 Another not less remarkable phenomenon is crepitation (crepita- 
 tio\ a name given to the peculiar sound occasioned by the friction 
 between the fragments of a bone, either broken, or separated from 
 its apophyses or the cartilages to which it is naturally united. 
 
 A bone which has been laid bare by a wound or abscess, may 
 present to the eye alterations in color and structure ; it sometimes 
 becomes of a dull white color, or presents a blackish tint ; soften- 
 ing of its tissue may occur, giving rise to a more or less abundant 
 sanies, and causing it to break down readily under the pressure of 
 a blunt instrument (caries). 
 
 The slow decay of a bone, in a greater or less portion of its 
 extent, gives rise to peculiar symptoms. This decay sometimes 
 commences without any known cause, as in vertebral disease, in 
 which it produces angular curvature of the spine. It is by the 
 wearing away of the sternum and ribs, that an aneurismal tumor 
 becomes apparent through the thoracic parietes. The walls of the 
 cranium are sometimes worn away by fungous tumors, and by 
 gently depressing them, the bony circle which surrounds them 
 may be felt. In the latter case, before the destruction of the bony 
 tissue is yet quite complete, the thin lamina which remains, if 
 compressed, emits a sound like that of parchment. 
 9 
 
98 SYMPTOMS. 
 
 II. The muscles present functional changes by far more numer- 
 ous. Their action may be increased, diminished, destroyed or 
 variously perverted. 
 
 Increase of muscular strength has only been observed in a few 
 nervous affections, and particularly in mania, in which patients 
 have been known to break the bonds which confine them, and 
 successfully resist many persons. 
 
 In most diseases, the force of the contractions is diminished ; 
 the step is unsteady, the upright position painful or impossible, the 
 motions feeble and uncertain, and often immediately followed and 
 even preceded by a feeling of lassitude : many patients are obliged 
 to remain quiet, and some are unable to leave their beds. Among 
 the latter, there are also those who are unable to retain the sitting 
 posture, to feed themselves, turn themselves in bed, and even to 
 move their arms : in extreme cases, the hand of the patient, hav- 
 ing been raised and abandoned to itself, falls like an inert body, 
 obedient to the laws of gravity. This diminution of muscular 
 power occurs, in different degrees, in incomplete paralysis ; it may 
 in this case be confined to certain parts, like the affection of which 
 it is the symptom. There is a peculiar alteration in the muscular 
 contractility, to which no special name has been given, but which 
 we shall here notice. We refer to that so constantly observed in 
 typhoid fever, and which, often occurring at the commencement of 
 this affection, becomes one of the most important signs in its diag- 
 nosis. This alteration consists in a kind of titubation or trembling, 
 and uncertainty in the gait and motions generally, which has been 
 justly compared to that occasioned by intoxication. 
 
 The complete abolition of muscular contractility and voluntary 
 motion, constitutes paralysis (paralysis) ; * a term applied to the 
 loss of sensation as well as of motion, and to the simultaneous 
 abolition of both these faculties. Hence, in medical language, to 
 avoid ambiguity, the terms paralysis of motion, paralysis of sen- 
 sation^ should be employed. Paralysis is general in comatose 
 affections, syncope, asphyxia, &c. It has been more generally 
 designated by the term resolution des membres [resolutio membro- 
 rum]. If it affect but one side of the body, it is called hemiplegia /j- 
 if the lower half, paraplegia, or paraplexia ; J if the arm of one 
 side and the leg of the opposite, it is called crossed paralysis, 
 which is very rare. It is sometimes confined to one or both wrists, 
 as is occasionally observed in metallic colic, and more rarely in 
 typhus. Paralysis often affects certain muscles which are devoted 
 to a particular kind of motion, as is sometimes observed in lead 
 colic, in which the extensors are principally affected, the hands 
 and wrists being constantly and powerfully flexed. In some 
 cases, it appears to affect but a single muscular fasciculus : this 
 has been suspected in those cases, in which the tongue loses the 
 
 from nanalvw, I relax. 
 f 'HutnlijYia, (um^r^ta, from f^navq, half, and nirjoao), I strike. 
 , from wAijoow, I strike ; Tracer, dim. particle. 
 
SYMPTOMS. 99 
 
 power of articulating certain letters, but appears to retain all its 
 other motions. In permanent ptosis, or falling of the upper eyelid 
 (collapsus palpebrce), the elevator muscle is alone paralyzed. 
 The muscular contractility may be variously perverted. 
 
 1. Tremor consists in a feeble and involuntary agitation, attrib- 
 uted by most physiologists to alternate contraction and relaxation 
 of the muscles, or alternate contraction of opposite muscles. This 
 symptom, which may be general or partial, occurs in the cold 
 stage of intermittent fever and some nervous affections ; it is often 
 produced by the action of mercury and lead on the economy, and 
 sometimes by the use of coffee and alcoholic liquors ; it frequently 
 occurs in old persons from the effects of age. 
 
 2. Rigidity (rigiditas) should be considered as a perversion of 
 muscular contractility. The actual muscular power is, in this 
 case, always diminished, although any attempt at communicated 
 motion is met with more than ordinary resistance, as will be found 
 to be the case, in attempting to draw the arm of the patient out of 
 bed. This rigidity is evident to the patient himself; he moves his 
 limbs slowly and with effort. Rigidity, like paralysis, may extend 
 to all the muscles, or be confined to one side of the body, one half 
 of the face, or to a certain few muscles ; it is often connected with 
 some disease of the brain, particularly softening of its substance. 
 
 3. Cramp (crampus) is a sudden but permanent contraction of 
 one or more muscles, accompanied by hardness of their tissue, 
 numbness and inability to execute any movement of the part thus 
 affected. The muscles forming the calf of the leg are particularly- 
 liable to this affection. Many persons in health suffer from it; it 
 is of frequent occurrence in women during the last months of 
 pregnancy ; it sometimes accompanies hysteria and painters' colic, 
 and is of almost constant occurrence in the different species of 
 cholera. 
 
 4. Subsultus tendinum is a twitching communicated to the ten- 
 dons by the involuntary and instantaneous contraction of the 
 muscular fibres. This symptom is more observable at the wrist 
 than elsewhere, and may be felt by examining the pulse of the 
 patient. It is common in acute diseases of an ataxic form. 
 
 5. Carphologia * or carpologia, f consists in an automatic and 
 continual agitation of the hands and fingers, which, in some cases, 
 appear to seek flocculi in the air, and in others, to ramble about 
 on the bedclothes. This symptom, which frequently accompanies 
 very severe acute diseases, sometimes presents itself under a differ- 
 ent form, the patient continually endeavoring to pick imaginary 
 flocculi from the bedclothes : this is called crocidismus, J which 
 many authors have confounded with carphologia. 
 
 6. Convulsions (convulsiones) \\ consist in involuntary contrac- 
 ons of the muscles. They are divided into clonic and tonic.$ 
 
 * KaQ(prj, flocculus ; *yo>, I collect. 
 
 j- KaQTtog, wrist, a part of the hand ; I collect with the hand. 
 
 . X()oxi(JiLu>. This word signifies to pluck off the nap. 
 
 * From convellere, to shake. 
 
 $ Some authors have sought to establish a distinction between convulsion and 
 
100 SYMPTOMS. 
 
 i 
 
 A. dome convulsions (spasmi clonici) * consist in violent 
 and involuntary contractions, which alternate with relaxation of 
 the contracted muscles, or with contractions of other muscles. 
 The effects of these convulsions in hysterical females are various. 
 Some throw their limbs to the right and left, unconsciously strik- 
 ing themselves, and rapidly flexing and extending their forearms 
 and fingers. In others, particularly if the arms be confined, the 
 body is alternately raised and depressed during the whole attack. 
 We saw at the Hospital Saltpetriere, in one of the wards of M. 
 Landre Beauvais, a young girl suffering from hysteria, who, in 
 each attack, after the ordinary convulsive motions had passed off, 
 suddenly and unconsciously rose, and holding the arms extended, 
 rapidly turned herself about, until the supervention of another 
 paroxysm. These were not of long duration. We recollect 
 another case, that of a young girl at the Hotel Dieu, who, while 
 the attack lasted, rolled about upon the floor of the ward. These 
 clonic convulsions are not always general ; they are sometimes 
 partial in different nervous diseases, and even in hysteria and 
 epilepsy. Dr. Whytt observed a very curious example of partial 
 spasm in a young girl aged eight years. The masseter and tem- 
 poral muscles were alternately contracted and relaxed and at 
 irregular intervals, so as to imitate the pulsations of the heart, 
 with this difference, that the muscular contractions were more 
 than one hundred and forty, while the cardiac pulsations were not 
 above ninety, in the minute. A violent fright put an end to this 
 affection, the cause of which was unknown, and which resisted 
 every method of treatment. In connection with clonic convulsions, 
 may be mentioned the involuntary shaking of the limbs, to which 
 Gaubius applied the term palpitatio membrorum. 
 
 B. In tonic convulsions (spasmi tonici^)-\ the muscular contrac- 
 tion is permanent, so that the affected part is in a state of absolute 
 immobility, which no internal or external effort can overcome. 
 The equal and permanent contraction of all the muscles is called 
 tetanic.J If the anterior muscles of the body be more strongly con- 
 tracted, causing flexion of the head on the chest, and curvature of 
 the body forward, the phenomenon is called emprosthotonos ; \\ if, 
 on the contrary, the body be bent backwards, so that the back of 
 the head approximates to the spine, it is called opisthotonos.^ 
 Lastly, to that variety, in which the muscles of one side are more 
 powerfully contracted than those of the opposite, producing lateral 
 
 spasm. They have applied the term convulsion to those which we have called 
 clonic, and the term spasm, to tonic convulsions. But as Castelli observes, the 
 words spasm and convulsion have always been employed synonymously, and as 
 we have elsewhere remarked, no change should be made in the acceptation of 
 words sanctioned by custom. 
 
 * Snanpog, from anato, I contract ; xlovog , agitation. 
 
 } Tovof, tension. 
 
 f TtTavoui, I stretch. 
 
 I 'EfinQooBtv, forward ; rovog, tension. 
 
 & "Omadiv, backward ; TOVOS, tension. 
 
SYMPTOMS. 101 
 
 curvature of the body, the term pleurosthotonos is applied.* It 
 sometimes happens that, in tonic convulsions, lateral and backward 
 curvature of the body take place simultaneously, as we had occa- 
 sion to remark in the case of a young man recorded in the Journal 
 de Medecine. f Permanent or tonic convulsion is not always 
 general, being sometimes confined to a particular part, to the ele- 
 vator muscles of the jaw, for example, and to those which separate 
 the lips. In these cases it is called trismus.% Cynic spasm and the 
 risus sardonicus, which have been already mentioned, are also 
 tonic convulsions. || 
 
 C. Can the muscular fibres which enter into the composition of 
 the stomach, intestines, heart and urinary bladder, become the seat 
 of convulsions, analogous to those observed in the voluntary mus- 
 cles? Among the numerous facts which may serve to throw light 
 upon this question, the emission of urine, of fecal matters and of 
 spermatic fluid, in epileptic attacks the vomiting which occurs in 
 hysteria, and the impossibility of swallowing, in some varieties of 
 tetanus, are phenomena which would incline us to the belief that 
 this derangement of contractility may affect all the muscles, 
 whether voluntary or involuntary. If in these cases convulsive 
 action be admitted, should it be referred to the tonic or clonic con- 
 vulsions? This question, which appears to us of little importance, 
 we think entirely insoluble. 
 
 7. There is another perversion, or anomaly of muscular con- 
 tractility, which is observed in catalepsy (catalepsid) ; H in these 
 cases, the patient retains, during the whole attack, the same posi- 
 tion that he had assumed at the time of seizure, or remains in that 
 in which he may be placed, however uncomfortable it may be. 
 That this is not rigidity, is evident from the facility with which the 
 limbs are moved ; and the need of relaxation felt by the muscles in 
 a state of contraction in health is no longer experienced in cata- 
 lepsy. This symptom generally shows itself in females suffering 
 from hysteria. We have known it to occur every other day in an 
 insane woman. There is a variety of catalepsy which we once 
 had occasion to observe, in which the patient retained the same 
 posture that he had at the time of the attack, but did not preserve 
 that communicated to him ; the limbs yielded to an external force 
 
 * IIlevQooQev, laterally ; rovog, tension, 
 f Tome xxix. 1814. 
 
 JT^trr^og, gnashing. 
 A curious symptom is mentioned by Dr. Kellie, in the twelfth volume of the 
 inburgh Medical and Surgical Journal, as occurring in infants during dentition. 
 It consists in a spastic contraction of the flexor muscles of the thumbs of the 
 upper, and of the toes in the lower extremity, the former being rigidly contracted 
 and permanently bent downwards, and laid flat upon the palms of the hand, and 
 the latter bent down to the plantar aspect of the foot. This affection lasted from 
 a few days to three months. TRANS. 
 $ A privative, owuAog, regular, 
 ^f Karalaupavw, I seize. 
 
 9* 
 
102 SYMPTOMS. 
 
 which placed them in a new position, but resumed the first, as soon 
 as the force was withdrawn. 
 
 8. A very remarkable perversion of muscular contractility is ob- 
 served in the disease called St. Vitus 1 Dance {Chorea Sancti Viti). 
 If the patient seek repose, he experiences sudden twitchings in the 
 affected limbs ; if he attempt to extend his hand to any object, it 
 becomes affected by two kinds of motion, which tend to draw 
 it in opposite directions ; the one voluntary, by which the patient 
 endeavors to accomplish his purpose ; the other, involuntary and 
 irresistible, which opposes his efforts ; so that it is only by a series 
 of oblique and divergent lines, that he succeeds in reaching the 
 object. The lower limbs may also be similarly affected, pro- 
 ducing an irregular and unsteady gait ; whence the term dance or 
 chorea which has been applied to this affection. 
 
 9. There is still another anomaly of muscular contractility, 
 not less remarkable; it consists in being unable to execute any 
 motion in a regular manner, unless with rapidity. Such is the case 
 with those who are unable to walk, but who run without diffi- 
 culty ; so it is, as Gaubius remarked, in those who stutter when 
 speaking slowly, but in whom this peculiarity disappears if they 
 articulate rapidly. 
 
 10. We shall, finally, notice contracture [contractura^ which 
 consists in permanent and chronic rigidity of the flexor mus- 
 cles. These organs, whose length and thickness diminish, at 
 the same time becoming harder, form under the skin inflexible 
 cords, which prevent the extension of the limbs. This phenome- 
 non is generally owing to a lesion in some part of the nervous 
 system. 
 
 Such are the principal symptoms furnished by the active and 
 passive organs of locomotion. They aid in completing what has 
 been already said in regard to the exterior of the body. 
 
 SECTION THIRD. 
 
 Symptoms furnished ly the Voice and Speech. 
 
 The voice, in health, is loud and sonorous ; it aids, by its inflec- 
 tions, in expressing the various feelings, which man is capable of 
 experiencing. The speech, or articulated voice, is ordinarily free 
 and distinct. 
 
 I. The voice rarely becomes stronger under the influence of dis- 
 ease ; this, however, is sometimes the case in delirium. In most 
 affections, and particularly those of the vocal and respiratory or- 
 gans, it becomes more feeble. It may be entirely lost, constituting 
 aphonia* This symptom should not be confounded with mussi- 
 tation (mussitatio), in which the tongue and lips move as in the 
 act of speaking, without producing any sound ; these two affec- 
 
 * A privative, ywvij, voice. 
 
SYMPTOMS. 103 
 
 tions are observed in some acute diseases ; they are also of frequent 
 occurrence in the neuroses, and particularly in hysteria. Aphonia 
 frequently occurs in the last stage of croup ; it may also depend on 
 disease of the brain, spinal marrow or recurrent nerves. When it 
 becomes chronic, it is generally owing to destruction of the vocal 
 cords by ulceration, which is almost always of a syphilitic or tu- 
 bercular nature, and in the latter case often co-existing with 
 phthisis pulmonalis, as is shown by the researches of Louis. We 
 should always be led to suspect the existence of this disease when 
 aphonia has persisted for several months, and even when but of a 
 few weeks' duration ; it is, in some circumstances, the first sign 
 that reveals it. 
 
 The voice may become modified in tone as well as strength ; it 
 is preternaturally clear in some malignant fevers, and before, or 
 during delirium ; it is shrill in certain forms of angina, whistling 
 in tetanus, hoarse in hydrophobia and in pulmonary or laryngeal 
 phthisis, nasal in different affections of the pituitary membrane, 
 and discordant in certain diseases of the larynx, as was observed 
 by Portal in the case of a woman whose voice, while speaking, 
 became alternately shrill and hoarse. In some varieties of melan- 
 choly, the voice, like the attitude of the patient, is in imitation of 
 that of certain animals, as the dog and wolf; these varieties of mel- 
 ancholy have consequently received the names cynanthropia * and 
 lycanthropia. \ Lastly, it has been observed that deafness effects 
 a change in the voice, which, being no longer regulated by the ear, 
 becomes altered in its tone and inflections. 
 
 II. The speech presents certain alterations, which may accom- 
 pany those of the voice, or be manifested alone. 
 
 1. In certain grave fevers, the words are pronounced in a hesi- 
 tating and trembling voice (vox tremuld). 
 
 2. Stammering (balbuties) is a defect of speech which prevents 
 the free articulation of certain letters or syllables which, after an 
 effort to pronounce them, are quickly repeated; this occurs in 
 some diseases of the brain and in grave fevers. It is. as is well 
 known, natural to some persons, and undoubtedly connected with 
 some defect of organization. 
 
 3. Articulation is slow in many diseases ; prompt in others. In 
 others there is great fluency of speech. The latter symptom was 
 observed by Senac several times at the commencement of the 
 paroxysms in intermittent fevers. 
 
 4. Portal had under his care a woman who commenced speak- 
 ing with difficulty, but was unable to keep silent after uttering 
 the first words : she was compelled to express by words all the 
 thoughts that occurred to her, even when at church. This was 
 the same patient in whom the discordance of sounds, which we 
 have just mentioned, was noticed. There is a similar case, at 
 present, in Paris. 
 
 , dog ; ai&Qojrroe, man. 
 , wolf; UV&QWTIOS, man. 
 
104 SYMPTOMS. 
 
 5. Loss of speech may exist independently of that of the voice, 
 as is observed in dumbness, which consists in an inability to 
 produce articulate sounds. The loss of the voice, on the contrary, 
 is always accompanied by that of speech. The latter has been 
 observed previous to apoplexy and in nervous diseases. It is 
 sometimes the effect of poisoning. Sauvages relates that the 
 robbers in the vicinity of Montpellier, caused their victims to 
 drink wine in which had been infused the seeds of the thorn 
 apple ; this narcotic, according to that physician, produces a 
 transient dumbness, which gave the robbers sufficient time to 
 escape. 
 
 The peculiar method of exploration, to which Laennec has 
 given the name auscultation* applied to the voice, led that phy- 
 sician to the discovery of still other interesting phenomena, which, 
 render the diagnosis of many frequent and grave diseases much 
 more complete. These symptoms will be considered in connection 
 with those which belong to respiration ; we have thought it better 
 to consider all the phenomena furnished by the auscultation of the 
 respiratory passages in the same article. 
 
 SECTION FOURTH. 
 
 Derangements of Sensibility and of Sensation, considered as Symptoms, 
 
 The faculty of feeling is, in the natural state, imparted, vari- 
 ously modified, to many organs; it may, as is well known, 
 become developed, under the influence of disease, in all the others, 
 with the exception of the epidermis and its productions. It is by 
 virtue of this faculty that different impressions are transmitted to 
 the sensor ium commune ; some, called internal sensations, inform 
 us of certain phenomena which are taking place within our 
 bodies; others, to which the term sensations has been particularly 
 applied, acquaint us with certain conditions or qualities of exter- 
 nal objects about us. The faculty of feeling, considered generally, 
 and the sensations, both internal and external, present under the 
 influence of disease, numerous changes which we shall proceed 
 to examine. 
 
 I. The derangements of sensibility which occur in disease, 
 have been, by many physicians, considered as the effect of an 
 unequal distribution of this faculty. Excessive pain in any parr., 
 they suppose to be the result of a morbid accumulation of sensi- 
 bility, which in some subjects constantly takes place in some par- 
 ticular organ, and in others, successively in different parts. This 
 theory does not appear to us to accord with facts. If there 
 be some individuals in whom the sensibility, when augmented in 
 any part, becomes diminished in all others, this is by no means 
 
 * From auscultate, to listen. 
 
SYMPTOMS. 
 
 105 
 
 the case in the greatest number. It generally happens, as has 
 been observed in hypochondria and hysteria, that the sensibility 
 is diminished or increased in all the organs at once : it is equally 
 augmented in all parts during the first period of certain acute 
 cerebral affections ; it becomes everywhere simultaneously dimin- 
 ished, and even extinct, in the second and third periods of these 
 affections. 
 
 Loss of sensibility is often connected with that of muscular 
 contractility, particularly in cases where there is also loss of con- 
 sciousness : the same cause, as compression of one of the cerebral 
 hemispheres, may produce both these effects. There is then pa- 
 ralysis of motion and of sensation. In many cases of cerebral com- 
 pression, in which there is a diminution or entire suspension of 
 motion,, the faculty of it is preserved, as also in some rare affec- 
 tions, whose material cause is unknown, the muscles preserve 
 their contractility, while the integument that covers them is 
 deprived of feeling. Some very ingenious researches have been 
 recently undertaken, with a view to throw light upon this point 
 in pathology : these led to the supposition that the exclusive office 
 of the anterior and posterior fasciculi of which the medulla 
 oblongata and spinalis are composed, is to transmit, the one 
 motion and the other sensation, so that lesions confined to either 
 one or the other, or to the parts from which they take their origin, 
 produce derangement alone of one or the other of these func- 
 tions, while those which affect both these nerves, or the whole 
 spinal cord, would produce simultaneous derangement of motion 
 and sensation. In support of this opinion, may be mentioned 
 certain cases communicated to the Academy of Medicine, or pub- 
 lished in the periodical collections ; but these facts, which have 
 been contradicted by other experimenters, are yet too limited in 
 number, and require further confirmation. 
 
 II. The internal sensations, in the healthy individual, chiefly 
 consist in the wants connected with the regular exercise of the 
 functions ; in disease, these wants, together with the functions on 
 which they depend, become deranged ; other sensations also man- 
 ifest themselves, which belong exclusively to disease, and which 
 demand the attention of the physician ; such are the various kinds 
 of pain. 
 
 As the nature of pain is familiar to all from experience, it will 
 be useless to attempt its definition. 
 
 Pain may be produced by various causes with which we are but 
 partially acquainted ; its effects may be less difficult to appre- 
 ciate ; it varies in its nature, intensity, type, and seat. 
 
 The causes productive of pain in diseases are : 1, considerable 
 alterations in the tissue of parts which are its seat, as wounds, 
 inflammations, ulcerations, and organic affections ; 2, a too vio- 
 lent or long sustained action ; 3, an inexplicable modification in 
 the motion of organs which become primarily or sympathetically 
 painful, without any manifest cause. 
 
 The effects of pain are generally more apparent : 1, it de- 
 
106 SYMPTOMS. 
 
 ranges the functions of the suffering organ ; in the muscle, it ob- 
 structs or hinders the motions, in the mouth, affecting mastica- 
 tion, in the thorax, respiration ; 2, it also determines, in some 
 cases, an afflux of fluids, either to the surface or tissue of organs ; 
 
 3, it may produce sympathetic disturbance in distant parts, as 
 vomiting in headache, and convulsions in many kinds of pain ; 
 
 4, it may cause, when occurring in its highest degree of intensity, 
 disorder of nearly all the functions, arid when prolonged may 
 result in death. 
 
 Pain may exist variously modified ; each of its principal vari- 
 eties has received particular names : 1, that which consists in a 
 feeling of distension, has been called tensive ; it occurs especially 
 in phlegmonous inflammation; 2, a heavy pain is a feeling of 
 weight which accompanies collections of fluid in natural or acci- 
 dental cavities, and which is sometimes felt in many other affec- 
 tions ; 3, a throbbing- pain is marked by its pulsations which are 
 isochronous with those of the heart ; it is felt particularly in 
 inflammatory tumors, in which suppuration is about to take place; 
 4. lancinating pain is characterized by transient lancinations or 
 shootings which do not correspond to the arterial pulsations ; this 
 kind of pain is peculiar to cancer and neuralgia ; 5, a boring pain 
 has been admitted, because those who experience it, compare it to 
 the sensation which a wimble or screw would produce in entering 
 and turning on itself in the suffering part ; it is felt in some cases 
 of rheumatism ; 6, a contusive pain resembles that produced by a 
 bruise : it frequently occurs among the precursory phenomena of 
 acute diseases ; 7, the pain which is felt in anthrax arid in gan- 
 grenous erysipelas, is compared by patients to that produced by 
 the contact of ignited bodies ; this has been termed burning pain ; 
 
 8, the prurigenous pain, or itching, occurs in diseases of the skin ; 
 
 9, there is another kind of pain, which is called formication 
 (formicatio), from its resemblance to the sensation which would 
 be caused by a multitude of ants creeping over the part. Finally, 
 pain may be tearing or pungent. Some patients compare their 
 sensations to a wound whose edges have been removed, or the 
 surface of which has been irritated by some mechanical agent ; 
 others, to compression of the part by an iron band, or the fall of a 
 heavy weight upon it, &c. Pain may become changed in char- 
 acter in the course of a disease : thus, in the first stage of phleg- 
 mon it is tensive, in the second, throbbing, and heavy, when sup- 
 puration has taken place. 
 
 Pain varies in its degree of intensity : this may be determined 
 by the report of the patient, his expression of countenance, and 
 the functional derangement it occasions. It may depend upon the 
 cause which produced it, or the sensibility of the individual and 
 particularly of the suffering organ. It is increased and diminished 
 under different circumstances ; it is sometimes aggravated by heat, 
 at others, by cold ; in the one case it is excited, in the other, mod- 
 erated by external pressure ; prolonged movement in the former 
 in the latter, diminishes it. The expression of the 
 
SYMPTOMS. 107 
 
 physiognomy, under the influence of pain, varies with the constitu- 
 tion and character of the patient. 
 
 The type of pain is sometimes continuous, with or without 
 exacerbation, sometimes intermittent, with or without regularity. 
 In the first case, the pain is uninterrupted, and of different or 
 equal intensity ; in the second, it ceases and reappears at regular 
 or irregular intervals. Every pain which is reproduced without 
 one of the types peculiar to intermittent fever, and the duration of 
 which, at each return, is about the same as that of a paroxysm, 
 deserves particular attention, as it is generally due to the same 
 causes which produce intermittent fevers, and will yield to the 
 same treatment. 
 
 There are certain pains, which are felt simultaneously in all 
 parts of the body, as those which precede arid accompany the 
 invasion of some acute diseases ; but they are generally partial, 
 and even confined to a limited portion of the body. In some cases, 
 they remain seated in the same place, in which case they are 
 termed fixed ; in others, they change their seat once or more ; 
 these being called vague or movable. * Fixed pains should 
 always arouse the attention of the physician, for they are often 
 indicative of important visceral changes. Thus, a circumscribed 
 and continuous pain in the head, occurring in old persons, often 
 proceeds from cerebral softening, in its incipient stages. 
 
 There are certain other painful sensations, which, though not 
 exactly corresponding to pain, closely resembles it: such are the 
 general uneasiness and inquietude which accompany different dis- 
 eases ; such also is anxiety which consists in extreme uneasiness, 
 often more uncomfortable and insupportable than acute pain, and 
 which, though generally felt throughout the whole body, is partic- 
 ularly referred to the epigastric region, obliging the patient contin- 
 ually to change his position. The highest degree of anxiety is 
 anguish, which is ordinarily attended by palpitations, dyspnoea, 
 and a change in the expression of the features and plaintive res- 
 piration ; such are also those internal movements attributed by 
 patients to the displacement of some viscus, to some foreign body, 
 and often to a ball or globe (globus hystcricus), which, rising from 
 the hypogastric region or the left side, seems to ascend to the 
 pharynx, producing a sense of suffocation. 
 
 * Pain has received different names, according to the portion of the body which is 
 its seat. Cephalalgia (xetpaVi^ head, alyog, pain) signifies pain in the head ; her- 
 micrania (i'^n/$, half, xQanor, head) hy corruption migraine, that confined to one 
 of its sides, &c ; to cephalalgia is applied the epithet frontal, supraorbitar, synci- 
 pital occipital, when it is exclusively confined to either of these regions. Pain in 
 the ear is called otalgia ( <?, WTO?, ear) ; that of the teeth odontalgia (odov$, oSov- 
 TOC, tooth). By the term point de coti (stitch in the side) is understood a pain 
 occupying the lateral part of the chest. Pain situated in the epigastric region 
 has received various appellations, as cardialgia (xandia, orifice of the stomach), 
 cardiogmus (xao<Jtu>yi/o?, pain of the cardia), epigastralgia (tTti, upon, yanrrg, 
 belly). Pain in the intestines is known by the name colic (xu>Aov, colon). Those 
 of the kidneys, liver, and spine, have been termed by some authors, nephralgia 
 (veifQog, kidney), hepatalgia (;/iap, liver,) rachialgia (()a/s, spine). Pain seated 
 in the nerves is called neuralgia (rsvyw, nerve), and that felt in the bones 
 osteocopus (oartov, bone, AOTJTW, I break.) 
 
108 SYMPTOMS. 
 
 To this same series of symptoms, might be added the sensation 
 of cold or heat, which some persons experience in the whole or a 
 part of the body ; but the consideration of the changes in animal 
 heat, more naturally belongs elsewhere. 
 
 III. External sensations. In health, the organs of sense receive 
 the impression of external objects, and transmit it, with prompt- 
 ness and precision, to the brain ; under the influence of disease, 
 these impressions may become wearisome, the perception confused, 
 irregular or defective. Derangement of the sensations is some- 
 times produced by an affection of the organ which is its seat, and 
 sometimes by the connection or association which may exist 
 between that organ and the suffering part. 
 
 The sight, hearing, taste and touch, may suffer the same de- 
 rangements as other functions, as exaltation, diminution, abolition, 
 and the various perversions, among which authors have classed 
 hallucinations, and illusions of the senses. But, as Esquirol* has 
 justly remarked, in hallucinations, the mind is the sole seat of the 
 affection ; those, thus affected, indulge in day-dreams, their dis- 
 ordered brains giving a body and reality to images reproduced by 
 the memory, or created by the imagination, without the interven- 
 tion of the senses. In illusions, on the contrary, the patient is 
 deceived in regard to the nature and cause of his real sensations. 
 Illusions are not uncommon, even when the nervous system and 
 organs of sense are free from disorder ; but they are perceived by 
 the reason, and by it the patient is enabled to guard against them. 
 The case is different with the sick, and particularly the insane 
 man, whose reason is often at fault, and whose sensations are con- 
 sequently received as real, and as conveying no false impression. 
 
 A. Exaltation of vision occurs in ophthalmia, in inflammation 
 of the retina, and of the meninges ; dimness of vision takes place 
 in typhus, &.; its entire abolition, in blindness, amaurosis, cata- 
 ract and certain nervous affections. The sight is sometimes singu- 
 larly perverted : 1. ft may exhibit objects which have no real 
 existence, as sparks of fire, flashes, floating specks or spots resem- 
 bling flies, cobwebs, light shadows, &c., (metamorphopsia). 
 2. It may change the color, form, and number of objects presented 
 to the eye : thus in plethora and internal ophthalmia, objects some- 
 times appear of a red color ; and during the first few days of 
 jaundice, they are said to be colored yellow ; in certain neuroses, 
 in some forms of amaurosis, and in incipient cataract, only one 
 half or a portion of the object is visible : this is called hemiopsia * 
 (visus dimidiatus) \ in other cases they appear double : this is 
 diplopiaf or double vision (visus duplicates), which is ordinarily 
 only observed when the two eyes are open ; in a very remarkable 
 case related by Maurice Hoffman, however, it persisted when one 
 
 * ESQUIROL, des Illusions chez les alienes, a paper read at the Acadamie des 
 Sciences, 1832 
 
 -///tiov$, half; oTirouai, I see. 
 j double ; w'V' eye. 
 
SYMPTOMS. 109 
 
 eye was closed. * This affection rarely exists, without strabismus ; 
 if the want of concordance of the optic axes be not at first appa- 
 rent, it will become evident if the patient be directed to turn his 
 eyes successively to the right and left, and upward and downward. 
 
 B. The hearing becomes frequently acute in meningeal in- 
 flammation, &c. ; obtuse in typhus and grave fevers ; it is not 
 entirely abolished except in diseases of the ear, as chronic otitis 
 with caries, and perforation of the tympanum, lesions which not 
 uncommonly occur after variola, typhoid fever, and in the latter 
 stages of phthisis pulmonalis. The hearing may be perverted in 
 two ways ; in one case, the patient imagines he hears sounds, 
 which have no existence, as beatings, tinnitus, the ringing of bells, 
 the noise of the wind, the murmur of water, the music of some 
 instrument, words and even speeches ; in the other, he does not 
 properly appreciate the sounds which he really hears, they ap- 
 pearing to him more acute or grave than they really are j and he 
 does not recognize the voice of his friends. 
 
 C. The exaltation of smell has been observed in the neuroses 
 and some other diseases. Bally relates that when suffering from 
 yellow fever at St. Domingo, he distinguished, in the cold water 
 which he drank, the odor of the flowers which grew upon the 
 banks of the stream from whence it was drawn. Diminution of 
 this sense is much more frequently observed, as in coryza, ozaena, 
 and all the acute diseases in which the pituitary membrane be- 
 comes deprived of its moisture. If this membrane be entirely dry, 
 the sense of smell no longer exists. In some cases of ataxic 
 fevers, and in the lighter forms of hysteria, the patient complains 
 of smelling odors which in fact do not exist, or perceives in sub- 
 stances a different smell from that which belongs to them. 
 
 D. The taste is rarely exalted in disease ; this symptom has 
 however been observed in the neuroses. It is diminished in nearly 
 all acute affections, and often suspended in the last stage of grave 
 fevers in which patients take without repugnance the same 
 remedies which had before excited nausea from having merely 
 swallowed them. This sense also presents other anomalies ; some 
 patients perceive an acid, bitter, saltish, coppery, or putrid taste 
 in all their food, whether liquid or solid ; to others, substances 
 which are disgusting or insipid, have a delicious flavor, while food 
 of a superior flavor is to them positively disagreeable. This 
 symptom is particularly observable in hysteria. 
 
 E. The touch, taken in its most limited acceptation, rarely 
 furnishes many remarkable symptoms ; it may be diminished or 
 abolished ; it is rarely depraved. Sarcone remarked, in the epi- 
 demic of Naples, that, of all the senses, this was least affected. 
 
 * Ephem. Natur. Curios., vol. ii., obs. 1. 
 10 
 
110 SYMPTOMS. 
 
 Taken in a more general sense, this sense may be exalted in the 
 whole or a part of the body, as in general nervous affections, and 
 in local phlegmasise. It becomes more or less diminished, or 
 completely abolished, in apoplexy, paralysis of sensation ; it may be 
 perverted, the patient incorrectly appreciating real sensations, or 
 experiencing those which are imaginary, as in the sensation of a 
 drop of water falling upon some part of the body, a pin penetrat- 
 ing the skin, or the crawling of some animal over the body ; but 
 these last phenomena belong to hallucinations, as well as to illusions 
 of the senses, and constitute one of the signs of a disordered 
 intellect. 
 
 SECTION FIFTH. 
 Symptoms furnished by the Affective Functions. 
 
 These functions, in health, present the greatest variety in differ- 
 ent individuals. 
 
 Disease almost always produces a degree of sadness or impa- 
 tience, ennui or inquietude. All these effects may be produced 
 simultaneously, or successively, but in most cases, the derange- 
 ment of the affective functions is more manifest. They are some- 
 times exalted, as is observed in hypochondriacs; patients thus 
 affected are at once susceptible of the strongest attachment and the 
 most profound hatred ; the least evidence of good will affects them 
 to tears, and on the slightest occasion they will form the blackest 
 suspicions. In others, the opposite is observed ; they appear indif- 
 ferent to their own fate, and that of their nearest friends ; in some 
 cases of typhoid fever and mania, the moral sensibility is almost 
 entirely abolished. The character and affections may be perverted r ; 
 persons who in health are the most amiable, become peevish ; 
 those most imperious and obstinate, docile ; the most resolute, 
 pusillanimous ; and the timid, resigned and even courageous, 
 under the influence of disease. This has not escaped the observa- 
 tion of those unconnected with the profession, and it is a common 
 remark, that those who in health are the most amiable, are the 
 worst patients. Disorder of the moral affections is still more mani- 
 fest in some individuals, who, during a part or the whole course 
 of a disease, take an aversion to their nearest and most intimate 
 friends. This symptom is not unfrequently observed in hypochori- 
 driasis and mania. 
 
SYMPTOMS. Ill 
 
 SECTION SIXTH. 
 
 Symptoms furnished by the Intellectual Functions. 
 
 The intellectual functions relate principally to the attention, 
 memory, imagination and judgment ; these presenting, in health, 
 infinite varieties, and, in disease, being susceptible of numerous 
 alterations. In some cases, there is perversion of the judgment and 
 imagination, while the attention and memory remain unaffected ; 
 in others, the memory is alone at fault ; but generally all these 
 functions are simultaneously deranged. 
 
 Exaltation of the intellectual powers is a prominent symptom in 
 some patients, and particularly in melancholies ; we are often 
 struck with the clearness and surprising accuracy of the memory 
 by which they are enabled to recollect events long since forgotten, 
 the appropriateness and precision of their language, their rapidity 
 and strength of judgment, and fertility of imagination, in short, 
 a degree of intelligence far surpassing that which they ordinarily 
 possess when in health. Nor is it rare to observe an extraordinary 
 development of the intellectual functions, connected with exalta- 
 tion of the moral sensibility, in acute disease about to terminate 
 fatally. The dying often speak with an eloquence which they 
 were not before known to possess, and express sentiments which 
 they did not appear susceptible of experiencing. 
 
 The intellectual functions are more often enfeebled than exalted 
 in disease. This diminution of the intellectual powers, occurs in 
 most diseases, particularly those of an acute character. It is prin- 
 cipally in typhus that this symptom is noticed ; it is difficult to fix 
 the attention of the patient ; he comprehends with difficulty the 
 questions that are put to him, replying slowly, and having but a 
 vague idea of what is going on around him, the place where he is, 
 or his relations to those about him ; his physiognomy is not in 
 harmony with surrounding circumstances ; his attention is not 
 directed towards the object that excites it ; his features are without 
 expression, and the body remains in one posture. 
 
 There is an entire absence of the intellectual faculties in idiocy, 
 and those diseases, in which there is a suspension of all the func- 
 tions of relation, as violent apoplexy, and epilepsy. 
 
 Perversion of one or more of the intellectual or affective faculties 
 constitutes delirium.* 
 
 This affection is more likely to occur during childhood and 
 youth than at any other period of life, and in persons of great ner- 
 vous susceptibility. There are some individuals, in whom a slight 
 indisposition, or febrile attack, is accompanied with this affection. 
 But this symptom does not generally occur, except in severe acute 
 diseases, or in chronic affections when drawing towards a fatal 
 close. 
 
 * Delirium, de, from ; lira, ridge between two furrows. 
 
112 SYMPTOMS. 
 
 Delirium does not alone occur in affections of the brain and its 
 membranes ; it is more often observed, as a sympathetic phenome- 
 non, in the thoracic and abdominal phlegmasise, eruptive fevers, the 
 various kinds of typhus, and in typhoid fever. It is with the brain 
 as with the heart, these two viscera being associated with the 
 affections of all others, and the disturbance of their functions being 
 generally sympathetic. This subject will be again considered in 
 the chapter on diagnosis. 
 
 Delirium may present itself under various forms ; it generally 
 appears in the relations of the patient with external objects, in his 
 gestures, actions, and in the words by which he expresses his ideas 
 of surrounding circumstances; but there is also an internal deliri- 
 um, sometimes observed, which depends solely upon disorder of 
 the cerebral functions, and is not excited by any external circum- 
 stance ; it is characterized by muttering, carphologia, automatic 
 gestures, conversations with absent persons, &c. 
 
 There is a state of complete delirium in which the order of ideas 
 and moral affections is entirely perverted, the patient being contin- 
 ually in error on every subject; this is observed in mania. In 
 other cases the disease affects but a single idea. This is partic- 
 ularly observable in monomania, (melancholy of Pinel,) the patient 
 entertaining erroneous ideas, as to his rank, the place where he 
 is, and the passage of time ; and consequently speaking and acting 
 in accordance with this error. In complete, as in partial delirium, 
 there is sometimes a predominant idea, which almost always relates 
 to the habitual occupation of the patient, as is particularly noticed 
 in coachmen, errand boys, &c. It has been observed that in those 
 cases which present a predominant idea, it is almost impossible to 
 dispel it, or to excite others in its place. 
 
 Delirium may be constant, or transient ; in the latter case it may 
 recur at regular intervals. 
 
 The two principal varieties of this affection, which have been 
 particularly described by authors, are the mild or tranquil and 
 furious delirium. 
 
 Mild delirium (subdelirium) can, in some cases, only be distin- 
 guished by a change in the gestures, actions, and language of the 
 patient ; he tosses his arms to and fro without any determinate 
 object ; tries to get out of bed, or uncover himself; he at one time, 
 preserves an obstinate silence (taciturnetas,) and at another, talks 
 incoherently (vaniloquium) or mutters unintelligibly between his 
 teeth. We have seen a case in which delirium could only be dis- 
 tinguished by the plaintive cries constantly uttered by the patient. 
 To most questions which were put to him, he replied promptly ; 
 but when asked why he thus complained, he appeared unable to 
 comprehend the question. Mild delirium may also show itself, by 
 a more or less marked alteration in the physiognomy, sound of the 
 voice, and in the mild, or severe, free, or respectful mode of ex- 
 pressing himself, being not in accordance with the usual manner 
 of the patient. It is not uncommon for them to speak harshly to 
 those whom they have generally treated with respect, and vice 
 
SYMPTOMS. 113 
 
 versa, having no recollection of the circumstance after recovery. 
 In the case of a young man sick with typhus fever, who was under 
 our care, the patient nearly recovered his senses about the twelfth 
 day, the only evidence of any remaining delirium being the famil- 
 iar tone with which he addressed an old friend of his family for 
 whom he had always shown proper respect. Tranquil delirium 
 should not be confounded with those distressing dreams which 
 occur during sleep, and which cease upon arousing the patient. 
 
 Furious delirium presents itself under a totally different form ; 
 the patient shouting, singing and uttering threats ; talking in the 
 most obscene and extravagant manner, railing against absent per- 
 sons, quarreling and trying to leave his bed, throwing from him any 
 object he can lay hold of, spitting upon, and striking his assistants, 
 &c. The same patient may be alternately affected with mild and 
 furious delirium. In the epidemic of Naples, according to Sarcone, 
 furious delirium ceased during the remission; but the patients 
 abandoned themselves to the most frightful despair, turning their 
 eyes with a suspicious air upon their assistants, fearing to read in 
 their countenances the unhappy fate with which they believed 
 themselves threatened ; the least sign of affection caused them to 
 weep and tremble with fright. 
 
 Delirium presents other varieties, according to the difficulty of 
 its cure. If it be light, it is perceived by the patients themselves, 
 who endeavor to correct their own judgment. If the delirium be 
 still more apparent, they may still have a desire to overcome it, 
 but the difficulty is greater ; at this time the physician may cor- 
 rect, at least for the moment, the ideas of the patient, and obtain 
 sensible answers; but the amendment is but transient, and the 
 delirium soon returns. When it exists in a still higher degree, 
 nothing can suspend it, even momentarily. 
 
 The duration of delirium is very variable. It may last for a few 
 minutes only, or continue for weeks, months, and even years. 
 
 After recovery from this affection, patients are often unable to 
 recall anything that has occurred, not even what appeared to have 
 been the result of reflection ; in other cases, they have a confused 
 and even clear recollection of what they have experienced. 
 
 SECTION SEVENTH. 
 Symptoms furnished by Sleep. 
 
 The usual duration of healthy sleep, is nearly uniform in each 
 individual ; it is tranquil, and refreshes the wearied body. In dis- 
 ease, it may be prolonged, diminished, suspended or disturbed, 
 and fails to restore strength. 
 
 It is prolonged in certain diseases accompanied by cerebral con- 
 gestion, and diminished in nearly all acute affections. The com- 
 10* 
 
114 SYMPTOMS. 
 
 plete suspension of sleep or agrypnia* (insomnia, pervigilium) 
 may occur in a great number of diseases, and from various causes, 
 such as intense pain, tinnitus aurium and other imaginary sounds, 
 difficulty of respiration, frequency of cough and of the excretions, 
 restlessness, mental agitation, violent passions and nocturnal par- 
 oxysms. Complete sleeplessness is one of the principal symptoms 
 in "delirium tremens ;" it is also a marked symptom in typhoid 
 fever ; for, in no other acute disease, is it so complete and constant. 
 Sleep may be disturbed by night-mare, dreams, &c. 
 
 Nightmare (incubus),^ epkialtes% oneirodynia, $ consists in a 
 feeling of suffocation, which supervenes during sleep, producing a 
 momentary but inexpressible anguish, and causing the patient to 
 start and awake in terror. The person, who experiences this 
 symptom, feels a sensation of great weight on his chest, imagines 
 that some danger threatens him, or that he is pursued by a phan- 
 tom ; he makes ineffectual efforts to escape from his imaginary 
 dangers and to cry for help, and when he awakes is often bathed 
 in perspiration. This symptom is particularly noticed in hypo- 
 chondriasis and in cardiac aneurism, and may sometimes arise 
 from indigestion. 
 
 Most of the physicians of antiquity paid great attention to 
 dreams ; they supposed that during sleep, that is, when the opera- 
 tions of the mind are undisturbed by any external sensation, the 
 suffering of the diseased organ is more distinctly felt, producing in 
 the sensorium commune a disposition to certain dreams. This 
 opinion is true, to a certain extent. In diseases accompanied with 
 great difficulty of respiration, the patient imagines that the dilata- 
 tion of the chest is prevented by the pressure of a considerable 
 weight upon it. Galen mentions a man who dreamed for a long 
 time, that one of his legs had become petrified ; a short time after, 
 the limb became paralytic : the transient numbness which often 
 precedes paralysis, sufficiently explains this phenomenon. It was 
 more justly thought that ill nourished persons dreamed of eating 
 certain articles of food. It has been pretended that in plethora 
 and inflammatory fevers, patients perceive in their dreams, bodies 
 of a red color ; that those suffering from dropsy, dream of water, 
 streams, &c. ; but these assertions do not accord with observation. 
 
 In general, when occurring in disease, dreams are wearisome and 
 painful. They may present to the imagination, obstacles, precipices,^ 
 fires, in short, any object of embarrassment and terror, sometimes 
 causing the patient to awake suddenly in a state of fright. 
 
 It is said that the Egyptians and Greeks placed their sick in the 
 temples, that the gods might make known to them, in their dreams, 
 the proper method of their cure. Now that the age of superstition 
 has passed away, no one believes these salutary dreams to be the 
 inspiration of heaven ; but respectable persons do not hesitate to 
 
 * " ' Ay$a, chase ; VTTVO?, sleep. 
 ] Incubus, from incumbere. 
 y E(fia^1tg, from e<paMonat. 
 
 Ovtioog, dream ; odwy, pain. 
 
SYMPTOMS. 115 
 
 accord to the disciples of Mesmer, the power of giving, with the 
 magical sleep produced by their manipulations, the knowledge of 
 every disease and its appropriate remedies. 
 
 Lastly, the sleep of invalids does not restore the vigor of the 
 frame ; and in some affections, the paroxysms of which occur in 
 the night, the symptoms are of a more aggravated nature in the 
 morning after a disturbed slumber, than towards the close of the 
 day, after twelve or fifteen hours of wakefulness. 
 
 Somnolency or drowsiness (somnolentia) is a state intermediate- 
 between waking and sleeping. It is often observed in typhoid 
 fevers and in certain cerebral affections. 
 
 Topor or cataphora * is a dull and heavy sleep, from which the 
 patient can with difficulty be roused : this phenomenon occurs in 
 the same diseases as somnolency. 
 
 Coma f is a still more profound sleep, from which it is more 
 difficult to awaken the patient. Of this there are two varieties : 
 1. The coma vigil (coma agrypnodes), which is accompanied by 
 delirium, the patient keeping his eyes closed, excepting when 
 spoken to, muttering to himself, and frequently changing his posi- 
 tion ; 2. coma somnolentum, in which the patient speaks when 
 aroused, but remains silent and immovable in the intervals. 
 These two varieties are frequently observed in typhoid fevers. 
 
 Lethargy $ (lethargus, veternus) is a constant and still more 
 profound sleep, from which however it is not impossible to awaken 
 the patient ; but when roused from this state he forgets everything 
 he has said, and appears unconscious of what he is saying, 
 speedily relapsing into his former condition. 
 
 Lastly, earns \\ consists in complete insensibility, from which 
 nothing can arouse the patient, even for a few instants : these 
 different symptoms most generally occur in the last stage of 
 cerebral diseases, or in cases of concussion or sudden compression 
 of the brain. 
 
 Topor, coma, lethargy and cams, are somewhat analogous to 
 sleep, only differing as it were in degree. It is for this reason, that 
 they have been considered in connection with somnolency. 
 
 SECTION EIGHTH. 
 
 There are three other symptoms in which the functions of rela- 
 tion are particularly affected, and to which we ought, perhaps, to 
 allude before passing to the consideration of the disturbances of 
 the internal functions ; these are lipothymia, syncope, and vertigo. 
 
 Lipothymia || or lipopsychia, IT consists in an almost entire sus- 
 
 * Karaffooa, fall ; xaTuysQouat, I fall. 
 Ktiua, profound sleep. 
 .Jt,6ij, oblivion ; oyo$, idleness. 
 , profound sleep. 
 , I leave ; Qvuog, mind. 
 , idem ; yvxij, soul. 
 
116 SYMPTOMS. 
 
 pension of all the functions, with discoloration of the face and 
 relaxation of the limbs. Respiration and the circulation continue, 
 but are hardly perceptible. This symptom, when slight, is called 
 fainting (animi deliquium). 
 
 Syncope * presents the same phenomena, together with a more 
 complete suspension of the respiration and circulation. Syncope, 
 lipothymia and fainting may occur in consequence of acute pain, 
 or lively emotions, copious bloodletting or abundant and painful 
 stools. The ingress of air into the circulatory system, during a 
 surgical operation, may occasion fatal syncope. This symptom is 
 not unfrequently observed at the commencement of eruptive fevers, 
 in the course of pestilential fevers, in gangrenous affections and 
 cases of profuse suppuration. The periodical return of this affec- 
 tion constitutes one of the severest forms of malignant intermittent 
 fever. It is not uncommon at an advanced period of chronic 
 diseases, and in persons very much reduced in strength, it often 
 precedes sudden death. 
 
 Vertigo (vertigines) produces in the patient a sensation of turn- 
 ing, or gives to external objects the appearance of rotation around 
 him ; this sensation is almost always accompanied by palpitation 
 of the heart and a feeling of faintness. Vertigo tenebricosa f (capitis 
 omnubilatio) is the term applied to that variety in which the sight 
 becomes obscured as if by a cloud. This affection occurs at the 
 commencement of many severe acute diseases, often returning 
 during their course, particularly if the patient execute any move- 
 ment, as in attempting to sit down or rise up. Vertigo, accompa- 
 nied with a sudden loss of consciousness and soon followed by 
 headache with a feeling of debility and heaviness, constitutes 
 a form of epilepsy, apparently lighter, but more frequently 
 followed by mental alienation, than the more common form of 
 that disease. 
 
 ARTICLE SECOND. 
 Symptoms furnished by the Internal or Assimilative Functions. 
 
 WE have now considered the principal derangements presented, 
 in disease, by the functions which serve to establish the relations 
 of man with external objects. We shall next proceed to the 
 examination of those furnished by the internal functions, diges- 
 tion, respiration, the circulation, calorification and the secretions. 
 
 * Svyxonrtn, I fall down, 
 f Verier e, to turn. 
 
SYMPTOMS. 117 
 
 SECTION FIRST. 
 Symptoms furnished ly Digestion. 
 
 In health, the appetite returns at regular intervals, its gratifica- 
 tion is attended with pleasure, the thirst is moderate, the stomachic 
 digestion effected with freedom, without eructation or oppression, 
 the faecal matters are of proper consistence, in quantity propor- 
 tionate to the food, and their excretion is accomplished without 
 pain. Each of the organs which contribute to the performance of 
 this function presents a healthy appearance ; the teeth are white, 
 smooth, and firmly implanted in their alveoli ; the gums are firm, 
 smooth and of a pale red color ; the inner surface of the mouth is 
 moist and of a reddish hue ; the abdomen, in which is contained 
 most of the digestive apparatus, is of its natural size and sup- 
 pleness. 
 
 Under the influence of disease, every act of digestion, and all 
 the organs which contribute to its performance, present more or 
 less marked derangements, which we shall consider in the order of 
 their succession. 
 
 A. Hunger, the appetite or the desire of taking food is seldom 
 increased in disease : this symptom is, however, sometimes ob- 
 served in mania and verminous affections. In some cases, hunger 
 is so urgent, that unless it is satisfied, fainting ensues ; this is 
 called boulimus, * a phenomenon of common occurrence in hy- 
 steria, but still more frequently observed during pregnancy. In 
 other cases, the patient eats with voracity until the stomach 
 relieves itself by vomiting; this is called (fames canind)-\. In 
 other diseases, the food which is devoured with greediness, is 
 almost as soon expelled by the anus ; this has been called (fames 
 lupina) J . The two latter symptoms are of rare occurrence. 
 
 Diminution of appetite (dysorexia)^ accompanies nearly all the 
 acute and chronic diseases of moderate intensity. 
 
 In those of greater severity, and particularly in acute diseases 
 attended with violent febrile symptoms, the appetite is entirely 
 lost ; this is termed inappetentia or anorexia || . An entire and pro- 
 longed absence of appetite, and progressive emaciation, are some- 
 times the two only symptoms indicative, in adult age, of chronic 
 disease of the stomach. 
 
 In certain chronic diseases, the appetite is unequal to a remark- 
 able degree; the patient being one day affected with insatiable 
 hunger, and the next, suffering from complete anorexia, this alter- 
 nation sometimes occurring the same day. 
 
 * Bov, augmentative particle ; Jit/*og, hunger. 
 
 t Canis, dog. 
 
 t From lupus, wolf. 
 
 Jvg, with difficulty; oojs, appetite. 
 
 || A privative, o^eitf, appetite. 
 
118 . SYMPTOMS. 
 
 In others, the desire of food is not real ; this is commonly called 
 a false appetite. In these cases no sooner does the patient taste 
 his food, than he feels already satiated ; this is particularly ob- 
 served in phthisis. 
 
 The appetite may become depraved in two ways. 1. There is 
 disgust (cibi fastidium. apositia) * or aversion for food. Disgust 
 should not be confounded with anorexia : the latter is only an entire 
 absence of appetite, while the former consists in real repugnance for 
 food. This repugnance is sometimes so great, that the sight of food, 
 or the mention of its name, is alone sufficient to produce nausea. 
 It is of rare occurrence except in grave diseases, while anorexia ac- 
 companies the slightest disorder. 2. The other variety of depraved 
 appetite, is that in which an almost general loathing is combined 
 with a desire for some particular article of food ; if this substance 
 be eatable, the symptom is called malacia f ; if, on the contrary, 
 it be not eatable or noxious, it constitutes picaj..' Both these 
 symptoms frequently occur in hysteria and mania, and often in 
 pregnancy. In connection with these affections of the appetite, 
 may be mentioned the sensations of bitterness, clamminess, dryness 
 of the mouth, experienced in many diseases, and particularly in 
 febrile affections and gastric disorder. 
 
 B. The thirst is increased in most acute diseases, and particu- 
 larly in diabetes. It is rarely diminished, and more rarely abol- 
 ished in patients whose intellectual faculties remain unimpaired. 
 In the derangement of the ideas and sensations, accompanying 
 delirium, the absence of thirst and refusal to drink exist toge'ther 
 with other phenomena. f 
 
 C. The examination of the different parts of the mouth, fur- 
 nishes us with important symptoms. We have before described 
 the morbid appearances presented by the lips, and now proceed to 
 consider those furnished by the teeth, gums, tongue, internal 
 surface of the cheeks and back part of the mouth. 
 
 The symptoms furnished by the teeth, may depend upon some 
 affection of these organs themselves, or be connected with the 
 existence of other diseases. 
 
 In certain acute affections in which the secretion of the mucous 
 membranes acquires a remarkable degree of acidity, the teeth 
 become the seat of a peculiar sensation, in which they are said to 
 be set on edge, (dentium hebetudo) ; this phenomenon is sometimes 
 observed in continued fevers. 
 
 The teeth of the lower, in gliding upon those of the upper jaw, 
 produce a grinding sound (stridor dentium), a symptom which 
 accompanies some acute cerebral affections ; in other cases, as in 
 the cold stage of intermittent fever, there is what is termed chat- 
 
 * * Ana, OITIOV, aversion for food. 
 
 f Malaxia, softness. 
 
 | Pica or Kioaa, magpie, its opposite colors form a contrast analogous to that 
 afforded by the depraved, when compared with the natural, appetite. 
 
SYMPTOMS. 119 
 
 tering of the teeth (dcntrum collisus, crepitus), in which the teeth 
 strike rapidly against each other. According to some authors* 
 the force with which the teeth sometimes come together is sufi- 
 cient to fracture them. In scorbutic affections, mercurial stom- 
 atitis, and simple chronic engorgement of the gums, the teeth 
 sometimes become loose and even entirely detached from their 
 sockets. Lastly, in chronic diseases they appear elongated, owing 
 to the shrinking of the gums which is coincident with the general 
 emaciation. 
 
 A thorough examination of the teeth is important, as many 
 affections of the mouth are often produced and kept up by a 
 decayed or falsely directed tooth. Among others, may be men- 
 tioned caries and necrosis of the maxillary bones, odontalgia, 
 fistula of the face, and enlargement of the lymphatic glands of the 
 neck, which may be owing to no other cause than dental caries. 
 Apthae, ulceration of the mucous membrane of the mouth, and 
 particularly of the tongue, with hardened and inverted edges and 
 a greyish and fungous surface, are not unfrequently caused by 
 the inequalities of a broken or wrongly directed tooth. 
 
 The gums present some important changes : they are swollen 
 in mercurial salivation and scurvy ; in the former case, they are 
 red, in the latter, blackish and flabby; in both cases, they exhale 
 an odor sui generis. It has been remarked by M. Rostan, at the 
 Salpetriere, that after loss of the teeth, and when the gums had 
 become callous from mastication, swelling did not take place in 
 them to the same degree as before ; and if the teeth of one jaw be 
 lost, while those of the opposite remain, the gums of the latter 
 become swollen, while those of the former retain their usual 
 appearance. * The gums become pale in diseases of debility, and 
 particularly in passive dropsies ; they are of a redish brown color 
 in some anginose affections. 
 
 The state of the tongue, in disease, has always, and very justly, 
 claimed the attention of physicians. The importance of the signs 
 which it furnishes, has, it is true, been much exaggerated ; but if 
 they be reduced to their true value, the tongue furnishes semiology 
 with numerous interesting facts. 
 
 In health, the tongue is generally of a red color, smooth surface, 
 slightly granulated towards its apex, and covered with pointed vil- 
 losities and hemispherical glandules towards its base ; its surface is 
 moist, it is free in its movements, the object of which is principally 
 in speaking, mastication and deglutition. In chronic diseases, 
 even in those of the stomach, the tongue often remains in its 
 natural condition ; this is sometimes the case in acute diseases ; 
 and this phenomenon which is without value in the first, is gen- 
 erally a favorable sign in the latter case, provided the other 
 symptoms be not unfavorable. Under the influence of disease the 
 tongue presents changes in relation to its volume, form, movements, 
 
 * De recondita Febr. int. turn, remit. ; Natura, p. 43. 
 f Cours de Mcd. Clin., t. 1, p. 250. 
 
120 SYMPTOMS. 
 
 color, moisture, coats, eruptions of which it is sometimes the seat, 
 and lastly, its temperature and tactile and gustatory sensibility. 
 
 The volume of the tongue becomes rarely increased in affections 
 of which it is not the special seat. In some acute diseases, how- 
 ever, this organ becomes so voluminous as to fill the whole mouth, 
 preserving the impression of the teeth upon its surface. This 
 phenomenon should lead the physician to suspect the influence of 
 some mercurial preparation. At other times swelling of the tongue 
 is in consequence of violent angina ; it is in these cases owing to 
 stagnation of blood in this organ ; it is always a symptom indica- 
 tive of great danger. 
 
 Shrinking of the tongue is a frequent symptom in typhus and 
 other grave fevers ; it is at the same time in a state of dryness and 
 tremor, conditions equally unfavorable. 
 
 In marasmus, the tongue rarely becomes diminished in size. But 
 a single example of partial atrophy of this organ has been recorded. 
 This case, mentioned in the forty-fourth bulletin of the anatomical 
 society, relates to a man, one half of whose tongue was pale, dis- 
 colored, wrinkled and atrophied without any change in its sensi- 
 bility. The patient died with symptoms of paralysis, and the 
 autopsy revealed an hydatid cyst in the left occipital fossa which 
 compressed the glosso pharyngeal nerve. 
 
 The form of the tongue, in disease, presents remarkable varie- 
 ties ; it becomes in some cases, conical, in others, pointed. The 
 latter modification has been recently pointed out as peculiar to 
 inflammation of the stomach, but this is not in accordance with 
 the results of experience. These peculiarities in the form of the 
 tongue do not indicate with certainty the nature and seat, more 
 than the danger of the disease. The pointed form depends solely 
 upon the mode of contraction of the intrinsic muscles of the organ. 
 
 Difficulty in the motions of the tongue either in the articulation 
 of sounds, or the act of protruding it, is a frequent symptom in the 
 course of grave fevers ; this condition is always an unfavorable 
 sign. 
 
 In some cases of hemiplegia, when the tongue is thrust out of 
 the mouth, its point appears drawn away from the paralyzed side ; 
 it has been attempted to explain this phenomenon by supposing 
 paralysis of the genio-glossus and stylo-glossus muscles. But this 
 deviation is often but apparent ; its point being nearer one commis- 
 sure than the other, the tongue is supposed to deviate from its right 
 direction ; but it is the commissure, not the tongue which is affected. 
 
 Paralysis of the tongue whether it consist in the deviation of its 
 point, or is apparent from the difficulty in pronunciation and mas- 
 tication, constitutes, in all cases, an important diagnostic sign, as 
 it is an almost certain index of a cerebral lesion. 
 
 The color of the tongue may be altered either immediately and 
 by a change in the color of the organ itself, or mediately, by the 
 coat with which it becomes covered. Paleness and discoloration 
 of the tongue rarely occur except in cases of chlorosis and anemia. 
 
SYMPTOMS. 121 
 
 In organic affections of the heart it partakes of the lividity of the 
 neighboring parts. 
 
 The coats which form upon the tongue are generally confined to 
 its superior surface, and are of various colors. Those most com- 
 monly observed are white, yellow, greenish, brownish and black. 
 These coats may be thick or thin, tenacious or easily removed, dry 
 or moist, of uniform or unequal extent, disposed in patches, or 
 presenting undulations analogous to those observed on geographical 
 charts. These coats, it would appear from the chemical analysis 
 of Vauquelin, Laugier and M. Denis, have the same origin with 
 the dental tartar. According to others, they are formed by the 
 drying of the salivary fluid. 
 
 Whenever the surface of the tongue presents one of the above- 
 mentioned coats, some morbid condition generally exists. I say 
 generally, for there are many persons in whom abstinence alone 
 produces a whitish coat ; and in others, this is constant at all times 
 in the day, although their health, in other respects, is perfectly 
 good. There are others, as we have before mentioned, who, being 
 obliged to sleep with the mouth open on account of the natural 
 straitness of the nasal fossae, awake with a dry and often yellowish 
 tongue. With these exceptions, a coated tongue almost always in- 
 dicates disease. There are others in whom the superior surface of 
 the tongue receives and preserves the color of the food and drinks 
 taken, becoming of a dark livid hue by the contact of red wine, 
 and colored drinks and food generally, as syrups prepared from 
 red fruit, chocolate, &c. But this aptitude of the tongue to receive 
 and retain coloring matters rarely occurs except in disease, when 
 the villosities of the organ become impregnated with the colors with 
 which they are brought in contact. 
 
 Are we to believe with the physicians of antiquity that the state 
 of the tongue is a true index to that of the stomach ? Is it true 
 that a yellowish, or greenish coat upon the tongue, is indicative of 
 bile in the stomach ; that a blackish coat should cause us to fear 
 the presence of putrid matters in the digestive passages ? Lastly, 
 are we to suppose with Broussais, that redness of the tongue is a 
 pathognomonic sign of gastritis ? Accurate observation has long 
 since shown the entire inconsistency of these various assertions 
 with facts. Thus, it was found by M. Louis, in analyzing a great 
 number of cases, in his researches on phthisis, that redness of the 
 tongue existed in an equal number of patients in whom the stomach 
 was found healthy, with those in whom this organ presented a 
 grave lesion. The researches of the same author upon typhoid 
 fever led to nearly the same results as to the state of tongue in the 
 course of that disease. Indeed, whatever aspect this organ pre- 
 sented, no correspondence between it and that of the stomach 
 could be detected, being the same in those cases in which there 
 was a grave lesion of the mucous membrane of the stomach, as in 
 those which presented a healthy appearance. According to the 
 skilful observer whom we have just cited, the blackish color, 
 11 
 
122 SYMPTOMS. 
 
 roughness and cracked appearance of the tongue, are chiefly owing 
 to the intensity of the febrile action, whatever be its cause. 
 
 The tongue may preserve its natural moisture and supple- 
 ness, although its surface at the same time be covered by white, 
 yellow, or greenish coats; but is constantly dry, or clammy, 
 when loaded with a blackish, or brownish fur. Dryness of this 
 organ is more or less considerable ; it may be also partial or gen- 
 eral. When existing in a slight degree, it is only apparent from 
 the sensation experienced by the patient, and a kind of noise which 
 accompanies the motions of the tongue, and which is owing to the 
 detachment of this organ from the parts of the mouth, particularly 
 the mucous membrane of the palate, to which it was adherent. 
 The finger placed upon the tongue and drawn slowly over its sur- 
 face, seems to be gently retained by a viscid substance. This is 
 rather a simple diminution in the degree of moisture, than a state 
 of dryness. In a more advanced stage, the coating is more viscid ; 
 the tongue in this case is said to be pitchy (poisseuse). Lastly, 
 when this phenomenon is still more marked, the organ is com- 
 pletely deprived of moisture. Dryness of the tongue sometimes 
 occurs only during sleep, disappearing when the patient awakes, 
 or after he has taken liquid food ; at other times, it continues dur- 
 ing a part of the day, or for several days. In the latter cases, it 
 becomes also smooth, shining and red, or rough, wrinkled and 
 black. This condition of the tongue, in acute diseases, is generally 
 indicative of danger. If it occur in the course of a chronic disease 
 it almost always announces approaching death. 
 
 A phenomenon of great importance in semeiology, is the ex- 
 istence of whitish and yellow patches or pimples, often confluent, 
 sometimes disposed in the form of a pultaceous coat, and some- 
 times in thin and reticulated, or thick and opaque membranes, 
 which are alternately detached and reproduced, generally appear- 
 ing simultaneously or successively upon the upper surface and 
 sides of the tongue, the internal surface of the cheeks and the 
 velum pendulum palati and its pillars. The appearance of these 
 patches is of little importance as a diagnostic sign, for it belongs to 
 no particular disease, but is of great utility in prognosis. In 
 chronic diseases, it is an inauspicious omen, particularly if the 
 eruption last beyond a certain number of days, or is reproduced 
 many times. In acute affections, though not so grave a sign, it 
 may with other symptoms lead us to fear the result. The same 
 eruption occurs temporarily, particularly in old persons, without 
 any derangement of the health ; its semeiotic value is not the same 
 in these cases as when occurring in the course of a grave disease. 
 
 The superior surface of the tongue sometimes presents, particu- 
 larly towards its apex, very small red spots, considered by M. 
 Roux as a certain sign of the existence of syphilitic virus. We 
 only call the attention of observers to this sign, the value of which 
 we have not as yet been able to appreciate. The grayish ulcera- 
 tions which sometimes appear upon the edges and point of the 
 tongue, and which should not be confounded with those occasion- 
 
SYMPTOMS. 123 
 
 ally produced by inequalities of the teeth, are of syphilitic origin, 
 as their appearance indicates. The same may be said of those 
 flat, hard, circumscribed tumors of a red or grayish color, from 
 two to five lines in breadth, which appear upon this organ, and 
 arise from the same cause. 
 
 Lastly, the transverse and often irregular cicatrices which the 
 surface of the tongue sometimes presents, should lead us to suspect 
 epilepsy, the existence of which is often concealed from the phy- 
 sician. This may, consequently, become in some cases a highly 
 important sign. 
 
 A change in the temperature of the tongue becomes rarely suffi- 
 cient to claim the attention. In the last stages of acute or chronic 
 disease, it may become very cold, a sign indicative of approaching 
 death. In cholera, the coldness of the tongue was an almost 
 constant symptom, and in many cases in which it occurred, 
 the patients recovered. It is perhaps unnecessary to add that this 
 phenomenon would be without value, if the patient had just 
 before taken ice or cold drinks. 
 
 In the course of certain cerebral affections, and in those diseases 
 which affect the nerves distributed to the tongue, the tactile or 
 gastatory sensibility of this organ may become diminished. From 
 the experiments of physiologists, confirmed by pathological obser- 
 vations, it would appear that paralysis of sensation is the result 
 of a material lesion of the lingual nerve. 
 
 The parts which form the posterior part of the mouth, are also 
 the seat of symptoms appreciable to the sight ; they may become 
 swollen, red, dry, and ulcerated. The velum palati may be de- 
 pressed by an abscess in its substance, or by a tumor developed in 
 the nasal fossae ; it may be partially destroyed or perforated by 
 an ulcer. It has been observed to deviate to the right or left in 
 some cases of facial paralysis. The uvula may deviate from the 
 median line, become pendent, infiltrated, or entirely destroyed. 
 The brown or blackish coat sometimes observed upon other parts 
 of the mouth, extends also to this ; apthas often manifest them- 
 selves here ; and it is generally upon the velum, sometimes upon 
 the tongue and inner surface of the cheeks, that those whitish 
 patches which occur in the last period of chronic diseases, and 
 which announce a fatal termination, appear. 
 
 D. Mastication is often difficult and painful in disease. Odon- 
 talgia, swelling of the face, dental caries, rheumatism of the 
 ternpero-maxillary articulation, fracture of the maxillary bones, 
 dislocation of the lower jaw, are all diseases which may render 
 mastication impossible. To these may be added, disease of the 
 gums, tongue, and cheeks, the integrity of which is necessary to 
 performance of this function. 
 
 E. Deglutition appears to be more rapidly performed in some 
 acute affections, the patients swallowing the contents of a cup 
 presented to them almost instantly ; it is slower and accomplished 
 
124 SYMPTOMS. 
 
 with difficulty in nearly all the diseases of the pharynx and 
 oesophagus, as angina, paralysis, and schirrus ; the existence of a 
 neighboring tumor compressing the pharynx or oesophagus, the 
 presence of a foreign body in these passages, hysteria, grave 
 fevers, diseases of the brain and upper part of the spinal marrow, 
 are all affections in which deglutition may become difficult Diffi- 
 culty of deglutition has been designated dysphagia.* It presents 
 many remarkable varieties. Some patients can swallow liquids, 
 but are unable to swallow solid substances ; this is often observed 
 in angina ; in other diseases, as paralysis, the deglutition of solids 
 can be accomplished, while that of liquids is impossible. These 
 opposite phenomena have been satisfactorily explained ; in angina, 
 the inflamed mucous membrane cannot bear the contact of a solid 
 body, while in paralysis the muscles of the pharynx being en- 
 feebled in their action, cannot contract with sufficient force, to 
 conduct liquids from the mouth to the ossophagus, but can act 
 upon a more voluminous and consistent body as the alimentary 
 bolus. 
 
 Morgagni^ according to a dissertation of Spies on deglutition, 
 speaks of a singular variety of dysphagia observed in an old man : 
 this person was able to swallow all kinds of food, but the last 
 alimentary bolus remained in the oesophagus till the next meal, 
 unless rejected by the mouth, during the interval, in the effort of 
 coughing. In the explanation of this phenomenon, Morgagni 
 supposed that the action of the muscles of the oesophagus alone, 
 was insufficient to force the bolus from the pharynx into the 
 stomach, which could only be accomplished by the weight of 
 another bolus, together with the contraction of the oesophagus. 
 This disorder of deglutition he very ingeniously compared to a 
 similar lesion presented by the excretion of urine in old persons ; 
 the bladder being incapable of emptying itself completely of the 
 urine it contains. 
 
 Deglutition may become impossible from causes analogous to 
 those which render it difficult. 
 
 The absolute impossibility of swallowing liquids, together with 
 a horror for every kind of drink, constitutes hydrophobia^ a 
 symptom which generally occurs in rabies and sometimes in 
 typhoid affections and hysteria. When this symptom exists, the 
 sight of water, or of any shining body, often occasions convulsions 
 almost tetanic in their nature. 
 
 Deglutition may be depraved in two ways : 1, there may be 
 continual efforts to swallow, with successive action of the muscles 
 destined to this purpose, while the mouth remains empty ; this has 
 been observed in elongation of the uvula and some nervous affec- 
 tions ; 2, food carried into the posterior part of the mouth, instead 
 of being transmitted directly into the oesophagus, may pass either 
 into the nasal fossae, as is the case in diseases of the velum, or 
 
 * Jvc, with difficulty; (payo>, I eat. 
 
 t De Sedibus et Cuusis mort., epist. 1, art. 14. 
 
 J r K(%o(jo|*ia, from vvtiwq, water ; (popoc, fear. 
 
SYMPTOMS. 125 
 
 into the larynx, a much rarer and more serious phenomenon, and 
 which can only take place in cases of ulceration of the opening 
 of the larynx (Archives, Septembre 1839, Memoire de M. Earth), 
 or in the agony and in patients who swallow involuntarily. It 
 is hardly necessary to add that in cases of ulceration, rupture, or 
 wound of the oesophagus, the food may escape from it, and pass 
 into the cavity of the chest. 
 
 There is another derangement of deglutition, in which fluids 
 poured into the mouth, are carried by their weight alone through 
 the oesophagus, producing a sound by their fall into the stomach as 
 if poured through an inert tube. This symptom occurs only in 
 the moribund. 
 
 F. Stomachal digestion becomes rarely more active under the 
 influence of diseases ; in maniacs, however, the action of the 
 stomach appears sometimes greater than in health ; but in most 
 diseases it is enfeebled, as is apparent from the sense of weight in 
 the epigastrium, and the general uneasiness and aggravation of all 
 the symptoms after a meal. Patients who take no food often 
 experience various phenomena which indicate functional disturb- 
 ance of the stomach; as nausea, retching, regurgitations, vomiting 
 and epigastric pain. 
 
 1. Nausea consists in a simple desire to vomit, retching 
 (vomituritio) in ineffectual efforts to accomplish this object. Both 
 these symptoms accompany many diseases, and particularly those 
 of the digestive organs. 
 
 2. Under the term subsultus prczcordiorum, a peculiar phenom- 
 enon has been also described, which consists in a convulsive 
 action of the stomach which prevents the admission of more food, 
 and the expulsion of what it already contains, notwithstanding 
 the efforts of the patient. 
 
 3. Regurgitation (regurgitatio) is the act by which certain 
 gaseous or liquid, rarely solid, substances, rise from the stomach or 
 oesophagus into the mouth, unaccompanied by the efforts peculiar 
 to vomiting. Renvois is the term applied to matters thus rejected. 
 Regurgitation may be complete or incomplete, in the one case, the 
 substances rising into the pharynx and mouth, in the other, being 
 arrested in some part of the oesophagus and again passing into 
 the stomach ; it may be rare or frequent ; and lastly, it may 
 afford relief to the patient, or cause increased suffering. 
 
 The renvois or substances rejected by regurgitation may be 
 gaseous, liquid, or solid : the gases or eructations (ructus) ma'y be 
 inodorous, as is observed in nervous diseases ; they may exhale 
 the odor of sulphuretted hydrogen (decayed eggs), that of sub- 
 stances last eaten, or be slightly rancid (nictus nidorosi)* as in 
 
 * The sense of the word nidorous is not well defined ; it indicates, in its ety- 
 mological acceptation, the odor of animal matters in a state of combustion ; but 
 most authors have employed it to express a repulsive odor. 
 11* 
 
126 SYMPTOMS. 
 
 indigestion. The liquids which rise into the mouth are sometimes 
 insipid; they are sour in carcinoma of the stomach, bitter in 
 bilious disorders, and sharp and burning in pyrosis. Solid 
 matters rejected by regurgitation almost always consist of the 
 remains of the preceding digestion, which have not undergone 
 the necessary elaboration. The renvois are generally gaseous or 
 liquid ; in some cases regurgitation of both takes place simulta- 
 neously. Solid matters are almost always accompanied by a cer- 
 tain quantity of liquid. 
 
 In connection with this phenomenon may be mentioned, rumi- 
 nation or merycismus* which consists in masticating, a second 
 time, food carried into the mouth by a sort of antiperistaltic con- 
 traction of the stomach and oesophagus. This affection, upon 
 which Dr. Gintrac of Bordeaux has written an interesting treatise, 
 is, in most cases, congenital. It however sometimes occurs acci- 
 dentally in old persons affected with cerebral disease, in whom 
 there is insufficient mastication together with too great ingestion 
 of food ; in these cases, the food rising into the mouth undergoes 
 a second mastication, without occasioning the person trouble or 
 inconvenience. 
 
 4. Vomiting (vomitus) is the act by which substances contained 
 in the stomach are ejected by the mouth, with effort, and in cer- 
 tain quantities. 
 
 Vomiting takes place under various circumstances, and may 
 depend upon an affection of the stomach or other parts of the econ- 
 omy more or less remote. It has occurred in gastric derangement, 
 simple indigestion, gastrites, softening and cancer of the stomach. 
 The affections of the various parts contained within the abdom- 
 inal cavity, in which vomiting is liable to occur, are inflammations 
 and organic lesions of the peritoneum, intestines, liver, kidneys, 
 bladder, cellular tissue of the illiac fossse, and uterus, intestinal 
 and epiploic hernia, occlusion of the intestines whatever be its 
 cause, hepatic nephritic and saturnine colic, and pregnancy. The 
 thoracic phlegmasise, and particularly acute bronchitis, whooping 
 cough and tubercles, produce, in the paroxysms of coughing, 
 obstinate vomiting ; some cases of tonsillitis and pharyngitis, and 
 simple oedema of the uvula may produce sympathetic vomiting, 
 which may also occur in certain affections of the brain. In ner- 
 vous persons, vomiting frequently follows a severe moral or phy- 
 sical shock ; various acute diseases, and particularly the eruptive 
 fevers, are ushered in by this phenomenon. From the frequency 
 of this symptom, and from the numerous affections in which it 
 occurs, it becomes highly important for the physician to be familiar 
 with all the circumstances connected with it, and the diseases to 
 which it belongs. We shall again refer to this subject in the 
 chapter on diagnosis. 
 
 The matters rejected by vomiting, vary in their nature, consis- 
 tence, quantity, color and odor. 
 
 rumination. 
 
SYMPTOMS. 127 
 
 These may consist of the residue of digestion, as in the attack 
 of acute diseases, mucus, green or yellow bile, various medi- 
 cinal, and, in cases of poisoning, poisonous substances, &c. They 
 may consist; 1, of liquid or coagulated blood in haemorrhage of 
 the stomach, which is generally symptomatic ; 2, of a brownish, 
 black, pultaceous substance, resembling chocolate or coffee grounds, 
 in cancer of this organ ; 3, of pus when an abscess opens into 
 its cavity ; 4, of fsecal matters, when, from any cause, occlusion of 
 the intestines has taken place. We saw at the Hotel Dieu a man, 
 suffering from articular rheumatism following dysentery, reject, by 
 vomiting, a bloody and viscid substance, resembling in appearance 
 the sputa in pneumonia. In cholera, the matters vomited resemble 
 rice water or whey ; in one case they exactly resembled milk, both 
 in color and consistence. Among them are also sometimes found 
 lumbrici, hydatids and biliary calculi ; also portions of cysts, false 
 membranes or tumors which -have been detached from the inner 
 surface of the stomach, or some other part of the digestive canal. 
 
 The consistence of these matters, is variable ; they are generally 
 liquid, sometimes clear and watery, at others, thick, viscid and 
 resembling paste. They are sometimes mixed with a certain 
 quantity of gas or solid matters, as in indigestion. Their quantity 
 may vary ; this, in many cases, it becomes highly important accu- 
 rately to ascertain, particularly in the vomiting of pus and blood. 
 Their color and odor generally depend upon their nature. 
 
 Some patients while making the most violent efforts to vomit, 
 reject nothing but gas, which is generally insipid and inodorous, 
 and produced by simple exhalation. This is observed in certain 
 neuroses, and particularly in hysteria. In the "single case of dry 
 cholera, observed by Sydenham, in the autumn of 1669, there was 
 evacuation of wind from above and below, without any other 
 excretion. 
 
 5. The pain of which the epigastrium is the seat, varies in its 
 character, type, intensity, and particularly in its causes. Ot these, 
 the principal are, inflammation of the stomach, the presence of 
 indigestible or poisonous substances in this viscus, the various 
 organic affections peculiar to it, rheumatism of the muscles of this 
 region, the constriction of a portion of the epiploon in an opening of 
 the linea alba, peritonitis, any affection of the liver or pancreas, an 
 acute or chronic affection of the lungs and pericardium accom- 
 panied by a frequent cough, leucorrhoea, habitual pressure on the 
 epigastrium by tight corsets, hysteria, &c. This enumeration, 
 though incomplete, is sufficient to show the error of those who 
 refer all epigastric pain to inflammation of the stomach. There 
 are few grave diseases which may not be accompanied by epigas- 
 tric pain. 
 
 6. Pain in the stomach, of a peculiar character, sometimes 
 occurs, to which the term cramp in the stomach has been applied : 
 it is compared by patients to the pain caused by cramp in the 
 muscles of the leg, and generally produces forced flexion of the 
 body forward, during the whole time of its duration. 
 
128 SYMPTOMS. 
 
 7. There is still another symptom furnished by the stomach, and 
 to which authors have not referred. This consists of a peculiar 
 sound caused by the fluids and gases contained in this viscus, and 
 which may be produced by a slight blow upon the trunk, or rapid 
 pressure made with the hand over the epigastric region, and several 
 times repeated. This phenomenon occurs mostly in diseases ac- 
 companied by distension of the parietes of the stomach, and par- 
 ticularly in. cancer of the pylorus. It is sometimes met with in 
 healthy mdi\ iduals. 
 
 G. The symptoms furnished by the intestinal canal are less 
 numerous and more difficult to distinguish. Among these may be 
 mentioned those internal movements, sometimes felt in diarrhoea, 
 the commotion and twisting occasionally experienced by patients at 
 the commencement of dysentery, those various movable pains, 
 of a dull, rather than acute character, sometimes followed by cold 
 sweats and fainting, and which have been termed intestinal colic 
 or simply colic, occurring in inflammation of different portions of 
 the intestinal canal, particularly the colon, lastly, those partial tu- 
 mefactions of the abdomen, produced by the gaseous distension of 
 some part of the intestinal canal, or by agglutination of the intes- 
 tines with each other, &c. These symptoms need only to be 
 enumerated. There are some others which should be mentioned 
 more in detail; as borborygmi, and also those various changes 
 which supervene in the course and excretion of matters and in 
 the matters themselves. 
 
 1. The term borborygmi* is applied to the sound produced by 
 displacement of the gases contained within the abdomen. These 
 noises accompany intestinal disorders and hypochondriasis ; they 
 are not unfrequently observed in healthy persons, particularly 
 females, and, as has been before remarked, are often caused by 
 habitual compression of the abdomen. 
 
 2. There is another intestinal sound, somewhat analogous to 
 borborygmi, but differing in being more moist and generally more 
 circumscribed. We refer to the gurgling (gargouillement), often 
 heard in intestinal hernia, particularly while employing taxis in 
 its reduction ; it is here produced, as in the stomach, and cavities 
 of the lungs, by the concussion of liquid or gaseous matters con- 
 tained in a cavity. An analogous sound occurs in schirrus con- 
 traction and internal strangulation of a portion of the intestines, 
 which aids in their diagnosis. But it is chiefly in typhoid fever 
 that gurgling, which is confined to the coecal region, and ordi- 
 narily accompanied by local pain on pressure, becomes an important 
 sign. Of all acute affections, typhoid fever is the only one in 
 which this symptom exists, being in this disease almost constant, 
 although varying in intensity and duration ; it is owing to a pecu- 
 liar alteration affecting the ilio-crecal valve and the extremity 
 of the small intestines which is peculiar to this disease. In 
 
 , from poQpoqvtw, I make a dull noise. 
 
SYMPTOMS. 129 
 
 obscure cases this phenomenon becomes an important diagnostic 
 sign. 
 
 3. The course of alimentary matters through the intestinal 
 canal, may be retarded or accelerated, as we shall see hereafter, 
 in referring to their characters. Under certain circumstances, in 
 consequence of grave and rare lesions of the intestines, the alimen- 
 tary matters may arrive at the termination of the intestinal tube, 
 without having traversed its whole extent. In the examination of 
 the body of an aged woman who died at Salpeteriere, in whom 
 there was disease of the gall-bladder, a large communication was 
 discovered, which permitted the finger to pass from the duodenum 
 into the enlarged gall-bladder, and from the latter into the trans- 
 verse colon ; a yellowish mass which filled these three organs 
 clearly indicated the course of the alimentary matters. Perfora- 
 tions between contiguous portions of the intestine, have been often 
 observed, producing similar results. Patients, in these cases, are 
 in a condition analogous to that produced by an artificial anus. 
 
 4. The alvine excretion or defecation (alvina excretio, defcecatio) 
 is the act by which the contents of the rectum are expelled from 
 the body. This may be more or less frequent than in the natural 
 state, constituting, in one case, diarrhoea (alvus citd), and in the 
 other, constipation (aim obstipatio, alvus compressa). 
 
 These two symptoms are so frequent, that there are few serious 
 diseases in which one or the other, and sometimes both succes- 
 sively, may not exist. Constipation and diarrhoea sometimes exist 
 to an almost incredible degree ; some patients have been known to 
 have no evacuation for several months ; in others, on the contrary, 
 the excretions are so frequent as almost to allow no interval 
 between them. We recollect a patient at the hospital De la Charite, 
 who was obliged for several days to keep a vessel constantly be- 
 neath him : the excretions were so frequent as hardly to allow 
 sufficient time for the vessel to be emptied of its contents. 
 
 Constipation, when habitual, and existing within certain limits, 
 is not a serious, and often not a morbid symptom. There are 
 individuals who do not go to stool oftener than once in eight, ten, 
 or even fifteen days, and experience no inconvenience whatever. 
 It is otherwise, if constipation supervene accidentally in persons 
 not habitually disposed to it, particularly if accompanied with 
 other derangements of health ; it is owing in such cases, either to 
 a want of action in the intestines themselves, or to some obstacle 
 to the course of the faecal matters. In the most aggravated cases of 
 this affection, the contents of the distended intestine, which cannot 
 be excreted, are rejected by the mouth. To this complex phenome- 
 non, marked by obstinate constipation, and the vomiting of the 
 contents of the stomach and intestines, the term ileus has been 
 applied. This, which the ancients considered a disease, is in fact 
 but a symptom, and may be occasioned by all the causes capable 
 of producing occlusion of the intestines, as external and internal 
 strangulation, invagination, schirrus contraction, tumors situated 
 either without or within their cavity, a foreign body, and sometimes, 
 
130 SYMPTOMS. 
 
 particularly in old persons, a voluminous mass of indurated faeces. 
 The latter cause may produce a kind of hectic fever called 
 stercoral, and even death. It is important that the physician be 
 familiar with all the causes capable of producing constipation, and 
 ileus, which is sometimes dependent upon it. 
 
 Defecation may be accompanied with pain in the anus or in the 
 abdomen ; these pains almost always occur in constipation ; they 
 are sometimes absent at the commencement of diarrhoea, but 
 often supervene when this affection has lasted for several days and 
 the evacuations have become very frequent. In certain diseases 
 of the rectum, defecation is exceedingly painful. To this pain is 
 sometimes added a constant and ineffectual desire to go to stool 
 together with a burning and smarting sensation about the anus ; 
 this constitutes tenesmus or epreintes (desidendi conatus), a symp- 
 tom peculiar to dysentery. Tenesmus is sometimes followed by 
 no excretion, sometimes a small quantity of bloody mucus is 
 squeezed out with violent efforts. Tenesmus should not be con- 
 founded with the pain excited by the excretion of faecal matters 
 in persons affected with haemorrhoids, fissures, or contraction of 
 the anus ; in all these cases, the excreted matters are of a healthy 
 consistence ; they act mechanically upon the parts, which they irri- 
 tate, but the desire of going to stool is only felt at remote intervals, 
 and the pain ceases or becomes diminished during the intervals. 
 In tenesmus, on the contrary, the pain and desire to evacuate are 
 constant, and the excreted matters are either remarkably altered 
 or do not exist at all. Tenesmus does not necessarily indicate an 
 affection of the large intestine. It sometimes depends upon pres- 
 sure exerted upon the rectum, by a tumor in the pelvis, or in the 
 uterus towards the close of gestation. Tenesmus in the male 
 may be also owing to the presence of a calculus, of greater or less 
 size, in the bladder. 
 
 Defecation, under some circumstances, takes place independently 
 of the will of the patient. This symptom presents itself under 
 various forms: 1, in some cases of diarrhoea, in which the patient, 
 thinking to expel wind, involuntarily allows the escape of fluid 
 matters ; the same phenomenon frequently occurs in schirrus of 
 the rectum ; 2, at other times he experiences a pressing desire to 
 evacuate, and the excretion takes place in spite of all his efforts to 
 the contrary ; 3, in other cases, it occurs without producing any 
 sensation, and sometimes, even without the knowledge of the 
 patient ; this happens in violent acute diseases, and towards the 
 close of chronic affections. This incontinence of faecal matters, 
 has been also observed in affections of the spinal marrow : invol- 
 untary discharge of these matters or of flatus, is often the first 
 index of these diseases. 
 
 There are some cases in which the excretion of the faeces be- 
 comes otherwise deranged ; the faecal matters are sometimes ex- 
 pelled from the body, before having traversed the whole length of 
 the intestinal canal. Either from the opening of an abscess into 
 the intestinal cavity or a wound of these organs, and more fre- 
 
SYMPTOMS. 131 
 
 quently from tfre occurrence of gangrene in strangulated hernia, 
 there is formed in the place of the wound or hernial tumor, either 
 a small opening called a stercoral fistula, through which a part of 
 the intestinal contents pass, or a supplementary or artificial anus, 
 which gives issue exclusively and uninterruptedly to the faecal 
 matters. 
 
 In some cases, in which the intestine opens into the bladder, 
 these matters are expelled mixed with the urine, but being here 
 also retained by a sphincter, the patient is in the same disgusting 
 condition, as if suffering from an artificial anus. In a very re- 
 markable, and perhaps the only, case on record, the faecal matters 
 pursued a still more extraordinary course. An old woman was 
 admitted to the Hotel Dieu (service of Dr. Husson) in such a state 
 of debility, as to be unable to give any account of her complaihts. 
 All that was noticed was that the bed was continually soiled by 
 faecal discharges. Upon examining the body after death, the large 
 intestines were found completely filled with voluminous faces, of 
 a stony hardness, and which must have been retained for several 
 months ; upon further examination, it was ascertained that owing 
 to cancerous ulceration, a communication had been formed between 
 the large intestine and the fundus of the uterus, and that all the 
 faecal matters passed through the cavity of the latter organ and 
 vagina, and ran out at the vulva. The specimen was presented 
 to me by Dr. Husson, the younger, and it has since been exhibited 
 to the students, in the amphitheatre of the Hotel Dieu. 
 
 4. The excreted matters or excrements (faces) present, in dis- 
 ease, numerous alterations, according to their nature, consistence, 
 quantity, color, odor, form, and the foreign substances occasionally 
 found with them. 
 
 These matters may be watery, as in the intestinal flux with 
 which Morgagni was attacked, and serous diarrhoea ; they may 
 partake of a mucous character, resembling the white of an egg or 
 the spawn of frogs, in some cases of chronic colitis ; they are bilious 
 in many diseases; their admixture with a certain quantity of 
 chyme, constitutes the codiac flux ( fluxus ccBliacus) * [chylous 
 diarrhcea] ; they consist of half digested food in lientery (lienterid)^ ; 
 they are streaked with blood in some cases of diarrhoea in which 
 the stools are very frequent ; blood is uniformly mixed with the 
 mucous discharges in dysentery ; it flows pure and liquid from 
 the anus, when it comes from the rectum, and particularly in the 
 haemorrhoidal flux ; it is black and changed when from the stom- 
 ach, as is often observed after haematemesis, in persons affected 
 with cancer of this organ. Liquid blood of a blackish color and 
 very fetid odor, when discharged from the anus in large quantities, 
 and in the course of a continued fever, indicates, almost with 
 certainty, the existence of liberations in Peyer's patches, and 
 becomes in some obscure cases a very important diagnostic sign ; 
 
 * JToiJia, belly. 
 
 t jJfievreQia, from Ztiog, smooth, and erreoor, intestine. 
 
132 SYMPTOMS. 
 
 for among all the acute affections peculiar to our climate, typhoid 
 fever is the only one in which these hemorrhages occur. Lastly, 
 a frequent or continual, and often involuntary, discharge of sanious 
 and stercoral matters, is one of the characteristic signs of cancer 
 of the rectum, and sometimes of fistula in ano. Finally, this 
 excretion may be mixed with pus in chronic inflammation and 
 ulceration of the intestines ; it is entirely purulent when an abscess, 
 contiguous to the intestinal canal, opens and discharges itself 
 into it. 
 
 The matters excreted from the anus may be in a gaseous, 
 liquid, or solid form. The faetidity of the gases becomes increased 
 in intestinal disorder and putrid fevers ; their quantity becomes 
 greater in hypochondriacs, who are relieved by its emission : this 
 excretion is sometimes suspended in obstinate constipation ; it is 
 painful in inflammation of haemorrhoidal tumors, dysentery, &c. 
 Excreted matters are, in some diseases, harder than in health, as 
 in cancer of the stomach, and particularly lead colic : in the latter 
 disease they form small black hard balls, resembling the excre- 
 ment of sheep, and are hence called ovilles.* When liquid, they 
 vary in consistence from that of water to that of pulp : in the 
 latter case they are termed pultaceous.\ 
 
 The quantity of excreted matters varies, both in each particular 
 excretion, and relatively to the number of excretions in a given 
 time. At the commencement of dysentery, the quantity of rnucus 
 expelled is so small as to resemble the sputa, and hardly to stain 
 the linen with which it comes in contact. In certain cases of 
 diarrhoea following obstinate constipation, and in cancerous con- 
 traction of the intestines, a single excretion sometimes furnishes 
 several pounds of faecal matter. When the discharges are very 
 frequent, as in the dysentery observed by Zimmerman, in which 
 some patients went to stool two hundred times in twelve hours, 
 the quantity of matter excreted was very considerable. 
 
 The form of the faecal matters, it is sometimes highly important 
 to ascertain ; as in cases of cancer of the rectum previous to ul- 
 ceration, in which they are elongated, and often flattened into the 
 form of a ribbon, and preserving to a certain extent the size and 
 form of the intestinal contraction. 
 
 The excretions are sometimes transparent and colorless, common- 
 ly opaque, and of a yellow, brownish or greenish, and sometimes 
 white, black or red color. The yellow color depends upon the 
 quantity of bile they contain. The peculiar color of yellow ochre, 
 which, they sometimes present in typhoid fever, is thought by Dr. 
 Bright to indicate the period when ulceration of the intestines 
 takes place. This opinion of the English pathologist has not as 
 yet been verified. Fluid alvine discharges, in which occur a greater 
 or less quantity of thick and whitish clots, resembling a decoction 
 of rice or whey, were characteristic of the Asiatic cholera ; it was 
 
 * Ovis, sheep, 
 f Puts, pulp. 
 
SYMPTOMS. 133 
 
 shown by chemical analyses made at Moscow, Warsaw, Berlin, 
 London, and Paris, that a portion of the elements of the blood, 
 the serum and the salts, were then evacuated by the intestine, 
 and that the white flocculi were formed by albumen in the con- 
 crete form, which seemed to be in excess in patients affected with 
 his disease. 
 
 If the stools be of a deep black color, the presence of blood is 
 indicated ; a dark green color depends upon the presence of bile. 
 The excreted matters sometimes resemble chocolate or coffee 
 grounds, which indicates that sanguineous exhalation has taken 
 place in the upper portion of the digestive tube, particularly 
 the stomach ; it is owing to blood which has undergone partial 
 digestion. 
 
 The peculiar fetidness of the excrements often becomes increased 
 in disease ; a cadaverous odor is noticed in adynamic fevers and 
 chronic ulceration of the intestines. They exhale the odor of 
 anatomical maceration in certain cases of malignant dysentery. 
 
 The faecal matters may contain foreign bodies, formed within 
 the body, or introduced from without. They often present mucous 
 pellicles or shreds, which appear to be the result of phlogosis of 
 the mucous coat, or of gangrene or ulceration of this membrane; 
 portions of intestine which have become separated by gangrene 
 after intestinal invagination, have been found in them ; also tu- 
 mors, biliary or intestinal calculi, different species of worms, &c. 
 
 Foreign bodies from without present the greatest variety : they 
 are sometimes substances incapable of affording nourishment ; and 
 sometimes, partially digested alimentary matters. Kernels envel- 
 oped in their epidermis,* as dry peas, for example, which have 
 been retained for several months, have been expelled unchanged. 
 
 The changes which take place in the nature, consistence, quan- 
 tity, and color of the excreted matters, do not depend solely upon 
 disease, being also the effect of remedies. The influence of pur- 
 gatives upon the frequency of the alvine excretions and consist- 
 ence of the excreted matters, is familiar to every one. Rhubarb 
 imparts to them a yellow and sometimes a reddish color, resem- 
 bling water, to which a few drops of blood have been added. 
 The preparations of iron give them a black color, probably from 
 the formation of a sulphuret of iron ; calomel imparts to them a 
 dark green color. Under these circumstances it is important not 
 to confound the phenomena of the disease with those produced by 
 remedies. 
 
 * De Sedib. et Caus. morb. epist. xxxi. art. 27. 
 
 12 
 
134 SYMPTOMS. 
 
 SECTION SECOND. 
 
 Symptoms furnished ly Respiration. 
 
 In the healthy condition, the respiration is easy, regular, and 
 without noise ; its* frequency, that is, the number of inspirations 
 and expirations in a given time, is relative to the age and condi- 
 tion of each individual. The number of respirations is generally 
 about thirty-five per minute in the first year of life, twenty-five in 
 the second, twenty, at puberty, and eighteen in the adult age. 
 It is a little more in females, lively persons and those of small 
 stature, than in those in opposite conditions ; this number becomes 
 increased in all persons after physical exercise, declamatory efforts, 
 profound emotions, &c. The dilatation of the chest in infancy 
 takes place principally by the motion of the ribs ; in old age, by 
 that of the diaphragm, and, in the adult, by the movements of 
 both combined. 
 
 In disease, respiration furnishes numerous symptoms. Having 
 first studied those which belong to the alternate movements of 
 inspiration and expiration, we shall proceed to consider those 
 which are accidental, as coughing, sneezing, &c. 
 
 $ I. Respiration, considered in the alternate movements of 
 inspiration and expiration, presents numerous changes in respect, 
 1, to the frequency of these movements; 2, their quickness; 3, the 
 quantity of air inspired and expired ; 4, the difficulty of respira- 
 tion ; 5, its irregularities ; 6, the sound accompanying it ; 7, the 
 qualities of the air expired ; 8, and finally, to these phenomena 
 should be added those furnished by auscultation, succussion, per- 
 cussion, inspection, and mensuration of the chest. 
 
 In order for the physician to appreciate v these various changes, 
 the patient should either be seated or upon the back ; he should 
 wait till the emotion occasioned by his presence shall have passed 
 away, and even then avoid the appearance of examining this 
 function, since such is the influence of the will, that it ceases to 
 act according to its ordinary rhythm the moment it attracts the 
 attention of the patient. The most simple mode of accomplishing 
 this, is to place the finger upon the pulse of the patient, while 
 counting with the watch the number of respirations in the 
 minute. 
 
 1. Respiration is frequent, when the number of inspirations and 
 expirations is greater, in a given time, a minute for example, than 
 in the ordinary condition ; it is rare, when the number is less. It 
 is only in cerebral affections that rareness of the respiration is 
 observed.* Its frequency, on the contrary, is increased in a great 
 number of diseases, and especially those of the heart and lungs. 
 
 * Floyer counted as few as seven respirations in the minute, in more than one 
 case of asthma ; and Graves has recorded as few as twelve in some cases of 
 fever. TRANS. 
 
SYMPTOMS. 135 
 
 2. Respiration is quick when the movements of inspiration and 
 expiration are performed with rapidity ; slow, in opposite condi- 
 tions. Quickness and frequency, slowness and rareness, exist 
 simultaneously in most thoracic diseases. In some cases, how- 
 ever, as in pleurisy, respiration is quick without frequency, or at 
 least its quickness far surpasses its frequency ; at other times, it is 
 quick and rare, as in the agony, in which the patient at long inter- 
 vals makes a rapid but ineffectual effort at inspiration, which is 
 succeeded by an interval of repose. 
 
 3. Respiration is full when the quantity of air inspired is 
 greater than usual ; small when less, as in pleurisy and peripneu- 
 monia. 
 
 The dilatation of the chest, and consequently the quantity of 
 air which penetrates the lungs, is not always equal in the two 
 sides. Pleuritic effusion, or the hepatization of a lung, is a more or 
 less complete obstacle to the entrance of the air into the corres- 
 ponding side. If the patient's chest be uncovered, it will be seen 
 that, while the movements of one side are in the normal propor- 
 tion, the other, which is the diseased side, remains immovable, 
 or nearly so. If, instead of examining these phenomena by the 
 eye only, one of the hands be placed on each side of the chest a 
 little below and outside the nipples, these differences become 
 doubly evident, being marked in proportion to the quantity of air 
 which the patient is compelled to inspire into one lung, in order 
 to the performance of the functions of both. 
 
 4. Dyspnoea* or difficulty of respiration, presents itself under 
 various forms. Respiration is simply laborious, when the respi- 
 ratory efforts of the patient do not oblige him to remain seated. 
 In many cases, it is not experienced by the patient, except after a 
 hurried walk, or ascending a flight of stairs. If the dyspnoea 
 compel him to retain the sitting posture, it is called orthopncea^ 
 which is particularly observed in the advanced stages of organic 
 affections of the heart, in the paroxysm of suffocation in pulmo- 
 nary emphysema and nervous asthma, and in double hydrothorax 
 and simultaneous inflammation of the two lungs. When there 
 is at the same time danger of suffocation, it is termed suffocating, 
 panting dyspnoea ; lastly, there is painful dyspnoea, in which the 
 thoracic movements are as it were arrested by the pain experienced 
 in executing them, as in pleurisy. High respiration is that in 
 which the patient is obliged to remain sitting, as in orthopnaea, 
 and to dilate the thorax, by elevating its sides, as in full respira- 
 tion. Difficulty of respiration is*sometimes so great, that the con- 
 tractions of the inspiratory muscles, and particularly those of 
 the diaphragm, are as it were convulsive : the chest and abdomen 
 are alternately raised, the neck is bent backward, the point of the 
 sternum, at each inspiration, is drawn towards the spine, partic- 
 ularly in children, and in some cases all the muscles in the body 
 
 * Jvartvota, from Svg, with difficulty, and nvtw, I breathe. 
 t OgQoTivoia, from OQ&O?, right, and 7rveu>, 1 breathe. 
 
136 SYMPTOMS. 
 
 are in a state of spasm, indicative of the anxiety of the patient 
 and of his inability to produce sufficient dilatation of the chest. 
 Finally, respiration may be completely suspended, constituting 
 apncea* Difficulty of respiration presents also this remarkable 
 peculiarity, that in some cases, both the inspiration and expira- 
 tion are equally difficult, and in others, one of these movements, 
 which is always expiration, is performed with a degree of free- 
 dom, while the other is very laborious, as is observed in oedema of 
 the glottis. 
 
 In some cases of habitual dyspnoea, it is important accurately to 
 ascertain the period at which this phenomenon first made its 
 appearance, as this knowledge may enable us to determine the na- 
 ture of the organic lesion which produces this derangement; it 
 appears from the researches of M. M. Louis and Jackson, that dys- 
 pnoea which has lasted from infancy, particularly when occurring 
 in paroxysms, is an almost pathognomonic sign of pulmonary em- 
 physema, f 
 
 5. Respiration is unequal when the quantity of air inspired 
 varies in a certain number of successive inspirations ; it is irregu- 
 lar when the intervals between the alternate movements of respi- 
 ration are unequal, or do not occur in the usual order; as in 
 intermittent respiration, in which the interval between certain 
 expirations and the following inspiration, is sufficiently long for 
 the performance of an entire respiration ; also in interrupted res- 
 piration (interrupta\ in which inspiration and expiration, but 
 half performed, succeed each other with rapidity, without being 
 separated by an interval of repose ; also in broken respiration, in 
 which the dilatation of the chest takes place by several inspiratory 
 efforts, and its contraction by as many successive expiratory move- 
 ments. This respiration resembles that of persons weeping; it 
 has been also observed in hysteria, and often in the rigor which 
 forms the first stages of intermittent fevers. 
 
 6. In health, a slight, and almost imperceptible murmur accom- 
 panies respiration; during sleep, there may be more or less 
 snoring. In disease, the respiration may become sibilant, sighing, 
 plaintive, stertorous, or rattling. Sibilant respiration is charac- 
 terized by a peculiar whistling sound, and is sometimes heard both 
 in inspiration and expiration, as in the most severe forms of pul- 
 monary emphysema, and particularly in compression of the trachea 
 by a tumor ; in other cases, as in some anginose affections, it only 
 accompanies inspiration. Sighing respiration (suspiriosa) is that 
 in which, at intervals, after a full inspiration, prompt expiration 
 takes place, accompanied by a peculiar sound, called a sigh. 
 Plaintive respiration (luctuosa) is characterized by groaning which 
 accompanies each expiration ; this has been particularly observed 
 in phlegmasiae of the chest, and in some grave fevers. A sound like 
 that of Si flute, or that produced by a brazen tube, sometimes ac- 
 companies inspiration. This symptom is not unfrequently noticed 
 
 * A privitive, TTSVO, I breathe 
 
 t Mem. de la Soc. Med. d'Observation, p. 186. 
 
SYMPTOMS. 137 
 
 in croup ; in some cases, but more rarely, expiration is alone sono- 
 rous, the sound in the inspiration being obscure. Stertorous 
 respiration, is that accompanied by a loud and vibrating sound ; it 
 is observed in severe cases of apoplexy, and in the second stage of 
 the epileptic paroxysm ; in rattling respiration, this sound is more 
 feeble. Stertor differs from snoring in the difficulty of the thoracic 
 movements attending the former, and in the place where it is pro- 
 duced ; stertor appears to proceed from the trachea and larynx ; 
 snoring from the nasal fossse or posterior part of the mouth. 
 
 7. The changes produced by disease in the expired air, relate to 
 its temperature, odor and chemical composition. The breath is 
 burning in inflammatory fever, cold in adynamic affections and 
 cholera. Its odor is sweetish in certain febrile diseases, acid in 
 some affections of the stomach. In some cases, this acidity is so 
 marked as to impregnate the air of the apartment ; this symptom 
 always indicates a grave and generally fatal lesion of the stomach. 
 The breath is fetid and nauseous in bilious fevers and gastric 
 irritation : it is sometimes alliaceous, or resembles the odor of a 
 dead body after maceration, in gangrene of the lungs and certain 
 cases of chronic pleurisy with perforation, sometimes even before 
 the sputa present this character. It is hardly necessary to remark 
 that the odor of expired air does not depend solely upon diseases 
 of the respiratory organs; those of the teeth, mouth, nasal fossae, 
 and pharynx equally affect it, as in mercurial salivation, scorbutic 
 swelling of the gums, membranous pharyngitis and sylphilitic ul- 
 ceration of the throat, affections in which the breath becomes 
 intolerably fetid. 
 
 Chemistry has furnished physiology with valuable results in 
 respect to the changes which the air undergoes in the healthy lungs. 
 It is to be regretted that it has not yet afforded an explanation of the 
 modifications which are incontestably produced in the various affec- 
 tions of the air passages. Inflammatory induration of the lungs, 
 the presence of tubercles in this organ, its compression by pleuritic 
 effusion, inflammation of its mucous membrane, together with the 
 membranous concretions which form upon it in some cases, are 
 all affections in which the air that penetrates the lungs, undergoes 
 modifications, which it would be interesting fully to appreciate, 
 and which certainly differ from those that take place in health; 
 unhappily, the researches undertaken by Nysten and some others, 
 have as yet thrown little light upon this point in pathology. It 
 was remarked by John Davy and afterwards by M. Rayer, that, in 
 the cold stage of Asiatic cholera, no change, or almost none, was 
 effected in the air, by respiration. * 
 
 8. To these phenomena, which have for a long time attracted 
 the attention of physicians, may be added those discovered by 
 Laennec, and which are only perceptible by means of an acoustic 
 cylinder, called a stethoscope,! or by the immediate application of 
 
 * Gaz. Medical, 1832. 
 
 t From ortjQog, chest, and OXOTCSW, I examine. 
 12* 
 
138 SYMPTOMS. 
 
 the ear to the chest. This method of exploration constitutes in the 
 first case mediate, and in the second, immediate, auscultation, of 
 which Laennec may be said to be the inventor ; for if it be true that 
 the application of the ear to the parietes of the chest, and the ap- 
 preciation of the sounds there produced, be twice mentioned in the 
 works of Hippocrates, it is no less certain that these two passages, 
 justly forgotten from their insignificance and obscurity, did not 
 lead to the discovery of a method of exploration, which, in a few 
 years, Laennec so far perfected, that time has neither added to, 
 nor detracted from, the results of his observation.* 
 
 If the ear be applied directly, or armed with the stethoscope, to 
 the chest of a healthy person, during inspiration, a very soft sound, 
 or murmur, is heard, produced by the entrance of air into the cells 
 of the lungs. This sound is not equally distinct in all parts of the 
 chest, being most apparent where the walls of the chest are thinnest, 
 as in the hollow of the armpits, below the clavicles, and below 
 and within the scapulae. It is much louder in children than in 
 adults. In the latter, it varies in intensity, independently of any 
 lesion of the lungs ; in some persons it is only perceptible during 
 rapid inspiration; in others it preserves the characteristics of 
 puerile respiration through life. If auscultation be practised dur- 
 ing expiration, no sound, in some cases, can be distinguished ; in 
 others, a slight murmur is perceptible, but less distinct and of 
 shorter continuance than that heard in inspiration. 
 
 In disease, the natural murmur heard during inspiration, may 
 be diminished, cease, be increased or replaced by other and very 
 different sounds, in a greater or less portion of the chest. 
 
 The respiratory murmur becomes less distinct, at the com- 
 mencement of those diseases of the chest, which at a later period 
 cause complete suspension of the respiratory sound in the portion 
 of lung affected. This suspension occurs in the second and third 
 stage of pneumonia, in emphysema, cancerous and tubercular 
 degeneration, cysts and other accidental productions developed in 
 the pulmonary tissue, effusions of serum, pus, blood or air into the 
 cavities. The vesicular murmur may become less distinct, or en- 
 tirely suspended, throughout a greater or less portion of the lungs, 
 when there is compression of the principal bronchus, by a tumor 
 in the thorax. This is sometimes observed in cases of aneurism 
 of the aorta, and this symptom may indicate the direction in which 
 the tumor is developed. In some of these diseases, the ear can 
 distinguish no natural respiratory murmur or sound whatever ; 
 this is the case in great pleuritic effusion ; in most other diseases, 
 the respiratory murmur is replaced by morbid sounds, to which 
 we shall allude hereafter. 
 
 The absence of the respiratory sound in a portion of the chest, 
 may be fixed and permanent in the hepatization of pneumonia ; 
 
 * De r Auscultation Mediate, ou Traite du diagnostic des Maladies des poumons 
 et du Caeur, fondd principalement sur ce nouveau moyen d ' exploration, par 
 R. T. H. LAENNEC. 
 
SYMPTOMS. 139 
 
 Laennec observed in some cases of pulmonary catarrh, a transient 
 suspension of this murmur in a limited portion of the lungs, a phe- 
 nomenon which he attributed to the momentary occlusion of some of 
 the bronchial tubes by the mucus secreted by the parts ; according 
 to him, this absence of the respiratory sound may cease and reap- 
 pear alternately, either in the same part or in any other. We 
 have never verified this phenomenon, and as the disease alluded 
 to by Laennec is a very frequent one, we cannot divest ourselves 
 of some doubts as to its production. 
 
 The respiratory murmur sometimes becomes more intense ; thus 
 it may acquire, in the adult, the force and tone which it presents 
 in children after forced exercise, in certain neuroses, and particu- 
 larly when the other lung hasr become wholly or partially unfit 
 for respiration. In the latter case, the respiratory murmur may 
 be increased, not only in the healthy lung, but also in the healthy 
 parts of the diseased lung. 
 
 In some cases, the vesicular sound does not present its natural 
 softness and smoothness, but becomes rude to the ear. Rudeness 
 of the respiratory murmur, as it occurs in inspiration and expira- 
 tion, is but the first degree of bronchial inspiration, and is observed 
 in those affections in which the latter phenomenon becomes after- 
 ward apparent. 
 
 This roughness of the respiratory sound is, in some cases, per- 
 ceptible in the expiration before becoming so in inspiration ; the 
 expiration is often at the same time prolonged. Dr. Jackson, of 
 Boston, was the first to call the attention of physicians to this 
 subject, and pointed out this phenomenon, when existing at the 
 summit of the lungs, as indicative of incipient tubercles. M. 
 Andral, in his notes to Laennec' s book, and, more recently, M. 
 Fournet, have more thoroughly investigated those diseases of the 
 lungs, in which the expiration becomes modified either in force or 
 duration. These phenomena are important in the diagnosis of 
 certain thoracic diseases, at that period of their development when 
 the characteristic signs are absent. ^ 
 
 In certain conditions, the soft murmur of respiration is replaced 
 by a louder and rougher sound, called bronchial or tracheal respi- 
 ration. This is supposed to be produced in the principal bronchial 
 divisions, by resonance of the air, which penetrates but partially or 
 not at all, into the ultimate ramifications or their terminating vesicles. 
 
 This sound or souffle is particularly audible, if the ear be applied 
 over an indurated portion of the lungs or a moderate pleuritic 
 effusion. It often proceeds from a dilated bronchus, or from exca- 
 vations produced by ulceration of the pulmonary tissue ; in the 
 latter case it is called cavernous respiration. 
 
 This last variety of sound is generally more superficial and 
 circumscribed than ordinary bronchial respiration. It is particu- 
 larly observed beneath the clavicles, in the supra and infra spinous 
 fossae and in the axillae. It is sometimes intermittent, the cavity 
 being occasionally filled with liquid, or the bronchial tube, com- 
 municating with it, being obstructed by mucus. 
 
140 SYMPTOMS. 
 
 Under the name veiled souffle [souffle voile], Laennec has de- 
 scribed a variety of blowing respiration, which is heard in a pul- 
 monary cavity, in which it seems as if each vibration of the 
 voice, cough or respiration, agitates a sort of movable veil 
 interposed between the cavity and the ear of the observer. Laennec 
 pointed out this phenomenon as occurring in those tubercular 
 cavities, whose walls are thin and not adherent to the chest, 
 abscesses of the lungs while surrounded with an inflammatory 
 induration, and some cases of dilated bronchi ; this phenomenon, 
 according to him, is very common in pneumonia, when the tissue 
 surrounding the bronchus from which the sound proceeds, remains 
 healthy or has suffered but slight engorgement. But the veiled 
 souffle of Laennec is not so frequenf as has been supposed, nor has 
 it the semeiological value which has been attached to it. It may 
 easily be confounded with the other degrees of bronchial sound. 
 
 The last variety of souffle is that called by Laennec the amphoric 
 sound, from its resemblance to that produced by blowing into an 
 empty vessel with a narrow neck, as a decanter or bottle. This 
 phenomenon is produced when the inspired air penetrates into a 
 vast hollow cavity in the parenchyma of the lungs, and particu- 
 larly when it passes into the cavity of the pleura, through an 
 ulcerated lung. 
 
 The different modifications of the respiratory murmur, just in- 
 dicated, become increased and diminished with the material lesion 
 on which they depend, furnishing the physician with valuable 
 signs, by which he is enabled to distinguish a diminution or in- 
 crease in the local disorder, when all the other signs, not excepting 
 those afforded by percussion, might be insufficient ; the return of 
 the respiratory murmur, in pneumonia and pleurisy, for example, 
 sometimes indicates the approaching recovery of the patient, 
 several days before the disappearance of the flat sound given by 
 percussion. 
 
 Auscultation of the chest, besides furnishing the physician with 
 the means o|pippreciating the changes in the intensity of the re- 
 spiratory murmur, also enables him to distinguish the different 
 sounds ordinarily produced by the passage of air through the 
 various liquids which may be contained in the bronchi. These 
 various sounds have by Laennec been designated by the term rale 
 or rhonchus, which he distinguished into the crepitant, subcrcpitant, 
 mucous, dry, sonorous and sibilant. 
 
 The crepitant rhonchus or crepitation, is a slight sound heard 
 on auscultation, and which has been compared to the crepitation 
 of salt when thrown upon hot iron. It is almost exclusively heard 
 in inspiration, and does not always entirely mask the respiratory 
 murmur, which becomes less distinct at this point. The rhonchus 
 which presents the above characteristics only occurs in the first 
 stage of pneumonia, and is consequently one of the most important 
 signs of this disease.* It is of equal value, when, instead of 
 
 * This rhonchus is also heard in certain forms of pulmonary congestion, in 
 eedema, apoplexy of the lungs, and, according to Stokes, in incipient phthisis. It 
 
SYMPTOMS. 141 
 
 being formed by numerous and distinct bubbles, it conveys to the 
 ear a dry, continuous sound, resembling that produced by rubbing 
 silk, or tearing a piece of taffeta. The latter is the most accurate 
 comparison, and the sound is often designated by the term, bruit 
 de taffetas. 
 
 There is another crepitant rhonchus heard in the commencing 
 resolution of pneumonia, when the lungs are passing from the state 
 of red hepatization (second degree) to simple engorgement (first 
 degree). This has been called byLaennec the crepitant rhonchus 
 of return or subcrepitant, being a variety of the dry crepitant, 
 rhonchus. It is formed by Bubbles, which are numerous, less 
 regular, larger and more moist, being more distinct during inspira- 
 tion than expiration. It belongs' also to capillary bronchitis, being 
 particularly evident at the base of the lungs. Some authors have 
 regarded this rhonchus as belonging also to pulmonary emphysema ; 
 but according to M. Louis, it only exists in this disease when com- 
 plicated with pulmonary catarrh, and in this case, results from the 
 bronchitis, and not from the dilatation of the vesicles. When this 
 rhonchus is continuous, confined to one of the scapulae fossae 
 or to some point just beneath the clavicles, and does not succeed 
 pneumonia, it indicates the presence of tubercles in their softening 
 stage. The subcrepitant rhonchus which depends upon this grave 
 lesion, ordinarily consists of bubbles which are larger and fewer 
 than in the subcrepitant rhonchus of simple catarrh ; they are also 
 somewhat ruder in sound, being generally designated by the term 
 moist or dry crackling, according to the sensation produced upon 
 the ear. This constitutes the first degree of a phenomenon which 
 will be hereafter considered, called gurgling (gargouillemenf). 
 
 The mucous rhonchus consists of still larger bubbles, which are 
 more moist and ordinarily more unequal than the preceding ; it 
 is produced by the passage of the air through fluids contained in 
 the trachea or bronchi, or acccumulated in the ulcerated cavities 
 which succeed tubercular softening. This sound is similar to that 
 heard in the throats of dying persons. It sometimes exists over a 
 large extent of the chest in those affected with pulmonary catarrh, 
 and is always confined to one or more circumscribed spots t in 
 phthisis. It often disappears after coughing, from the displacement 
 of the mucus by which it is produced. 
 
 In some diseases, if the ear be applied over some point of the 
 chest, a sound is distinguished analogous to that produced by the 
 agitation of a liquid mixed with air bubbles. This phenomenon, 
 which in its lightest form may be easily confounded with the mu- 
 cous and subcrepitant rhonchi, but which is easily distinguishable 
 from these when strongly marked, has been termed gurgling or 
 the cavernous rhonchus. It is chiefly heard at the summit of the 
 lungs, and is a certain sign of cavities arising from tubercular 
 
 is a curious fact, mentioned by Hourmann and Dechambre, that in old persons 
 the babbles which produce this rhonchus are larger, owing to the increased size 
 of the pulmonary cell, caused by the absorption of the intercellular tissue. 
 TRANS. 
 
142 SYMPTOMS. 
 
 softening. It may also exist, though more rarely, in dilatation of 
 the bronchi and in the cavities produced by circumscribed gangrene 
 or pulmonary abscass, but generally in such cases so differing in 
 situation and extent, as not to lead to error in the diagnosis. In 
 order to the production of this sound, the cavity should not only be 
 entirely rilled with liquid, but in extensive communication with 
 the bronchi. It is chiefly audible when the patient coughs, or 
 draws a full and deep inspiration. 
 
 Gurgling is, in most persons, heard over a circumscribed and lim- 
 ited space, one or two inches in size, for example. In cases where 
 it is perceptible over a greater extern, it commonly varies in inten- 
 sity and form, at different points, and the cause of this is easily 
 explained ; this phenomenon being almost always produced by the 
 agitation of air with a liquid in ulcerated cavities following tuber- 
 cular softening, and these cavities being often numerous and vary- 
 ing in their size and form, in the quantity and consistence of the 
 fluids which they contain, and the different conditions of the open- 
 ing by which they communicate with the bronchial tubes, the 
 sounds resulting from this agitation must vary at different points 
 within a short distance of each other. 
 
 There are, however, some cases in which a manifest gurgling 
 is distinctly audible, over the whole of one side of the chest, together 
 with a dull sound on percussion, the gurgling being everywhere 
 the same as to its intensity and form. The diagnosis, in the first 
 case of this kind that I observed, was so obscure, that I hesitated 
 in giving an opinion. The patient had, at first, presented all the 
 signs of a considerable pleuritic effusion ; dull sound, absence of 
 respiratory murmur and vocal resonance, together with dilatation of 
 the diseased side. When I saw him, a month afterwards, the dull 
 sound still continued ; but to the ear, applied successively in front, 
 behind, above and below, a gurgling sound was everywhere dis- 
 tinguishable, the same in form and degree, as if the pulmonary 
 tissue had been entirely transformed into a multitude of ulcerated 
 cavities, alf presenting similar phenomena, and consequently ma- 
 terial conditions exactly identical, a circumstance which, without 
 being strictly impossible, was entirely inadmissible. This young 
 man after leaving Paris died in the provinces; no examination 
 after death was made. 
 
 I again observed this gurgling, uniform in rhythm and intensity, 
 together with a dull sound on percussion, over the whole of one 
 side of the chest, in a patient at La Charite. This man rejected 
 by the mouth, a few days after his entrance into the ward St. Jean 
 de Dieu, more than a pound of fetid pus, which must have come 
 from the cavity of the pleura. This second case afforded me the 
 explanation of the former, and led me to suppose that an excava- 
 tion formed in the pulmonary tissue, opening into the bronchial 
 cavity, and situated just beneath the pleura, the cavity of which 
 is filled with pus, may, under some conditions not yet with cer- 
 tainty determined, if a thin pellicle alone intervenes between the 
 ulcerated cavity of the lungs and the pus contained in the pleura, 
 
SYMPTOMS. 1 43 
 
 or if there exist a valvular opening preventing the passage of air 
 into the pleura and the production of pneumo thorax, give rise to a 
 phenomenon as remarkable as that observed in the two cases just 
 alluded to. The gurgling was probably produced, as it ordinarily 
 is, in the tubercular cavity, and thence transmitted to the whole 
 periphery of the chest by the liquid contained in the pleura, as, 
 under other circumstances, this liquid transmits the voice (ego- 
 phony), and the respiratory murmur bronchial respiration.* 
 
 The patient last alluded to, after having vomited pus in abun- 
 dance, and at various times, gradually recovered so as to be able 
 to leave the hospital. I advised him, should the symptoms again 
 present themselves, to return. He, however, finally recovered, at 
 least to all appearance. This case, though incomplete, fixed my 
 opinion upon the value of this symptom, which I believe has not 
 before been pointed out. 
 
 A third case, more recently observed at Hotel Dieu, gave 
 farther evidence of the value of this sign. A negro who was ad- 
 mitted into the ward Sainte Madeleine, presented symptoms of 
 pleuritic effusion, with intense fever: to these phenomena, was 
 soon added a gurgling similar to that which occurred in the two 
 other cases, being audible over the whole of one side of the chest, 
 and everywhere under the same form and with equal intensity. 
 A few days after, a large quantity of pus was rejected by the 
 mouth. After the death of the patient, we were able to ascertain 
 with certainty, that the cavity of the pleura being filled with pus, 
 communicated with the bronchi by means of a tubercular cavity. 
 The insufflation of air into the trachea showed the point at which 
 the pleura was perforated, and permitted us to trace the nstulous 
 track to one of the bronchial divisions. 
 
 In these three cases only, have I observed this form of gurgling 
 with the conditions described, and in all these the disease com- 
 menced in the same manner, by a pleuritic effusion. 
 
 I have twice observed a form of gurgling somewhat analogous 
 to that in the preceding cases, from which it should be distin- 
 guished. 
 
 A patient was admitted to the Hotel Dieu for a chronic affection 
 of the chest, who presented, independently of the cough, opaque 
 sputa, dyspnoea, and the other ordinary phenomena of hectic fever, 
 a dull sound over the whole anterior part of the left side of the 
 chest. At whatever point of this portion the ear was applied, 
 gurgling was audible ; this gurgling, as in the three other cases, 
 was everywhere the same as to form, but its intensity, instead of 
 
 * The co-existence of a pleuritic effusion with tubercular cavities in the lungs 
 is by no means rare, although the kind of gurgling which I have pointed out has 
 only been observed in a very few cases ; it is necessary then, in order to the 
 production of this phenomenon, not only that this complication exist, but that it 
 should exist under peculiar conditions, without which it could not take place. 
 This phenomenon appears to me a certain sign of the simultaneous existence of 
 the two lesions just indicated ; but iis absence by no means proves the non-exis- 
 tence of this complication. 
 
144 SYMPTOMS. 
 
 being the same wherever the dull sound existed, progressively 
 diminished from the summit of the thorax where it was f ery man- 
 ifest, to a point below the heart where it became obscured. I was 
 led to suspect in this patient a lesion analogous to those which ex- 
 isted in the three others, but confined to the anterior part of the 
 chest, in short, a partial effusion into the pleura with perforation 
 of the pulmonary parenchyma about to take place, or already 
 completed. The exceeding rareness, however, of pleurisies con- 
 fined to this region, and the progressive diminution in the gurgling 
 sound from the summit towards the base, caused me to be circum- 
 spect in the diagnosis. After death, we found at the summit of 
 the left lung, a collection of small tubercular cavities, in an extent, 
 of the size of a pullet's egg, the rest of the anterior portion of the 
 pulmonary parenchyma being indurated and presenting a grayish 
 appearance. In this case the gurgling had evidently been pro- 
 duced in the ulcerated cavities at the summit of the lung, and the 
 sound had been transmitted by the indurated lung, and in the 
 whole extent of the induration, with the progressive diminution in 
 intensity, above mentioned. I had occasion to observe in another 
 case, under analogous anatomical conditions, the same phenome- 
 non, but less marked and heard over a less extent. 
 
 It follows from these cases that a similar sound, heard over a 
 great extent, or over the whole of one side of the chest, should lead 
 us to suspect two distinct lesions, the one which gives rise to the 
 production, the other to the transmission, of the gurgling. The first, 
 generally consists of one or more ulcerated cavities in the pulmo- 
 nary parenchyma, the second, in induration of the lung, or pleu- 
 ritic effusion. If the gurgling be perceptible over the whole of one 
 side of the chest, with the same form and intensity, its transmis- 
 sion depends upon a pleuritic effusion ; it is owing to pulmonary 
 induration, if the sound, the same as to its form, progressively di- 
 minishes in intensity over the extent in which it is heard. In the 
 latter case, the transmission is almost always confined to a part of 
 the chest ; in the former, it ordinarily extends over its whole side. 
 
 The sonorous rhonchus is a dull sound, sometimes extremely 
 loud, which at one time resembles the snoring of a person asleep, 
 at another, the base note of a violincello, and occasionally the 
 cooing of a pigeon. This phenomenon must not be confounded 
 with the guttural sound produced by some persons when asleep, 
 and which any one may imitate at will. The latter is produced 
 in the throat ; that which we are now considering, proceeds 
 from the chest, and is only perceptible by auscultation. It seems 
 to depend upon a change in the thickness and humidity of the 
 bronchial mucous membrane. 
 
 The sibilant rhonchus commonly resembles a prolonged whistle, 
 low or acute ; sometimes, the chirping of small birds, the sound of 
 a pump, or the clacking of a valve. It appears to be owing to a 
 small quantity of very viscid mucus which partially fills up the 
 bronchial ramifications, or to swelling of the mucous membrane. 
 These two varieties of the dry rhonchus, but particularly the 
 
SYMPTOMS. 145 
 
 latter, occur in acute or chronic pulmonary catarrh, and at every 
 period of the disease. These rhonchi, both the sibilant and sono- 
 rous, are heard over almost the whole extent of the chest in patients 
 with typhoid fever ; they are louder, and audible over a greater 
 extent, than in bronchitis, although there is less dyspnoea than in 
 the latter affection. 
 
 Independently of the sound perceptible to the ear in the various 
 kinds of rhonchus, there sometimes exists, particularly with the 
 sonorous rhonchus, a sort of trembling, perceptible to the hand, in 
 that portion of the chest corresponding to the part affected. When 
 the lesion which produces the rhonchus is deeply seated, this 
 trembling is not so distinct ; the absence of this phenomenon be- 
 comes then a sign which may aid in determining the particular 
 seat of the disease. 
 
 There is another variety of sound, differing from the rhonchus, 
 which may be distinguished by auscultation during the respiratory 
 movements, and still more easily if the patient speaks or coughs. 
 This sound, called by Laennec metallic tinkling, resembles that 
 emitted by a plate of glass or metal when gently struck with a hard 
 body. This phenomenon has only been observed in patients with 
 ulcerated cavities in the lungs or pleuritic effusion. In both cases, 
 it appears indispensable to its production, that the cavity contain 
 a liquid together with air, and that it communicate with the bron- 
 chi. According to Laennec, this sound is produced by the reso- 
 nance of air agitated at the surface of the liquid, or the falling 
 of a drop of fluid from the summit of the cavity into the fluid 
 collected in the under part of it. Other physicians (M. M. Dance 
 and Beau) have endeavored to explain this phenomenon by sup- 
 posing that in the act of speaking, coughing or breathing, air 
 escapes through the pulmonary fistula into the liquid effusion, 
 and rises to its surface in the form of bubbles of a greater or less 
 size, which, in breaking, cause a vibration in the air above, thus 
 producing the resonance which constitutes metallic tinkling. * 
 
 * However satisfactory the explanations which have hitherto been offered 
 to account for this curious phenomenon, none has as yet been found to hold good 
 in all cases. 
 
 We have been kindly permitted to quote two cases which fell under the observa- 
 tion of Dr. J D. Fisher of this city, as proving the truth of this assertion, and 
 illustrative of the ingenious theory proposed by him, in accounting for the pro- 
 duction of this sound. 
 
 The first was a case of pneumothorax, in which the metallic tinkling was heard 
 in its maximum intensity over the right scapula, and at the acme of each respira- 
 tion. Upon examination, a communication was found to exist between the bronchi 
 and cavity of the pleura by means of a small opening, almost exactly opposite the 
 point where, during life, the sound was most distinct, and far above the level of the 
 fluid which was in small quantity and of the consistence of thick cream. Upon 
 examining this opening, it was found to be covered by a small semi-circular flap, 
 apparently formed by a thin lamina of the pleura, about three lines in diameter, 
 and which, upon blowing into the trachea, was forced open, a slight click being at 
 the same time audible. 
 
 The second case was that of a large cavity in the lungs, with exceedingly thin 
 walls, and in which the sound was also heard at the acme of respiration. This 
 13 
 
146 SYMPTOMS. % 
 
 Metallic tinkling is not always the same. Thus, when it takes 
 place in a cavity, it is only audible over a circumscribed space, 
 while, if symptomatic of pulmonary fistula and pneumothorax. it 
 is heard over a great extent. Laennec remarks that this phenom- 
 ena is more appreciable, when the fistula is large and the quantity 
 of air in the chest very considerable. 
 
 The metallic tinkling generally coincides or alternates with am- 
 phoric respiration. Great respiratory efforts render them more 
 manifest, and may reproduce them when not permanent. 
 
 There is still another phenomenon which we shall point out, not 
 without importance as a diagnostic and prognostic sign ; we refer to 
 thoracic succussion, a method of exploration employed by Hippo- 
 crates, and clearly pointed out in his works, but the semeiological 
 value of which he did not fully appreciate. This method consists 
 in forcibly shaking the patient's chest, while the ear is placed near 
 this cavity : the sound of fluctuation is then distinctly heard, some- 
 times extending to the assistants at a distance, and the patients 
 
 sound was produced after the death of the patient, by blowing through the trachea. 
 In this case, as in the other, the cavity was found to contain but little fluid, and 
 the bronchial opening, which was of considerable size, existed above its level, its 
 truncated portion being remarkably smooth. This opening was only discoverable 
 by blowing into the trachea, when, as the air passed into the cavity, the walls, 
 which were previously in close contact, and, as it were, glued together by the 
 viscid secretion of the part, were seen suddenly to separate with a sound almost 
 precisely similar to that produced during life. 
 
 It would appear then that, at least, in these two cases, the principal condition 
 necessary to the production of the metallic tinkling, according to the theory of 
 Dance and Beau, and the experiments of Fourriet, Bigelow and others, viz. the 
 existence of an opening below the surface of the fluid, was absent. The theory 
 of Laennec would also seem, in these cases, insufficient to explain this phenome- 
 non, as the sound occurred at regular intervals with each respiration, the patient 
 being in a state of rest. 
 
 In order to the farther elucidation of this point, Dr. Fisher made the following 
 experiment, which seems fully to confirm the views which he had previously enter- 
 tained. 
 
 Having inserted an elastic flexible tube into the neck of a distended bladder, 
 upon blowing into it, the amphoric resonance was distinctly heard. He now poured 
 a thick solution of gum arable into the tube, to render the conditions, as nearly as 
 possible, similar to those in the above mentioned cases, when upon again blowing 
 into it, a click exactly resembling the metallic tinkling was distinctly heard. 
 
 He concluded, from these observations and experiments, that if an unobstructed 
 opening into a large cavity, exist, amphoric resonance will be produced, while if 
 there be, in this opening, any impediment to the passage of the air, as viscid mu- 
 cus, or, as in the first case, a valvular formation, which suddenly yields, the me- 
 tallic tinkling is the result. 
 
 The following, then, are the conditions which, according to Dr. Fisher, are 
 necessary to the production of this sound; 1, a cavity of considerable size with 
 thin walls; 2, a communication between this cavity and the bronchia, by an open- 
 ing in which there exists some obstruction which suddenly yields to the force of 
 the air. 
 
 Without denying the possibility of the occurrence of this sound under the con- 
 ditions hitherto considered necessary to its production, it must be admitted that 
 there are cases in which these conditions entirely fail, and in which some other 
 explanation must be sought. The theory proposed by Dr. Fisher affords a satis- 
 factory explanation of this sound in cases which are inexplicable by any other, and 
 may be found to account for its production in nearly all cases. TRANS. 
 
SYMPTOMS. 147 
 
 themselves often perceiving it when executing any movement, as 
 descending a staircase, examples of which are related by Ambrose 
 Pare, Willis, Morgagni, Boyer, &c.* This sound, regarded by 
 Hippocrates as a sign of serous effusion in the chest, is never 
 heard in simple hydrothorax ; it only occurs in cases in which the 
 pleura contains liquid and air together, and is sometimes produced 
 when an enormous hollow cavity in the lungs exists. As we have 
 seen, metallic tinkling, amphoric respiration arid the hippocratic 
 fluctuation, are phenomena equally characteristic of a determinate 
 alteration ; wherever any one of these exist, the prognosis must be 
 grave, since it reveals the existence of pathological conditions 
 almost necessarily fatal. 
 
 Thoracic fluctuation should not be confounded with an analo- 
 gous sound sometimes produced in the stomach when the body is 
 shaken, the stomachal gurgling which has been before alluded to : 
 it is sufficient to be warned of this error in order to guard against 
 it. 
 
 Independently of these sounds that we have just considered, 
 and all of which are owing to the passage of air into the natural 
 or accidental cavities, there is another which depends upon the 
 friction of serous surfaces against each other. This sound has 
 been described by Laennec, under the term, ascending and de- 
 scending murmur (murmur ascensionis et descensionis). 
 
 But Dr. Reynaud was the first who thoroughly investigated 
 the anatomical conditions which give rise to this sound and as- 
 certained its true value as a 'diagnostic sign. In the ordinary act 
 of respiration, during the alternate movements of elevation and 
 depression of the thoracic parietes, there is a rubbing of the pul- 
 monary against the costal pleura ; but owing to the smoothness 
 and moisture of these surfaces, no sound is probably produced, or 
 if it exist, it is confounded with the natural murmur of respiration. 
 But when more or less roughness or inequality exists, produced by 
 false membranes adherent to the surface of the pleurae, a rough 
 friction sound, like that of rumpled parchment, a file, or new leather, 
 accompanying both respiratory movements, but particularly that 
 of inspiration, is audible at a point corresponding to this lesion. 
 In some cases, by applying the hand over this part, a peculiar 
 and characteristic tremor is perceived. The friction sound may 
 occur at the commencement of dry pleurisy, or towards the termi- 
 nation of pleurisy with effusion, when, in consequence of the 
 reabsorption of the fluid, the two opposite surfaces of the pleura, 
 covered with false membranes, come in contact. Laennec was 
 probably wrong in attributing the ascending and descending fric- 
 tion sounds to interlobular emphysema of the lungs. 
 
 -Besides these phenomena furnished by means of thoracic aus- 
 culation, there are others occurring in rare diseases, that have 
 not yet been observed since this mode of exploration became 
 known, which it cannot fail to reveal. 
 
 * Laennec, torn. ii. p. 587 ; 4 e edition. 
 
148 SYMPTOMS. 
 
 In hernia of the lungs through the intercostal muscles, for ex- 
 ample, the application of the stethoscope over the tumor would 
 undoubtedly enable us to hear the entrance and egress of the air, 
 thereby adding a new sign to the diagnosis of this affection. In 
 cases in which borborygmi are audible above the region of the stom- 
 ach, the existence of hernia of the stomach or intestines through 
 the diaphragm, might, according to Laennec, be safely inferred. 
 This certainty, however, cannot exist until an assertion, which is 
 probable, but the truth of which is not yet demonstrated, shall 
 have been confirmed by experience. The varieties presented in 
 the concavity of the diaphragm, and those which exist, conse- 
 quently, in the position of the stomach, the facility with which 
 sounds are transmitted to a certain distance, the peculiar noise pro- 
 duced by the rising of the air from the stomach into the oesopha- 
 gus, appear to us to justify the doubts that we have entertained in 
 respect to the pathognomonic value of this phenomenon. 
 
 Auscultation of the voice furnishes the diagnosis of thoracic dis- 
 eases with certain phenomena interesting to the observer, and 
 very useful in a diagnostic point of view. When a healthy man 
 speaks or sings, his voice generally produces over the whole extent 
 of the thoracic parietes a kind of vibration perceptible to the hand. 
 If the ear, or stethoscope, be applied to the chest, this vibration is 
 less apparent ; but a remarkable resonance is observed, particularly 
 in those regions where the soft parts are thinnest, or those corres- 
 ponding to the larger bronchi more or less superficially situated. 
 Thus, this vocal resonance is particularly apparent in the axillae, in 
 the superior and anterior regions of the chest, in the interscapular 
 space, and at the superior and internal angles of the scapulae, partic- 
 ularly the right, the lung of that side being more voluminous and 
 the bronchus larger. This natural resonance of the voice is want- 
 ing in some persons ; in others, it is hardly perceptible ; it is par- 
 ticularly observed in those who have a deep, sonorous voice, and 
 full chest. In disease, this resonance undergoes important modi- 
 fications ; it may be diminished, completely cease, or be replaced 
 by other phenomena, known as bronchophony, aegophony and 
 pectoriloquy. 
 
 The natural vibration of the thoracic walls is generally dimin- 
 ished in hepatization of the lungs ; it entirely ceases in cases of 
 pleuritic effusion, so that it is sometimes possible to mark exactly 
 the level of the liquid by the point where the resonance begins to 
 be again perceptible ; but this phenomenon is of far less importance 
 than those we are about to consider. 
 
 Bronchophony * is a resonance of the voice more or less loud and 
 diffused, an accurate idea of which may be obtained by applying 
 the stethoscope over the larynx of a person while speaking. In 
 disease, this phenomenon is produced under the same anatomical 
 
 bronchus ; (pwvrj, voice. In accordance with Greek etymology it 
 should be written broncophony ; but we have thought that the word created by 
 Laennec, and accepted by science should be preserved ; besides, the terms bronchi, 
 bronchial, are employed. 
 
SYMPTOMS. 1 49 
 
 conditions which give rise to tnbal or bronchial respiration, that is, 
 in red and gray hepatization of the lungs, pleuritic effusions, and 
 pulmonary induration produced by tubercular matter, melanosis, 
 &c. When broncophony and tubal respiration depend upon dis- 
 ease of the parenchyma of the lungs, these sounds remain the same 
 in whatever position the patient be placed. If, on the contrary, 
 they are owing to effusion, by placing the patient in different posi- 
 tions, these phenomena are rendered more marked', or more obscure, 
 and the point where they are produced, if nothing oppose the fall- 
 ing of the fluid in obedience to the laws of gravity, may become 
 changed. Now, observation shows that this is far from common, 
 and that in most cases, in which the effusion has existed but a few 
 days, the liquid remains within the same limits, whatever be the 
 attitude of the patient. In regard to the theory of bronchophony, 
 Laennec thought that it resulted from impermeability of the air 
 cells and ultimate bronchial ramifications, and the consequent 
 resonance of the voice in the large bronchial tubes. The explana- 
 tion of this, as of other phenomena, is a secondary consideration. 
 The phenomenon itself and its semeiological value are important 
 points, which happily are understood. 
 
 ^Egophony, * like bronchophony, consists in increased resonance 
 of the voice, but presenting different characteristics. This reso- 
 nance is sharp, trembling, or broken, like that of a goat, and 
 seems more like the echo of the patient's voice, than the voice 
 itself. If this phenomenon occur in a part adjacent to a large 
 bronchial trunk, towards the root of the lung for example, in addi- 
 tion to a remarkable resonance, and under the influence of these 
 two conditions united, the voice presents modifications, resembling 
 that produced by a counter placed between the teeth and lips of a 
 person while speaking, or bredouillement* which constitutes the 
 language of Punchinello. /Egophony may be perceptible in nearly 
 all parts of the chest; but it is heard particularly between the 
 spine and scapulae, around the latter bones, and in a zone two or 
 three inches wide, extending between the scapula and nipple. It 
 is sometimes distinguishable on the first day ; it however becomes 
 more marked in the few days following, and afterwards disappears, 
 the effusion being either absorbed or increased. This phenomenon, 
 may, like bronchophony, become obscure, disappear, or change its 
 place according to the position of the patient, if adhesions do not 
 prevent displacement of the fluid. 
 
 Laennec ingeniously explained the phenomenon of segophony. 
 by supposing it to be produced by the vibration of the voice, 
 transmitted through a thin and trembling layer of fluid. The 
 same author also remarked that a pleuritic effusion by compres- 
 sing the bronchial tubes, flattens them like the mouthpiece of a 
 
 *./fi, atyog, goat; tfmvi h voice. 
 
 f A precipitate and indistinct mode of utterance, in which a part of the 
 words only is pronounced, and several of the syllables viciously changed. It is 
 analogous to stuttering in some respects. TR. 
 
 13* 
 
150 SYMPTOMS. 
 
 bassoon or hautboy, instruments which produce a bleating sound. 
 The false membranes which sometimes cover the surface of the 
 pleura, have also been supposed to give rise to the same phe- 
 nomenon. 
 
 Whatever be its explanation, we cannot grant to this phenomena 
 all the importance attributed to it by Laennec, and consider it as 
 a pathognomonic sign of pleuritic effusion ; for, on the one hand, 
 there are many healthy persons in whom aegophony exists, 
 as Laennec himself admits ; and on the other, it has been 
 noticed in cases of hepatization of the lungs, as has bronchophony 
 in some cases of pleuritic effusion. If, however, aegophony be 
 not pathognomic of effusion, it should certainly lead us to suspect 
 its existence. It is sometimes difficult to distinguish between 
 segophony and bronchophony ; they often exist together, a circum- 
 stance which has led to the term broncho-aegophony. 
 
 Pectoriloquy* consists in a peculiar resonance of the voice, 
 which, in mediate auscultation, seems to issue directly from the 
 chest of the patient, and pass through the central canal of the 
 stethoscope; if the physician employ immediate auscultation, it 
 appears as if the patient were speaking in his ear. 
 
 Laennec distinguishes several varieties of pectoriloquy, which 
 he severally terms perfect, imperfect, and doubtful. The first is 
 alone of any real value. The two others, rather resemble bron- 
 chophony, or the ordinary resonance of the voice. They may be 
 distinguishable, in the healthy state, in certain parts of the chest, 
 particularly at the summit, and as far as nearly to the third rib. 
 But that circumscribed and distinct resonance of the voice, which 
 constitutes pectoriloquy, should be considered as pathognomonic 
 of a hollow cavity in the lungs, whether it be owing to a simple 
 dilatation of a bronchus, partial suppuration of the lungs, or, as 
 generally happens, to tubercular softening. 
 
 In order to the occurrence of pectoriloquy, the existence of a 
 well defined superficial hollow cavity in the lungs, of medium 
 size, that of a nut or small gullet's egg, for example, with hard- 
 ened walls, is necessary ; the cavity should be empty and commu- 
 nicate freely with the bronchi ; there must be absence of aphonia, 
 which is a frequent symptom in the last stage of phthisis, as if 
 this exist, pectoriliquy cannot be produced. The phenomenon 
 fails, or is less perfect, if the cavity be filled with a liquid, be 
 too large or irregular in its shape, and communicate with the 
 bronchi by means of small openings alone, which are not in pro- 
 portion to the size of the cavity. In general, pectoriloquy is more 
 apparent when the voice is sharp, than when low or hoarse. This 
 phenomenon disappears and returns alternately in some persons : 
 this intermittence is generally owing to the transient occlusion of 
 the cavities or of the bronchial tube which communicate with it. 
 Gurgling often accompanies pectoriloquy, and adds to its value as 
 a sign. 
 
 * YrorapectuSj breast ; loqui, to speak, 
 
SYMPTOMS. 151 
 
 Percussion, as well as auscultation of the chest, furnishes many 
 important signs, which we shall now proceed successively to con- 
 sider. 
 
 In disease, the sound of the chest, on percussion, may be clearer 
 than natural, more dull, or entirely flat. The sound becomes clearer 
 whenever the quantity of air in the chest becomes increased, and the 
 nearer this fluid is to the point percussed ; this is the case in pneu- 
 mothorax and pulmonary emphysema. In the first of these affec- 
 tions the chest sounds like a drum over a greater or less portion of 
 its extent ; in emphysema the sound is less clear in pneumotho- 
 rax, but clearer than in the healthy state. In both affections, the 
 clear sound may be confined to a limited space, or it may extend 
 over the whole of one side in pnenmothorax, and over both in 
 emphysema. In one of these diseases the excess of resonance is 
 owing to the presence of air in the pleura ; in the other, to its 
 accumulation in the dilated pulmonary vesicles. A sound clearer 
 than natural may also be elicited, when percussion is practised 
 over a large empty cavity superficially situated. If the cavity 
 be partially filled with a fluid, and the thoracic walls be thin and 
 elastic, the sound on percussion is that called by Laennec le bruit 
 de pot fele, the sound of the cracked pot, in which the resonance 
 of a cavity with gurgling is distinguished. This has as yet never 
 been observed except in phthisical patients, just beneath one of the 
 clavicles. 
 
 The sound of the chest becomes obscure or dull, whenever the 
 lung is indurated, or when a solid or liquid body interposes be- 
 tween this viscus and the thoracic parietes at the point percussed. 
 The sound of the chest is slightly diminished in pulmonary con- 
 gestion, the first stage of pneumonia, and some cases of tubercles 
 before becoming united into a compact mass, and in slight effu- 
 sions of liquid. It is completly flat (tanquam percussi femoris) in 
 all cases of pulmonary induration, in rare cases of tumors within 
 the chest, and finally, in liquid effusions so abundant as to press the 
 lungs backward towards the vertebral column. In the latter case, 
 by varying the position of the patient, it might be possible to alter 
 the results of percussion, if the effusion were partial, and there 
 were nothing to prevent the fluid from obeying the laws of gravity. 
 Nothing of this kind is observed when the dull sound is owing to 
 pulmonary induration, or the presence of a tumor. 
 
 In enumerating the causes which produce a dull or obscure 
 sound of the chest on percussion, we have not referred to the 
 adhesions of the costal with the pulmonary pleura, as, in our 
 opinion, they have no part in producing this effect. To be con- 
 vinced of this, it will be sufficient to recall those cases of phthisis, 
 in which the chest sounds clear over almost its whole extent, 
 although the adhesions are stronger, and a more constant symptom 
 in this than in any other disease. Adhesions do not affect the 
 resonance of the chest, unless there be serous or gelatinous infil- 
 tration into the cellular network of which they are composed. 
 
 Whenever the sound elicited by percussion is flat or even 
 
152 SYMPTOMS. 
 
 obscure, that peculiar elasticity which is always felt in percussing 
 a healthy chest, is no longer perceptible. There is, on the con- 
 trary, a feeling of hardness or resistance, which is in proportion to 
 the density of the body producing the dullness. 
 
 The rules relating to the employment of auscultation and per- 
 cussion, together with the semeiological value of the phenomena 
 furnished by these two important methods of exploration, will be 
 considered in the chapter on diagnosis. 
 
 $ II. Respiratory phenomena. Having now presented the prin- 
 cipal symptoms furnished by the respiration itself, we shall pro- 
 ceed briefly to consider some of the respiratory phenomena, as 
 laughing, yawning, sneezing, hiccough, coughing, exspuition, and 
 expectoration. 
 
 1. Laughing (risus) consists in an interrupted expiration, ac- 
 companied with a cheerful expression of the features, and partic- 
 ularly retraction of the lips. This is a phenomenon peculiar to 
 health, rather than a symptom of disease. There are, however, 
 many affections in which it occurs under the latter form, depending 
 either upon the state of the mind, as in the delirium of acute dis- 
 eases and certain forms of mental alienation, or upon a special 
 derangement of the nervous system, as in hysteria, and, as some 
 have asserted, in wounds and inflammation of the diaphragm. 
 
 2. In yawning (oscitatio) there is suddenly a deep, slow, and 
 sonorous inspiration, with separation of the jaws, and accompan- 
 ied with flexion, followed by the slow and gradual extension of 
 the limbs, and particularly the arms. This latter movement, 
 called pandiculation (pandiculatio) sometimes occurs without the 
 yawning, which it almost always accompanies. Both these 
 symptoms frequently appear at the commencement of the parox- 
 ysms in intermittent fever, and towards the close of an hysterical 
 attack. 
 
 3. Sneezing (sternutatio) consists in a violent and convulsive 
 expiration, by which the air is driven rapidly, and rushes sonor- 
 ously, through the nasal fossae, carrying with it the mucus adher- 
 ing to these parts. Sneezing, although, like yawning and stretching, 
 occurring in health, is a frequent symptom in coryza, and in the 
 first period of rubeola. 
 
 4. Hiccough (singultus) is the result of a sudden and involun- 
 tary contraction of the diaphragm, accompanied with contraction 
 of the glottis which prevents the entrance of air into the trachea. 
 This symptom occurs under various circumstances, as in the 
 lightest affections, and even in persons in perfect health, and in 
 very grave diseases, as, abdominal inflammation, and particularly 
 peritonitis, strangulated hernia, and all cases of stoppage in the 
 course of faecal matters, in which its appearance confirms the 
 diagnosis, and renders the prognosis more unfavorable. 
 
 5. The cough, (tussis) according to physiologists, consists in 
 violent, short, and frequent expirations, in which the expired air, 
 in passing through the larynx, produces a peculiar sound. This 
 is not a correct definition. One of the most constant phenomena 
 
SYMPTOMS. , 153 
 
 accompanying coughing is a momentary occlusion, or at least, a 
 considerable contraction, of the glottis. This contraction does not 
 concur alone in the production of the peculiar sound observed ; it 
 prevents the egress of air, which afterwards escapes with great 
 rapidity, thus more easily, by communicating to it the impulse 
 which it receives, carrying with it the mucus adherent to the 
 parts in its course. 
 
 Many varieties of cough have been admitted, of which the 
 principal are the idiopathic *. and sympathetic, moist and dry 
 cough. If the exciting cause of the cough be seated in any of 
 the air passages, it is idiopathic : it is called sympathetic when it 
 depends upon an affection of some viscus more or less remote. 
 The idiopathic cough may be guttural or pectoral, according as the 
 irritation which excites it, is above or below the glottis. The 
 sympathetic also varies with the organ which causes it. That 
 arising from an affection of the stomach, has been called stomachal 
 cough : it is said to be dry, to increase after a meal, to be accom- 
 panied with epigastric pain, nausea, and retching, and to be unaf- 
 fected by cough medicines and mucilaginous preparations, but to 
 yield to acid drinks, emetics, and spontaneous vomiting. A vermin- 
 ous cough has been admitted, supposed to be connected with the 
 presence of worms in the digestive canal, and which their expulsion 
 will alone remedy. Certain diseases of the liver give rise to a cough 
 called hepatic. A similar effect has been known to follow certain 
 affections of the uterus. Dahaen relates the case of a woman, 
 who was, for a long time, affected with continual coughing, and 
 who was not relieved of this troublesome symptom, until the spon- 
 taneous expulsion of a fibrous tumor from the uterus. 
 
 The moist cough (tussis humidd) is that which excites a more 
 or less abundant excretion of mucus by the mouth ; in the dry 
 cough (tussis siccd) there is no excretion. x ln most cases, the 
 cough occurs but once or twice in succession, then ceasing, to re- 
 turn again at a more or less remote period. When the cough is 
 both dry and obstinate, the term ferine has been applied to it 
 (tussis ferind). In many diseases, it occurs rapidly many times, 
 so that a single inspiration is followed by five or six successive 
 expirations, constituting paroxysms of coughing (tussis accessus). 
 It is, in such cases, accompanied with redness'of the face, watery 
 eyes, headache, tinnitus aurium, fullness of the cervical veins, 
 retching, and sometimes vomiting, as -is noticed in pertussis, 
 phthisis pulmonalis, and some varieties of bronchial catarrh. 
 Finally, the cough, in certain affections, presents a peculiar tone 
 and rhythm easily distinguishable, but difficult to describe. Thus 
 
 * The word idiopathic has been generally employed as synonymous with 
 essential, and applied to diseases rather than symptoms. But this word being 
 evidently the opposite of sympathetic, and it being impossible, in the present 
 state of the science, to apply the latter word to a disease, we have thought it 
 more proper to apply these two words to symptoms, reserving for disease the 
 words essential and symptomatic, these alone being suitable to the present state 
 and deficiencies of the science. 
 
154 SYMPTOMS. 
 
 in the last stage of phthisis, when the lung has become filled with 
 numerous and large cavities, the cough has a peculiarly hollow 
 sound ; in laryngeal phthisis the cough is low, hoarse, broken and 
 rough. In croup, it is said to resemble the bark of the dog, the 
 howling of the fox, the crowing of the cock, &c. Nothing precise 
 is indicated by these terms of comparison. 
 
 The exploration of the cough by auscultation, furnishes some 
 remarkable phenomena. The various kinds of rhonchus are gen- 
 erally more marked during coughing than during respiration : thus 
 in incipient penurnonia and in the same disease when on the de- 
 cline, the crepitant rhonchus is often imperceptible, except during 
 cough, or the full inspiration which follows it. In phthisical pa- 
 tients, if the ear be applied over the ulcerated cavities, a gurgling 
 is sometimes distinguished during the cough, which is entirely 
 imperceptible in the ordinary movements of respiration. In some 
 cases, instead of the gurgling, the fluctuation of a liquid is audible ; 
 this sound is similar to that produced by emptying a bottle of the 
 liquid it contains. 
 
 Exspuition (expuitio) is the act by which the matters accumu- 
 lated in the pharynx are rejected : it is by means of the guttural 
 cough, that exspuition is effected. The mucus of the posterior 
 part of the nasal fossae, which is carried back into the throat by a 
 peculiar inspiratory effort, a sort of snuffing, that of the bronchi, 
 which is forced up into the pharynx by the pectoral cough, are 
 both rejected in the act of exspuition. 
 
 Expectoration (expectoratio), a term which has been improperly 
 applied to the expectorated matter, is the act by which matters 
 contained in the trachea, and particularly the bronchi, are expelled 
 from them. This occurs in three different ways : 1. When the 
 bronchi contain but a moderate quantity of sputa, they are forced 
 by the pectoral cough into the pharynx, thence into the mouth, 
 and are finally rejected. 2. In cases in which a great quantity of 
 liquid is suddenly or rapidly poured into the bronchi, as in certain 
 cases of haemoptysis, or the rupture of an aneurismal cyst or 
 pleural abscess into the air passages, the expectoration resembles 
 vomiting; the lungs, strongly compressed by an almost- convulsive 
 contraction of the expiratory muscles, transmit this compression 
 to the bronchi; the liquid with which they are filled escapes 
 through .the glottis, and issues in abundance from the mouth, and 
 sometimes from the nose: this is a kind of pectoral vomiting; in 
 such cases the patient is often said, both by the physician and 
 others, to have vomited blood or pus. In nursing infants and chil- 
 dren previous to the fifth or sixth year of age, expectoration rarely 
 occurs in any other way. At this age, the sputa are generally 
 expelled by pectoral vomiting which follows the efforts to cough : 
 in other cases, after being forced into the pharynx by the pectoral 
 cough, they are carried by deglutition into the stomach, whence 
 they pass into the intestines or are rejected by vomiting, properly 
 so called. 3. In other cases, in which the quantity of fluid exhaleci 
 is small in quantity, it sometimes happens that this liquid rises 
 
SYMPTOMS. 155 
 
 
 
 gradually into the larynx and even the pharynx, without exciting 
 any cough, and is expelled by simple exspuition. This mode of 
 excretion, which is not uncommon in haemoptysis, it is difficult to 
 comprehend, particularly in the vertical position. Some physi- 
 cians have supposed, it is true, that, in such cases, the expectora- 
 ted matter is secreted in the larynx ; but this supposition, which 
 is without confirmation, leaves still unexplained the ascent of 
 the blood or mucus. It seems to us, on the contrary, that it 
 may be understood by taking into account, 1, the form of the 
 air passages, which, being narrow at their termination, become 
 gradually larger, to their junction with the trachea ; 2, the com- 
 pression which they undergo at each expiratory effort ; 3, the 
 specific lightness of the mucus, by its admixture with the air ; 4, 
 and particularly the difference in the duration of inspiration and 
 expiration : the latter being short, the air issues from the air pas- 
 sages with more velocity than it enters them, necessarily commu- 
 nicating to the matters contained in the bronchi and trachea an 
 ascending movement, which more than counteracts that imparted 
 to them by inspiration. 
 
 Thus, sometimes, matters, when poured in abundance into the 
 bronchi, are carried into the mouth by a single impulsion, as is ob- 
 served in certain cases of haemoptysis and emphysema, in which 
 the blood and pus are suddenly rejected in great quantity ; they 
 are sometimes arrested, as before stated, in the pharynx, and 
 afterwards forced by exspuition into the mouth, whence they are 
 rejected from the body. 
 
 The act by which the mucus lodged into the mouth or exhaled 
 into this cavity is rejected, is called spitting (excreation). When 
 this is often repeated, the phenomenon is termed crachottment ; it 
 occurs particularly in gastric derangement, and in cases in which 
 the mouth is bitter and pasty, and in nausea. Spitting, exspuition 
 and expectoration have this in common, that they may be produced 
 by a rapid expiration ; but the cause which produces expectoration 
 is below the glottis, that which excites exspuition is above, and 
 that of spitting is in the mouth ; in the first case, the obstacle 
 which augments the force of the expired air is the glottis, in the 
 second, the isthmus of the fauces, and in the third, the lips.* 
 
 Expectoration, exspuition and spitting may be rare or frequent, 
 easy or laborious, and sometimes impossible. They are often ac- 
 companied with pain, as is observed in peripneumonia, angina and 
 inflammation of the tongue. 
 
 The term sputa, is applied to the matters which come from the 
 bronchi, trachea, larynx, pharynx, isthmus of the fauces, and the 
 posterior part of the nasal fossae or mouth, and which are rejected 
 through the opening of this latter cavity, commonly in a liquid 
 form, and in small masses at once. These matters are generally 
 the result of a morbid secretion of the mucous membrane which 
 covers these organs, or of their glands and follicles ; they may 
 
 * The words exspuition and spitting having heen vaguely employed by authors, 
 we have thought it better to give them a precise signification. 
 
156 SYMPTOMS. 
 
 
 
 also be formed in the substance of these parts or proceed from 
 those more remote, having forced a way into their cavity. 
 
 The formation of sputa is not incompatible with health. There 
 are many persons, who every day reject a certain quantity, either 
 from the mouth or pharynx, or from the trachea or bronchi, 
 without being supposed to suffer from disease. 
 
 The sputa present remarkable differences, according to the parts 
 from which they proceed. In order correctly to appreciate their 
 different qualities and quantity, the physician should require that 
 there be a vessel for the exclusive purpose of receiving them. 
 
 Their qualities can be but imperfectly determined when mixed 
 with urine, or received upon a cloth which absorbs their more 
 fluid portion. 
 
 The sputa formed in the mouth, are more often owing to an 
 increased secretion of the mucous membrane, than to that of the 
 parotid, submaxillary and sublingual glands. They are com- 
 monly clear and almost serous, like the saliva itself; they rarely 
 acquire much consistence or opacity, unless in acute diseases of 
 the gravest character. They may flow from the mouth, by their 
 weight alone ; they may be drawn out without the assistance of 
 the organ which contains them ; but they are generally expelled 
 by the peculiar act to which the term spitting or sputation has 
 been applied. 
 
 The sputa from the isthmus of the fauces and pharynx, are 
 generally owing to inflammation of these parts ; they are clear, 
 tenacious and ropy, sometimes mixed with small cheese-like lumps, 
 which proceed from the follicles of the tonsils, and in certain cases, 
 with pus, formed, either in the tissue of these glands, or in the 
 substance of the velum pendulum palati, or, what is rare, in the 
 parietes of the pharynx, and are rejected by exspuition. 
 
 The sputa which come from the larynx and trachea are gen- 
 erally small in size and quantity, and differ but slightly from those 
 furnished by the bronchial ramifications in analogous affections. 
 
 The study of the latter (expectorated matters) is of the highest 
 importance in all respects ; they are generally the result of a mor- 
 bid secretion of the mucous membrane ; but in many cases, they 
 proceed from other parts, particularly the parenchyma of the lungs, 
 and the pleura ; and sometimes from the neighboring large arteries, 
 liver, or the cellular tissue which unites this viscus to the dia- 
 phragm. 
 
 The sputa, considered independently of their origin, and in 
 regard only to their physical qualities, present numerous varieties, 
 which have received distinctive appellations. 
 
 They are called serous, when clear and resembling water ; mucous -, 
 when of a thicker consistence ; and viscid, when adherent to the 
 vessel in which they are contained : this viscidity is sometimes so 
 great that the vessel may be turned upside down, without their 
 becoming detached, or even, in some cases, their molecules moving 
 among themselves. The sputa are called sanguinolent, when 
 they consist of a mixture of blood and mucus, as in pneumonia ; 
 
SYMPTOMS. 
 
 157 
 
 bloody, when they contain pure blood, as in haemoptysis. They 
 are said to be spotted or streaked with blood, when this liquid 
 appears in small masses or in streaks, as in severe bronchitis ; 
 frothy, when mixed with bubbles of air, giving them the appear- 
 ance of froth ; purulent, when they contain pus, and puriform, 
 when they only appear to contain it. 
 
 Their color also presents numerous varieties ; they may be 
 white, yellowish, rusty, greenish, red, brown, black, or gray ; in 
 some cases, transparent, in others opaque, and often, colorless. 
 They may also present different shades of color at once. Their 
 form is generally rounded when they are easily detached from the 
 mouth, and not adherent to its sides ; they are, on the contrary, 
 elongated, stringy, or stellated, when viscid ; this latter form is fre- 
 quently observed in typhoid fever. They are sometimes firm, dis- 
 tinct, and almost hemispherical ; sometimes frothy, flattened, and 
 run together so as to form an homogeneous mass. They vary also 
 in consistence ; this is, in some cases, aqueous, in others, similar to 
 that of a solution of gum arabic, the white of an egg, or even gluey ; 
 they are still thicker in some cases of chronic catarrh, in which they 
 appear nearly solid. Their odor is generally slight ; it is sometimes 
 ammoniacal, fetid and alliaceous like that of the breath, (p. 137.) 
 Their taste, in some cases, is sweetish ; in others, saltish, bitter or 
 sour ; but the taste generally attributed by patients to the sputa, is 
 rather that of the coat which covers the lining membrane of the 
 mouth,' or the drinks which they take. In some persons, the sputa 
 cause a sensation of cold, or heat in the parts over which they pass ; 
 but their temperature is generally that of the body. Their volume 
 varies in the same persons ; in some, however, they are extremely 
 small, or are remarkable for their large size ; in the latter case they 
 may form discs, from one and a half to two inches in diame- 
 ter. They vary also in quantity ; being small from some patients 
 each day, while others are spitting continually, so as to fill the 
 vessel several times in the course of twenty-four hours. It should 
 also be remarked that in the same individuals, the sputa may differ 
 widely, in all respects, not only in the different periods of the same 
 disease, but also in each nycthemerum ; * they are generally more 
 abundant, consistent, more opaque and more easily rejected in the 
 morning than at other periods of the day. Finally, it is not un- 
 common for the same individual to reject, in the course of a few 
 minutes, several sputa, differing from each other principally in re- 
 gard to their color and consistence. These differences are still 
 more marked in patients, who, already affected with a chronic dis- 
 ease of the lungs, are attacked with acute inflammation of these 
 viscera : in such cases, the sputa resemble those from two different 
 patients who make use of the same spit-cup, but are in fact the 
 result of two diseases of the same organ, in the same individual. 
 
 To these considerations respecting the various appearances of the 
 sputa, we shall add others which are the consequence of the first, 
 
 * Nv*, night; ?(?, day. 
 
 14 
 
158 SYMPTOMS. 
 
 and which enable us to determine, from their inspection, the organ 
 from which they proceed, and the nature of the disease with which 
 that organ is affected. 
 
 The manner in which the sputa are rejected often suffices to in- 
 dicate their origin ; those that are rejected by simple sputation, or 
 which flow out of the mouth, by their own weight, originate in 
 this cavity ; those which have been forced by a sort of snuffing, 
 or by exspuition, into the mouth, proceed, in the first case, from 
 the nasal fossse, in the other, from the larynx or pharynx ; those 
 which are carried into the mouth by the pectoral cough (expectora- 
 tion), come from the trachea or bronchi, into which they have been 
 exhaled or poured, owing to grave alterations of the pulmonary 
 parenchyma, pleura, and even more remote organs. It is useful, 
 though not always indispensable, for the physician to know the 
 manner in which the sputa are rejected, in order to ascertain their 
 origin ; their inspection alone suffices for the solution of the double 
 problem, under consideration. 
 
 The serous and frothy sputa sometimes originate in the mouth, 
 and sometimes in the bronchi. In the first case, if the mouth be 
 free from alj lesion, they indicate, either an affection of the stom- 
 ach, or, in the woman, pregnancy. If the membrane of the mouth 
 be of a bright red color, they announce an approaching apthous or 
 pseudo-membranous eruption ; if they are owing to mercurial in- 
 fluence, the swelling, redness, patches, whitish excoriations, and 
 the specific odor of the mouth, would enable us to distinguish them 
 from the first. The serous and frothy sputa, the result of expec- 
 toration, are observed in pleurisy and incipient bronchial catarrh. 
 In the former case,, their quantity is very small, in the latter, it may 
 be very considerable. 
 
 The mucous sputa generally come from the larynx, pharynx, 
 bronchi or nasal fossse. Some patients reject every morning on 
 awaking, one or two small, rounded and dried mucous masses ; 
 these generally come from the nasal fossae, and are formed during 
 the night upon the free border of the velum pendulum palati, 
 whence they are forced into the pharynx and rejected. 
 
 The mucous sputa which originate in the pharynx are generally 
 viscid, transparent, contain but little air, and are rejected by 
 exspuition and with an expression of pain. The mucous sputa 
 which come from the larynx are generally smaller in quantity, and 
 accompanied with some alteration of the voice. Patients not un- 
 frequently cough up sputa, formed by the union of small trans- 
 parent globules of a grayish or slate color, which resemble starch 
 or tapioca, and whose origin is somewhat obscure. They are 
 thought by some physicians to come from the larynx; the numer- 
 ous follicles with which the isthmus of the fauces is furnished, 
 would lead us to suppose that here might be their origin. 
 
 The mucous sputa secreted in the bronchi are generally of a 
 larger size, a rounded form, which they preserve in the vessel, and 
 a color varying with the nature and period of the disease. They 
 are transparent in recent catarrh ; transparent, viscid and stellated 
 in typhoid fever ; and opaque in chronic catarrh. 
 
SYMPTOMS. 159 
 
 Many persons, in health, every morning reject several sputa, of 
 a grayish or blackish color ; this color is owing to the smoke which 
 collects from lamps, candles, &c., particularly in small apartments. 
 
 In many diseases, the sputa are purulent ; the product of the 
 secretion of the mucous membrane lining the air passages, may 
 also in some cases present the appearance of pus which arises from 
 ulceration, tubercular softening, or the rupture of an abscess in the 
 neighboring parts. The importance of distinguishing between 
 purulent sputa and those simply puriform, has been long recog- 
 nized, and attempts have been made to find some sign distinctive 
 of each. Numerous chemical experiments have been tried; the 
 miscroscope has been employed in the examination of mucous and 
 pus, but no satisfactory results have as yet been obtained ; it is for 
 this reason that we have considered the sputa presenting these 
 characteristics in connection with each other. 
 
 Pus which escapes suddenly and in abundance from the mouth 
 (vomica) always comes from the pleural cavity, and has been 
 transmitted into the bronchi by means of a perforation of the pul- 
 monary parenchyma, being generally owing to tubercular ulcera- 
 tion which has made an opening, either at once or successively 
 into the pleura and a bronchial division. The signs of pneumo- 
 thorax soon appear, to confirm the diagnosis already established 
 from the vomiting of pus, which is sometimes preceded and an- 
 nounced by the gurgling mentioned above. When pus or a 
 puriform liquid is rejected from the mouth in abundance, (eight or 
 ten ounces in the twenty-four hours,) but by successive efforts and 
 in small quantities at a time, we may infer that it either proceeds* 
 from the pleura, as in the preceding case, or from dilated bronchi. 
 Auscultation and percussion show to which of these two affections 
 these sputa shoulcTbe referred. 
 
 Pus when rejected pure, but in small quantities, may be owing 
 to one of the two preceding diseases, or to one or more tubercular 
 cavities. If the sputa be very fetid, they come from dilated 
 bronchi or the cavity of the pleura ; if they do not possess this pe- 
 culiarity, they may originate in one of these two sources, or a 
 tubercular cavity. The progress of the disease and the explora- 
 tion of the chest can alone enable us to decide these various points. 
 
 Sputa which contain only streaks or dots of pus commonly mix- 
 ed with mucus, and which are rejected by expectoration, may 
 proceed from the larynx or lungs. The sensation which precedes 
 and excites their expulsion, the alteration of the voice, the small 
 size and quantity of the sputa, generally indicate their origin to be 
 ulceration of the larynx of a tubercular or syphilitic nature. If 
 the expectorated sputa be voluminous and abundant, if they pre- 
 sent opaque streaks which are parallel or zigzag in their disposi- 
 tion in a mass differing in opacity, and swimming in a clear and 
 serous liquid (pittiite diffluente), they generally proceed from 
 tubercular softening ; as the disease progresses, the proportion ot 
 the clear and serous fluid diminishes, while that of the purulent 
 matter increases ; so that in the last period, the sputa no longer 
 
160 SYMPTOMS. 
 
 contain the clear fluid and are free from stria, presenting the ap- 
 pearance of homogeneous pus, but not mixing with water, and 
 affecting but slightly, if at all, its transparency. 
 
 There is a disease in which the sputa present so close a resem- 
 blance with those of phthisis, that a physician ignorant of this fact, 
 would not hesitate, from inspection of the expectorated matters, to 
 affirm that they belonged to the latter disease. It is in the rubeola 
 of adults, that this peculiarity is noticed. In this case, however, 
 the fluid, in which the solid portions of the expectoration float, is 
 slightly turbid or opaque, while in phthisis it is always trans- 
 parent. 
 
 Pure blood, when it issues from the mouth in abundance, with 
 cough, ordinarily comes from the bronchi ; it may, however, also 
 come from the nasal fossas, but in this case, if the head of the 
 patient be inclined forward, the blood will flow from the nostrils as 
 well as the mouth, leaving no doubt as to its source. The blood 
 which comes from the bronchi in large quantities may be the re- 
 sult of a simple exhalation which, in some cases, replaces some 
 other suppressed haemorrhage, but it is generally connected with 
 the presence, in the lungs, of tubercles in their crude or softening 
 stage, or it may also proceed from the rupture of an aneurismal 
 tumor into the air passages. In the latter case, a sudden and fatal 
 haemoptysis is sometimes the first sign of arterial lesion. 
 
 Pure blood, when thrown up in moderate quantities, may proceed 
 from the same sources, not excepting the latter. We have seen, in 
 the case of a porter at the Hospital de la Charite, who presented all 
 the signs of an arterial aneurism of the chest, the occurrence of 
 moderate haemoptysis which recurred at intervals during the few 
 weeks previous to his death. On examining the body after 
 death, a perforation of the aneurismal sac and trachea at their 
 point of contact was discovered together with such a disposition 
 of the fibrinous concretions as to form an incomplete and movable 
 partition, which alternately permitted and prevented the escape of 
 arterial blood into the trachea. In this case, as in many others, 
 the concretions formed an imperfect substitute for the coats of the 
 artery, thus retarding the death of the patient. 
 
 Moderate haemoptysis may be also connected with an organic 
 lesion of the heart. In all cases, the careful exploration of all the 
 circumstances which accompany the haemorrhage is indispensa- 
 ble, in order to determine its seat and nature. 
 
 In many cases, the blood is rejected mixed with other liquids, 
 as saliva, mucus, and pus v 
 
 Blood which is rejected by sputation comes from the mouth ; it 
 sometimes precedes and announces the opening of an abscess of 
 the alveoli or tonsils ; it may also arise from suction of the gums, 
 a physical lesion of any part of the mouth, and scorbutic swelling 
 of the gums : in the latter case, it has a peculiar odor, is clear, 
 and of a serous consistence ; it often fills the mouth on awaking, 
 and does not flow during the waking state, except on pressure of 
 the gums. 
 
SYMPTOMS. 
 
 When blood appears in the sputa in the form of blackish spots, 
 it generally proceeds from the nasal fossae ; when in narrow 
 streaks, it almost always depends upon the efforts of the patient 
 in exspuition or expectoration in cases of angina, catarrhal, pa- 
 renchymatous or serous inflammations of the chest. 
 
 Sputa formed by an intimate admixture of blood with mucus, 
 are of the highest importance in a semeiological point of view ; 
 they may in some cases reveal the existence of an inflammation 
 of the pulmonary parenchyma, when there is no pain in the side, 
 no considerable difficulty of breathing, nor any phenomena of 
 auscultation or percussion to indicate such a lesion. Sputa which 
 are viscid, transparent, mixed with small air bubbles, and of a 
 red, yellow, or greenish color, clearly, and with certainty, indicate 
 the existence of pneumonia ; those which resemble a thick solu- 
 tion of gum arabic, ar % e of a red color, and with or without a 
 frothy appearance of their surface, are also characteristic of pneu- 
 monia, although not very viscid, and often deprived of air ; the 
 same is true of serous sputa of a reddish or brownish color (juice 
 of the prune or liquorice), which announce a near and almost 
 inevitably fatal termination of that disease. The sputa of pneu- 
 monia, however, do not constantly present a reddish, yellow, 
 or green color ; there are some persons in whom, towards the 
 decline, and even during the whole course of this disease, the 
 sputa are thick, transparent, and presenting so remarkable a degree 
 of viscidity, as to roll about in the spittoon, leaving it almost dry 
 and free from stain. 
 
 In some cases, and particularly at an advanced stage of pul- 
 monary phthisis, the sputa appear to consist of a mixture of blood 
 and pus ; being opaque or of a dull red color, resembling choco- 
 late. 
 
 The false membranes which are sometimes thrown out with the 
 sputa, may come from various sources. That they occasionally 
 proceed from the mouth and throat is evident from simple inspec- 
 tion of these parts. The absence of membranous productions in 
 the mouth and throat shows that they come from some part of the 
 air passages below the epiglottis ; their form and size sometimes 
 enable us to determine their source. An alteration of the voice 
 generally indicates, in such cases, that they proceed, at least in 
 part, from the larynx. 
 
 The sputa sometimes contain hard and concrete matters, having 
 a colculous or osseous appearance, as portions of dental tartar, 
 small calculi formed in the salivary glands and canals, sequestra 
 proceeding from denuded and ossified cartilages of the larynx, 
 osseous or stony fragments developed in the bronchi, tubercular or 
 melanotic products and hydatids. The portions of tartar are 
 easily recognized by their peculiar form, and the depression 
 they leave in the part of the gum which they occupied ; salivary 
 calculi are at once distinguishable by their form and the lesion of 
 the organs in which they were developed. A sequestrum formed 
 in the larynx generally produces, before its expulsion, severe 
 14* 
 
162 SYMPTOMS. 
 
 accidents, and particularly violent fits of coughing, sometimes 
 threatening suffocation ; the flattened form of these fragments 
 assist in their diagnosis. Bony or calculous concretions formed in 
 the lungs have almost always a branching form which distin- 
 guishes them from all others. Hydatids are easily recognized ; 
 they may come from the lungs or liver ; the concomitant signs 
 generally enable us to determine in which of these two organs 
 they were formed. In regard to the presence of tubercular mat- 
 ter in the sputa of phthisical patients, some physicians consider it 
 common and easily distinguishable. We are not ourselves of this 
 opinion ; during the thirty years in which we have daily and 
 carefully examined the sputa of these patients, we have never 
 been able to distinguish these pretended melanotic and tubercular 
 fragments. 
 
 Lastly, the odor of the sputa furnishes important signs. In 
 the mercurial and scorbutic swelling of the gums, and in certain 
 syphilitic ulcers of the throat, the excretion exhales the same odor 
 as the mouth : a f&cal odor of the sputa generally indicates the 
 presence of pus which proceeds from the mouth and isthmus of the 
 fauces. The alliaceous odor is peculiar to pus formed in the 
 pleura, and rejected through a perforation in the pulmonary pa- 
 renchyma. In gangrene of the lungs the odor is not less character- 
 istic. A urinous fetor of the sputa should lead us to suspect a 
 lesion of the pleura analogous to that described by Dahaen, (a 
 renal abscess opening into the bronchi, through the diaphragm 
 and ulcerated pleura and lung of the left side.) 
 
 SECTION THIRD. 
 
 Symptoms furnished by the Circulation. 
 
 The circulation which consists in the progressive movement of 
 the fluids continually carried from all parts of the body towards the 
 heart by means of the veins and lymphatic vessels, and those 
 carried from the heart towards the capillary system by means of 
 the arteries, is performed, in health, without derangement, and in 
 harmony with the organs which concur in its production. Under 
 the influence of disease, this function presents numerous derange- 
 ments ; some evidently affecting the entire circulation, or at least 
 that of the blood ; others being alone appreciable in certain organs, 
 as the heart, arteries, or veins. 
 
 The course of the blood may be accelerated through all its 
 canals, as is observable in most acute diseases, in which the pul- 
 sations of the heart cannot increase in strength and frequency, 
 in a given time, without compelling the veins to furnish, and the 
 arteries to receive, a corresponding supply of blood. A general 
 sluggishness in the movement of the blood is equally appreciable 
 under opposite circumstances. 
 
 The force of the circulation may be increased or diminished in 
 
SYMPTOMS. 163 
 
 all parts of the circulatory system. We daily see persons in whom, 
 while the pulsations of the heart and arteries are stronger than in 
 health, the veins are harder and more voluminous, and the capil- 
 lary system more injected, as is apparent in the increased color 
 and marked tumefaction of the integuments; these phenomena 
 are particularly remarkable in the affection known as inflamma- 
 tory fever. In other diseases, on the contrary, and particularly 
 chronic affections without febrile reaction, the impulse of the heart 
 is almost imperceptible, the pulse soft, the veins flabby or hardly 
 apparent, the skin pale or unequally colored and often covered with 
 livid or blueish patches which indicate the languor of the capillary 
 circulation. Lastly, in some cases, the course of the blood may 
 be momentarily suspended in all parts of the circulatory system, 
 as in syncope, in which the pulsations of the heart and arteries 
 cease, and the blood no longer flows from orifices made in the 
 veins.* 
 
 Notwithstanding the necessary and reciprocal dependence of 
 the different parts of the circulatory system upon each other, we 
 are led from many facts to admit that each of them, as Laennec 
 has observed, has also a peculiar existence, which is more appar- 
 ent in the pathological, than in the healthy, condition. It appears 
 certain, for example, that the capillary circulation is not entirely 
 dependent upon the arterial and venous circulation ; partial con- 
 gestions of blood in the capillaries of certain organs, haemorrhages 
 which occur in any part without apparent disturbance of the rest 
 of the circulatory system, stasis of the blood in the capillaries of 
 inflamed parts, all tend to confirm this opinion. The independence 
 of the arterial system has not been as generally admitted; it hav- 
 ing been shown, however, by auscultation, in certain cases, that 
 the arterial pulsations were remarkably strong, while those of the 
 heart were extremely feeble, Laennec was led to conclude with 
 some other physiologists, that the arteries also have a special 
 action, a contractility peculiar to themselves. The action which 
 the veins exert in counteracting the influence of gravity and 
 temperature, would show that the course of the blood in these, 
 is not entirely subordinate to the general circulation. 
 
 We shall now proceed to examine successively the symptoms 
 furnished by each of the organs of circulation, the heart, arte- 
 ries, capillary system, veins, and the lymphatic vessels and 
 glands. 
 
 $ I. Circulation of the Blood. A. The pulsations of the heart 
 may become variously deranged. 
 
 Many of the symptoms of which it is the seat, have claimed 
 the attention of physicians of all ages, particularly in the diseases 
 which affect this organ itself. The force and feebleness of its pul- 
 sations, their regularity, the place and extent in which they are 
 
 * Many persons have been able to suspend for a certain time, by an effort of 
 will, the motions of the heart and the arterial pulsations ; some have died in 
 attempting to repeat this dangerous experiment. 
 
164 SYMPTOMS. 
 
 felt, have been carefully investigated by observers, and added as 
 signs of more or less importance to the history of these different 
 lesions. Many practitioners have for a long time been in the habit 
 of examining this organ by the immediate application of the ear 
 over the region which it occupies ; but it is to the work of 
 Laenriec that we are indebted for the accurate knowledge and 
 appreciation of this, as also many other pathological phenomena. 
 
 The pulsations of the heart should be examined with reference 
 to the four following points, viz: the extent and place in which 
 they are audible, the stroke or the force of the impulse of the 
 organ, the nature and intensity of the sound, and finally, the 
 rhythm according to which these different parts contract. 
 
 1. In a healthy man, and in the adult age, the pulsations of the 
 heart are only audible in the space comprised between the cartila- 
 ges of the fifth and seven true ribs, and in the corresponding 
 points of the sternum. The pulsations of the left cavities are 
 principally felt in the first, and those of the right in the second 
 point. This space in which the motions of the heart are percep- 
 tible is much more limited in very fat subjects, and those who 
 have been subjected to repose and diet ; it is greater in lean indi- 
 viduals, whose chests are narrow, in children after exercise or 
 meals, or under the influence of a lively emotion. In these cases, 
 the pulsations may be perceptible over the greater part, or even 
 the whole of the left side. When under the influence of disease, 
 the pulsations of the heart are audible over a greater extent than 
 in health ; they become progressively perceptible, 1, in the left 
 side of the chest, from the arm-pit to the region of the stomach ; 
 2, in the same region of the right side ; 3, in the posterior 
 part of the left chest; 4, in the posterior right chest. When 
 perceptible over a greater extent in disease, they depend upon 
 a lesion of the heart itself, and, according to some authors, 
 to lesions of the neighboring parts. Laennec thought that in- 
 duration of the pulmonary tissue, effusion of serum into the 
 pleura, and the presence of tubercular cavities, might occasion 
 this phenomenon ; but generally, in these cases, the difference is 
 not well marked and often doubtful : it is particularly in the 
 heart itself that are found the causes which increase the extent, 
 over which its pulsations are felt. It was the opinion of Laennec 
 that this extent was in direct ratio with the feebleness and thin- 
 ness of the parietes of the heart ; that the size of the heart does 
 not affect the extent over which the pulsations are perceptible, 
 unless accompanied with enlargement of its cavities. The trans- 
 mission of the sounds of the heart appear to us also to depend 
 upon certain conditions presented by the chest, and which render 
 it more fitted to conduct the sounds produced within its cavity. 
 There are some individuals in whom, when in a state of complete 
 physical and moral quiet, the pulsations of the heart are trans- 
 mitted to almost all parts of the chest, although presenting in the 
 precordial region no more than their ordinary force, and unaccom- 
 panied by any signs of disease, either of the heart or other tho- 
 racic organs. 
 
SYMPTOMS. 165 
 
 The space, in which the pulsations of the heart are audible, may 
 become diminished ; this is observed in rare cases of atrophy of 
 this organ. 
 
 The cardiac pulsations may be perceptible in a place differing 
 from that where they ordinarily appear. This phenomenon may 
 be owing to a general transposition of the viscera ; such cases are 
 congenital, and present nothing morbid. But generally, when the 
 pulsations are perceptible above or below, to the right or left of the 
 place where they are ordinarily felt, the phenomenon is owing to 
 some pathological condition. The presence of a tumor or the ac- 
 cumulation of fluid in one side of the chest, in the mediastinum or 
 abdomen, are the more common causes of this displacement. In 
 some cases, the pulsations differ in their place of appearance at 
 different times ; this phenomenon which authors have considered 
 as peculiar to hydropericardium, is very rare, and difficult to 
 detect. 
 
 2. The beating or impulse is a sensation of percussion conveyed 
 to the ear, or hand of the observer, by the cardiac pulsations. 
 
 When the conformation of the heart is in perfect harmony with 
 that of other parts, this impulse is almost imperceptible ; often 
 entirely so ; it increases under the influence of the causes which 
 hasten the pulsations of this viscus, and becomes again natural 
 when these cease to act. 
 
 In hypertrophy of the heart this impulse generally becomes 
 stronger as the thickness of the parietes of this viscus is increased ; 
 and is sometimes carried to such a degree as to heave the head of 
 the observer ; the greater the hypertrophy, the more slowly this 
 heaving takes place. There are, however, numerous exceptions to 
 this ; for it is not uncommon to meet with patients in whom the 
 heart has acquired an enormous size, from thickening of its walls 
 and dilatation of its cavities, without any corresponding increase 
 in the force of the impulse ; it is even sometimes feebler than in 
 the normal condition. 
 
 The impulse is produced at the moment of vent^c,ular contrac- 
 tion. Hypertrophy of the auricles may, however, also give to the 
 ear or hand a very perceptible impulse ; but this is deeper and 
 more feeble than that which depends upon ventricular contraction. 
 In health, there is never but one impulse to each systole of the 
 heart ; in some diseases of this viscus, succeeding the first impulse 
 which corresponds to the contraction of the ventricles, two others, 
 isochronous with their dilatation, have been observed. M. M. 
 Andral * and Bouillaudf each cite a case of this kind. We have 
 also had occasion in several instances to observe this phenomenon, 
 without being able to find by comparison of the symptoms and 
 anatomical lesions, a satisfactory explanation of this triple impulse. 
 
 The impulse is ordinarily confined to the precordial region ; it 
 sometimes extends to the neighboring portion of the sternum and 
 
 * Notes a la quatritjme edition de Laennec, t. Hi. p. 26. 
 f Traitd climque des Maladies du C&ur, t. 1, p. 148. 
 
166 SYMPTOMS. 
 
 epigastrium, rarely beyond, unless the heart be both thickened and 
 dilated. 
 
 The absence of impulse, like that of sound, in the precordial 
 region depends, either upon a natural feebleness in the contractions 
 of the heart, or rather upon the position of this viscus, it being situat- 
 ed deep in the mediastinum, and entirely covered by the lungs, an 
 anatomical disposition not urifrequently occurring, and which is 
 sometimes produced by pulmonary emphysema. The impulse of 
 the heart is also wanting in cases of considerable effusion of liquid 
 into the cavity of the pericardium. 
 
 3. Nature and intensity of the sound. If the ear or stethoscope 
 be applied to the region of the heart in a healthy person, two suc- 
 cessive, and different, sounds are heard ; the first, is dull and pro- 
 longed, coincides with the vertricular systole and is isochronous 
 with the pulse. Succeeding this, is another, which is clearer and 
 smarter, being analogous to the sound produced by the flapping of 
 a bellows' valve, and occurring during the diastole of the ventri- 
 cles. Many theories have of late years been proposed by physi- 
 cians and physiologists, in order to explain the mechanism and 
 cause of these two sounds. They have, by some, been referred to 
 the contraction of the auricles and ventricles, by others, to the im- 
 pulse of the blood against the parietes of the heart and great vessels ; 
 others have attributed them to the collision of the particles of this 
 fluid with each other, and again others to the successive impulse 
 of the point and base of the heart against the anterior parietes 
 of the chest ; but the theory of Roannet, which refers the sounds 
 of the heart to the action of the valves is that which at present is 
 most generally admitted. According to this physician, the first 
 sound is produced by the closure of the mitral and tricuspid 
 valves ; the second, by the sudden closure of the sigmoid valves of 
 the aorta and pulmonary artery. This theory is favored by the 
 greater number of pathological facts ; there are however many 
 abnormal sounds of the heart, which cannot be explained by this, 
 or any other ,y*t proposed.* 
 
 In health, the two sounds of the heart have each a peculiar 
 character, which, in disease, may become variously modified. At 
 one time, the sounds become duller or more clear; at another, 
 they are replaced by others which have received various names. 
 It is exceedingly rare for the both sounds to be altered at the same 
 
 * From the highly interesting and conclusive experiments of Drs. Pennock and 
 Moore, of Philadelphia, and the committees of the British Association, it would 
 appear that the first sound of the heart is probably caused by a combination of that 
 caused by the contraction of the auricles, the flapping of the auriculo-ventricular 
 valves, the rush of blood from the ventricles, and the sound of muscular contrac- 
 tion. But it is to the latter that it appeared mainly attributable, its dull sound and 
 prolonged duration being owing to the progressive character of the full systolic 
 effort from fundus to apex. 
 
 The second sound, according to these experiments, is caused exclusively by the 
 closure of the semilunar valves, from the reaction of the arterial columns of blood 
 upon them. The cause of the second sound corresponds nearly with Roannet's 
 theory. TRANS. 
 
SYMPTOMS. 167 
 
 time ; in most cases, one alone presents modifications in its tone, 
 nature or duration. 
 
 The sounds of the heart are dull and stifled, in cases of consid- 
 erable hypertrophy, thickening of its valves, or when the free play 
 of the latter has been obstructed by the formation of concretions 
 upon their surface. In those cases, they are sometimes dry and 
 hard, a modification to which M. Bouillaud has applied the term 
 bruit de parchemin * or parchment sound. 
 
 Increased clearness of the sounds is a very rare phenomenon ; it 
 is however observed in dilatation with attenuation of the parietes 
 of the heart. 
 
 It frequently happens that the sounds of the heart are replaced 
 or masked by a bellows murmur, so called from its exact resem- 
 blance to the sound of that instrument. This murmur is loud or 
 feeble, sometimes just perceptible, and sometimes confined to a 
 limited space, or extending over the whole precordial region ; in the 
 latter case, there is generally some point in which it presents its 
 maximum intensity, a circumstance which may be of importance 
 in the diagnosis of the disease. In some very rare cases, both the 
 normal sounds of the heart are masked or replaced by this mur- 
 mur, which may lead us to supect, either the simultaneous altera- 
 tion of both orifices, the arterial and auriculo ventricular, or a 
 twofold alteration in one of those orifices, causing its contraction, 
 and inefficiency of its valves. 
 
 The bellows sound whatever be its degree of intensity, is not 
 pathognomonic of any particular disease of the heart, for while, on 
 the one hand, it may exist in nearly all the affections of this viscus, 
 on the other, it fails in some of the most severe, and particularly 
 in contractions of its orifices. The bellows sound may exist in 
 simple pericarditis, hypertrophy, and particularly that form called 
 concentric hypertrophy. But it is most often found in fibrous, car- 
 tilaginous or cretaceous contractions of the orifices, and inefficiency 
 of the valves. It also frequently exists in cases in which the ac- 
 tion is increased without any material lesion of its tissue, as in 
 nervous palpitations. Finally, it may be heard in plethoric indi- 
 viduals, pregnant women,f but particularly in anemic persons, in 
 young girls affected with chlorosis, and after abundant haemor- 
 rhages, as has been shown by the observations and experiments of 
 Dr. Marshall Hall, of London.^ 
 
 It follows from these facts, that the bellows murmur may be de- 
 veloped in various and even opposite conditions : how uncertain 
 then are all those explanations in which this sound is attributed to 
 a single mechanism. 
 
 Many other sounds have been revealed by auscultation, which 
 Laennec has justly considered but varieties of the bellows sound, 
 and which have been designated by the terms, filing (bruit de 
 lime), rasping (bruit de rape), sawing- (bruit de scie), and musical 
 
 * Trait& des Maladies du Coeur, t. 1, p. 162. 
 
 t Vide a good thesis by M. Jucquemier Paris, 1837, No. 366. 
 
 J Med. chirurg. trans, t. xvii. 
 
168 SYMPTOMS. 
 
 or whistling sounds. The rasping or filing sound gives to the ear 
 a sensation of harshness or roughness, which has been compared 
 to the sound produced by filing wood. If, in these cases, the hand 
 be applied to the precordial region, a peculiar vibration is felt 
 called the purring tremor (premissement cataire), first pointed out 
 by Corvisart, and which Laennec compared to the purring of cats. 
 The sawing sound closely resembles the sound of the saw, when 
 heard at a little distance. It has also been compared by M. Bouil- 
 laud to the sound of the letter S, when prolonged. The whistling 
 or musical sound which Laennec never distinguished except in the 
 arteries, we have several times observed in the heart itself; in one 
 case it was so intense as to be heard at the distance of several feet. 
 
 The rasping, filing and sawing sounds and the purring tremor 
 are most commonly heard in contraction of the orifices, particularly 
 if the valves present cretaceous, rough or unequal indurations. 
 We have, however, several times observed the rasping sound in 
 cases of anemia, and after abundant bleeding. The same phe- 
 nomenon has been noticed under similar circumstances of Dr. 
 Marshall Hall. 
 
 The musical or whistling murmur of the heart has not been con- 
 nected with any distinct lesion of this viscus ; in the two cases 
 which had presented this phenomenon and in which an autopsy 
 was made, the existence of hypertrophy with dilatation of the 
 left cavities was discovered, without lesion of the orifices. 
 
 We shall close the history of the anormal sounds of the heart, 
 by briefly noticing the bruit argentin,* or silvery sound, pointed 
 out by Laennec, and the semeiological value of which is not yet 
 determined. It may be imitated, says M. Filhos, by placing the 
 pulp of the middle finger just within the meatus externus, so as 
 completely to close it, and at the same time tapping it lightly with 
 the other hand.f Most authors have considered this sound as 
 peculiar to hypertrophy, occurring when the contractions of the 
 heart have become very powerful. Laennec supposed it to be 
 exclusively owing to the presence of air bubbles within the 
 pericardium, together with hypertrophy of the heart ; but this 
 opinion has not yet been verified by autopsies. M. Bouillaud 
 attributed the same phenomenon to the stroke of the heart against 
 the thoracic parietes. He thought that the silvery sound which is 
 always produced during the ventricular systole, was only a sound 
 superadded, and which does not render the two normal sounds 
 inaudible. 
 
 If, in the healthy condition, the gliding of the heart within the 
 pericardium be unaccompanied by any appreciable sound, this is 
 no longer the case after the formation of false membranes upon 
 the serous envelope of the heart, which destroy its smoothness, 
 and which are the result of inflammation. Thus abnormal sounds 
 may be produced in the pericardium, as in the pleura, and under 
 
 * This is the metallic tinkling of Bouillaud, or the auricula-metallic sound of 
 M. Filhos. 
 
 f Theses de Paris, 1833, No. 132, p. 14. 
 
SYMPTOMS. 169 
 
 the same conditions. These sounds were observed by Laennec, 
 but he did not attach to them due importance. He speaks of a 
 sound of leather, which he at first thought depended upon pericar- 
 ditis, but which he afterwards confounded with the metallic tink- 
 ling, attributing it to the presence of air bubbles in the pericar- 
 dium.* M. Collin was the first to give a correct description of 
 this phenomenon, and point out its semeiological value by con- 
 necting it with the existence of false membranes, and thus con- 
 stituting it one of the pathognomonic signs of pericarditis. This 
 sound presents various degrees of intensity ; to the feeblest of 
 these, M. Bouillaud proposed to apply the term grazing (frole- 
 ment) ; he compared this sound to that produced by the rumpling 
 of taffeta, parchment, or a bank note between the fingers ; this 
 sound which is very superficial, is heard during the systole and 
 diastole, but is more marked during the former.f The sound of 
 new leather (cuir-neuf), investigated by M. Collin, resembles 
 that produced by a horseman on a new saddle. This sound is 
 observed under the same circumstances as the preceding ; but it 
 seems to depend on false membranes, which are harder and more 
 resistant. Lastly, when the false membranes have become fibro- 
 cartilaginous, a much ruder sound is produced, for which M. Bouil- 
 laud has proposed the term scraping sound (bruit de raclemenf).^ 
 These different sounds are often important in the diagnosis of peri- 
 carditis. 
 
 4. The term rhythm, Laennec applied to the order of succession 
 in the contractions of the different parts of the heart, and to 
 their respective and relative duration. In health, the first or dull 
 sound which coincides with the ventricular systole is nearly iso- 
 chronous with the pulsation of the radial artery. Succeeding 
 this, is the second or flapping sound, between which and the first, 
 according to M. Marc d'Espine, there is a very short interval of 
 silence, during which, with great attention, the arterial pulsation 
 can be distinguished. To this succeeds a brief, but well marked, 
 period of repose, after which the ventricles again contract with 
 the dull sound and the gradual progression peculiar to them. The 
 contraction of the ventricles, the flapping sound and the pause 
 which succeeds, are not of equal duration. The duration of the 
 first sound is almost double that of the second, the latter being 
 about equal to the interval of repose, and sometimes a little less. 
 
 This succession in the motions and sounds of the heart is best 
 distinguished when the pulsations of this organ are fewest in a 
 given time ; indeed, when the number of the arterial pulsations 
 becomes much increased, the ear can no longer clearly distinguish 
 the period of silence to which we have just alluded. 
 
 In disease, the duration of each sound may become modified ; 
 thus, in some cases of hypertrophy, the first sound is so prolonged 
 as sometimes to mask the flapping sound, at the same time short- 
 
 * T. 3, p. 5, 4th edition. 
 
 f Trait6 Clinique des Maladies du Cceur, t. 1, p 457. 
 j L. c. p. 198. 
 15 
 
170 SYMPTOMS. 
 
 ening the period of silence, and rendering it almost imperceptible. 
 A loud and continuous bellows murmur is also not unfrequently 
 heard in the precordial region, which replaces or entirely masks both 
 the normal sounds, together with the interval of silence. We have 
 previously referred to those cases in which the rhythm of the car- 
 diac pulsations is so perverted, that following a single ventricu- 
 lar systole, two, three, or four other impulses coincident with the 
 diastole are distinguished. Finally, the natural rhythm of the 
 heart may be perverted by intermittences, irregularities, or ine- 
 qualities in its pulsation : the latter may be accelerated or retarded, 
 all which phenomena will be considered in connection with the 
 pulse. 
 
 The symptoms furnished by auscultation of the heart should 
 never be separated from those which are the results of percussion. 
 In the healthy condition, percussion over the precordial region gives 
 an obscure sound over an extent not exceeding two inches square. 
 This space increases, and its sound becomes duller, owing to 
 increased size of the heart, or a liquid effusion into the pericardium. 
 In a treatise published in 1826, M. Louis proclaimed the impor- 
 tance of the signs furnished by percussion of the precordial region 
 in the diagnosis of pericarditis ; he proved that the more or less 
 rapid increase in the extent over which a dull sound is obtained, 
 is the most certain sign of liquid effusion and, consequently, peri- 
 carditis ; for an effusion confined to the pericardium is an almost 
 constant sign of inflammation ; hydropericardium without inflam- 
 mation rarely occurs except in cases of general dropsy. 
 
 B. The term pulse (pulsus) is applied to the beating of the 
 arteries produced by the afflux of blood propelled by the heart at 
 each contraction. 
 
 Galen was the first to call the attention of physicians to this 
 phenomenon. Those who preceded him have hardly alluded to 
 it, and seem to have overlooked it. 
 
 The pulse, in health, is equal, regular, supple, and moderate in 
 strength. The number of the pulsations varies with the age, 
 temperament, sex, stature, idiosyncrasy and other accidental cir- 
 cumstances. It has been for a long time supposed that the num- 
 ber of arterial pulsations, during the first months of life, were 
 about one hundred and forty per minute ; at the second year, one 
 hundred ; at puberty, eighty ; from sixty-five to seventy-five in 
 adults, and from fifty to sixty in old age. But it would appear 
 from works recently published that this estimation of the fre- 
 quency of the pulse, in the different periods of life, is incorrect. 
 Billard asserts that the frequency of the pulse in the new bom 
 infant is often no greater than in the adult, and in forty infants 
 from one to ten days' old, he found eighteen in whom the pulse 
 was less than eighty in the minute.* Dr. Valleix indicates the 
 number eighty-seven, as the medium of the frequency of the 
 
 * Mai. des Enf , p. 67. 
 
SYMPTOMS. 1 71 
 
 pulse in infants aged from two to twenty-one days.* Finally, 
 M. M. Leuret and Mitivie, by studying the comparative frequency 
 of the pulse in a great number of persons, both old and young, 
 have shown it to be greater in the former than in the latter, since 
 the mean, in the aged, was seventy-three, and, in the youth, 
 sixty-five, f It would be desirable that the researches upon the 
 frequency of the pulse during the first periods of life, be made 
 upon other than hospital patients, as these are badly nourished, 
 and not in the ordinary healthy conditions. It is also necessary 
 that the results should be deduced from a great number of facts. 
 The frequency is a little greater in women, in individuals of a 
 sanguine or nervous temperament, and, it is said, in those of small 
 stature. It has been shown, by repeated observations, that the 
 proportion of adult subjects in whom the number of arterial pul- 
 sations is below sixty, and even fifty per minute, is greater than 
 is generally supposed. There are many persons in whom the 
 pulse is not over thirty-six or forty, in others, it has been observed 
 as high as one hundred per minute. Whitt saw a woman whose 
 pulse, in health, beat one hundred and twenty per minute. 
 
 Beside these individual varieties, the number of pulsations be- 
 comes increased after a meal, by exercise, emotions, and during 
 pregnancy; it is diminished in the sitting or horizontal posture, J 
 by repose, diet, loss of blood, and particularly the use of digitalis ; 
 it is not rare however for the pulse to become accelerated after 
 abundant haemorrhages, and all excessive evacuations. In some 
 persons, the frequency of the pulse during convalescence is less 
 than in health. It has been said that the pulse presents, at dif- 
 ferent hours of the day and night, slight modifications, which, 
 according to the assertions of Brian Robinson, coincide with those 
 of the barometer and thermometer. But these observations, sup- 
 posing them to be correct, are unimportant, as offering no useful 
 application. The pulse also presents varieties in different individ- 
 uals, in regard to the force, regularity and equality of its pulsa- 
 tions ; it is highly important for the physician to be acquainted 
 with the normal condition of the circulation of persons to whom 
 he is called in sickness ; this knowledge is always useful, and often 
 indispensable in order to appreciate the changes effected in the va- 
 rious circulatory phenomena, and particularly the pulse, through 
 the influence of disease. 
 
 I have seen a lady whose pulse, during the paroxysms of inter- 
 mittent fever, did not beat above sixty per minute, to the great 
 astonishment of her physician. This astonishment would have 
 ceased had he counted the number of pulsations during the inter- 
 mission, these being not above forty per minute. 
 
 There are many precepts which should not be neglected in the 
 mode of feeling the pulse. 
 
 * CZm., des Mai. des Enf., p. 18. 
 
 f De la Frequence du pouls. 
 
 I Guy's Hospital Reports, April, 1836. 
 
172 SYMPTOMS. 
 
 The physician should wait till the patient shall have recovered 
 from the emotion produced by his presence, requesting him to pre- 
 serve absolute silence and to remain in the sitting or horizontal 
 posture. The pulse may be examined at the temples, lateral parts 
 of the neck, arm, thigh, wrist, and wherever the arteries are suffi- 
 ciently large and superficial ; but the radial artery is generally 
 preferred, at the place where it ceases to be covered by the muscles 
 of the fore arm, opposite the radio-carpal articulation. 
 
 If the patient be up, he should be placed in the sitting posture ; 
 if in bed, he should be upon his back, so that he may neither in- 
 cline to the right or left, and thus impede the circulation of blood 
 in the arteries. The arm should be placed nearly in a state of ex- 
 tension and sustained in its whole length, so that the muscles may 
 be relaxed. The fore arm should be nearly prone that it may rest 
 upon the cubital edge, and the radial edge be a little raised. Care 
 should be taken that no bandage or clothing impede the flow of 
 blood in the axillae, at the elbow or any other point. All bandages 
 should be removed so that there be the least possible compression. 
 By means of these various precautions, we may be certain that 
 there is no foreign obstacle to the flow of blood through this vessel. 
 
 The artery of the left side should be felt by the right hand, and 
 vice versa ; the four fingers placed parallel on the same line should 
 be applied over the track of this vessel ; the index finger should be 
 nearest the hand of the patient; and the little finger, applied 
 lightly, should be the first to receive the impulse of the blood ; at 
 the same time that the four fingers are placed over the radial 
 artery, the thumb, or rather the palm of the hand should rest upon 
 the dorsal face of the fore arm, thus affording a solid support to 
 the fingers by which the pulse is examined. The latter should at 
 first receive a slight lateral movement, in order to ascertain the sit- 
 uation of the vessel. When the fingers are all placed upon the 
 artery, the pressure should be gradually increased and diminished 
 several times in succession, so as to appreciate the influence of the 
 pressure upon it, and thus more easily ascertain its different quali- 
 ties. Twenty or thirty successive pulsations should, in this man- 
 ner be examined. It is not without advantage to examine the 
 pulse in the two arms alternately, or at once ; it should also, in 
 particular cases, be examined in other places, wherever it may 
 throw light upon the diagnosis. It may be also examined several 
 times, or at least a second time, before leaving the patient. How- 
 ever minute these precepts may appear, they cannot be neglected 
 without inconvenience. It is better to accustom oneself from the 
 beginning to this mode of examining the pulse ; it may be then'done 
 without effort, and by the simple effect of habit. 
 
 The changes effected by the influence of disease upon the arte- 
 rial pulsations are twofold ; those which are appreciable at each 
 beat ; and those only perceptible by the comparison of a certain 
 number with each other. To the first series belong quickness and 
 slowness, hardness and softness, fullness and smallness, feebleness 
 and strength ; to the second, frequency and rareness, irregularity 
 
SYMPTOMS. 173 
 
 and inequality ; these different conditions of the pulse will be suc- 
 cessively considered. 
 
 The pulse is quick (pitlsus celer), when the arterial pulsation 
 takes place with quickness; slow (pulsus tardus), on the contrary, 
 when it is performed more slowly than in health. 
 
 Hardness and softness of the pulse are characterized by the 
 greater or less degree of tension of the artery during its pulsation. 
 If the beat gives the finger the impression of a hard body striking 
 against it, the pulse is hard (P. durus); it is soft (P. mollis) when 
 it gently strikes the finger, and is easily compressible. The cordy, 
 tense and resisting pulse are but varieties of the hard pulse. It 
 would not be impossible, in old persons, to confound, with hardness 
 of the pulse, the resistance which depends solely upon ossification 
 of the arteries. The latter is easily recognizable from the firmness 
 of the parietes in the interval, and their annular disposition. 
 
 Fullness and smallness of the pulse are measured by the volume 
 which the artery presents in pulsating: the pulse is full (P. mag- 
 nus) when the artery is large and full ; it is small (P. exilis) when 
 the pulsations of the artery are slender and weak. The/w//, devel- 
 oped, and great, are but varieties of the large, pulse ; the contracted 
 pulse is that which is at the same time small and hard. 
 
 The strong- pulse is characterized by its volume and the force of 
 the pulsations ; the feeble pulse by the opposite qualities. Strength 
 of pulse (P. robur) consists consequently in hardness and great- 
 ness united; feebleness (P. debilitas), in the smallness and softness 
 of the pulsations. The vibrating pulse, occurring in cardiac aneu- 
 rism, is a very strong pulse; the depressed pulse, of diseases which 
 tend to a fatal termination, is a very feeble pulse. 
 
 Thus slowness and quickness, softness and hardness, smallness 
 and fullness, are the principal qualities of the pulse, which, by 
 their different degrees and combinations, constitute the varieties 
 appreciable in each pulsation. 
 
 There are two other varieties which are sometimes confounded, 
 bat ordinarily very distinct ; we refer to the trembling pulse and 
 the pulsus dicrotus. In both these cases the arterial pulsation is 
 not single ; it gives in the latter case the sensation of a double 
 beat, which has been compared to the rebounding of the hammer 
 on the anvil. In the first, the pulsation is, as it were, uncertain 
 or hesitating; the fingers placed upon the artery distinguish at 
 each contraction of the heart a trembling pulsation, instead of. a 
 single beat. It is not very uncommon to meet with persons in 
 whom it is difficult to determine whether the pulse be redoubled 
 or trembling. , 
 
 P- The frequency and rareness of the pulse are measured by the 
 number of arterial pulsations in a given time. The pulse is fre- 
 quent (P. frequens} when this is greater than in health ; when it is 
 less, the pulse is infrequent (P. rarus) (p. 170). Of all the qualities 
 of the pulse, frequency is alone that which can be measured with 
 rigorous precision by means of the watch. This mode of estimat- 
 ing the frequency of the pulse is very useful to the beginner. 
 15* 
 
174 SYMPTOM8. 
 
 who becomes thus accustomed to value it with precision ; but it 
 becomes unnecessary to the experienced physician, who only has 
 recourse to it in those affections, in which it is important to note 
 the slightest alterations in the number of the arterial pulsations 
 from day to day. It has been recommended by some physicians 
 to count the pulse during a whole minute ; but a half minute ordi- 
 narily suffices, or, what, is better, two quarters, the one serving to 
 correct the other. If the frequency of the pulse be extreme, it will 
 be found necessary to count the number of pulsations occurring in 
 five seconds, several times in succession, since the cyphers which 
 represent the low numbers are nearly all monosyllables, and may 
 be pronounced as rapidly as the most frequent pulse, which is not 
 the case with the higher numbers. I have been able, in this way, 
 to count accurately one hundred and sixty, one hundred and eighty, 
 and even two hundred pulsations in the minute ; while in attempt- 
 ing to count an entire minute, or even a half minute, o it would be 
 found impossible to count above one hundred and fifty. Fre- 
 quency of the pulse is much more common in disease than its in- 
 frequency, the latter rarely occurring except in certain periods of 
 some cerebral affections, in concussion of the brain, and in certain 
 organic lesions of the heart. We recollect a young man at La 
 Charite, suffering from the latter disease, whose pulse did not ex- 
 ceed twenty-eight, and sometimes not even twenty-five pulsations 
 per minute. Finally, we saw with Dr. Meniere, a patient in 
 whom the number of the arterial pulsations was not above fourteen 
 per minute, this infrequency lasting for about twelve hours. Fre- 
 quency of the pulse, on the contrary, occurs in nearly all acute 
 diseases and in a great number of chronic affections. It is almost 
 always accompanied by quickness; sometimes, but rarely, the 
 pulse is frequent without being quick, or quick and at the same 
 time rarej when the pulse beats more than eighty times per min- 
 ute, it is very difficult to judge of its quickness ; this is entirely 
 impossible if the pulsations exceed one hundred and twenty, or 
 even one hundred. 
 
 The constant relation which exists, in health, between the fre- 
 quency of the respiration and that of the pulse, is also generally 
 apparent in disease, being in the proportion of four to one. We 
 are assured by Giannini that we can thus by examination of the 
 respiration alone, and without touching the patient, determine the 
 frequency of the pulse in all diseases. This assertion may be gen- 
 erally correct, so far as it relates to other than thoracic affections ; 
 but it presents numerous exceptions, particularly in nervous dis- 
 eases, in which this relation between the circulation and respiration 
 is often deranged. 
 
 The pulse is regular (P. regularis) when the pulsations succeed 
 each other at equal intervals ; it is irregular (P. irregularis), 
 when the pulsations return at unequal intervals. The pulse pre- 
 serves its regularity in most mild acute diseases ; in persons whose 
 pulse is naturally irregular, the arterial pulsations may become 
 regular under the influence of disease. Dehaen observed two 
 
SYMPTOMS. 175 
 
 cases of this kind, noticing with anxiety the irregularity which 
 appeared towards the period of convalescence ; but the patients 
 themselves, who were aware of the peculiarity of their natural 
 pulse, viewed it as a favorable sign. Irregularity of the pulse 
 may present itself under various forms ; sometimes one of the 
 pulsations appears to fail completely, this is the intermittent pulse 
 (P. intermittent) ; sometimes, but more rarely, a pulsation occurs 
 in the interval between two regular pulsations ; this is called an 
 intercurrent pulse (P. intercidens). Intermmittence and inter cur- 
 rence may occur at equal intervals ; but the periodicity rarely lasts 
 more than a few minutes, or at most, a few hours. They are or- 
 dinarily symptomatic of an organic lesion of the heart ; they may 
 appear in neuroses, and in some cases have appeared to be con- 
 nected with the presence of worms, or the accumulation of gas in 
 the intestinal canal, and the acute abdominal pain which occurs in 
 some intestinal phlegmasiae ; they appear in the last few hours af 
 life in most diseases, and finally, are not unaffected by cerebral 
 influence. A professor of medicine at Bologna, having accidentally 
 remarked an intermittence in his own pulse, became in conse- 
 quence very anxious ; he was constantly placing his fingers upon 
 the artery, and observed at each time that the pulse became more 
 irregular ; Morgagni, whom he consulted upon the case, advised 
 him to pay no attention to it, and the intermittence soon disap- 
 peared. * 
 
 Laennec was led, from auscultation, to admit false intermis- 
 sions ; in these, the contraction still takes place, but in so rapid 
 and feeble a manner, that no pulsation is felt in the artery ; in 
 such cases, there is intermittence of the pulse, and simply inequal- 
 ity in the contractions of the heart. 
 
 During intermission of the pulse, the artery is almost always 
 soft and unresisting. Some physicians appear to have observed 
 cases in which the artery was full and tense ; Laennec supposed 
 that this kind of intermittence takes place after ventricular con- 
 traction, and that while it lasts there is probably a permanent con- 
 traction of these organs. 
 
 The equal pulse (P. cequalis), is that in which the pulsations 
 resemble each other in quickness, fullness, and hardness. The 
 pulse is unequal (P. inequalis), when the pulsations differ from 
 each other in these respects. 
 
 The sense that we have attached to the words unequal and 
 irregular, differs from that given to them by most authors, who 
 have employed these two expressions indifferently. We have 
 thought it better to. give to each a precise signification, as was the 
 case in regard to respiration ; we have applied the word regularity 
 to the rhythm, and inequality to the other qualities of the pulse. 
 
 The pulse may cease to be distinct or become confused, from 
 extreme frequency, but particularly the feebleness, irregularity, and 
 inequality of the pulsations. There is no degree of frequency in 
 
 * De sed. et Caus. morb.. Epist. xxiv., art. 20. 
 
1 76 SYMPTOMS. 
 
 which the pulse may not be counted, but, generally, as its frequency 
 increases, it becomes more feeble, irregular, and unequal, so that it 
 is impossible to determine with accuracy the number of pulsations 
 per minute. In this, and in many other cases in which this de- 
 rangement does not exist to such a degree, an approximate evalu- 
 ation is alone practicable. The puTse may become insensible 
 (pulsuum defectio}, like that which occurs in the moribund, and 
 sometimes after excessrVe evacuations in persons who are not 
 otherwise seriously indisposed. 
 
 Is the pulse the same, or does it present remarkable differences, 
 in the various arteries in which it may be examined? This 
 question comprises many others which will be successively consid- 
 ered. 
 
 The fullness and hardness of the pulse vary with the size of the 
 artery examined ; the larger the artery, the stronger is the pulse. 
 Thus in cases in which the arterial pulsations become insensible 
 at the wrist, they are manifest at the bend of the arm, and full and 
 hard in the groins. For the same reason, it may, and frequently 
 does, happen, that the strength of the pulsations differs in the same 
 subject in two corresponding vessels, the two radial arteries, for 
 example. This difference depends upon the unequal size of this 
 artery in the two arms, or the variable depth at which it is seated. 
 
 Many physicians have, from certain cases, been led to suppose 
 tnat, in some cases of congestions, and in certain neurosis, the 
 pulsations in the arteries which are distributed to the affected 
 organ, are stronger than in those of the rest of the body. In 
 most cases, there is supposed to be increased strength in pulsations 
 of such an artery, as the superficial temporal, the strength of 
 which in the healthy condition is not appreciated, and which, in 
 disease, is generally estimated rather from the evidence of the pa- 
 tient than that of the senses of the physician ; now, the sensation 
 experienced by the patient may depend upon increased sensibility 
 of the parts surrounding the vessels, as well as the often doubtful 
 increase in the strength of the arterial pulsations. 
 
 Do the differences presented in the force of the arterial pulsa- 
 tions in different parts of the body, exist in their quickness, fre- 
 quency, regularity, or equality? 
 
 It is difficult to conceive how the quickness can vary in the 
 different arteries ; as, however, there is a difference in the con- 
 tractility of the various parts of the arterial system, it might not 
 be impossible for the quickness with which the pulsation is 
 effected, to differ slightly in one artery from that of another ; but 
 this phenomenon, if it exist, would be difficult to appreciate. The 
 greater frequency of the pulse in an artery, which some authors 
 pretend to have observed, cannot be admitted ; in certain local 
 congestions, the pulse may seem to the patient to beat oftener in 
 the inflamed part than elsewhere ; but from a knowledge of the 
 laws of the circulation, we cannot admit the existence of any 
 other pulse in the arteries, than that dependent upon the affiux of 
 blood propelled by the contraction of the heart ; now, as the whole 
 
SYMPTOMS. 
 
 177 
 
 arterial system has a common origin in this organ, it is evidently 
 impossible for the pulsations to be more frequent in one artery 
 than another. 
 
 It has, however, sometimes happened, that the number of pul- 
 sations in a given time was not the same in the two sides ; a very 
 remarkable case is related by Morgagni. A child who received 
 an injury in the back by a fall from a tree, was attacked with pal- 
 pitation, which had not disappeared after a lapse of nine years, 
 and which became particularly troublesome at certain periods of 
 the year. Morgagni having seen this patient in one of these 
 paroxysms, found upon examination a difference in the pulse of 
 the two sides: " after a careful examination, he found that the 
 arterial pulsations upon the left side were natural in frequency, 
 while, on the right, they were less frequent, in the proportion of 
 three to one." * 
 
 This fact, together with others less authentic, seem to be di- 
 rectly opposed to what we have just said; but they only prove 
 that, in some cases, the course of the blood may be temporally 
 intercepted in one artery, without being so in others, and that, 
 owing to the transient obliteration of an artery, intermissions con- 
 fined to that vessel may occur. The peculiar lesion which pro- 
 duces such an effect, at one time interrupting the course of the 
 blood in a vessel, at another, permitting its flow, has not yet been 
 ascertained by examination after death, the only means of obtain- 
 ing a satisfactory explanation of this phenomenon. 
 
 This differs from those cases in which the pulsations of an 
 artery become gradually enfeebled, and at last entirely insensible, 
 while those of the corresponding vessel preserve their normal con- 
 dition. This difference, which has been particularly observed in 
 the radial arteries, is generally owing to the development of a 
 tumor in the vicinity of the arterial trunk, compressing it the more 
 as it increases in size, and in some cases completely obliterating 
 its cavity. This is particularly observed in those cases of aortic 
 aneurism, in which the subclavian artery is pressed by the tumor 
 against the bony parietes of the chest. 
 
 Such are the principal changes effected by disease in the arterial 
 pulsation; many others have been admitted by authors; Galen 
 described more than thirty.f To these Solano of Lucca, and Bor- 
 
 * De sedibus et Causis, morb., epist. xxiv. art. 33. 
 
 f The following are the different varieties of pulse admitted by Galen. 
 
 1. Long: in which the artery strikes several, or all four fingers. 
 
 2. Short : in which it strikes but one or two at most. 
 
 3. Large: in which it is increased in diameter. 
 
 4. Narrow: in which it is diminished in diameter. 
 
 5. High : that which seems to raise itself to a point in order to strike the finger. 
 
 6. Low : that in which the pulsations are hardly perceptible. 
 
 7. Great : the artery is increased in length, breadth and elevation. 
 
 8. Small: one whose pulsations are slender and weak. 
 
 9. Quick. 
 
 10. Slow. 
 
 11. Frequent. 
 
178 SYMPTOMS. 
 
 due have added still others, and have asserted the existence of a 
 pulse peculiar to the affections or the crises of each organ ; hut the 
 works of these physicians, in other respects, deserving of merit, 
 are generally considered as ingenious speculations rather than the 
 results of observation, All these minute distinctions of the ars 
 sphygmica have been justly abandoned. 
 
 But it is not only important for the physician to admit no alter- 
 ations of the pulse but those connected with conditions really ap- 
 preciable, such as quickness, fullness, hardness and frequency ; 
 but it is also necessary that these alterations should not be noted, 
 unless they be very apparent, and such as might easily be recog- 
 nized by every physician with senses fitted to receive these impres- 
 
 12. Rare. 
 
 13. Strong: that which strikes the finger strongly. 
 
 14. Feeble : that which strikes feebly. 
 
 15. Hard: the pulp of the finger yields to the pulsation. 
 
 16. Soft : the pulsation yields to the pressure of the finger. 
 
 17. Full: the artery, full and resisting. 
 
 18. Empty : the artery disappears and yields to the fingers ; it has no solidity. 
 
 19. E'jual. 
 
 20. Unequal. 
 
 21. Myurus : so called when it sinks progressively, becoming smaller and 
 
 smaller, like a rat's tail (v$, rat; OVQO, tail). 
 
 22. Deficient Myurus : that which seems every instant about to cease. 
 
 23. Myurus, which diminishes at the two extremities : that which strikes the first 
 
 and last finger less sensibly than those between. 
 
 24. Intermittent: in which the pulsations fail from time to time. 
 
 25. Intercurrent : in which a superfluous pulsation occasionally seems to occur, 
 
 26. Deficient: that which ceases altogether. 
 
 27. P. Caprizans : the pulsation is interrupted in the midst of its diastole, and 
 
 is afterward finished more rapidly than it was commenced. 
 
 28. P Dicrotus: that in which the finger is struck twice at each pulsation, like 
 
 the hammer on an anvil. 
 
 29. Undulating : that which resembles in its movements those of the waves. 
 
 30. Vermicular : the pulsations resemble the progression of a worm. 
 
 31. P. Formicans : these pulsations resemble the motion of an ant. 
 3-2. Tremulous. 
 
 33. Palpitating. 
 
 34. Canvulsive : the artery is tense and hard like a cord. 
 
 35. P. Serrinus: that which strikes the fingers unequally, like a saw. 
 
 36. Ardent : that which seems to raise itself to a point, striking the finger 
 promptly and forcibly. 
 
 The Chinese physicians, who, it is said, pretend to know the nature and dura- 
 tion of a disease by the examination of the pulse alone, have distinguished still 
 other varieties. They admit a pecking pulse, resembling the stroke of a bird's 
 beak ; another, similar to drops of water falling through a chink, or a frog en- 
 tangled in the grass and seemingly unable to advance or go back ; they have 
 also a pulse which they compare to boiling water, and another which is flutter- 
 ing like a fish continually plunging and afterwards rising so slowly as to enable 
 one to catch it by the tail. (Recherches Hist, sur la Medec. des Chinois.) From 
 these comparisons we may judge of the others. 
 
 Le P. Leconte remarks that the Chinese physicians before visiting a patient, 
 take care to inform themselves of all that he has experienced ; and afterwards 
 having examined the pulse for a long time, without asking any question, they tell 
 with a prophetic air all that they had previously ascertained. 
 
 The critical pulses will be enumerated in the article on Crisis. 
 
SYMPTOMS. 179 
 
 sions, and capable of discerning them. The pulse is not necessarily 
 feeble or strong, hard or soft, small or full ; in many cases it pre- 
 sents none of these characteristics ; being, according to the expres- 
 sion of some authors, moderate. We would not insist on so trival 
 a truth, were we not convinced that many physicians have entirely 
 neglected it. 
 
 The organs of arterial circulation furnish also other symptoms, 
 dependent upon their dilatation or aneurismal rupture ; as the 
 pulsations often felt in an aneurismal sac, or in tumors contiguous 
 to healthy or diseased arteries ; also their hsemorrhages which are 
 often fatal, their denudation, wounds, lacerations, and lastly, their 
 ossification, which in old persons is often manifest in the superfi- 
 cial arteries during life. 
 
 Auscultation has also been applied to the study of the arterial 
 pulsations, and has furnished phenomena not without interest. In 
 the healthy subject, if the stethoscope be applied over the track of 
 an artery, a peculiar dull sound is heard which is isochronous 
 with the ventricular systole. This sound, which is caused by the 
 impulse of the blood against the walls of the vessel, varies in in- 
 tensity, according to the size of the artery and the force with which 
 the blood is propelled. This pulsation, this dull sound may, when 
 heard in certain regions where it does not normally exist, reveal to 
 the physician the existence of a very grave disease, the aneuris- 
 mal dilatation of a vessel. So when a simple or double pulsation, 
 which is circumscribed more or less forcible, and distinct from the 
 pulsations of the heart, is distinguishable upon the anterior and 
 superior part of the chest, or behind, near the vertebral column, 
 aneurism of the aorta may be suspected. The existence of this 
 lesion becomes certain if, at the point where the pulsation is per- 
 ceptible, there is also an abnormal sound, as the rasping or bellows 
 sounds, and the strength -of the pulsation be sufficient to raise the 
 hand. 
 
 The bellows sound is, of all the abnormal sounds of the arteries, 
 that most commonly observed. It may be feeble or intense, 
 continuous or intermittent, circumscribed or diffused ; it may co- 
 exist in the aorta, carotids, subclavian and crural arteries, the only 
 vessels of the trunk generally ausculted. Sometimes the sound is 
 confined to one or two arteries. In other cases, it is but the reso- 
 nance or expansion of the same sound produced in the heart, and 
 it is often produced in the vessel where it is audible. 
 
 The bellows sound may exist in certain diseases of the arteries, 
 as ossification of their parietes, aneurismal dilatation and varicose 
 aneurism. It may depend upon compression of the vessel caused 
 by a voluminous tumor ; as is observed in cases in which the iliac 
 and hypogastric arteries are compressed by an ovarian cyst ; but 
 the arterial bellows sound is generally observed in chlorosis, ane- 
 mia, and after abundant loss of blood, as in uterine haemorrhage 
 and amputations. 
 
 This bellows sound presents itself under various forms, most of 
 which have received distinctive appellations. Thus in chlorosis, a 
 
180 SYMPTOMS. 
 
 sound is audible, particularly in the carotids, to which Bouillaud 
 has applied the name bruit de diable, from its resemblance to that 
 produced by a child's toy of that name ; in other cases, it resembles 
 that of the bellows of a forge ; in others, the cooing of a dove ; 
 finally, a kind of whistling is sometimes perceptible, which degen- 
 erates, in some cases, into a double toned, and slightly monoto- 
 nous, musical humming. This sound was called by Laennec, 
 who was the first to describe it, a modulated whistling, or music 
 of the arteries. These last varieties of the bellows sound have, 
 like the others, been principally observed in cases of chlorosis, 
 anemia, and accidentally, in some nervous subjects. 
 
 Within a few years many experiments have been tried and de- 
 scribed, in order to explain the mechanism of the arterial sounds : 
 When there is dilatation of a vessel, or roughness or unevenness of 
 its surface, or when a communication exists between an artery and 
 vein by a narrow opening, or finally when the calibre of a vessel 
 is diminished by any external pressure, the bellows murmur may 
 be naturally explained by the friction of the blood against the 
 unequal surfaces or contracted parietes of the vessel. But how 
 are these various sounds produced in cases of anemia and chloro- 
 sis? This question is unanswerable. It would appear, from 
 recent investigations, that rapidity in the motion of the blood, and 
 particularly the low density of this fluid, are both conditions 
 necessary to the formation of these sounds. * 
 
 The symptoms furnished by the circulation in the capillary 
 system and veins, are much less numerous than those observed in 
 the arterial circulation. 
 
 C. The florid or livid redness of the skin in the whole or any 
 part of the body, marbled appearance, ecchymoses, paleness and 
 spontaneous haemorrhages, are all phenomena which belong to the 
 capillary circulation. 
 
 Among these phenomena, there are those, such as the florid red 
 color of the skin and active hsemorrhages, which almost al- 
 ways coexist with an evident increase of the vital forces ; they 
 have generally been considered as owing to an increased ac- 
 tion of the capillary vessels. Others, as the marbled appear- 
 ance, livid spots and passive haemorrhages, which ordinarily 
 appear in enfeebled persons, are attributed to debility of the same 
 system. 
 
 The ecchymoses following contusions, also appear to depend 
 upon the capillary vessels, which are moreover the seat of certain 
 traumatic hsemorrhages, in which the blood flows from the surface 
 of a wound. In both these cases, the haemorrhage is owing to a 
 rupture or section of the capillary vessels, being entirely independ- 
 ent of any increase or diminution in the circulatory force. 
 
 It has been thought, by some authors, that the blood may have 
 a retrograde course. The sudden paleness consequent upon a 
 
 *Memoire de M. de La Harpe, Archiv. Gener. de Medec., 1838. 
 
SYMPTOMS. 181 
 
 lively emotion or sudden impression of cold, is, according to Spren- 
 gel,* entirely inexplicable, unless a rapid retrograde motion of 
 the blood in all the arterial and venous vessels, be admitted; but 
 this phenomenon may be explained by supposing that the blood 
 contained in the capillary vessels is suddenly forced into the veins, 
 and that the supply of arterial blood is, at least partially, cut off. 
 
 D. The venous circulation presents some very important symp- 
 toms. The veins over the whole surface of the body may become 
 distended in certain affections, and particularly in plethora and 
 febrile heat; they disappear, on the contrary, in anemia -and in 
 the chill which occurs at the commencement of acute diseases, 
 and in the paroxysms of intermittent fever. Partial dilatation of 
 the veins accompanies various diseases, as local congestions and 
 apoplexy, in which the veins of the neck are often enlarged ; it is 
 also observed in the vicinity of cancerous tumors, particularly 
 those of the mammas ; also in cases of compression of the veins 
 of a limb by a tumor: it constitutes one of the most certain signs 
 of deep-seated tumors of the thorax or abdomen ; and, in other 
 circumstances, dilatation of the veins of the neck, head, chest and 
 superior extremities, is the only sign indicative of compression of 
 the superior vena cava. We have referred above, to those dila- 
 tations of the subcutaneous abdominal veins frequently observed in 
 patients suffering from ascites. There are cases in which their 
 dilatation is considerable, at the same time that the abdominal 
 parietes are indurated ; each of these vessels seems, in such cases, 
 to be contained in a solid canal whose angular sides and semicircular 
 floor are perfectly distinguished by the finger. M. Raynaud, who 
 has called attention to the dilatation of the superficial abdominal 
 veins, regards it as indicating the existence of some obstacle to the 
 course of the blood in the vena porta, and as the result of a col- 
 lateral circulation, by means of which the blood passes from the 
 divisions of the inferior, to the superior, vena cava. The post- 
 mortem examination of those who presented this peculiarity, does 
 not in all cases clearly reveal the impediments to the internal cir- 
 culation, pointed out by M. Raynaud ; but some lesion of the 
 abdominal viscera is always found, generally consisting in an 
 alteration of the liver, known as cirrhosis, a species of atrophy in 
 which there is probably some diminution in the diameter of the 
 branches of the vena porta, and a modification of the circulation 
 in some degree corresponding to the opinion of this physician. 
 
 In certain parts of the body and particularly in the lower limbs, 
 in which the venous circulation is rendered more difficult by the 
 laws of gravity, superficial, sinuous, knotty tumors of a bluish 
 color are often observed, which momentarily disappear by external 
 pressure arid cold, and increase under the opposite conditions. 
 From these symptoms the affection of the veins called varix is at 
 once recognizable, a disease in which the length of these vessels 
 
 * SPRENGEL, Pathol. General, p. 147 
 16 
 
182 SYMPTOMS. 
 
 increases with their size, as is proved by their sinuosities, a phe- 
 nomenon not observable in the healthy condition. 
 
 The venous blood may pursue a retrograde course, but this can 
 only occur in certain vessels and for a short space. This phenom- 
 enon is not uncommonly observed in the external jugular veins, in 
 cases of'cardiac aneurism. At each contraction of the heart the 
 reflux of blood can be distinguished by the eye, its diminishing 
 undulations rising often to the upper part of the neck. This symp- 
 tom is, by authors, termed a venous pulse. There is another 
 affection, in which a retrograde flow of the blood in the veins is 
 sometimes noticed ; we refer to the aneurismal varix. By means 
 of the accidental communication occurring between two contigu- 
 ous vessels, a portion of the arterial blood passes into the vein, 
 producing in it pulsations isochronous with those of the arteries, 
 and giving to the blood an impulse contrary to its natural course, 
 the influence of which, however, is felt but a few inches. 
 
 The manner in which the blood escapes differs in wounds of the 
 arteries, capillaries and veins. In the first case, it issues with 
 force and by interrupted jets ; in the second, it is effused in small 
 quantities ; in the third, it may form a continuous jet, the force 
 and volume of which varies according to several circumstances. 
 
 A phenomenon noticed by all authors is the absence of haemor- 
 rhage in certain wounds of the vessels ; as in lacerated wounds 
 and those inflicted by fire-arms, and more particularly after the 
 carrying away of a limb by a projectile ; but this is by no means 
 always the case, rapid and fatal haemorrhages having been often 
 observed, particularly in gunshot wounds, if any large artery have 
 been wounded. 
 
 E. Having now enumerated the principal symptoms furnished 
 by the circulation, it remains to consider those furnished by the 
 blood* itself. This subject, so interesting in a scientific point of 
 view, has been almost wholly abandoned since the close of the last 
 century, at which time, Parmentier and Deyeux published the re- 
 sults of their experiments upon this fluid, and in which the cele- 
 brated author of the Nosographic Philosophique sapped to its 
 foundations the superannuated doctrine of humorism. Since that 
 time, most physicians, convinced that the blood is insusceptible of 
 any alteration in the living body, have neglected to make any in- 
 vestigations for the purpose .of elucidating this important question. 
 
 The treatise of these two celebrated chemists, however, from its 
 being opposed to the ancient doctrine, seemed more fitted to attract, 
 than to divert, the attention of the learned upon the subject under 
 discussion; and if it had the contrary effect, the fault is not so 
 much attributable to the work, as to those who lived at the time 
 of its appearance. Its influence can only be appreciated by refer- 
 ring to that period. 
 
 Its object was to " determine, from modern chemical discoveries 
 and accurate experiment, the nature of the alterations which the 
 blood undergoes in inflammatory diseases, putrid febrile diseases 
 
SYMPTOMS. 183 
 
 and scurvy." The experiments were tried; 1, on the blood of a 
 young man affected with pneumonia ; 2, on that of three individ- 
 uals who presented symptoms of scurvy, , connected, in two, with 
 general plethora, and with pain in the side in the other; 3, on 
 the blood of a certain number of individuals suffering from affec- 
 tions vaguely designated by the term putrid fevers, in many of 
 which no putridity existed. 
 
 Let us suppose for a moment that the results of the observations 
 and experiments made on this small number of patients had all 
 been contrary to the doctrine previously admitted, would they suf- 
 fice to overthrow it? Certainly not; and we do not hesitate to 
 say, that an opinion which had been held for so many centuries, 
 and had withstood so many contending systems and theories, de- 
 served a more thorough examination before discarding it. This 
 should only be accomplished by a mass of well observed facts. 
 Now, the treatise in which it is undertaken to proscribe it, contains 
 but a single fact, and that favorable to the opinion it combats. 
 The other experiments undertaken in the cases of scurvy demand- 
 ing bleeding, and putrid febrile diseases, -many of which did not 
 present this character, do not afford the necessary conditions to 
 serve as a base for rigorous conclusions. 
 
 Let us now pass to the results of these experiments. 1. Chemi- 
 cal analysis showed no difference between the blood in pneumonia 
 and that in scurvy ; but, without here referring to the uncertainty 
 inherent in chemical analyses, the results of which vary with the 
 progress of the science, we should recollect that there are many 
 natural, and, particularly, organized, bodies, which are distinct 
 from each other in their physical properties and their action upon 
 the economy, although no such difference is indicated by chemical 
 reagents. This remark, the truth of which is sufficiently evident, 
 should suffice to put us on our guard against the hasty application 
 of chemistry to organized bodies ; chemical analysis may show no 
 difference between the blood of scorbutic patients and that of 
 persons suffering from an inflammatory disease, although it may 
 be as great as between wholesome and poisonous substances, 
 which, by chemical examination, are undistinguishable from each 
 other, as the phlegmonous and variolic pus, for example, which is 
 susceptible of producing very different effects upon the economy. 
 2. In regard to the physical properties of the blood, its consistence 
 and the formation of the buff, Parmefitier and Deycux observed 
 that they were not constantly the same in similar affections, and 
 were sometimes alike in diseases of an opposite nature. From the 
 careless manner in which the diseases are characterized in this 
 treatise, we should be cautious in regard to the conclusions deduced 
 from these results. 
 
 Our only object in thus appearing to criticise this treatise, was 
 to combat the consequences which have arisen from it, and which 
 would, perhaps, be disclaimed by the authors themselves. They 
 justly called in question an opinion the truth of which had not been 
 previously doubted, and are not responsible for errors which they 
 
184 SYMPTOMS. 
 
 did not inculcate. We have not maintained an opinion contrary 
 to that which they expressed ; we have only proposed to bring the 
 question back to where it should be, and call the attention of 
 faithful observers to a subject too hastily abandoned. Without 
 Avaiting for new facts to shed more light on this obscure point in 
 pathology, we will consider the less doubtful points respecting it. 
 
 We thus expressed ourselves in 1817, and again in 1824, respect- 
 ing the hitherto contested alterations of the blood in the course of 
 diseases. Since that time there has been an entire change of opin- 
 ion upon this interesting subject. The fluids of the economy, arid 
 particularly the blood, have been the subject of curious researches 
 both by chemists and distinguished physicians, which seem to 
 promise important results. 
 
 Some experimenters, and particularly Rossi and Bellingheri, 
 have compared the electrical state of the blood in health and dis- 
 ease ; but the result of these researches, which need to be confirmed 
 by others, has, as yet. afforded no useful indication in diagnosis 
 or therapeutics. 
 
 The blood, in disease, presents other more apparent changes, 
 which we shall proceed briefly to consider. 
 
 While the blood circulates in its vessels, it escapes our observa- 
 tion, and cannot consequently be submitted to examination; it is 
 only when it flows from the body that its physical properties 
 become apparent. 
 
 The qualities of the blood can rarely be correctly appreciated 
 in spontaneous haemorrhages. This fluid, in issuing drop by drop, 
 is coagulated in small masses, so that its color and consistence are 
 alone appreciable ; and even these may be with difficulty deter- 
 mined, if, as is often the case, the blood be mixed with other 
 matters. It is only in blood-letting, in which a certain quantity 
 of this fluid flows rapidly from a vessel of medium size, that all 
 its qualities become appreciable. The force with which the blood 
 escapes, in the operation of phlebotomy, deserves attention, par- 
 ticularly in its two extremes. Thus, in vigorous subjects, the jet 
 is strong and continuous, while in those suffering from debility, 
 the blood flows slowly, with difficulty and often guttatim. In 
 the cold stage of cholera, the slowness with which the blood issues 
 from an incision of the veins, and even arteries, is owing not only 
 to the diminished contraction of the heart, but also to the thick- 
 ness, viscidity, and almost gelatinous state, of the blood. The 
 sound which is supposed to accompany the issue of the blood, and 
 the quantity of froth which appears upon its surface in the cup, it 
 is unimportant to notice. Its color can only be distinguished while 
 flowing; its contact with the air, and particularly its separation 
 into different parts, soon produce marked changes in its appear- 
 ance. It is more red in inflammatory diseases than in adynamic 
 affections and /scurvy, in which it is of a blackish hue, and dis- 
 eases of debility, as chlorosis, anemia and dropsy, in which it is 
 generally pale. Some physicians, Huxham among others, assert 
 that they have perceived in the blood at the moment of its escape 
 
SYMPTOMS. 185 
 
 from the vein a fetid odor in those affected with putrid fever ; 
 these assertions require confirmation. Nevertheless, such an odor 
 may possibly have been noticed, if, as has recently been advanced 
 by Dr. Bonnet of Lyons, * the blood in typhoid fever contains 
 hydrosulphate of ammonia, a salt detected by Vauquelin in putri- 
 fied blood, and it be true that in some cases of anthracoid 
 diseases, a spontaneous development of the hydrosulphuric acid 
 takes place in this fluid, f Pringle also recognized a putrid odor 
 in blood newly drawn. J Some authors have asserted that this 
 fluid exhales a urinous odor in retention of the urine, but this 
 opinion has not yet been verified. 
 
 In health, the blood has a saltis 
 
 i taste. It has been supposed, 
 
 by some authors, that, in diabetes, this peculiarity was less marked, 
 and some have asserted that the serum exhibited a sweetish taste 
 (DOBSON). M. Guibourt found, upon examination of diabetic 
 urine, the serum to possess the ordinary flavor. 
 
 The temperature of the blood may be modified in certain dis- 
 eases. Thus in those affected with cholera, it was generally lower 
 by four or five degrees (Reaumur) than in other diseases. 
 
 The blood, allowed to remain at rest for a few hours, ordinarily 
 separates into two parts : the serum, and the coagulum. The pro- 
 portion, between the coagulum and serum, varies according to 
 different circumstances, some of which only are known. The 
 serum is generally less abundant at the commencement of inflam- 
 matory fevers and the phlegmasiae, sometimes being wholly absent ; 
 the blood, in these cases, is said to be rich ; but towards the latter 
 periods of the disease, the coagulum becomes smaller and the 
 serum more abundant, in proportion to the number of times blood- 
 letting has been performed ; sometimes also a portion of the serurn 
 remains in the coagulum, which can only be squeezed out by pres- 
 sure. In .these cases, the coaguium is softer than when spon- 
 taneously disengaged from all the serum, and if it exhibit a buff, 
 this is thicker from being infiltrated with serum. 
 
 The quantity of serum, which is small in robust persons, is con- 
 siderable in those of feeble constitution, but particularly in those 
 affected with anasarca and chlorosis, and also in those who have 
 submitted to repeated blood-letting : in these cases the blood is said 
 to be poor. In the latter, the serurn is pale and free from the citrine 
 color which is natural to it ; it appears that the soluble salts which 
 it generally contains, are found in less proportion. This has been 
 also observed in Bright' s disease ; for it results from the experi- 
 ments of Dr. Christison that, from the first period of this affection, 
 there is a great diminution in the density of the serum, which 
 depends upon a more or less considerable reduction in the propor- 
 tion of albumen and salts. In consequence of this loss of albumen, 
 
 * Gas. Medic., t. v. p. 601. 
 
 f Nouv. Biblioth. Medec. 
 
 j Maladies des Arntees, p. 388. 
 
 || Maladies des Reins, t. 1, p. 2-27. 
 
 16* 
 
186 SYMPTOMS. 
 
 the serum of the blood is less coagulable by heat, # while an 
 opposite change takes place in the urine. 
 
 The serum may also contain various substances which can only 
 be discovered by inspection or chemical analysis. Thus it is 
 sometimes of a reddish color, owing to a portion of the coloring 
 matter of the blood which it contains, a circumstance, according 
 to some authors, indicative of a state of -general debility or a 
 cachectic condition. In bilious diseases, particularly jaundice, 
 the serum presents a yellow or greenish tint, which, in some 
 cases, precedes the change in the color of the skin by several 
 days, and indicates the presence, in the blood, of the coloring mat- 
 ters of the bile. According to some chemists, the existence of 
 cholesterine (Boudet) and picromel (Orfila) has been detected in 
 these cases. 
 
 The serum sometimes presents a milky appearance, as was 
 observed by Christison in the first period of Bright's disease, and, 
 by Marshall Hall, in the blood which last flowed from animals 
 dying from haemorrhage. Some physicians were for a long time 
 deceived by this milky appearance of the serum, for they supposed 
 that the blood contained this fluid in substance, or at least, its 
 material principles ; but modern chemists are unanimous in attrib- 
 uting this peculiar appearance of the serum to the presence of 
 fatty matters in suspension, which are easily separated by means 
 of ether. 
 
 In cases of urinary absorption, and in the first and last periods 
 of the granular disease of the kidneys, the serum contains a con- 
 siderable quantity of urea (Christison, Rayer, Rees). Some chem- 
 ists have detected the same substance in the blood in cholera, 
 particularly in cases in which the urinary secretions was suspended 
 (Hermann, f O'Shaughnessy f). It has been recently advanced 
 by Dr. Copland, that urea is found in great abundance in the blood 
 of persons suffering from gout; but this assertion of the English 
 pathologist has not as yet been confirmed. 
 
 Many physicians or chemists, among whom we may mention 
 Rollo, Rees, Dobson, M'Gregor, and M. Bouchardat,|| assert that 
 they have discovered in the blood of diabetic patients, a consider- 
 able quantity of sugar ; but these results were formerly contested 
 by Nicolas and Guedeville, 11 Vauquelin** and Wollaston, ff and 
 more recently by M. M. Henry, Soubeiranjf and Guibourt; |||| 
 this question is not yet finally settled. 
 
 The coagulum varies in its form, consistence and the peculiar 
 
 * Archiv., 3d series, t. iv. p. 472. 
 
 f Bull, des Sc. Med. de FERUSSAC, t. xxvii. p. 7. 
 
 j Gaz. Medec., t. iii. p. 109, 1832. 
 
 Dictionary of Prac. Med. art. Blood. 
 
 || Revue et Journal des Connaisances Medicates, 1839. 
 
 % Diab. sucre. Paris, 1803. 
 
 ** Journal de Chimie, t. i. 
 
 \\Phil. Trans., 1811. 
 
 |j Journ. de Pharm., t. xii. p. 320. 
 
 IHI RAYER, t. i. p. 244. 
 
SYMPTOMS. 187 
 
 appearance of its surface. Its form is generally that of the vessel 
 into which the blood is received, that of a disc flat upon its su- 
 perior, and convex upon its inferior, surface. In some cases, the 
 superior surface becomes concave from inversion of its edges ; the 
 blood is then said to be cupped : it is particularly when the coagu- 
 lum is small that it presents this form, this occurring chiefly in 
 the second period of inflammations and after repeated blood-letting. 
 Much importance has been attached to the consistence of the 
 coagulum. It is generally firm in inflammatory diseases, and in 
 robust subjects ; it is, on the contrary, soft in chronic affections, 
 anemia and chlorosis ; it is diffluent in cases of miasmatic poi- 
 soning, in the last stage of grave fevers, in certain eruptive fevers, 
 and, particularly, in confluent variola, the severest form of scar- 
 latina, &c. The blood, in the cold or blue stage of cholera, is 
 black, viscid, resembling current jelly, and reddening but slowly, 
 by exposure to the air. Increase in the density of the clot, its 
 volume, and the small quantity of serum, indicate an abundance 
 of globules ; paleness of the coagulum, denotes a diminution of 
 the coloring principle, and consequently the iron with which it is 
 combined. 
 
 Is there a condition of the clot which is characteristic of any . 
 disease ? Can it be admitted, for example, that a soft and diffluent 
 and curdy coagulum, or a serum holding in suspension a portion 
 of the coloring matter of the blood, are lesions characteristic of 
 typhoid fever 'I We think not. We cannot indeed regard, as pe- 
 culiar to typhoid fever, those alterations which often fail, particu- 
 larly in the first stage of this disease, the only period when 
 blood -letting is generally practicable, and which we have often 
 observed in other diseases. 
 
 The surface generally differs in appearance from the rest of 
 the coagulum; it is distinct in color and nature, -and of variable 
 thickness. In health and many diseases, this surface is of a rosy 
 or vermilion color in the thickness of a half a line or a line. In 
 inflammations, and particularly those of several days' duration, 
 the blood is almost constantly covered with a crust of a greater or 
 less thickness and solidity, often lardaceous, to which the term 
 inflammatory crust or buff has been applied (crusta inflammatoria). 
 This buff is so frequent in the thoracic phlegmasise that, by many 
 authors, it has been called the pleuritic crust (crusta pleuriticd). It 
 also almost constantly exists in rheumatic fever, and very fre- 
 quently in most acute diseases accompanied with intense iever. 
 The buff does not, however, necessarily indicate the existence of a 
 phlegmasia, since it occurs in the blood of plethoric persons, 
 otherwise healthy, and almost always accompanies pregnancy. 
 
 The thickness and firmness of the buff, is generally in propor- 
 tion to the violence of the inflammation and the robustness of the 
 individual. It is almost always of a greyish white color : it is of 
 a rosy hue when thin, and yellow when the serum in which it 
 floats presents this color. By pressing it, a few drops of serum 
 can generally be squeezed out. The formation and thickness of 
 
188 SYMPTOMS. 
 
 the buff do not exclusively depend upon the qualities of the Mood; 
 they are in part owing to the manner in which it flows out and 
 the form of the vessel into which it is received. If it flow slowly, 
 it coagulates in falling, as has been before remarked, and forms an 
 homogeneous mass in which neither coagulum, serum nor buff can 
 be distinguished. If it flow in a jet from a narrow opening, the 
 conditions are more favorable, and a buff may be formed ; but it 
 is generally thin, and the serum is but imperfectly separated from 
 the coagulum ; if the blood flow in a full stream and from a large 
 opening, the separation of the elements of the blood takes place 
 more readily, and the buff which it presents is of a thickness and 
 consistence proportionate to the richness of the blood. These dif- 
 ferences often appear at a single bleeding, if the blood be allowed 
 to flow into several cups and with unequal force, as often happens. 
 It is sometimes possible to judge from the different thickness of the 
 buffy coat in various points of its extent, that there has been great 
 inequality in the flow of the blood. Finally, the thickness of the 
 buff varies with that of the clot; that is, the thickness of the layer 
 of blood drawn from the veins, which depends upon the form of 
 the receiving vessel. If, for example, in bleeding a patient, four 
 ounces of blood be drawn into a plate, the buffy coat is only one 
 or two lines in thickness ; half of this quantity, received in a 
 tumbler, would present a buff five or six lines in thickness. 
 
 There is another circumstance that exerts a marked influence 
 upon the thickness of the buffy coat ; we refer to the manner in 
 which the separation between the serum and coagulum is effected. 
 This separation, which is never absolutely entire, so varies, that 
 in some cases, the clot contains twice the quantity of serum as in 
 others. Now, the buff is never so thick as when infiltrated with 
 serum. This disposition is at once apparent from the transparency 
 of the buff, and the facility with which the fluid escapes ; if the 
 finger be placed underneath the clot so as to raise it, a multitude 
 of small drops are at once visible on the surface of the buff, which 
 rapidly increase till they unite by their circumferences and flow 
 of. We have sought to ascertain the causes which produce this 
 retention of the serum by the coagulum; but from the different 
 experiments which we have made by varying the form and, in 
 some cases, the temperature of the vessel into which the blood was 
 received, and taking into account the size of the opening in the 
 vein, the force with which the blood flowed out, and the nature of 
 the affection from which the patient suffered, we have been able 
 as yet to learn nothing respecting the conditions necessary to the 
 production of this phenomenon. 
 
 The existence of a buffy coat, according to most authors, indi- 
 cates an increase in the proportion of fibnne; according to others, 
 a modification of the albumen ; there are also many who attribute 
 it to a matter spontaneously coagulable. The production of this 
 phenomenon is enveloped in much obscurity. 
 
 The blood may contain various deleterious principles, some of 
 which are discoverable by chemical reagents; thus, Urfila has been 
 
SYMPTOMS. 189 
 
 able to detect the presence of arsenious acid in the blood of those 
 poisoned by this substance. There are other deleterious princi- 
 ples which can alone be suspected to exist in the blood : thus in 
 the inoculation of the contagious and eruptive diseases, every 
 thing indicates that, between the insertion of the virus and the 
 development of the symptoms, the blood undergoes some alteration, 
 the detection of which is beyond the reach of physical or chemi- 
 cal exploration. The presence of the virus of rubeola in this 
 liquid, would have been shown by the experiments of Fr. Home 
 and Sparanza, who inoculated rubeola with the blood of those 
 affected with this disease, if these experiments had been repeated 
 a sufficient number of times, by different experimenters with the 
 same success, and with all the necessary precautions. 
 
 If, as is proved by the observations of modern chemists, the 
 blood in its normal condition contain oxgyen, azote and carbonic 
 acid in a free state, it is probable that many alterations in this 
 fluid may depend upon a change in the normal proportion of these 
 gases. Dr. Clanny has pretended that the blood in typhoid fever, 
 contains less carbonic acid, and consequently advises the use of 
 Seltzar water. # But, on the one hand, the opinion of Dr. Clanny 
 upon this alteration of the blood needs confirmation ; and, on the 
 other, respecting the curative method proposed by him, we may 
 remark, that having treated a great number of patients, at La 
 Charite, by the exclusive employment of gaseous drinks, no more 
 cures were obtained by these, than by cooling and acidulated 
 drinks. 
 
 Such are the principal alterations furnished by the blood in dis- 
 ease ; if there be many, which are doubtful, there are others, 
 too evident to admit of question. All physicians are, at the pres- 
 ent day, convinced of the necessity of studying these alterations, 
 which are already of interest, and promise henceforth results of 
 immeasurable importance. 
 
 The microscopical characters of the blood, both in health and 
 disease, have also been recently investigated. But as no positive 
 results have yet been obtained from these researches, as experi- 
 menters have arrived at different and often contradictory conclu- 
 sions, we abstain from giving opinions which need confirmation. 
 We shall only premise to those engaged in these investigations, that 
 the blood-globules readily undergo an alteration during the 
 formation of the clot, and that hence it becomes necessary to defi- 
 brinate the blood as it issues from the vein ; in this way a fluid may 
 be obtained, which is easily preserved for a considerable time, and 
 in which the properties of the globules remain unchanged. 
 
 $ I. Circulation of Lymph. The phenomena which occur in 
 the lymphatic vessels, it is rarely possible to appreciate. The 
 redness which sometimes makes its appearance in their course, 
 and their hard and knotty feel, are symptoms of their inflamma- 
 
 * A Lecture upon typhoid fever. Lond. 1828. 
 
] 90 SYMPTOMS. 
 
 tion. Many cases have been cited in which they presented dila- 
 tations similar to those in varicose veins. But, generally, the 
 alterations of lymphatic vessels are not appreciable till after 
 death. 
 
 The lymphatic glands which, with the vessels of the same 
 name, concur in the circulation and elaboration of the lymph, 
 present symptoms more apparent. They often become increased 
 both in volume and sensibility, a phenomenon to which the term 
 engorgement has been applied, and which may appear in an acute 
 or chronic form. This engorgement of the lymphatic glands 
 almost always follows a lesion of some part, in greater or less 
 proximity, and more frequently, the application of virus or some 
 acrid substance to the parts from which the lymphatic vessels, be- 
 longing to these glands, take their rise. In erysipelas of the face, 
 the submaxillary glands are the seat of a painful swelling, which 
 also occurs in some cases of angina, and particulary those termed 
 couenneuses. Chronic eruptions of the scalp, the difficult extrac- 
 tion of a tooth, and dental caries, are frequent causes of a chronic 
 and often circumscribed engorgement of the same glands and those 
 upon the side of the neck. Acute engorgement of the axillary 
 glands, ordinarily arises from an excoriation, a prick of the fingers, 
 particularly if the wound be inoculated with putrid matter, as 
 is too often the case in those who wound themselves in dissecting, 
 or who, having a scratch or excoriation upon the hand, bring it in 
 contact with an irritant and septic fluid, as pus or sanies. In 
 other cases, the glandular engorgement is owing to a phlegmasia, 
 wound, ulcer or blister upon the corresponding side of the chest. 
 In nursing women, diseases of the mammary gland are a frequent 
 cause of a painful engorgement in the axillae. The glands of the 
 groin, also, become frequently inflamed, and from the precise seat 
 of the engorgement, we may often determine whether it be symp- 
 tomatic of a lesion of the genital organs, the corresponding limb 
 or the inferior part of the trunk. If it exist in the internal part of 
 the groin, some disease of the genital organs should be at once 
 suspected, because it is in this part.of the inguinal region that the 
 lymphatic vessels which arise in the sexual organs, all centre. If 
 the engorgement occur at the inferior and external part of the 
 groin, it generally depends upon a lesion of the lower limb, as a 
 wound or excoriation upon one of the toes, produced by walking 
 or some other cause. If it is the superior lymphatic glands that 
 are inflamed, the cause must be sought in the abdominal parietes. 
 Lastly, if the phlegmasia is confined to the external side of the 
 inguinal region, the corresponding thigh, which is generally the 
 seat of the cause which produces the engorgement, should be 
 examined. 
 
 It seems then that inflammation of the lymphatic ganglia gen- 
 erally succeeds an evident cause of irritation, more or less remote. 
 But, there are cases in which the glands become inflamed and 
 painful, independently of any perceptible alteration of texture or 
 color in the neighboring parts. The occurrence of a glandular 
 
SYMPTOMS. 191 
 
 engorgement under these circumstances, when accompanied with 
 fever, generally indicates the speedy development of erysipelas 
 upon some not far distant part of the integuments ; thus if it be 
 the submaxillary or cervical glands that become affected, the 
 erysipelas will manifest itself upon the head ; if the axillary 
 ganglia or those of the groin, its appearance upon the superior or 
 inferior limb may be expected. In those cases where a glandular 
 engorgement precedes the inflammation which it ordinarily accom- 
 panies as a secondary phenomenon, it is probable, that, although 
 there be no change perceptible to the eye, or pain experienced by 
 the patient, a modification already exists in the capillaries of the 
 lymphatic or circulatory system, the first effect of which is inflam- 
 mation of the glands. 
 
 When the swelling of the subcutaneous and subaponeurotic 
 glands is very considerable, occupying many at once, and the in- 
 flammation of which extends to the surrounding cellular tissue, 
 the inflammatory tumor is called a bubo, a word particularly 
 applied to engorgements in the groin and axillary regions, and 
 sometimes to those of the neck and ham. When primary, a rare 
 circumstance, or depending upon a non-specific irritation, more 
 or less remote, they are called simple. They are termed syphilitic 
 and pestilential when caused by the virus which constitutes these 
 two affections : the former, are generally seated in the groin and 
 connected with the existence of chancres upon the external organs 
 of generation ; the latter, which are particularly observable in the 
 East, may appear wherever a certain number of glands exist 
 grouped together, as in the groins and axillae, sometimes in the 
 ham and cervical region, and more rarely in the cheeks ; it would 
 appear from the examination of bodies after death, that the deep 
 seated glands, in front of the vertebral column, often participate in 
 the engorgement of the superficial glands.* Syphilitic and pestilen- 
 tial buboes frequently terminate by suppuration. This termination 
 is rare, on the contrary, in simple buboes. When chronic engorge- 
 ment of several glands exists simultaneously in different regions, 
 presenting a chronic form, it denotes some constitutional affection, 
 generally a scrofulous taint. 
 
 A peculiar symptom sometimes presented by the lymphatic ves- 
 sels and glands, is a discharge of colorless fluid, following suppu- 
 ration or wounds of their tissue, which in some cases persists for a 
 long time, as is occasionally observed after syphilitic inflammation 
 of the inguinal glands. 
 
 In regard to the alterations of the lymph, its consistence, acri- 
 mony, &c., they have never been definitely determined : analogy 
 would lead us to suppose that this fluid, like all those which enter 
 into the composition of the human body, is susceptible, in disease, 
 of undergoing various modifications ; but these modifications have 
 not hitherto been the subject of serious investigation, being a 
 branch of research so entirely new and the difficulties with which 
 
 * Dela Peste orientate, etc., par BULARD. Paris, 1839. 
 
192 SYMPTOMS. 
 
 it is surrounded so great, that its elucidation can only be effected 
 by means of experiments performed upon healthy and diseased 
 animals. 
 
 SECTION FOURTH. 
 
 Symptoms furnished by Animal Heat. 
 
 The faculty by which the human body, in the healthy condition, 
 is enabled to maintain a uniform degree of heat, whatever be the 
 temperature of the surrounding medium, becomes still more appa- 
 rent in disease. In health, the heat of the body is always in- 
 creased to a certain extent when exposed to a temperature higher 
 than its own ; it becomes diminished under the opposite conditions. 
 In disease, on the contrary, the body may become chilled notwith- 
 standing the employment of warm applications; the heat may also 
 become burning, without being affected by the ingestion of cool 
 drinks, or the removal of clothing. Under other circumstances, 
 patients become morbidly susceptible of the influence of cold and 
 heat. 
 
 The appreciation of morbid heat, as of many other symptoms, 
 requires on the part of the physician long experience, which can 
 only be attained by close observation and the frequent comparison 
 between normal and abnormal heat, in the various conditions of 
 health and disease. The best instrument that can be employed, is 
 the hand. We are sometimes enabled by the thermometer to 
 ascertain the exact degree of the heat of the body; but this instru- 
 ment is entirely unfitted to show the other modifications sometimes 
 presented by abnormal heat. In many cases, indeed, we are 
 enabled to perceive a manifest increase of temperature, although 
 that indicated by the thermometer is not above the usual standard 
 of the blood in health. This is particularly evident from the 
 experiments of Hunter, who, having produced an artificial inflam- 
 mation in the vagina and rectum of an ass, in the chest and 
 abdomen of a dog and slut, was unable, in any of these cases, to 
 distinguish by means of the thermometer the slightest elevation of 
 temperature, whilst its increase was perceptible to the touch.* In 
 order to appreciate the varieties presented by the animal heat, the 
 hand employed should be moderately warm ; it should be applied 
 successively to various parts, and particularly to the extremities 
 of the limbs, face, chest, abdomen, and over the region which 
 appears to be the seat of the disease or predominant symptoms ; it 
 should be allowed to remain in contact with each of these parts, 
 for twelve or fifteen seconds, in order to ascertain if the sensation 
 transmitted to it, remains the same or differs by prolonged contact. 
 
 It has been said that the animal heat is, generally, more consid- 
 erable in children than adults ; that it is always less in the morn- 
 ing, becomes sensibly increased in the middle of the day, and is 
 
 * HUNTER (John), .4 Treatise on the blood and inflammation. Lond. 1794, 4lo. 
 
SYMPTOMS. 193 
 
 more elevated in the evening than at any other period; that during 
 calm sleep, the temperature is diminished by four or five degrees, 
 and at the moment of awaking, is sensibly increased, &c. ; but to 
 all these rules established by semeiologists, there are numerous 
 exceptions. 
 
 There are four principal modifications presented by the heat in 
 disease, it may be increased, diminished, abolished or perverted. 
 
 A. The heat may be more or less increased in different diseases, 
 or in different periods of the same disease. Between the slight 
 heat which occurs in many light affections, and the burning heat 
 observed in the most violent febrile diseases, there are various 
 shades. 
 
 In some cases, the heat is alone sensible to the patient, in others, 
 it is perceptible to the hand of the physician, or can be measured 
 by means of the thermometer. Some experimenters assert that 
 they have been thus enabled to distinguish an elevation or diminu- 
 tion of temperature of several degrees. Thus in some cases of 
 typhoid fever, the temperature has been known as high as from 
 33 or 34 c. to 40 or 41, * while in cholera, according to the 
 experiments made at Vienna, the temperature of the feet was as 
 low as 14, Re., and that of the tongue 15. There is no disease 
 in which the temperature is so low as in cholera, f 
 
 The heat may be general or partial ; in the first case, it may be 
 distributed equally over the whole body, or, as is most common, 
 be more elevated in certain regions. When the heat is confined to 
 a single region, it is sometimes in the diseased organ itself that it 
 appears, and sometimes in a part more or less remote, as the head, 
 in certain affections of the stomach, and the palms of the hands 
 in some diseases of the lungs. The skin, which covers a 
 phlegmon, is almost always very warm, and the heat of the fore- 
 head is often more or less elevated in cephalgia. It has been 
 asserted that the integuments of the abdomen and thorax also 
 become thus affected in the phlegmasiss of the organs contained in 
 these cavities, as is the case with the skin of the forehead in some 
 cerebral affections ; but here the analogy is fallacious. In most dis- 
 eases, and particularly febrile affections, the degree of heat sensible 
 to the hand, is greater in the regions of the chest and abdomen, 
 than at the extremities : this difference even exists in those cases 
 in which the seat of the disease is remote from these two cavities ; 
 and in the phlegmasiae of the lungs, the integuments of the abdo- 
 men are as warm as those of the thorax. 
 
 The heat presents analogous varieties, in relation to its type : it 
 sometimes continues uninterruptedly during the whole course of a 
 disease; it sometimes reappears periodically, as in intermittent 
 fevers, or at irregular intervals, being of transient duration 
 in females suffering from disordered menstruation, and nervous 
 
 *BOUILLAUD, CUn. de la Charite, t. 1, p. 294. 
 f GA.YMARD and GERA.RDIN, p. 121. 
 
 J7 
 
194 SYMPTOMS. 
 
 persons; in these cases it comes on in flushes, according to the 
 common expression; these flushes ordinarily occur in the face; 
 they are accompanied by redness of the part, and are frequently 
 followed by gentle perspiration. The partial and transient heat 
 which is sometimes felt in different parts, moving rapidly from one 
 to another, has, by authors, been termed nervous or erratic. 
 
 The heat, in disease, presents still other differences in relation to 
 the peculiar character which it offers; it sometimes resembles that 
 of a healthy person when warm : this is called free heat; when 
 accompanied by moisture, like that felt by a person after a warm 
 bath, it is called moist ; if the skin have lost its suppleness and 
 ordinary degree of moisture, the heat is termed dry ; it is burning, 
 when there is dryness together with a high degree of temperature ; 
 it is acrid and pungent, when it conveys to the fingers a disagree- 
 able sensation, well expressed by the epithet, and which instead 
 of diminishing, increases by prolonged contact, and which con- 
 tinues for some time after this has ceased. Some authors have 
 described other varieties, which they have termed hectic, and sep- 
 tic, heat ; but these secondary shades are of difficult and uncertain 
 appreciation, and, as it is impossible to give an idea of them by 
 words, we shall only mention them as belonging, the one to hectic 
 fever, the other, to parts affected with gangrenous inflammation. 
 
 B. Diminution of heat, or cold, presents the same varieties in re- 
 lation to its intensity, seat, type, and peculiar character. 
 
 Cold may be appreciable by the physician, or be only sensible to 
 the patient, in both cases its intensity may vary. Coldness is a 
 simple sensation of cold ; horripilation, a sensation accompanied 
 with bristling of the hairs over the body (goose flesh) ; when 
 attended with an involuntary tremor, it is called a rigor. A chili 
 may be general or partial, external or internal, transient or con- 
 tinual, with or without exacerbation. . Senac speaks of a fever 
 patient whose arm alone was cold. In regard to its peculiar char- 
 acter, it may be stinging, icy, or similar to that experienced by a 
 healthy person when exposed to the cold air. 
 
 Partial cold almost always affects the extremities, end of the 
 nose, back and loins. It is also, but very rarely, seated in the 
 affected organ, as is sometimes observed in chronic rheumatism. 
 
 A chill of greater or less intensity generally marks the com- 
 mencement of most of the phlegmasiae. If violent, and occurring 
 in a person previously in perfect health, it indicates, particularly 
 in the winter and spring, when these diseases are most frequent, 
 an attack of pleuro-pneumonia, and should lead the physician to 
 fear its development, even before the appearance of any other local 
 sign, and when there are considerable disorder of the stomach, or 
 brain, to direct our suspicions elsewhere. This phenomenon has 
 alone enabled us, in many cases, to prognosticate an inflammation 
 of the lungs, which did not become distinctly apparent till after one 
 or two days of fever. 
 
 Intermittent fever commences also by a rigor ; but this is gen- 
 
SYMPTOMS. 195 
 
 erally accompanied by a general tremor, which is not commonly 
 observed at the commencement of the phlegmasise. When the 
 phlegmasia terminates in suppuration, irregular chills supervene, 
 which proceed from the inflamed organ (Landre-Beauvais). Rigor 
 is often the index of an abundant suppuration, and, according to 
 Baillou, the absorption of pus into the blood.* Dance observed 
 the same phenomenon in phlebitis, when the pus had made 
 its way into the circulatory torrent. In these cases, there are vio- 
 lent chills, which, in some subjects, recur with a kind of periodi- 
 city, as in intermittent fever. 
 
 In a great number of cases, there is an alternation of cold and 
 heat in the same individual, the chill generally occurring first, 
 followed by the heat; the contrary is sometimes observed. Dimi- 
 nution and increase of temperature often succeed each other many 
 times within a short period. 
 
 C. The complete abolition of heat only occurs in cases of freez- 
 ing which may be partial or general ; it is probable that the tem- 
 perature is nearly as low, even in parts susceptible of complete 
 restoration. However, we know of no fact of this kind in which 
 the degree of heat was measured by the thermometer. 
 
 D. The heat is perverted in all cases in which the patient com- 
 plains of a sensation of cold in a part which is evidently warm, or 
 a sensation of warmth in a part which is cold. The latter phe- 
 nomenon often occurs in dry gangrene of a limb. The patient 
 complains of burning heat in the affected part, while to the assis- 
 tants it feels cold. To this disorder of the heat may be referred 
 those sensations of external and icy coldness and internal heat, 
 sometimes simultaneously felt, and vice versa. We have seen at 
 La Charite, in one of the wards of Lertninier, a case still more 
 extraordinary, that of a young man who had been for some 
 time suffering from intermittent fever. At the moment that he 
 experienced the rigor, that is, a sensation of cold with general 
 tremor, his skin became red, warm, and covered with a profuse 
 sweat. This singular phenomenon occurred during several succes- 
 sive paroxysms. 
 
 SECTION FIFTH. 
 Symptoms furnished by the Exhalations and Secretions. 
 
 The act by which certain fluids are separated from the blood by 
 means of the various organs, is called secretion. Of these, there 
 are two kinds ; those that occur in all parts of the body, and par- 
 ticularly on the free surface of different membranes, and are com- 
 
 * Batto. Gmstt/., lib. 1, p. 110. 
 
196 SYMPTOMS. 
 
 prised under the term exhalations ; and those, which have partic- 
 ular organs, furnished with excretory ducts, and which have been 
 more properly called secretions. These will be considered succes- 
 sively. 
 
 1st. Exhalations. 
 
 The exhalations not only serve the purpose of maintaining the 
 suppleness, preventing adhesion, or favoring the motion of the 
 membranous surfaces upon each other ; they act a still more im- 
 portant part in the general equilibrium ; they prepare, by elabora- 
 tion of the fluids, materials for nutrition. We shall not attempt to 
 follow physiologists in their discussions upon the form and modus 
 operandi of the exhalent organs ; the exhalent fluids, alone appre- 
 ciable to the senses, are what particularly should claim the atten- 
 tion of the physician. 
 
 The symptoms which depend upon the exhalations may be 
 divided into three groups ; to the first, belong the various changes 
 which supervene in the natural exhalations, as those which occur 
 in health ; to the second, may be referred the phenomena peculiar 
 to the morbid exhalations ; we class, in the third series, all that 
 relates to artificial exhalations. To the first series, belong the 
 cutaneous, mucus, serous, synovial, fatty, menstrual, and certain 
 other natural, sanguineous, exhalations ; to the second, the exhala- 
 tion of blood, pus, and some other fluids ; the exhalation furnished 
 by blistering and cauteries, will be ranked in the third series. 
 
 A. Natural Exhalations. 
 
 1. The cutaneous exhalation, or perspiration, in health, is con- 
 stant, gentle, and equal in all parts of the body. It becomes, at 
 intervals, more abundant, constituting sweat, which is always ex- 
 cited by an evident cause, as heat of the atmosphere, exercise, a 
 violent emotion, &c. 
 
 In disease, this exhalation may be undisturbed, preserving the 
 suppleness peculiar to the cutaneous surface. When moderately 
 increased, it produces moisture (mador) upon the skin. If the in- 
 crease is more considerable, so that the fluid appears in drops upon 
 the surface of the skin, and moistens the clothes, it is called sweat 
 (sudor). This may be general, or partial ; in the first case, it is 
 everywhere equal, as towards the decline of acute affections; 
 sometimes it is more abundant on the neck, chest, and forehead, 
 as is observed in phthisis. W 7 hen partial, it is often confined to the 
 palms of the hands, epigastrium and forehead. Sweating of the 
 hands and feet is habitual in some persons. Its sudden suppres- 
 sion has always been thought to be the cause of severe accidents, 
 as would appear from the observations recently published by Dr. 
 Mondiere.* 
 
 * I/' Experience, 1839. 
 
SYMPTOMS. 197 
 
 The temperature of the sweat may be mild, elevated or low ; the 
 latter is generally an unfavorable omen. 
 
 The sweat presents numerous varieties in relation to its density 
 and color ; it is sometimes thick, viscous and even pitchy as in the 
 dying, and sometimes thin and watery ; it is generally colorless ; in 
 some cases, it imparts to the linen worn a yellow tinge, in others, 
 it has been red (sueurs de sang). Cases have been also cited by 
 BorellL Borrichius and Fourcroy, in which the sweat was of a 
 bluish or black color. The sweat differs in other respects ; it may 
 be slight, moderate, abundant, transient, continual or periodical ; 
 it may be solely the effect of disease, or be excited by particular 
 causes, as a change of position, cough, warm drinks, &c. ; it may 
 relieve or enfeeble the patient, sometimes producing fatal results; 
 it is, in this case, called colliquative (sudores colliquativi) ; this 
 may appear at the commencement, towards the middle or decline 
 of diseases, or continue through their whole course. It consti- 
 tutes the predominant symptom in certain affections ; as in the dia- 
 phoretic, pernicious, intermittent fever, so well described by Torti, 
 arid to which he came near perishing a victim. Abundant sweating 
 is one of the principal symptoms in the sudor picardicus, and it was 
 also observed in that terrible epidemic, the sudor anglwus or sweat- 
 ing sickness, which in the middle ages ravaged a part of Europe. 
 
 The cutaneous transpiration may be diminished or suspended, 
 as is often observed in the first period of acute diseases, in diabetes 
 and dropsy, in which the skin is habitually dry. 
 
 However abundant it be, the transpiration may present appre- 
 ciable changes in its odor, a circumstance which the physician 
 should not omit to notice. The odor of the transpiration is gen- 
 erally a little acid ; sometimes, fetid. It has been compared, in 
 rubeola and scarlatina, to that of mouldiness ; it is cadavoric in 
 some adynamic fevers. 
 
 M. Landre-Beauvais and Dance * have noticed in cases of men- 
 tal alienation a peculiar odor of the transpiration with which the 
 furniture and apartments become durably impregnated, whatever 
 be the neatness of the individual. In the miliary sweat, the odor 
 exhaled has been compared by some, to that of chlorine, by others, 
 to that of rotten straw. 
 
 The odor of mice, supposed by some authors to be one of the 
 symptoms which frequently accompany fevers of bad character 
 and cerebral affections, arises both from the flowing of the urine 
 into the bed of the patient, and the oil cloth placed over the mat- 
 trass, the emanations of which, developed by the heat and com- 
 bined with those of the urine, produce this peculiar odor. In some 
 cases, the odor exhaled by the patient is owing to his food and the 
 qualities of the air which he breathes. In persons who eat garlic 
 and onions, the cutaneous exhalation is charged with this odor. We 
 have had at the hospital a groom, who, during the course of an 
 inflammatory bilious fever, continually exhaled a strong odor of 
 
 * Manuel de Semeiotique. 
 
 17* 
 
198 SYMPTOMS. 
 
 the stable. We satisfied ourselves that all his clothing was re- 
 moved, and that the odor, which was noticed by all who came 
 near him, proceeded from the patient himself. 
 
 In the course of acute febrile diseases and some cases of hectic 
 fever, the abundant sweating may be accompanied by numerous 
 eruptions of vesicles, particularly apparent upon the anterior part 
 of the trunk, about the size of a millet seed and rilled with a dia- 
 phanous fluid, generally more appreciable to the touch than to the 
 eye, breaking under the ringer, and leaving upon the pulp a sen- 
 sation of moisture : these have been called sudamina^ from their 
 resemblance to drops of sweat. Of all acute diseases in which 
 this phenomenon is observed, typhoid fever is that in which 
 it most commonly appears, a circumstance not without value in 
 the diagnosis of this disease. Abundant sweating is not necessary 
 to the reproduction of sudamina, and it is not uncommon to observe 
 them in persons who have been free from sweating. 
 
 2. Disorders of the mucous exhalation are more difficult to ap- 
 preciate, because the membranes from which they take place are 
 inaccessible to view. The alterations, however, which they pre- 
 sent at their orifices can be distinguished by the eye, and the 
 examination of the excreted matters, may throw light upon the 
 changes effected in the mucous exhalation in deep-seated organs, 
 as the intestines, bladder, &c. 
 
 In health, the mucus, the consistence and quantity of which 
 varies in the different parts of the body where it is exhaled, is 
 furnished in such a proportion as, without being sufficiently abun- 
 dant to escape, to prevent the adhesion of these membranes, facili- 
 tate their movements and the passage and progression of the 
 substances taken into their cavities. Its appearance and composi- 
 tion varies according to the mucous surface from which it is 
 exhaled. Thus that which comes from the neck of the uterus is 
 ordinarily clear, transparent, analogous to albumen, without odor, 
 always alkaline, and, when viewed with the microscope, appearing 
 homogeneous and free from globules (Donne) ; the vaginal mucus, 
 on the contrary, is thick, creamy, always acid, and never ropy.* 
 
 In disease, the mucous exhalation may become increased, dimin- 
 ished, suspended and variously changed. These changes rarely 
 occur simultaneously in all parts of the system. Their successive 
 appearance in all these parts is more frequently observed, as in 
 some catarrhal affections ; they are most frequently partial. In- 
 crease of the mucus exhaled, is noticed in the second period of 
 catarrh ; its diminution is sensible at the commencement of this 
 affection, and in the course of grave fevers ; the mucous membrane 
 of the mouth and nasal fossae, in these diseases, is often very dry. 
 
 The mucus may become altered in its qualities ; its odor may 
 be nauseous, spermatic, and sometimes acid or fetid ; its color 
 becomes green or yellow in chronic discharges ; sometimes red in 
 dysentery, black in some grave fevers, or it may be limpid and 
 
 * DONNE, Recherches sur les divers mucus. 
 
SYMPTOMS. 
 
 resemble the white of the egg, as in certain cases of bronchorrhoea ; 
 in other cases, it may be white and opaque, arid it is then often 
 impossible to distinguish it from pus. Its consistence becomes 
 diminished in the pituatary flux, and in serous diarrhoea, and is 
 increased in chronic catarrh ; it assumes, in some cases, a flaky, 
 membranous or tubular form, in which it is rejected in shreds. 
 The mucus may be excreted alone, as in coryza, angina, and 
 blennorrhagia ; it may be mixed with other substances, as urine, 
 in cattarrh of the bladder, fa3cal matters, in dysentery, and ali- 
 mentary substances in vomiting. From whatever surface it comes, 
 it may be mixed with blood or pus ; in the latter case, the purulent 
 matters form in the opaque mucus, narrow and irregular streaks 
 still more opaque : this is daily noticed in the second stage of 
 phthisis, and at an advanced period of vesical catarrh occurring 
 in old persons. 
 
 Another remarkable alteration presented by the mucus in disease, 
 is the contagious property it acquires in blennorrhagia, and, ac- 
 cording to some authors, in many other cattarrhal affections; by 
 virtue of this contagious property, it may cause, in a healthy per- 
 son, the development of an affection similar to that by which it 
 was itself produced. 
 
 3. In health, the serous exhalation should exist in such propor- 
 tion, that the membranes and areolae which it is destined to lubri- 
 cate, should be always moist, without ever containing fluid. The 
 disorders of this exhalation are difficult to appreciate, because the 
 organs are inaccessible to view, and there is no excretion whereby 
 to judge of the changes which take place. 
 
 Does the diminution or suppressson of the serous exhalation 
 ever occur during life, as the works of Marandcl would lead us to 
 suppose? This question, which belongs rather to pathological 
 anatomy than symptomatology, does not seem to us yet decided. 
 We only know that, where two opposite serous surfaces have become 
 adherent, all exhalation is necessarily suspended, or so modified as 
 no longer to belong to this kind of exhalation. 
 
 The increase of the serous exhalation is easy to distinguish 
 when it occupies the cellular tissue (p. 76). This is far from 
 being the case when there is an accumulation of this fluid in the 
 serous membranes; it may, however, give rise to phenomena 
 which may lead us to suspect it, when in small quantity, and to be 
 certain of its existence, when in abundance. The distension of 
 the cavity which contains the fluid, the symptoms arising from 
 compression of the neighboring organs, and, in some cases, the 
 fluctuation and the changes in the resonance of the parts, will 
 generally enable us to distinguish the accumulation of serum. 
 
 The changes in the color, consistence and nature of the exhaled 
 fluid, are never appreciable during life, unless there be an acciden- 
 tal opening in the parietes of the cavity containing it, or artificial 
 issue be given to it. This change, consequently, belongs to patho- 
 logical anatomy rather than to symptomatology. 
 
 4. The exhalation which occurs in the articular cavities, or in 
 
200 SYMPTOMS. 
 
 the synovial bursse, furnishes few symptoms. The distension of 
 the soft parts, obscure fluctuation, and sometimes, as in the knee, 
 the shock of the articular surfaces, under the pressure of the hand, 
 renders the accumulation of synovia apparent. In some cases 
 also, concretions are found in this fluid, which are entirely free and 
 felt at intervals in different parts of the joint. 
 
 5. Increase of the exhalation in the eye produces hydropthalmia ; 
 in the internal ear, it leads to rupture of the tympanum, &c. 
 
 6. We have elsewhere referred to the exhalation of fat in its 
 vesicles, and shall not here again recur to it. We shall also pass 
 over certain exhalations which are indicated by no sensible phe- 
 nomenon, as those which take place upon the internal surface of 
 the blood vessels, lymphatics, &c. 
 
 7. To these different kinds of exhalation, that may be added 
 which furnishes the digestive tube with the gases necessary to its 
 functions, and which presents, in disease, modifications more or less 
 remarkable, owing to which the abdomen becomes sometimes very 
 voluminous and resonant, and sometimes flattened, and almost 
 entirely dull on percussion. These variations in the volume and 
 resonance of the abdomen, frequently, rather depend upon some 
 obstacle to the circulation of the gases in these viscera, than to 
 their too abundant secretion ; but sometimes, particularly in hys- 
 terical females, the sudden changes which the abdomen presents, 
 without the occurrence of any gaseous emission, can only be 
 accounted for by supposing alternations of exhalation and absorp- 
 tion of these gases. 
 
 8. Lastly, the sanguineous exhalations, which, in health, period- 
 ically make their appearance and concur in maintaining the general 
 equilibrium of the functions, may, in disease, be increased, dimin- 
 ished, suppressed, or only diverted. The menstrual exhalation 
 frequently presents these various phenomena in the diseases of 
 females, and analogous disorders have been many times observed 
 in men accustomed to the haemorrhoidal flux or epistaxis, &c. 
 
 But if there are some normal hsemorrhages which are connected 
 with health, and form a part of its attributes, there are many 
 more which only appear under the influence of disease and, in 
 some cases, alone suffice to constitute it. 
 
 B. Morbid Exhalations. 
 
 At the head of morbid exhalations, may be mentioned those of 
 the blood, or hemorrhages,* and of pus, or pyogenia.-\ 
 
 1. Haemorrhages consist in the escape of blood from the vessels 
 destined to contain it : this flow is sometimes owing to the action 
 of a wounding instrument, which, by dividing the vessels in which 
 the blood circulates, furnishes the natural explanation of the acci- 
 dent produced. But, in many cases, the flow of the blood from 
 
 * -Atuct, blood 5 PSW, I run. 
 
 t TLvov, pus; ytVowui, I am generated. 
 
SYMPTOMS. 
 
 these canals, occurs independently of any external cause ; the 
 haemorrhage takes place, as it were, spontaneously, and is hence 
 called spontaneous, in opposition to the preceding, which is called 
 traumatic. Among the haemorrhages, called spontaneous, some are 
 connected with a material lesion of the part, from which the blood 
 proceeds, as tubercles, cancer, &c ; these are termed symptomatic. 
 Others, epistaxis, for example, occur, without the existence of any 
 lesion discoverable during life or by examination after death, to 
 account for such a phenomenon : these have been called essential, 
 as, being symptomatic of no appreciable affection, they themselves, 
 in the present state of the science, represent the disease. These 
 essential haemorrhages are by no means the most common ; if we 
 except epistaxis and the haemorrhoridal flux, which often relieve 
 the wants of the constitution, and which, like the menstrual flow, 
 contribute to health, they are, as we shall see in the chapter on 
 diagnosis, in most cases, symptomatic ; they are sometimes owing 
 to a lesion of the organ from which the blood flows, and of which 
 they constitute the first sign ; and sometimes to a general affection 
 of the economy, the blood, in these cases, often flowing from dif- 
 ferent parts, as in scurvy and some pestilential diseases. Spon- 
 taneous haemorrhages generally occur from the mucous membranes, 
 rarely from old cicatrices or any other point of the cutaneous 
 surface ; they sometimes appear in the cellular tissue, where they 
 form spots and ecchymoses, to which we have referred above. The 
 blood may be also exhaled into the serous and synovial mem- 
 branes, into the parenchyma of the viscera, muscles, &c. ; but, in 
 such cases, the haemorrhage is often manifested by no certain sign. 
 The blood which flows from the body, presents varieties in its 
 color, which may be florid red or livid, in its consistence, which 
 may be soft or firm, in its quantity, which may vary from a few 
 drops to several pounds, and in the substances with which it may 
 be mixed. Haemorrhages differ also in respect to the period of the 
 disease in which they occur, and the influence they exert upon its 
 progress and termination : they have hence been distinguished 
 into those that are favorable, prejudicial, or indifferent. 
 
 2. Pyogenia. The opinions of physicians upon the formation 
 of pus, have been very various : some, have pretended, with 
 Dehaen, that it is formed in the arterial system, to be exhaled in 
 the inflamed part ; others, that it can only be produced where it is 
 found to exist. Among the latter, some have regarded pus as 
 proceeding from the broken down parts where the suppuration is 
 taking place : others have considered it the result of a chemical 
 combination between the various fluids of the affected part, and par- 
 ticularly between the lymph and fat. These two opinions, the first 
 of which has been for a long time favored in the schools, and the 
 second of which has but few followers, are now generally aban- 
 doned, and pus is now considered as the result of a morbid 
 exhalation from the same organs which produce the natural exha- 
 lations. 
 
 A very remarkable phenomenon in the exhalation of pus, is, 
 
202 SYMPTOMS. 
 
 that it does not present the appearance and consistence peculiar to 
 it, till after it has remained for a certain length of time upon the 
 organ which furnishes it. Van Swieten remarked that when the 
 fluid furnished by a wound was hourly removed with a sponge, 
 the fluid thus obtained was not purulent, but a thin and turbid 
 serum. 
 
 All the tissues are not equally disposed to the formation of pus ; 
 but there is none, with, perhaps, the exception of the tendons, 
 cartilages and aponeurosis, in which inflammation may not pro- 
 duce suppuration. Inflammation does not always produce pus, but 
 it is generally supposed that the latter is never formed unless there 
 have been previous inflammation, either in the part where the pus 
 exists, or at a greater or less distance from it; in the latter case, 
 the pus may have reached the point it occupies in obedience to the 
 laws of gravity (abscess by congestion), or have been displaced by 
 the exhalent vessels after having been absorbed in a more or less 
 remote part of the economy (metastic abscesses). See METASTASIS. 
 
 The displacement of the pus in abscesses by congestion, is a 
 phenomenon which has long been known, and upon the production 
 of which there has been little diversity of opinion. Pus formed 
 slowly at some elevated part of the body, without being circum- 
 scribed by previous acute inflammation, may find its way down 
 between the meshes of the cellular tissue, and collect at the lowest 
 point, in the loins, for example, or in the superior part of the 
 thighs, and form a fluctuating tumor at some distance from the 
 place where it was produced. In regard to metastatic abscesses, 
 they have been of late particularly studied, but their history still 
 presents some obscure points. They have been frequently observed 
 in variola, in the period of desquamation : they appear, in these 
 cases, as brownish, fluctuating tumors, very tender on pressure, 
 being formed and discharging themselves with great rapidity, in a 
 few days or hours, and from which flows a reddish or sanious 
 pus : this fluid, which is doubtless absorbed from the variolic 
 pustules, finds its way to the skin, being very rarely deposited in 
 the internal parts. It is far otherwise with the abscesses which 
 follow wounds, surgical operations, parturition, between which and 
 the two first conditions there exists some analogy, and phlebitis 
 produced by venesection. In these cases, rigors and ataxic symp- 
 toms supervene, followed by the appearance of indolent fluctuating 
 tumors in different parts of the body, and sometimes in the sub- 
 stance of the muscles, varying in size from that of a nut to that 
 of a pullet's egg. In some cases, one or more articulations present 
 swelling and fluctuation, with or without pain. Examination 
 after death, reveals the existence of pus at all these points, and 
 often numerous internal abscesses, scattered through those viscera 
 which are the most vascular, as the lungs, liver and spleen ; more 
 rarely the brain and kidneys ; and, in many cases, there are evi- 
 dent traces of inflammation in some part of the venous system. 
 This assemblage of phenomena, has led all physicians to regard 
 these abscesses as produced by the passage of pus into the blood, 
 
SYMPTOMS. 203 
 
 whether the pus formed in the veins be thus carried throughout 
 the circulatory system, or be introduced into it by means of lym- 
 phatic or venous absorption. But in the attempts to explain the 
 formation of these abscesses, there has not been the same unanim- 
 ity of opinion ; some have supposed them to be merely depositions 
 of pus which has been absorbed ; others have considered that the 
 blood, altered by its mixture with pus, becomes, in various parts 
 of the economy, the material cause of a suppurative inflammation. 
 Neither of these opinions is wholly admissible ; the former, be- 
 cause these abscesses are formed not only in open cavities, as the 
 meshes of the cellular tissue and synovial membranes, but in the 
 parenchyma of the lungs, liver, spleen, brain, kidneys and mus- 
 cles, in which a cavity cannot be formed except by means of an 
 inflammatory process ; it may be added that the abundance of pus 
 found in metastatic abscesses, is often disproportionate to the extent 
 of surface where the pus was first formed, and finally, that the 
 pus deposited in an organ, itself becomes an agent of suppuration; 
 that the pus, as has been said, produces pus. In regard to the 
 second opinion, the alteration of the blood by pus, it does not 
 account for the rapidity with which these collections form in the 
 subcutaneous cellular tissue, often without the existence of pain. 
 It might also be asked, how a general cause can produce circum- 
 scribed, though multiple, results. It may then be admitted, from 
 observation, that the pus carried into the circulation, is deposited 
 in various quantities, in different parts of the economy, so as indi- 
 rectly to. form, in one part, an abscess, and in another, become the 
 material cause of a suppurative inflammation. In regard to the 
 causes, by virtue of which, pus that has been absorbed, is depos- 
 ited in some parts rather than others, and in various quantities, 
 they are in the present state of the science entirely unknown : the 
 artificial irritations established by the physician upon the skin, by 
 means of topical rubefaciants or vesicants, are not here called 
 purulent collections, and seem to have no influence upon the 
 unequal and inexplicable distribution of this deleterious fluid in 
 the various parts of the body. 
 
 The softening of tubercles is a phenomenon which appears op- 
 posed to the opinion above expressed, viz., that the presence of pus 
 is a sign of previous inflammation. A body, to all appearance 
 unorganized, is formed in the tissue of the lungs or some other 
 organ ; it acquires a certain size, and is then found to present an 
 opaque color, moderate hardness and great friability. At the 
 end of a certain time it becomes softened sometimes throughout its 
 whole extent, sometimes at its centre, and is converted into a mat- 
 ter analogous to the pus exhaled by an inflamed organ ; but si- 
 multaneously with the occurrence of this change, redness, swelling 
 and heat supervene in the surrounding parts, as in the case of sub- 
 cutaneous tubercles ; and hence it is natural to suppose that the 
 inflammation of the neighboring parts is not foreign to the trans- 
 formation of the tuberculous matter into pus. 
 
 The pus exhaled upon the surface of the skin, or external 
 
204 SYMPTOMS. 
 
 wounds, escapes freely. That formed internally sometimes extends 
 throughout the tissue of an organ, as is observed in the lungs, and 
 sometimes forms one or more collections termed abscesses. The 
 pus collected into an abscess ordinarily finds its way towards the 
 integuments or the canals through which it may be discharged 
 from the body, by the gradual absorption of the intervening parts. 
 Pus which extends throughout the tissue of an organ cannot be 
 evacuated in this way, and absorption is the only means by which 
 it can be removed. This absorption is manifest in some subcu- 
 taneous abscesses, particularly in buboes; such inflammatory 
 tumors after being soft and fluctuating, in a few days, and even a 
 few hours, may gradually flatten, and the fluctuation disappear. 
 
 Pus, considered in itself, presents varieties relative to its physical 
 and chemical properties, and its action upon the animal economy. 
 
 Its quantity is relative to the extent of the suppurating surface, 
 the period of the disease and many other circumstances. It may 
 be diminished by errors in diet, violent mental emotions, a febrile 
 recrudescence which should always lead us to fear a complica- 
 tion or purulent absorption, or any other supervening evacua- 
 tion. Hatter observed that the exhalation of this fluid was gen- 
 erally more abundant in the night than during the day. 
 
 The color of pus is ordinarily yellowish white, or greenish ; 
 it is sometimes reddish or livid; it has been noticed to be bright 
 yellow in persons affected with jaundice. Its color is sometimes 
 uniform throughout, sometimes diversified; in some cases it is 
 thick, homogeneous, and its globules, when examined with the 
 microscope, very abundant ; this is called laudable or healthy pus ; 
 it is observed in cases of healthy inflammation running a rapid 
 course, and occurring in persons of good constitution. In other 
 cases, it is clear and mixed with opaque flocculi ; it sometimes re- 
 sembles badly clarified whey, as is observed in chronic abscesses 
 which occur in scrofulous persons and those of bad constitution. 
 Sometimes serous or sanious pus becomes of a brownish color by 
 the contact of the air ; it blackens silver and lead instruments with 
 which it comes in contact; this has been attributed to the sulphur- 
 retted hydrogen gas contained in it. Some abscesses of the liver 
 furnish a thick, reddish matter, resembling the lees of wine, 
 which deposits, on standing, portions of the substance of the liver. 
 Surgeons, and Boyer in particular, did not admit that any other 
 than that presenting these conditions, proceeds from the liver, but 
 it is now proved that a phlegmonous pus has been found to exist 
 in this viscus, several examples of which have been published by 
 M. Louis, as occurring at La Charite and observed by us together. 
 
 The odor of pus is ordinarily nauseous, sometimes character- 
 ized by a penetrating, nauseous or insupportable fetor. It has been 
 long observed by surgeons that pus contained in an abscess of the 
 abdominal parietes, or at the margin of the anus, often exhales the 
 most fetid odor, analogous to that of the faecal matters, so as to 
 lead to the suspicion of a communication between the abscess 
 and intestines. Abscesses of the mouth and pharynx also yield a 
 
SYMPTOMS. 205 
 
 very fetid pus. Every one is familiar with the repulsive odor that 
 pus acquires in ahscesses of the labia majora in females, and in 
 urinal abscesses of both sexes. This fetor is not generally ap- 
 parent at the time the abscess is opened, except in those cases in 
 which it exists at the surface of the skin, or in the neighborhood 
 of organs which contain air. It may acquire this odor after the 
 abscess is opened, if air be admitted into the cavity. The taste 
 of pus, according to Schcvilgue, is nauseous and sometimes acrid : 
 its specific gravity is greater than that of distilled water. The 
 same causes which influence its quantity ordinarily modify its 
 other physical qualities, and particularly its consistence and color. 
 The chemical properties of pus, being of no practical value, we 
 shall not here consider. 
 
 The action of pus upon the economy deserves particular atten- 
 tion ; this varies according to the tissues. Upon the skin, pus 
 causes only redness and excoriation ; in the cellular tissue, through 
 which it flows, it excites the formation of new pus ; in the vicinity 
 of bones, it wears them away by exciting in their tissue interstitial 
 absorption. If it exist in circumscribed abscess, and come in con- 
 tact with the air, it soon acquires a strong odor, loses its homoge- 
 neousness, and produces general functional disturbance and death. 
 The same phenomenon occurs whenever the pus, without being 
 altered, is accumulated in one of the splanchnic cavities, or one of 
 the viscera important to life. We have above referred to the me- 
 tastatic phenomena which may result from its absorption. Finally, 
 this fluid may, in some diseases, become the vehicle of contagion, 
 as is observed in variola, syphilis and glanders. 
 
 The distinction between mucus and pus is one of the points which 
 most occupied the attention of physicians of the last century. 
 They supposed that pus was constantly the result of a solution of 
 continuity, and never owing to simple exhalation ; in order to re- 
 tain the name of pus for certain fluids which presented all its 
 characteristics, they were also obliged to suppose ulcerations where 
 they did not exist ; they supposed their existence in the urethra 
 and uterus when affected with catarrh. The chemical experi- 
 ments, which have been made, in order to determine the true 
 characteristics of pus, have terminated in nothing satisfactory. 
 The results of microscopical researches, have been equally unsuc- 
 cessful. It was thought for a long time that when globules, simi- 
 lar to those observed in the blood, were noticed in the secretion of 
 a mucous membrane, they indicated the presence of pus. But it 
 is now proved that mucus varies much in its physical and chemi- 
 cal composition, and that it often contains globules, which, in 
 their form and volume, resemble those of pus. Chemical reagents 
 and the miscroscope are useless when the appearances presented 
 by pus and mucus are distinct; they are also insufficient, when 
 these two fluids resemble each other. 
 
 3. There are still other essentially morbid exhalations which 
 need only to be enumerated ; such are those occurring between the 
 reticular tissue of the skin and epidermis, in pemphigus and all 
 18 
 
206 SYMPTOMS. 
 
 the vesicular and pustular eruptions. These fluids, in coagulating 
 and hardening by exposure to the air, form, upon the surface of 
 the skin, peculiar concretions, to which the term crusts or scabs 
 has been applied. Their study is not without importance in cutane- 
 ous pathology ; for by considering their form, surface, degree of 
 prominence or depression, color, hardness, degree of adherence, 
 etc., we are enabled to determine the kind of cutaneous disease 
 without having seen it in its elementary form. It is thus that 
 porrigo favosa is distinguished, its crusts being yellowish and pre- 
 senting a cuplike depression ; these crusts are yellow, thick and fria- 
 ble in impetigo; they are very adherent, thick, blackish and 
 elevated in the centre, in ecthyma ; while in vesicular and bulbous 
 affections, they are thin, easily detached, and of a yellowish or 
 brownish color. 
 
 The skin may be also the seat of another morbid exhalation, to 
 which the term squamous has been applied, and which is charac- 
 terized by the formation, upon the diseased surface, of an inorganic, 
 lamellar substance of a grayish white color, dry, friable, more or 
 less thick and adherent, and which is regarded as a morbid secre- 
 tion of the epidermis. Scales are observed in lepra, psoriasis, 
 pityriasis and icthyosis. 
 
 C. Artificial Exhalations. 
 
 Artificial exhalations are, in relation to symptomatology, of less 
 importance than all others. It may, however, be well for the phy- 
 sician to know the quantity and quality of the pus furnished by 
 cauterization, vesication, moxas and setons ; the aspect of the ex- 
 halent surface also deserves special attention. 
 
 In diseases, in which the strength is maintained, the pus of 
 artificial ulcers is in a certain quantity, of a proper consistence, 
 homogeneous, and its odor is not repulsive ; the surface from which 
 it proceeds is of a rosy or red color, and acutely sensitive without 
 being morbidly so. In diseases which tend to a fatal termination, 
 the pus is almost always serous or of unequal consistence, it is 
 sometimes mixed with blood and often emits xa very fetid odor; 
 the exhalent surface is pale or livid, sometimes ecchymozed or 
 black ; it is sometimes insensible, and sometimes the least touch 
 excites in it severe pain. When artificial ulcers exist before the 
 disease, it often happens that they become dry a few days previous 
 to its development, or the matter exhaled may present remarkable 
 changes. 
 
 $ II. Secretions properly so catted. 
 
 In health, the secretions concur, together with the exhalations, in 
 maintaining the general equilibrium ; the first increasing when the 
 second diminish, and vice versa. In disease, this order, sometimes 
 preserved, is often interrupted, and cases occur where both are 
 simultaneously increased or diminished. In the cases of hectic 
 
SYMPTOMS. 207 
 
 fever that fell under the observation of Cotugno at Naples, there 
 were, at the same time, continual perspiration, laxity of the bowels, 
 and a copious flow of urine. In the first and second stage of 
 many acute diseases, the secretions and exhalations are simultane- 
 ously suspended ; the skin is dry, the abdomen contracted, and the 
 urine is excreted in small quantities. 
 
 Independently, however, of this general disturbance, the particu- 
 lar secretions are subject to changes, which we proceed to enume- 
 rate. 
 
 1. The tears in health are secreted in such proportion, that 
 while the eyes and eyelids are constantly moistened, none of the 
 fluid flows out over the cheeks. Under certain circumstances, as, 
 the existence of vivid mental emotions, the exposure of the face to 
 cold winds, etc., the tears are secreted in greater abundance, filling 
 the eyes, and even escaping upon the face. In disease, the secre- 
 tion of the tears is seldom diminished ; it is increased, in the first 
 stage of eruptive fevers, particularly rubeola, in the decline of the 
 paroxysm in hysteria, and in some forms of monomania. The 
 tears are also more abundant in many diseases of the eyes, and 
 particularly ophthalmia. During the existence of tic douleureux 
 in the ophthalmic branch of the fifth pair, the secretion of the 
 tears is increased, and they often produce a sensation of warmth 
 or burning in the parts with which they come in contact.* In 
 some cases, the tears appears to be altered in their nature, becom- 
 ing more acrid, to judge from the effect which they produce 
 upon the skin of the face, over which their passage is indicated by 
 redness and excoriation. 
 
 The fluid secreted by the follicles of Meibomius sometimes 
 forms a kind of gummy concretion, (chassie), which has the effect 
 of producing adhesion of the eyelashes and consequently the free 
 edges of the eyelids. This alteration of the secretion occurs in 
 most cases of ophthalmia, particularly the ophthalmia of children, 
 and in the inflammation of the eyelids such as results from an 
 extension of erysipelas of the face. Lastly, the eyes often become 
 thus affected at the close of acute diseases which terminate unfa- 
 vorably. v 
 
 2. The secretion of the saliva in health is abundant during 
 meals, but diminishes, and its excretion almost entirely ceases, in 
 the intervals, unless excited by the imagination, or by mastication, 
 etc. In disease, the secretion of the saliva is sometimes increased 
 to a considerable degree, either in consequence of the disease itself, 
 or the remedies employed for its cure, as the different mercurial 
 preparations. This increase is termed salivation or ptyalism^ 
 (salivatio, ptyalismus), and is generally accompanied by swelling 
 of the gums, cheeks, tongue, and more rarely, the parotid region. 
 
 * The flow of tears over the cheeks does not always indicate an increased se- 
 cretion. The inertia of the puncta and lachrymal canals, the eversion of the lower 
 eyelid, the obstruction of the lychrymal sac or nasal canal, and certain diseases of 
 the eyelids, may also produce epiphora. 
 
 t IZrvaiLioubg, from TTTVCU, I spit. 
 
208 SYMPTOMS. 
 
 Salivation has been attributed to an increased secretion in the sali- 
 vary glands (parotid, submaxillary, sublingual) produced by the 
 elective action of mercury upon these glands ; but more exact ob- 
 servation having proved the existence of considerable swelling of 
 the mucous membrane of the mouth, unaccompanied often by any 
 swelling of the salivary glands, we should refer the increased 
 secretion of which the mouth is the seat, chiefly to its lining 
 membrane, and the numerous follicles with which its surface 
 is covered, according but a secondary influence, in the phenomenon 
 of salivation, to the salivary glands, properly so called. The sali- 
 vary secretion is also increased in inflammations of the throat, in 
 cases of aptha3, ulcerations and glossitis, and during dentition 
 which, according to most authors, it facilitates. Sydenham laid 
 great stress on ptyalism occurring in variola of adults, commencing 
 generally with the eruption and terminating towards the twelfth 
 day. Its termination before this period, he considered an unfavor- 
 able omen. If we consider, however, that this salivation is often 
 owing to an eruption of variolic pustules in the mouth, we shall 
 attach less importance to the phenomenon pointed out by Syden- 
 ham. 
 
 The secretion of saliva is diminished in most acute diseases, in 
 which the mouth is constantly dry. It appears to undergo a 
 change in many cases of neurosis, in which it becomes acrid and 
 burning; in some diseases of the bladder, in which it has a urinous 
 taste ; and in hydrophobia, in which it seems to acquire contagious 
 properties. Its excretion becomes difficult or impossible in cases 
 of obstruction or obliteration of the excretory ducts. It may 
 escape externally in cases of wounds or fistula of the ducts or 
 glands themselves. 
 
 The principal chemical modification which the saliva undergoes 
 is the passage from an alkaline to an acid state. This acidity has 
 been observed by M. Donne, to acccompany, most generally, an 
 irritated or inflammatory state of the stomach, either primary or 
 secondary, and he thought might serve to establish the diagnosis 
 of some gastric affections. But the researches of other physicians 
 on this point have not confirmed the results published by M. Donne, 
 and renewed examination will be necessary to remove this uncer- 
 tainty. The permanent acidity of the saliva seems, as some au- 
 thors have remarked, to exert an influence on the development of 
 dental caries. Lastly, the acidity of the saliva is one of the most 
 common causes of acidity of the breath, which has been before 
 considered (page 137), and which deserves the particular attention 
 of the physician. 
 
 3. The secretion and excretion after bile, occur in health without 
 any apparent phenomenon, the situation of the biliary organs not 
 permitting us to observe the changes they may present. It is 
 nearly the same in cases of disease ; necropsies frequently bring to 
 light lesions in this fluid itself, and in the disposition of its excre- 
 tory ducts, which had not been suspected in life. Even at the 
 present day, we have but a very imperfect knowledge of the dif- 
 
SYMPTOMS. 209 
 
 ferent modifications which health and disease may effect in the 
 composition of the bile. In fact, if we consult all the works on 
 pathology published since the time of Galen, and particularly dur- 
 ing the last two or three centuries, we shall find that the physi- 
 cians of this long period, have described a multitude of changes in 
 the bile, by the aid of which they have explained the nature of 
 many diseases and the forms under which they are presented; but 
 this doctrine, connected with the humoral ideas then entertained, 
 was supported by no positive proof. 
 
 The bile in its normal state, is liquid, of a yellow or greenish color, 
 viscous, ropy, bitter and slightly alkaline. It may present different 
 degrees of consistence or color, without our being able to determine 
 how far these modifications are consistent with health. The bile 
 is often changed, either in quantity or quality, in many diseases 
 of which the biliary apparatus is not the principal seat ; while in 
 many deep-seated, though partial affections of the liver, as cancer 
 and abscess, the bile undergoes apparently no remarkable change, 
 this organ preserving its normal texture in those portions of its 
 parenchyma which lie between the cancerous parts, or the puru- 
 lent collections. 
 
 M. Louis has satisfactorily established that alterations in the 
 bile and the gall-bladder are much more frequent in the course of 
 the typhoid affection, than in the other acute diseases ; and that of 
 all the chronic affections, pulmonary phthisis is that in which the 
 bile most frequently undergoes change, in such cases, closely re- 
 sembling treacle. M. Andral has noticed in the same affection, 
 that the bile is sometimes replaced by a fatty fluid. In atrophy of 
 the liver, and especially in cyrrhosis, the bile generally exists in 
 small quantity and is sometimes almost colorless and albuminous. 
 M. Hermann, of Moscow, is confident that in Asiatic cholera the 
 bile contains a very large proportion of resinous matter. This 
 fluid may acquire irritating and even poisonous properties, as has 
 heen proved by the experiments of Deidier * on the bile of persons 
 affected with the plague at Marseilles in 1720, and by Vicq 
 d'Azir, f in an epizooty which he observed in 1778. We are still 
 entirely ignorant whether an alteration in the bile is connected in 
 any way with those diseases of warm countries, described under 
 the name of bilious fevers, or with certain sporadic choleras. 
 English physicians are of opinion that a great number of the de- 
 rangements of the digestive organs, are connected with some 
 change in the composition of the bile; but nothing is with cer- 
 tainty known upon this subject. 
 
 A greater part of the alterations in the bile of which we have 
 just spoken, have only been verified after death by examination of 
 the fluid collected in the gall-bladder; they consequently belong to 
 pathological anatomy, rather than to symptomatology. Never- 
 theless, we have thought it best to enumerate in this connection 
 
 * Exper. sur la Bile, Zurich, 1722. 
 
 | Mo yens Cur. Contre les Malad., Peslil, p 94. 
 
 18* 
 
210 SYMPTOMS. 
 
 the changes noticed in autopsies in the composition of the bile, in 
 order to direct the attention of observers to the examination of the 
 fluid excreted, either by vomiting, or by stools, in the course of 
 diseases. We should hope that accurate observations of the bile, 
 especially when vomited in an almost pure state and in considera- 
 ble quantities, will furnish interesting results, and throw much 
 light, in many cases, on diagnosis. We are equally persuaded 
 that the chemical analysis of bilious stools and other stercoral 
 matters, will one day furnish signs of great value in the diagnosis 
 of diseases of the liver, the intestines and all the other digestive 
 organs. 
 
 The only changes hitherto noticed in the biliary secretion and 
 excretion, have reference either to its increase in bilious flux, or 
 to its suppression in cases of jaundice arising from occlusion of the 
 excretory ducts by calculi contained within them, or by the com- 
 pression of a tumor. Whenever any cause obstructs the excre- 
 tion of the bile, the alvine matter loses its natural color, and 
 becomes of a grayish tint ; while the fluids excreted, and particu- 
 larly the urine, assume the color of the bile, which also diffuses 
 itself over the whole skin, and exists to a considerable extent in 
 all the solids. Chemical analysis discovers in the urine, in the 
 serum of the blood, and in most of the humors of these subjects, 
 some of the materials that enter into the composition of the bile, 
 such as the coloring matter and perhaps the picromel. The yellow 
 color, so remarkable after death in all parts of the body, proves 
 also, that all the organs, cartilages, tendons and even bones, par- 
 ticipate in the general impregnation. 
 
 4. But however obscure the changes that take place in the secre- 
 tion of the bile, those that disease produces in the secretion of the 
 pancreatic fluid are still more so. Is there any increase of this 
 secretion in certain aqueous fluxes of the intestines, in serous 
 diarrhoea, for example ? Does the ptyalism that takes place in 
 certain abdominal affections indicate, as has been asserted, that 
 the secretion of the pancreatic fluid is diminished or suppressed ? 
 May not the formation of calculi in the pancreatic duct, give rise 
 to accidents analogous to those observed in hepatic and nephritic 
 colics? In the present state of the science it is impossible to an- 
 swer these questions. 
 
 5. The secretion of the urine is one of the most important, both 
 on account of its quantity and because its changes are readily 
 appreciated. In health, the quantity of the urine is about the 
 same every day, though its increase or diminution depends upon 
 the abundance of the other excretions, upon the quantity of food 
 and drink, and upon changes of temperature. At the time of its 
 excretion, the urine is warm, transparent, of a pale yellow color, 
 and slightly acid. It has an odor peculiar to itself unaccompa- 
 nied with fetidness. It is salt and bitter to the taste, and has a 
 specific gravity of 1.018. It often becomes turbid upon cooling, 
 recovering its transparency after its floating particles are precipita- 
 ted. After two or three days it becomes ammoniacal and fetid. 
 
SYMPTOMS. 211 
 
 The urine of the healthy man presents numerous changes in its 
 physical and chemical properties, according as it is secreted before, 
 during, or after, meals, and particularly according to the quantity 
 and nature of the food and drinks. Certain substances change, in 
 a remarkable manner, its color and its odor; it becomes blackish 
 after the simultaneous use of rhubarb and iron, cassia and the 
 chalybeates; sorrel broth, and the root of the strawberry and 
 madder, change its color to red ; turpentine gives it the smell of the 
 violet, and asparagus, an intolerable fetor. 
 
 In disease, the excretion of this urine and this fluid itself undergo 
 important changes. 
 
 The excretion of the urine may be attended with pain, as in 
 blennorrhagia ; dysuria* is where it is attended with difficul- 
 ty, as in the contraction of the canal of the urethra ; stran- 
 gury (stranguria) f where it flows guttatim, a symptom which 
 frequently accompanies vesical catarrh ; ischuria $ or the reten- 
 tion of the urine, is where its excretion is impossible ; and vesi- 
 cal tenesmus, where there is a continual and painful desire to 
 make water, and where the urine is excreted in small quantities 
 at a time and with a sensation of burning. The excretion some- 
 times occurs involuntarily, as in certain spasmodic affections of the 
 bladder, in which it takes place at the moment of the desire, and 
 in spite of the efforts of the patient to prevent it. In other cases 
 in which the excretion of the urine is involuntary, the patient is 
 unconscious of it, as in many diseases accompanied with delirium. 
 There are other cases in which, instead of being excreted at cer- 
 tain intervals and in a certain quantity, the urine flows drop by 
 drop without interruption ; this is called incontinence of urine. 
 Ordinarily, the urine is only excreted in this manner when the 
 bladder has acquired all the distension of which it is capable, 
 and its excretion is then said to take place by regorgement. In 
 another class of cases the urine flows interruptedly in jets, and its 
 excretions ceases and recommences many times before being com- 
 plete ; this symptom often arises from the presence of calculi or 
 clots of blood in the bladder, which at intervals obstruct the neck 
 of this viscus ; it is also of frequent occurrence in certain spas- 
 modic affections. The excretion of the urine is also subject, in 
 disease, to deviations. We have known it in perviousness of the 
 urachus, to escape at the navel, and, in the different forms of vesi- 
 cal or urethral perforation, to find its way out through the anus, 
 the scrotum and the neighboring parts, and the vulva. Some 
 authors have mentioned still more remarkable deviations of the 
 urine, such as urinous salivation, perspiration and vomiting. 
 Boerhaave thought he even discovered urine in the cerebral ventri- 
 cles. These last statements, however, can hardly be received 
 with implicit confidence. It may be that the fluids of which these 
 authors speak, have had the urinous odor and color, but we may 
 
 * JvnovQia; 3v?, with difficulty ; OVQOV, urine, 
 t 2T()uyyovoiu oT^aySj drop j oi)(joj r , urine. 
 , 1 retain; OVQOV, urine. 
 
212 'SYMPTOMS. 
 
 well donbt whether this phenomenon is owing to the actual pres- 
 ence of urine. 
 
 The urine, considered in itself, presents numerous changes in 
 sickness. These changes relate to its quantity and its physical 
 and chemical properties. The quantity of the urine increases 
 sometimes in the decline of diseases. It is unusually great in dia- 
 betes, and diminishes in dropsy. Entire suppression of the urine 
 never takes place, except in cases of occlusion of both the ureters 
 simultaneously, or of one only ; and in cases in which, either ow- 
 ing to congenital formation, or to complete atrophy of one of these 
 organs, but one kidney exists.* In a greater part of the nervous 
 affections, the urine is colorless, less acid and often neutral. It is 
 generally red and unusually acid at the commencement of acute 
 diseases, and brown, or black, in many fatal diseases. The latter 
 color generally arises from the coloring matters of the blood con- 
 tained in the urine. It may also be owing, according to some 
 chemists, to the accidental presence in the urine, of a peculiar acid, 
 called melanic. Lastly, the urine may become milky white in 
 cases in which it contains either pus, or a fatty substance, that can 
 easily be separated. But whatever its color, the urine may be 
 transparent or turbid. The urine is said to be transparent when 
 it preserves its translucency, or recovers it after momentarily los- 
 ing it in cooling. Turbid urine is that which remains so, and 
 does not become transparent by the precipitation of the particles 
 suspended in it. Opacity of the urine is caused by the presence of 
 mucus, blood, albumen, pus, etc., but more generally by an excess 
 of uric acid, urate of ammonia, or of the alkaline phospates. The 
 ancients termed the urine jumenteuse^ when it is turbid and con- 
 tains at the same time corpuscules or opaque particles floating in 
 it. This expression, however, though much used by old writers, 
 has no very definite meaning, and may be applied to urine differ- 
 ing very much in chemical properties. The smell of the urine 
 becomes ammoniacal in chronic catarrh of the bladder. In certain 
 adynamic diseases, and in many vesical affections it emits a 
 brackish smell. The discolored urine excreted during the declen- 
 sion of hysterical attacks, and in the first stage of intermittent 
 fevers in almost inodorous. In inflammatory diseases, on the con- 
 trary, it emits a very powerful odor. In diabetes mellitus the 
 urine acquires after fermentation an alcoholic smell. In Bright's 
 disease, it has sometimes the smell of boiled beef. This latter 
 smell is occasionally perceived in the urine of healthy persons, 
 especially after profuse perspiration. In many acute diseases, the 
 urine differs from day to day with regard to its color, transparency, 
 sediments, etc. ; this is termed variable urine. In certain gangren- 
 ous inflammations the urine is almost cold at the moment of excre- 
 tion. A diminution of its temperature has also been noticed in the 
 cold stage of intermittent fever. 
 
 * Vid. our Treatise on Nephritis, Archiv. Gen. de Med. v. 1, 3d Ser. pp. 5 
 and 477. 
 
 f Jumentum, beast of burden ; urine that resembles that of mules, horses, etc. 
 
SYMPTOMS. 213 
 
 Little is known of the taste of urine in a state of disease, on ac- 
 count of the natural repugnance to experiments of this nature. 
 We know, however, that in diabetes mellitus it has a sweet taste, 
 and that it is almost insipid after the hysterical paroxysm. 
 
 M. Rayer, has made numerous experiments upon the specific 
 gravity of the urine, which varies, in health, according as it has 
 been secreted after fasting, during or after meals, etc. He fixed 
 the mean specific gravity of the urine excreted at the hour of wak- 
 ing in the morning,* at 1.018, that of water being 1.000. The 
 same physician found that in diabetes mellitus, the density of the 
 urine is much more considerable, while it is less in diabetes insip- 
 idus. In Bright's disease, except in the first or acute stage, it is 
 generally lower than in health. The specific gravity of the urine 
 may be a circumstance of practical advantage in diabetes mellitus. 
 Examined at different hours of the day before and after meals, it 
 may indicate the increase or diminution of the sugar. 
 
 The elements of the urine undergo variation in disease to a 
 greater or less extent. Thus, the quantity of water may become 
 very great, as in diabetes msipidus ; in some nervous affections the 
 urine is almost entirely aqueous. The other elements of the urine 
 increase, on the contrary, in proportion, in most febrile diseases. 
 The quantity of urea rarely increases in sickness, although it is 
 very common, as M. Rayer has remarked to find it existing in a 
 less proportion, which arises, perhaps, as much from abstinence 
 from food, as from the influence exerted by disease itself on the 
 renal secretion. It has not yet been proved that the quantity of 
 urea is diminished in diseases of the liver ; but in the granular 
 affection of the kidneys its diminution is an almost invariable phe- 
 nomenon. The uric acid, which enters into the composition of the 
 urine in the proportion a thousandth in health, may increase in a 
 remarkable manner; this has been particularly observed during 
 the progress of rheumatic and gouty affections, and many inflam- 
 matory diseases, etc. This excess of uric acid often has the effect 
 of producing red gravel in different parts of the urinary passages. 
 This acid is generally found in combination with lime, soda, and 
 particularly ammonia. There may also be a disproportion of 
 phosphoric acid and the phosphates of lime and magnesia in the 
 urine, which we notice in cases of rachitis, molhties ossium, and 
 in some kinds of gravel ; in all these cases the urine is more or less 
 turbid. The salts of soda, potash, and ammonia, are sometimes 
 found in more considerable quantities, and render the urine either 
 neutral or alkaline. The alkalinity of the urine has also been 
 ascertained in phosphatic gravel, in certain cases of Bright's disease 
 and frequently in chronic nephritis, as in cases of old men enfeebled 
 by privation and misery. It has been stated that alkalinity of the 
 urine is frequent in the course of typhoid fevers. M. Rayer as- 
 serted that out of fifty cases he formed the urine alkaline but twice, 
 and for the space of three days only, and the observations of M. 
 
 * Maladies des Reins, t. 1, p. 71. 
 
214 SYMPTOMS. 
 
 Rostan agree on this point with those of M. Rayer. Brodie and 
 Hunkel have remarked the alkalinity of the urine after traumatic 
 or other lesions of the vertebral column ; but as this has been con- 
 tradicted, further observation will be necessary to determine it. 
 
 Mucus, which is one of the natural ingredients of the urine, may 
 become developed in unusual quantities. We observe this in some 
 inflammations of the bladder, in inflammations of the pelvis of 
 the kidneys, and of the ureters. 
 
 The urine may also become changed by the presence of different 
 substances foreign to its normal composition. Thus, sulphur has 
 been found in it, and rare cases are mentioned of phosphorescent 
 urine which shines in the dark at the moment of its emission. We 
 shall not here refer to the hippuric, oxalic, benzoic, carbonic, buty- 
 ric and prussic, xanthic and cystic, acids which have been acci- 
 dentally discovered in the urine under the influence of various and 
 often inappreciable causes. But there are other substances which 
 we find more commonly in the urine, whose existence in it is easy 
 to prove and which furnish signs too important to be omitted ; such 
 are, blood, albumen, sugar, pus, semen, fecal matters, gas, intesti- 
 nal worms, gravel, and many other foreign bodies. 
 
 The urine sometimes contains blood which may come from the 
 different parts of the urinary passages. It varies in quantity, and 
 is more or less thoroughly mixed with the urine ; sometimes is in 
 a fluid state, and sometimes exists in the form of blackish clots. 
 Occasionally it is discharged in the form of full or tubulous fila- 
 ments, which have been mistaken for worms. This clotted form 
 indicates the coagulation of blood in the urethra previously effused 
 in the kidney itself. Bloody urine, when left to repose, forms 
 a blackish sediment composed of bloody globules and fibrine. 
 The quantity of the blood is sometimes so small that we can 
 ascertain the existence of the globules only by the aid of the 
 microscope. The presence of blood in the urine is almost al- 
 ways an indication of a cancerous or calculous affection of some 
 part of the urinary passages, and particularly the kidneys or blad- 
 der ; it has been also observed in scurvy, in severe cases of variola, 
 and in pestilential diseases. 
 
 The urine may contain albumen in a greater or less quantity, 
 the presence of which we can ascertain by the application of heat 
 or nitric acid, which produce a white and flocculent precipitate. 
 The presence of a very great quantity of albumen in the urine, 
 together with a perceptible diminution of its specific gravity and 
 of the proportion of urea and of the salts which it contains, con- 
 stitutes the most important sign of that species of dropsy connected 
 with disease of the kidneys, first described by Dr. Bright. The 
 urine is also albuminous, but generally to a much less degree, in 
 the dropsy that succeeds scarlatina and the decline of certain 
 acute diseases, as Dr. Martin Solon has proved. The urine may 
 contain at the same time albumen, blood and pus in grave affec- 
 tions of the urinary organs and in some diseases of the prostate. 
 
 The opinion was for a long time entertained, and even recently, 
 
SYMPTOMS. 215 
 
 by men of great merit, that the urine of nursing women or of 
 women soon after parturition, may contain milk. These opin- 
 ions, however, were founded upon no exact observation or experi- 
 ment, and there is reason to suspect that the physicians and 
 chemists that entertained them, were deceived by the turbid 
 appearance of the fluid, by the presence of foreign matter, arid 
 particularly pus or a fatty substance. Authors, and especially 
 Prout, have spoken of chylous urine, that is to say, urine contain- 
 ing the organic principles of chyle, visible with the aid of the 
 microscope; but the characters of this kind of urine are not yet 
 clearly ascertained, and besides, the chylous appearance may be 
 owing to the presence of a fatty matter in the urine. Ancient 
 writers mentioned the existence of fat or oil in the urine, during 
 the course of chronic diseases with progressive emaciation ; but this 
 assertion has not been verified, and M. Rayer sought in vain for 
 these substances in the urine of phthisical patients. 
 
 Sugar is also found to exist in the urine. This has not only 
 been proved by the taste, but has been verified by chemists in a 
 more satisfactory manner, by the spontaneous fermentation of the 
 urine and by the actual separation of the sugar from its other ele- 
 ments. The presence of sugar in the urine is a pathognomonic 
 sign of that species of diabetes termed mellitus. This urine has 
 a specific gravity greater than that of the healthy individual, 
 although it contains less urea and less salts. 
 
 Urine containing pus presents, even at the moment of its emis- 
 sion, a turbid and milky appearance. Left in a quiescent state it 
 becomes transparent, and an opaque deposit collects in its lower 
 part, forming a stratum varying in thickness. This urine decom- 
 poses rapidly and becomes alkaline. Pus is generally readily dis- 
 tinguished by its qualities where it exists in the urine in any 
 considerable quantity ; but when its proportion is small, and when 
 mingled with mucus and salts, its presence is very difficult to 
 prove. Chemical and microscopic examination may be resorted 
 to under such circumstances, with advantage, but in the pres- 
 ent state of the science, as we have before remarked, it cannot inspire 
 entire confidence. The ascertained presence of pus in the urine 
 is always an alarming symptom in prognosis, and very important 
 in diagnosis. It is a certain sign either of inflammation of the 
 kidneys or bladder, or of an abscess formed near the urinary 
 organs and opening into their cavity. Examination of the symp- 
 toms preceding the emission of purulent urine and of the organs 
 themselves, enable us frequently to discover the parts in which the 
 pus has been formed. 
 
 In the course of blennorrhagia the urine sometimes acquires con- 
 tagious properties, doubtless owing to the particles of urethral 
 mucus which it carries away with it. Mertens, Astruc and Chaus- 
 sier, have seen individuals that have contracted a blennorrhagic 
 ophthalmia in consequence of bathing the eyes with urine in the 
 course of urethritis. 
 
 The urine sometimes contains, also, small solid concretions, 
 
216 SYMPTOMS. 
 
 some of which are as fine as sand, while others are somewhat 
 larger and equalling grains of hemp seed in size. The first kind is 
 excreted by the patient unconsciously. The second indicates its 
 passage through the canal of the urethra by pain more or less 
 acute, and sometimes by a sensation of tearing, according as the 
 surface of these particles is smooth or rough, and according as their 
 bulk is greater or less. In somes cases their expulsion is attended 
 with no pain, and the patient is only conscious of their existence 
 from the noise of their fall into the vessel that receives them. 
 These concretions are generally formed in the kidneys, and their 
 presence in the urine should always lead us to fear that they 
 actually exist in the kidneys, and that others are in process of for- 
 mation. In some rare instances these concretions are convex on 
 one side and concave on the other, and represent a portion of the 
 external layer of a calculus which has exfoliated in the bladder, 
 and are pathognomic of its presence. 
 
 The saline concretions which form in the urinary passages vary 
 considerably in regard to physical and chemical properties. The 
 smallest of them, those that do not exceed a pea in size, are termed 
 gravel ; all of greater bulk than this are called calculi. Their 
 number is more or less considerable, and is, generally, in inverse 
 ratio to their volume. They are round, oval or irregular in form, 
 sometimes presenting a rough surface (calculs muraux). Their 
 surface often presents one or more faces, an almost certain indica- 
 tion of the simultaneous existence of several stones in some part 
 of the urinary passages. There are cases of gravel or calculi 
 that break with the least pressure, while others have the resistance 
 and firmness of the hardest stone. A greater part of the urinary 
 concretions are formed of uric acid, and are then of a red color 
 bordering more or less upon yellow. Next in order of frequency 
 are calculi of the ammoniaco-magnesian phosphate, crystal ized 
 into prisms and of a whitish color. After these come calculi of 
 the oxalate of lime which are black, brown or grayish ; after 
 these, calculi of the phosphate of lime and magnesia ; and lastly, 
 M. Magendie has described a hairy gravel, of which he gives three 
 instances ; in these cases, hairs had formed upon the surface of the 
 saline concretions, probably proceeding from some cyst opening 
 into some of the urinary passages. 
 
 There have also been discovered in the urine masses of tuber- 
 culous and encephaloid matter coming from the kidneys, and fur- 
 nishing in some cases very important diagnostic signs. 
 
 In cases of seminal loss, of urethral strictures and diseases of 
 the prostate and of the ejaculatory ducts, the semen may flow back 
 into the bladder, and be excreted, mingled with urine. From the 
 experiments of M. Orfila, it appears that the urine excreted imme- 
 diately, or some hours, after a pollution or an ejaculation, carries 
 with it, and consequently contains, spermatozoa which had re- 
 mained in the canal of the urethra. However few in number 
 they may be, they always sink to the bottom of the vessel, and 
 can be readily distinguished with the microscope. 
 
SYMPTOMS. 217 
 
 In cases in which there is a communication between the urinary 
 passages and the rectum, or a portion of an intestine, the urine 
 may contain fecal matters, gas may escape through the urethra, 
 and worms may also be expelled in the same manner. We may 
 also explain in the same way the existence of foreign bodies in the 
 bladder, such as pins, fruit seeds, &c., which have been known to 
 form the nuclei of vesical calculi. Sometimes too, foreign bodies 
 find their way into the urinary passages through an external 
 wound, or are introduced by the urethra. The presence of sub- 
 stances in the urine, which can only come from the intestines is, in 
 most cases, a pathognomonic sign of grave and deep-seated altera- 
 tions which no other symptom could have revealed. 
 
 In cases in which a perforation has taken place between the 
 bladder and rectum, it is often possible, by introducing a probe into 
 the bladder and a finger into the intestine, to feel it ; it may even 
 happen that the opening of the communication is sufficiently large 
 to admit the passage of the finger itself from the rectum into the 
 bladder. 
 
 A great many substances administered under the name of med- 
 icines and introduced into the stomach, may be discovered in the 
 urine. Chemists assert that they have found, in the urine, iodine, 
 mercury, arsenic, iron, the acetate and tartrate of potash, the 
 alkaline sulphates and carbonates, the nitrate of potash, the sul- 
 phate of quinine, etc. 
 
 The urine, left to itself, does not generally preserve that homo- 
 geneousness which it has at the moment of excretion. Many of 
 its elements become separated Irom its mass, and form pellicles, 
 deposits and various suspensions. To thoroughly appreciate these 
 various phenomena, it is necessary to place the urine in a trans- 
 parent vessel at the very moment of excretion, and leave it, for five 
 or six hours at least, in a state of repose. 
 
 The pellicle, cream or crown (urince corona, cremor) is a sort of 
 very thin membrane that forms upon the surface of the urine. 
 
 The suspension which begins to appear in the urine some hours 
 after excretion, is of two kinds ; the first, called nebula (nubecula, 
 nubcs), is that which forms near the superior surface of the fluid; 
 the second, which settles near the bottom, is called encLorcma* 
 We may also observe in some cases a mean suspension in the 
 urine, midway between the surface and the bottom, which has re- 
 ceived no particular designation. The urine presents these various 
 suspensions in most acute diseases. According to some authors, the 
 suspension is more or less removed from the bottom of the vessel, 
 in proportion as the disease is nearer its termination or otherwise. 
 This rule, however, has numerous exceptions. 
 
 Deposits, also called sediment (sedimentum, hypostasis), f are 
 caused by the heaviest substances reuniting at the bottom of 
 the vessel, and forming a stratum of greater or less thickness. 
 
 ua, from uuaytw, 1 raise. 
 , from fTrormiw, I am under. 
 
 19 
 
218 SYMPTOMS. 
 
 Sediment does not generally appear till towards the decline of acute 
 diseases. It does not always form at this period, but it is rare to 
 observe it at any other. Ancient writers laid much stress upon 
 the importance of sediment as a diagnostic sign of intermittent 
 fevers. They considered this phenomenon invariable in the third 
 stage of the paroxysms. Sediment not only collects upon the 
 bottom of the vessel that receives the urine, but forms often upon 
 its lateral walls a thin stratum, sufficiently defined, however, to 
 give the fluid a turbid appearance. Upon inclining the vessel, this 
 disappears, and we then see on one side perfectly transparent urine 
 underneath the deposit, and on the other, the deposit alone forming 
 an opaque coat upon the walls of the vessel. The sediment is 
 generally of a whitish or grayish color ; as frequently, perhaps, in 
 intermittent fever^ (sedimentum lateritium), it is of a rosy color, 
 or the color of brick dust. It is often brown or black in jaun- 
 dice and some acute fatal diseases ; and in a few extremely rare 
 cases, of a bluish color, owing either to the presence of a peculiar 
 substance, called by M. Braconnot cyanourine, or to hydrocyanate 
 of iron, according to the observations of M. M. Julia,* Battf and 
 Mojon. J The sediment often has the appearance of dust, or of 
 meal or bran coarsely ground ; this is the furfuraceous sediment, 
 (sedimentum furfuraceurri) $. At other times it is formed of a 
 mucous matter either united into flocculi, or collected at the bottom 
 of the vessel in an even and semi-transparent stratum. This is 
 the mucous sediment. We designate by the epithet sandy or 
 gravelly, the sediment that contains sand or gravel (sedimentum 
 arenosum). Purulent sediment is that consisting of pus, etc. 
 Deposits, nebulas, and pellicles that form in the urine have been 
 examined by the microscope and subjected to chemical analysis. 
 The nature of these various urinary products varies according as 
 the urine itself is acid or alkaline. In acid urine, the nebulas and 
 enaeoremata are formed by thin lamellae of epithelium, urates, 
 uric acid and mucus. The yellow, reddish or red sediments are 
 formed of uric acid or urate of ammonia, distinguishable from 
 each other by their modes of crystallization which the micro- 
 scope enables us to determine with precision. Alkaline urine, more 
 or less discolored, is generally accompanied by a white or slightly 
 yellow sediment disposed into regular crystals, or forming an 
 amorphous and pulverulent mass : this sediment is generally com- 
 posed of phosphate of lime and the ammoniaco-magnesian phos- 
 phate, mingled often with pus adulterated by ammonia, which 
 gives it a viscous or mucous appearance. We may also find in it 
 sanguineous globules, spermatozoa, the coloring matters of the bile , 
 and occasionally various salts of which lime forms the base, etc. 
 
 * Journal de Chimie, vol. 1, p. 330. 
 
 f De Urina Sedimentum Ceruleum Demittente, 1809. 
 
 j Journal de Medec., vol. 72, p. 174. 
 
 Furfur, meal. 
 
SYMPTOMS. 219 
 
 $ III. Excretions. 
 
 Having examined in succession the principal morbid phenomena 
 presented by the secretions, it remains to say a few words with 
 regard to the derangements of the excretions, independently of 
 those of the secretions. 
 
 The excretions which are under the influence of the will, are 
 those alone of sufficient importance to be discussed in this place. 
 These excretions may become in disease more or less frequent than 
 in health, and may be accompanied with considerable efforts or 
 be effected too easily. They may be involuntary, as in many grave 
 diseases, and on the other hand, the will may be unable to promote 
 them, as in cases of retention of the urine and occlusion of the 
 rectum by hardened faeces. Sometimes the desire of excretion is 
 continual, painful and almost ineffectual, as in tenesmus of the 
 rectum or bladder. We can here only refer to these symptoms, 
 as they have been discussed elsewhere, but must confine ourselves 
 to the consideration of the phenomena which have not yet been 
 enumerated ; such are those which arise from the occlusion of the 
 excretory canals, whether these canals are, or are not, provided 
 with sphincters, and whether the excretions are involuntary or 
 otherwise. 
 
 The causes which produce occlusion of these canals are very 
 various, but may be divided into three classes. The canal is 
 sometimes choked by an obstacle contained in its cavity, a calcu- 
 lus, for example ; sometimes its cavity is obliterated by the thick- 
 ening of its walls, and sometimes by an external compression, as 
 of a neighboring tumor. This occlusion is followed by various 
 results. 1. The excretions of the fluid is prevented. This sup- 
 pression is often difficult to prove during life in cases in which the 
 secretory organs being double, like those of the urine, the occlu- 
 sion of one of the excretory canals does not entirely interrupt the 
 excretion of the fluid ; and in those cases in which the functions 
 of the secretory organs are of minor importance or merely auxil- 
 iary. But whenever the viscus to which the obliterated canal 
 belongs is single, and plays an important part in the economy, as 
 the liver, for example, the occlusion of the canal is soon followed 
 by remarkable phenomena, such as acute pains, a yellow color in 
 the skin and urine, discoloration of the faecal matters and various 
 derangements of the digestive functions. 2. Another consequence 
 of occlusion is distension of the canal from its source to the obsta- 
 cle, and after a certain time its contraction and, sometimes, entire 
 obliteration from the obstacle to its point of termination. This 
 distension is apparent in the duct of Steno, vasa deferentia and la- 
 crymal sac, but entirely escapes our direct observation whenever 
 the organ is deeply seated, as, for example, the liver, kidney and 
 pancreas. 3. The progressive distension of the canals by the 
 fluids which incessantly flow into them, represents a force which 
 has a tendency to remove the obstacle which produces the occlu- 
 
220 SYMPTOMS. 
 
 sion, to raise the tumor which presses upon the canal, to dilate its 
 lateral walls, or to push before it the foreign body contained in it. 
 In this last case, the distension of the canal, as far as the calculus, 
 would seem to favor its progression ; for it is difficult to suppose 
 that this distension being so considerable as far as the calculus, 
 might not extend beyond it. And, on the other hand, the obstacle 
 being situated at ths point of junction of two portions of a canal, 
 one of which is continually dilating while the other preserves its 
 natural size, may frequently fall back into the dilated portion, and 
 by its displacement suffer the collected fluid to escape through the 
 opening, at least for a time. 4. Lastly, if the obstacle is neither 
 pushed out nor displaced, death, sooner or later, may be the conse- 
 quence, as in cases of retention of urine, intestinal matters and 
 bile, sometimes by the rupture of the canal above the obstacle, and 
 sometimes, by the retention in the economy of substances natural- 
 ly excreted, the changes they undergo, the inflammation they pro- 
 duce in the parts containing them, and, in some cases, the infection 
 which follows their absorption into the circulatory current. 
 
 SECTION SIXTH. 
 Symptoms furnished by Absorption. 
 
 Having examined the principal disorders of the secretions and 
 excretions, it remains for us to speak of those presented by the 
 different species of absorption. 
 
 We may remark, in the first place, that in a great number of 
 cases, derangements of absorption may be confounded with those 
 of exhalation, since the same phenomenon, the accumulation of 
 serum in the pleura or peritoneum, for example, may be equally 
 the result of a diminished absorption or an increased exhalation. 
 
 But there are other circumstances, under which it is impossible 
 not to recognize the effect of absorption. The gradual or rapid 
 disappearance of pus collected in a bubo, of blood extravasated 
 under the skin in consequence of a contusion, of serum in the 
 cellular tissue or in a serous membrane, are evidently phenomena 
 which absorption alone can produce. Primary ulceration, when 
 not arising from a loss of substance, or from the separation of an 
 eschar, is regarded by most physicians as the result of a morbid 
 absorption acting upon the solids themselves, and carrying away 
 into the current of the circulation the elements of which they 
 consist. 
 
 It is generally believed that there is between the different absorp- 
 tions an analogy similar to that existing between the different 
 secretions. 
 
 Thus, when absorption is very active in the digestive canal, 
 after eating, for example, the exterior absorption, cutaneous and 
 pulmonary, is probably diminished. It undoubtedly becomes more 
 active in the morning before breakfast, since at this period of the 
 
SYMPTOMS. 221 
 
 day the gravity of the body is increased, as was proved by the 
 experiments of the celebrated Sanctorius, who, from the zeal and 
 perseverance with which he devoted himself to these inquiries, 
 deserves to have disciples and rivals. Many practitioners think, 
 not without reason, that medicinal preparations left to the action 
 of cutaneous absorption, mercurial ointment, for example, may be 
 administered to greater advantage at this hour of the day. 
 
 The absorption of the fat contained in the vesicles, in patients 
 subjected to a severe course of diet, comes in aid of the opinion 
 that when absorption is not sufficiently active in one part, it in- 
 creases in another. The same may be said of the advantageous 
 effects that sometimes follow a rigorous diet in the treatment of 
 certain engorgements ; the absorption which, for want of sub- 
 stance, is not effected in the digestive canal, acts with more energy 
 in other parts, and may cause the progressive diminution of a 
 hypertrophied viscus, as well as that of the whole body. Resolu- 
 tion, which we shall consider in another place, appears to be noth- 
 ing but a remedial absorption. 
 
 Besides this kind of equilibrium, which we observe in disease 
 between the secretions on the one hand and the absorptions on the 
 other, there are also cases in which these two functions act in con- 
 cert. In the course of an acute phlegmasia, pleurisy for example, 
 so long as the disease is making progress, and a sero-purulent fluid 
 is exhaled in the pleura, the skin is dry and the urine excreted in 
 small quantities. But when the absorption begins to act upon the 
 effused liquid, the skin often becomes moist and there is an abun- 
 dant flow of urine ; analogous phenomena take place, and are more 
 easily observed in the progressive diminution of anasarca and 
 ascites. In these cases, exhalation carries away through the skin, 
 kidneys, and mucous membrane of the digestive passages, a greater 
 quantity of fluid, in proportion as absorption takes up the serum 
 effused in the serous and cellular tissues. The considerable in- 
 crease of certain secretions, the urine, for example, in diabetes, 
 and abdominal serum in ascites, is necessarily connected with a 
 similar increase of absorption, and especially the pulmonary or 
 cutaneous absorption. The excretion of from twenty to forty 
 pounds of urine daily, for many months together, in diabetes, and 
 the daily increase of from ten to twelve pounds in the weight of 
 the body in some cases of ascites, in which the amount of food 
 taken is proportionally small, settle this question beyond a doubt. 
 As a general rule, whenever absorption becomes very active in any 
 tissues or organs, the exhalations and secretions become so in 
 others, and vice versa. It is by the application of this law to the 
 treatment of disease, that the physician endeavors to promote the 
 absorption of fluid collected in the serous membranes by increas- 
 ing the intestinal urinary or cutaneous secretions, and is sometimes 
 enabled to diminish the urinary secretion in diabetes, by promot- 
 ing profuse perspiration. 
 
 19* 
 
222 SYMPTOMS. 
 
 SECTION SEVENTH. 
 
 
 Symptoms furnished by Nutrition. 
 
 The derangements of nutrition in disease are almost infinite, 
 but in most cases are not appreciable by the senses during life, and 
 consequently do not belong to symptomatology. There are a few, 
 however, properly within its domain, which we proceed to enu- 
 merate. 
 
 Nutrition may be increased, diminished or perverted. It can 
 only be entirely lost in those parts already deprived of life. 
 
 Increased activity of nutrition is indicated by the increased 
 volume of all, or nearly all, the constituent parts of the body, but 
 more particularly of the viscera contained in the chest and abdomen, 
 of the muscles and of the adipose tissue. This may easily be con- 
 founded with the obesity produced exclusively by an accumulation 
 of fat in the cellular tissue. The latter phenomenon, though rare, 
 may occur in disease (page 76), while a general increase of vol- 
 ume of the muscles and viscera, is never a symptom. It is other- 
 wise when this increase is partial : such is that of which the heart 
 and liver are frequently the seat, and which we designate by the 
 term hypertrophy, an affection rarely simple, and nearly always 
 connected with some obscure modification in the texture of these 
 organs, and particularly with some disturbance in their functions, 
 more or less apparent. 
 
 In nearly all diseases of any importance, nutrition becomes lan- 
 guid. This is apparent from the emaciation that accompanies 
 them. When this languid nutrition exists in but one part of the 
 body, it gives rise to a partial emaciation or atrophy, a phenome- 
 non particularly owing to the entire inaction of organs, or to a 
 prolonged compression of them. It is also of frequent occurrence 
 in the muscles of limbs under the influence of these two causes, 
 and necropsies prove that the internal organs, as, for example, the 
 lung in pleuritic effusion, may also become the seat of it under 
 the influence of the latter cause. 
 
 Atrophy of an organ may also follow a disorder affecting the 
 circulation or innervation. This principle has been ingeniously 
 and usefully applied to the treatment of certain diseases. Thus, 
 Maunoir of Geneva, and Charles Bell, have produced the atrophy 
 of a voluminous testicle, by a ligature round the spermatic artery ; 
 and many other surgeons have arrested the progress, and brought 
 about the decrease of considerable tumors in the face, by tying 
 the common carotid artery on the corresponding side. The liga- 
 ture or division of nerves often produces atrophy, also, in the 
 muscles to which they are distributed. The suspension of nervous 
 action appears, also, to have had the effect, in some cases, of ar- 
 resting the development, and even causing the atrophy, of certain 
 morbid tissues. Dr. Duparque * states that he saw an ulcerated 
 
 * Maladies de V Uterus. 
 
SYMPTOMS. 223 
 
 cancer of the breast diminish and disappear, in consequence of a 
 paralysis affecting the side of the body corresponding to the dis- 
 eased part. This fact, alone, perhaps, in the annals of science, 
 requires confirmation. 
 
 Emaciation should not be confounded with leanness. The lat- 
 ter is that condition of the sound or diseased body in which there 
 is a natural thinness of flesh ; while the former is that state in 
 which there is a gradual wasting of the body. An emaciated per- 
 son may still have embonpoint, and a person may be lean who is 
 daily gaining flesh. We have spoken of this phenomenon in the 
 article devoted to the exterior of the body (page 77), and do not 
 propose to recur to it here. 
 
 Nutrition is as often perverted as diminished. It is to this per- 
 version that we may refer all the organic lesions which are not the 
 result of an external cause : the production of cysts, vicious cur- 
 vature of the bones, the various degenerations and the phlegmasiae 
 themselves, seem to be originally owing to a modification of nu- 
 trition. 
 
 Nutrition furnishes another class of phenomena which belong 
 still more to symptomatology. We refer to the irregularities of 
 growth in the growing period of life. The growth, which, in 
 health, is effected in different individuals according to a variable 
 progression, but always within certain limits, presents, in disease, 
 many remarkable anomalies. We see children whose growth 
 seems to be entirely suspended for one, and even for many years. 
 This phenomenon is not uncommon in rachitis, of which it is 
 sometimes the first symptom. We have seen at the Clinical 
 School of the Hotel Dieu, a person fifteen years of age, affected 
 with diabetes, whose growth had been suspended since he was 
 twelve years of age, the period at which the diabetes had com- 
 menced. We see a greater number of persons, whose length of 
 body increases one, and sometimes several inches during the very 
 limited course of an acute disease. These two opposite phenom- 
 ena are equally of unfavorable augury, though the latter indicates 
 immediate danger, while the former should lead us to fear that the 
 development of the body is permanently arrested. 
 
 ARTICLE THIRD. 
 Symptoms furnished by the Generative Functions. 
 
 THE symptoms of which we have hitherto spoken are, almost 
 without exception, common to the two sexes, but those which it 
 remains for us to enumerate are peculiar to the one or the other. 
 Having already pointed out the principal changes that disease 
 produces in the external organs of generation, in the section de- 
 voted to the consideration of the exterior of body, we shall now 
 merely say a few words upon the disorders of the functions de- 
 signed for the reproduction of the species. We shall consider them 
 successively in man and woman. 
 
224 SYMPTOMS. 
 
 A. In man, the secretion of semen is seldom increased in disease. 
 It may occur, however, in erotic melancholy, and is one of the 
 principal symptoms of * satyr iasis The diminution, or almost en- 
 tire suspension, of this secretion is, on the contrary, of frequent 
 occurrence, as may he inferred from the constant flaccidity of the 
 penis and the absence of erection, in the course of most diseases. 
 
 The excretion of the sernen is susceptible of different disorders. 
 It is attended with pain in the phlegmasise of the urethra. With 
 some individuals it takes place when the penis is not in a state of 
 erection, particularly during the efforts attending stools. In other 
 cases, the emission is feeble, or interrupted by some obstacle (dis- 
 permasici)* and the seminal fluid, instead of being excreted in jets, 
 flows slowly through the orifice of the urethra. In some persons, 
 emission takes place upon a simple touch, and before the introduc- 
 tion of the penis into the vagina. Sometimes there is a deviation 
 of the semen, which, after being forced into the canal of the ure- 
 thra, flows back into the bladder whence it is excreted mingled with 
 urine. This deviation is owing to the wrong direction of the 
 ejaculatory ducts which open into the canal of the urethra, from 
 before, backward, that is, contrary to the natural arrangement. 
 It sometimes follows, also, stricture of the urethra. 
 
 Impotency, or inability to effect the venereal act, may arise from 
 a multitude of different causes, the consideration of which would 
 be irrelevant in this connection. We will merely remark, after re- 
 ferring to the influence of imagination upon this phenomenon, that 
 sometimes the penis is not capable of erection, and sometimes 
 emission does not take place, at least at the proper time. The loss 
 of power of erection is, in a certain number of cases, the first, or 
 one of the first symptoms of a disease of the nervous centres, and 
 particularly the spinal marrow. 
 
 We observe, in some cases of disease, frequent and even habit- 
 ual erections, taking place independently of the natural causes 
 that excite them. This phenomenon occurs, particularly, in cases 
 of vesical calculi, and in certain chronic eruptions of the skin. 
 The application of a blister will produce it in some persons. 
 
 B. In woman, the functions of reproduction present a greater 
 number of symptoms. The menses, the lochia, and the secretion 
 of milk deserve particular attention. 
 
 In some young females the catamenia do not appear at the 
 usual age. This delay may be owing to the general state of the 
 constitution, or be connected with the condition of the uterus or its 
 appendages. In most cases, however, it is referable to disease in 
 a remote organ, and particularly the lungs. 
 
 The menstrual flux is sometimes increased in disease. This in- 
 crease, when very considerable, constitutes menorrhagia, and may 
 take place at the usual menstrual periods, or in their intervals. 
 When the blood escapes in clots, it is always important to examine 
 
 * Jvg, with difficulty ; ani^a, semen. 
 
SYMPTOMS. 225 
 
 it with care, in order to ascertain whether it contains a foetus or its 
 membranes, particularly when the flow of blood is accompanied with 
 expulsory pains analogous to those of parturition. Metrorrhagia 
 is often symptomatic of abortion either in progress or already effect- 
 ed, and is sometimes connected with disease of the uterus, such as 
 polypus, fibrous tumor, cancers, granulated metritis, etc. Metror- 
 rhagias, or morbid haemorrhages of the uterus, sometimes occur 
 spontaneously in the course of acute diseases, particularly dur- 
 ing eruptive fevers and variola, and give a graver character to 
 prognosis. In all these cases an examination of the uterus by the 
 touch is indispensable. The diminution of the periodical flux is 
 much more frequent, occurring in most chronic affections. In 
 their last stage it is almost always suspended. Deviations of the 
 menstrual flux have also been very frequently observed, and may 
 take place through a great number of different passages, but par- 
 ticularly through one of the mucous membranes or the skin. 
 
 The flow of lochia after parturition, may be unusually great; 
 more frequently, however, if any disease exist at this period, this 
 discharge is much diminished in quantity, and sometimes even 
 entirely suppressed, as in puerperal peritonitis. 
 
 The volume of the mammae is increased during pregnancy. 
 This phenomenon occurs, also, but rarely, in certain affections of 
 the uterus. There are a great number of females whose menstrual 
 periods are preceded and accompanied by a perceptible tumefac- 
 tion of the mammae, while at the same time they become the seat 
 of a sensibility more or less acute. It is particularly, however, a 
 few days after parturition that the mammae present a great in- 
 crease of volume, at the time that the secretion of milk is effected. 
 The absence of tumefaction of the mammae or their sudden falling 
 away, under such circumstances, is always a suspicious phenome- 
 non. The mammae diminish in volume, and sometimes become 
 actually atrophied, in women advanced in years. 
 
 The secretion of the milk never increases during the progress of 
 disease, but nearly always diminishes, and is sometimes suppress- 
 ed. This suppression is generally accompanied by shrinking of 
 the mammse, and sometimes by their induration, a phenomenon 
 attributed by some authors to the coagulation of the milk in the 
 mammary gland. The microscopic examination of the milk is not 
 without interest in a pathological point of view. By means of this 
 examination, the milk has sometimes been found to be mingled 
 with small quantities of pus. With regard to deviations of the 
 milk, of which so much has been said, and which was once thought 
 to have been proved by the milky appearance of pus in abscesses, 
 of leucorrhaeal mucus, or of the fluid furnished by the inflamed 
 pleura or peritoneum, they are no longer believed to take place, 
 and consequently need not here be discussed. The facts, that we 
 find this lactiform matter in men as well as women, and that if it 
 present the color of milk, it has none of its properties, are sufficient 
 to overthrow the hypothesis if it still has any advocates. Women 
 are also accustomed to attribute the fixed or undefined pains, and 
 
226 SYMPTOMS. 
 
 the cutaneous eruptions that follow delivery, to the presence of 
 milk in the economy. They designate these symptoms, whatever 
 they may be, by the term diffused milk. This second species of 
 deviation is a mere unfounded hypothesis. 
 
 Barrenness may follow more various causes than those that give 
 rise to impotency in man. The most common, are vicious confor- 
 mation or position of the os uteri, the obliteration of the fallopian 
 tubes, the various lesions of the ovaries, and the presence of polypi 
 in the neck of the uterus. 
 
 We may also refer to this head of disorders furnished by the 
 generative functions of women, the facility with which abortion is 
 effected in some, and the inability of others to carry the product of 
 conception during the natural period of pregnancy. 
 
 In both sexes the venereal desire (appetitus venerens) may be 
 increased, diminished or perverted. It is increased in satyriasis 
 and nymphomania, and in some cases of erotic melancholy. It is 
 diminished in most diseases, and particularly in leucorrhea in 
 women, and in both sexes in persons addicted to masturbation. 
 Its entire loss is designated by the term anaphrodisia (anaphrodi- 
 sia.*) It is perverted in certain cases of mania, and some other 
 neuroses, in which the patient is incessantly addicted to masturba- 
 tion, or is led to the commission of unnatural acts. 
 
 Such are the principal symptoms furnished by the generative 
 functions. To these we may add those that are discovered by 
 touch and the speculum uteri, of which we shall give a summary 
 in the chapter on diagnosis. 
 
 ARTICLE FOURTH. 
 
 Symptoms considered in Disease. 
 
 HAVING thus far treated of symptoms in the abstract, we shall 
 now proceed to consider them in connection with disease, of which 
 they constitute the elements. 
 
 Sometimes but one symptom makes its appearance ; as in cases 
 of vomiting, deafness or epistaxis ; but generally many occur 
 simultaneously. These symptoms are grouped in a thousand 
 ways, and by their various combinations, constitute the phenome- 
 nal part, or the apparent features of a disease : they lead to the 
 knowledge of internal lesions when these exist, and are of the 
 highest importance, in all cases, in enabling us to decide upon the 
 nature of the disease with which the patient is affected. The 
 symptoms which appear simultaneously in the same patient, are 
 often in intimate connection with each other ; they are not all of 
 equal importance, either in relation to the diagnosis of the disease 
 or the influence they may exert upon its progress ; lastly, they do 
 
 * A privative, aipgoSioia, pleasure. 
 
SYMPTOMS. 
 
 not all appear at the same time. We shall now briefly consider 
 them in these different points of view. 
 
 $ I. It is highly important in the appreciation of symptoms, to 
 be able in a case of general functional disorder, to distinguish 
 which function was primarily affected, and not to confound symp- 
 toms which may be called primary ', or local, with their accompany- 
 ing secondary, or general, phenomena. In pleurisy, for example, 
 there may be observed simultaneously, redness of the face, pain 
 in the chest, feebleness or disorder of the intellectual functions, 
 thirst, interrupted voice, cough, dyspnoea, frequency of the pulse, 
 increased heat, high colored urine, and many other symptoms 
 which may accompany the disease during the whole, or a part, of 
 its duration. The importance of isolating the primary, from the 
 secondary, phenomena, is here evident. The first, are pain in the 
 side, dyspnoea, and cough, to which may be added the difficulty 
 of speech ; the second, are the color of the face, headache, frequency 
 of the pulse, heat, disordered secretions, &c. The sensible changes 
 presented by the inflamed pleura explain all the primary phenom- 
 ena, as the pain, dyspnoea and cough. The connection between 
 the symptoms and this disease may be also easily explained. The 
 pleuritic pain, and probably also the inflamed state of the pleura, 
 oblige the patient to take short and frequent inspirations ; respira- 
 tion is so intimately connected with the circulation, that when one 
 is accelerated the other necessarily becomes so. The frequency 
 of these two functions causes elevation of heat, in the production 
 of which both appear to concur ; the increased heat augments the 
 thirst, and renders the urine more highly charged. 
 
 But it is impossible, in most cases, to discover the connection 
 between the various symptoms, and we are compelled to attribute 
 them to the invisible bond of sympathy. The relations between 
 all parts of the body in health as well as disease are so intimate, 
 that no one can become gravely affected in its structure or func- 
 tions, without all the others, or at least many of them, participa- 
 ting in some degree. Sympathetic phenomena, are those which 
 arise from this connection alone between the different organs, un- 
 accompanied by any primary lesion of the part which is their 
 seat, and sympathy * is the term applied to the organic condition 
 which presides over the production of these phenomena. This 
 produces, in disease, effects more various and extraordinary than 
 in health. Without here speaking of that universal or general 
 sympathy, by virtue of which the whole economy participates in 
 the disorder of some organ or function, as is observed in the in- 
 flammation of a viscus or any other internal disease, let us con- 
 sider for a moment the phenomena which depend upon special or 
 particular sympathy, or that which exclusively exists between 
 certain organs. 
 
 Hunter divided these numerous and various phenomena into 
 
 * 2vr t with, at the same time; rta&og, affection. 
 
228 SYMPTOMS. 
 
 three series, according to their appearance in organs which are 
 continuous, contiguous or remote ; this division is more simple and 
 natural than those since established. To the sympathy of con- 
 tinuity, may be referred the pain felt in the whole track of a nerve 
 when any part of it is irritated or contused ; the general convul- 
 sions and tetanus following laceration of a nervous filament ; the 
 itching of the nasal fossae in persons affected with intestinal worms, 
 and pain in the glans penis in those affected with calculus in the 
 bladder. The sympathy of contiguity produces vomiting in perito- 
 nitis, dysuria in haemorrhoidal swelling, dysentery, &c. Remote 
 sympathy sometimes affects similar organs, or those associated in 
 the performance of the same function, and, sometimes, parts be- 
 tween which no relation exists. In complete amaurosis of one 
 side, the oscillations of the iris are sometimes observed to be trans- 
 mitted from the sound eye to that which is incapable of distinguish- 
 ing the light, and, when one of these organs is inflamed, the other 
 cannot endure the light. These various phenomena are attributa- 
 ble to the similarity in the structure and functions of the affected 
 organs. The relation existing between the mammae and uterus, 
 and between the expiratory muscles arid lungs, seem to account, 
 to a certain extent, for the shrinking or swelling of the mammae in 
 certain affections of the uterus, and the involuntary cough excited 
 by the accumulation of mucus in the trachea. The examples of 
 remote sympathy between two organs which do not concur to the 
 performance of the same functions, are very numerous, and can- 
 not be explained by nervous anastomoses, although many physi- 
 cians have thus endeavored to account for it in some sympathetic 
 phenomena of this kind, and particularly in the pain of the right 
 shoulder, sometimes accompanying inflammation of the liver. 
 The cough sometimes observed in certain affections of the stom- 
 ach, liver and uterus ; the vomiting which occurs in diseases of 
 the brain, lungs, kidneys and uterus ; the trembling of the lower 
 lip and ptyalism which often precede vomiting, dilatation of the 
 pupils in verminous affections, and pain in the knee in hip disease, 
 are all sympathetic phenomena, most of which have been noticed, 
 but which are entirely inexplicable. 
 
 Such are the principal effects of morbid sympathy, which, as 
 has been said, transmits throughout the economy the irradiations 
 of the affected organ. 
 
 $ II. The symptoms which appear simultaneously in the course 
 of any disease, are not all of equal importance. There are those 
 which are principal or characteristic, and others, that are called 
 accessory. 
 
 When all the functions of the economy are simultaneously de- 
 ranged, many of them severely, no organ being more particularly 
 affected than the others, the most apparent phenomena become the 
 principal symptoms, the others being only accessory : this is par- 
 ticularly observed in malignant intermittent fevers. In those 
 diseases, on the contrary, in which a single organ is the seat of the 
 
SYMPTOMS. 229 
 
 affection, the importance of the symptoms is not determined by 
 their intensity, but by their seat and the function which is de- 
 ranged. Thus in peripneumony, a slight pain in one side and a 
 few rusty colored sputa are the principal symptoms ; while the 
 violent headache, high colored urine, and high fever, are but ac- 
 cessory phenomena. 
 
 $ III. Symptoms have been also divided into active and passive. 
 
 In defining disease to be a struggle of nature, in which she is 
 endeavoring to repel or destroy the morbid cause, it seems to be 
 forgotten that, in some affections, no sign of salutary reaction can 
 be perceived, and that most of the symptoms tend, on the con- 
 trary, to hasten the fatal result. Thus in pulmonary phthisis, the 
 night sweats, diarrhoea, cough and haemoptysis, daily aggravate 
 the condition of the patient. But there are, also, other affections 
 in which no favorable reaction can be discovered. The peculiar 
 phenomena developed around a thorn imbedded in the skin, the 
 fever which accompanies the inflammation of this membrane and 
 the subjacent parts, the suppuration which occurs around the for- 
 eign body, and causes its expulsion after having produced absorp- 
 tion of the integuments in the part corresponding to the abscess, 
 or destroyed the edges of the opening which gave exit to the 
 material agent of the disease, are symptoms which we may, with 
 some modern authors, term active. 
 
 In many acute diseases, most of the symptoms seem also to 
 indicate, if not a concurrence of all the forces of the economy 
 against the morbific cause, at least an evident struggle between 
 them. But it must be admitted that, in most cases, the distinction 
 into active and passive symptoms is utterly impossible. 
 
 $ IV. All the symptoms do not make their appearance at the 
 commencement of diseases. In those whose course is rapid, 
 the principal and characteristic symptoms are generally developed 
 about the second or third day; in those which progress slowly, 
 they may not appear for several months, and sometimes many 
 years. In both cases, various accidental symptoms, called epi- 
 phenomena, * occur in the course of the affection, which differ 
 from symptoms, properly so called, in not being as intimately con- 
 nected with the existence of the disease. To the epiphenomena, 
 or accidents, may be referred the supervenientia, the epigenemata, 
 and, what have been styled in the schools, the symptoms of the 
 cause, and the symptoms of the symptom. The supervenientia 
 are phenomena foreign to the disease, but developed by it ; as the 
 appearance of the menstrual flux before the ordinary period ; the 
 pains of dentition occurring in children, but which were not ex- 
 perienced previous to the existing disease ; and finally, the prodi- 
 gious multitude of parasitic animals, worms, and particularly lice, 
 observed in some patients. The epigenomata are accidents mani- 
 
 *"Em, upon j ycmojuat, I appear. 
 
 20 
 
230 PROGRESS OF DISEASES. 
 
 fested during the disease, but which depend upon some external 
 cause, as the negligence of the assistants, or imprudence of the pa- 
 tients themselves. The symptoms of the cause are accidental phe- 
 nomena which seem to depend, riot upon the disease, which does not 
 ordinarily produce them, but upon the determining cause of the 
 disease itself ; as in the case of haemoptysis occurring in the course 
 of an inflammatory fever. As this symptom does not ordinarily 
 accompany this disease, it has been considered rather the result of 
 the phlethora which produces the fever, than of the fever itself. 
 Finally, should this haemorrhage become sufficient to cause fainting, 
 the latter would be considered, in the language of the schools, the 
 symptom of a symptom. These distinctions have been justly 
 abandoned, and their distinctive appellations have become to us 
 almost unintelligible. The various accidents which may be added 
 to the symptoms of disease may, withoutin convenience, be classed 
 under the head of epiphenomena. 
 
 Such are the principal points of view in which symptoms may 
 be considered. In the chapter on diagnosis, we shall consider 
 their semeio'logical value. O. 
 
 CHAPTER VIII. 
 
 PROGRESS OR COURSE OF DISEASES. 
 
 THE progress of diseases (morborum decnrsus) may be denned 
 to be the mode of production and succession of the material lesions 
 and symptoms which characterize them. 
 
 The alterations occurring in the texture of organs during disease, 
 elude, in many cases, our means of observation. There is, how- 
 ever, p a considerable number of diseases in which we can, to a 
 certain extent, trace the internal modifications and most apparent 
 functional derangements. Without mentioning, in this place, those 
 diseases whose seat is the cutaneous surface, or those occupying 
 the orifices of the mucous membranes, or parts so near to these 
 orifices, that the eye can observe and follow through their various 
 phases, the changes which occur in their material disposition ; 
 there are certain other affections, as pleurisy, pneumonia and 
 scirrhus of the stomach, in which, by the aid of all our explorative 
 means, we are able to recognise the commencement, progress and 
 diminution of a pleuritic effusion, the progressive conversion of 
 pulmonary engorgement into hepatization, the extension of the 
 disease from the point primarily affected, to other portions of the 
 same organ, and the gradual increas'e of a tumor developed in the 
 greater curvature of the stomach. But it should be recollected 
 that material organic lesions are in most cases appreciable only 
 after death ; and in many instances, it is almost wholly by the 
 
PROGRESS OF DISEASES. 231 
 
 alterations which supervene in the symptoms, that the physician 
 can trace and study the progress of diseases, in which are com- 
 prehended their type, their form, either acute or chronic, the dis- 
 tinction of their periods, and the examination of the numerous 
 circumstances which influence them. 
 
 I. The type - (typus) is the order in which the symptoms 
 become aggravated or reproduced. 
 
 It is continued ( T. continuus) when the symptoms persist unin- 
 terruptedly from the commencement to the termination of the 
 disease; periodical or intermittent (T. periodicus, inter 'mittens) , 
 when they appear and disappear at intervals. 
 
 A. A disease of continued type is sometimes equally intense 
 throughout its course : it is then called continent (morbus conti- 
 nens) ; such is, in certain cases, the ephemeral inflammatory fever, 
 exhibiting, during its short continuance, variations so slight as not 
 to deserve notice ; no acute disease would be continent, if this 
 term be employed in a strict sense. The continued diseases 
 are not usually of uniform intensity; they have exacerbations 
 alternating with the decrease of the symptoms or remission. The 
 exacerbation, paroxysm or access, consists in a more or less marked 
 increase of one, many, or all of the symptoms belonging to the 
 disease ; the remission, in the opposite change. 
 
 There are certain continued affections, whose symptoms, instead 
 of presenting these opposite alternations, increase regularly in in- 
 tensity from the attack to the termination ; there are others, on the 
 contrary, which exhibit their greatest intensity at their commence- 
 ment, and become gradually less serious. The fever which pre- 
 cedes the appearance of the catamenia, often exhibits an increasing 
 intensity ; the contrary has been observed in regard to ephemeral 
 fever. 
 
 B. Periodical or intermittent diseases assume very various 
 forms, either in regard to the actual paroxysms* (accessus), (such 
 is the name given to the reappearance of the symptoms) or to the 
 interval between them. Certain paroxysms present, in the midst 
 of variable symptoms, a chill, succeeded by heat and perspiration; 
 others, which are also called attacks, do not exhibit these phenom- 
 ena. The first are peculiar to intermittent fever ; the latter are 
 common to all other periodical diseases, such as epilepsy, hysteria 
 and many nervous affections. The interval between the febrile 
 paroxysms is called apyrexia-\ or intermission (apyrexia, inter- 
 missio)-, the intermediate periods of the attacks have received no 
 particular appellation. 
 
 The intermittent or periodical type may present itself under 
 various forms : the principal are the quotidian (quotidianus), ter- 
 
 * TTaQo^vrtunc, oi/'e, acute j rtaqa, beyond, 
 t A privative, ifv^f^o;, fever. 
 
232 PROGRESS OF DISEASES. 
 
 tian (tertianus), and quartan (quartanus). In the first, the par- 
 oxysms occur every day, and resemble each other in duration, 
 violence and principal symptoms; in the second, the paroxysms 
 occur every second day; in the quartan type, every third day. 
 A type presenting recurrences every fifth, and one every sixth 
 day, have been admitted ; but they have been very rarely ob- 
 served, and many practitioners have thought that the reappear- 
 ance of certain fevers with these unusual types should be consid- 
 ered accidental. The existence of monthly or annual intermittent 
 fever is not now admitted. When an intermittent disease reap- 
 pears at irregular intervals, it is erratic or atypic (morbus erra- 
 ticus). 
 
 The quotidian, tertian, and quartan types present numerous 
 varieties : 1. In the double quotidian (quotidianus duplex), two 
 paroxysms occur every day. 2. In the double tertian (tertianus 
 duplex} , there is a paroxysm every day, those of alternate days 
 corresponding ; the third resembling the first, the fourth the second. 
 3. In the duplicated tertian (tertianus duplicatus), there are two par- 
 oxysms on the same day and one day of apyrexia. 4. If the type 
 be triple tertian (tertianus triplex), there are two paroxysms on 
 the first and on the third day, and one only on the second and 
 fourth ; these paroxysms correspond every second day. 5. The 
 double quartan type (quartanus duplex) has one paroxysm on two 
 successive days ; the paroxysm of the fourth day is similar to that 
 of the first, that of the fifth to that of the second, the apyrexia of 
 the sixth day corresponds to that of the third. 6. In the duplicated 
 quartan (quartanus duplicatus), there are two paroxysms on the 
 same day, occurring every third day. 7. In the triple quartan 
 (quartanus triplex), there is a paroxysm each day, as in the quo- 
 tidian and double tertian; but in the triple quartan, the paroxysms 
 correspond as to the hour, duration and severity, on each third 
 day ; the first three differ from each other, the fourth resembles 
 the first, the fifth the second, the sixth the third; in the double 
 tertian type, the paroxysm is different every other day, and corres- 
 ponds every second day ; in the quotidian there is constant simi- 
 larity of access. Of all these varieties of intermittent types, the 
 double tertian is the only one frequently met with : all the others 
 may be considered exceptional. 
 
 C. Diseases, and fevers in particular, occasionally run an inter- 
 mediate course between the continued and intermittent types; this 
 is called the re r inittent type (remittens). Like the intermittent, it 
 presents paroxysms of rigor, heat and sweating ; and like the con- 
 tinued type, certain symptoms which persist uninterruptedly 
 throughout the disease. Such is the exact definition given by 
 Pinelof the term remittent ; for, before his time, physicians con- 
 founded under this title, continued fever with exacerbations and 
 remittent fevers properly so called. 
 
 The cause of the periodicity of diseases is one of the most ob- 
 scure points in general pathology. We consider it quite natural 
 
PROGRESS OF DISEASES. 233 
 
 that phlogosis, degeneration, or any other organic alteration, should 
 produce phenomena which continue without interruption, as does 
 their determining cause. But it is quite otherwise with diseases 
 which disappear and return at intervals, particularly if their re- 
 turn be regular. If we suppose the existence of a material lesion, 
 how does it happen that its action is only transient ? If functional 
 derangement, unaccompanied by organic lesion, be assumed, we 
 admit an effect without a cause. Many physicians have endeav- 
 ored to explain a phenomenon whose conception even, presents 
 such difficulty. The majority have concluded that the productive 
 cause of the intermittent or periodical type ought to cease, at any 
 rate, partially, by the very effect of the paroxysm ; but that this 
 cause, engendered within, or introduced into the system, confined 
 to one point or disseminated through the whole body, was after- 
 ward reproduced with more or less promptitude, so as to excite a 
 fresh paroxysm. The cause has, by some, been attributed to cer- 
 tain fluids of the economy, as the mucus, the bile or the blood ; 
 by others, to the nervous system ; by others still, to fermentation 
 or remarkable disturbance, or to obstruction of the circulation in 
 any part of the body, the vena porta, for instance ; by another 
 class, it has been assigned to the sensitive principle; and lastly, 
 some ascribe it to irritation or intermittent phlegmasia. 
 
 These and all other explanations are pure hypotheses, unsup- 
 ported by sound reasons, and the majority of which are in opposition 
 to facts. The periodicity of diseases is well known, but inexplica- 
 ble. We recognise it, moreover, in a multitude of phenomena both 
 out of the system and within it, and in no way can it be explained. 
 The ebb and flow of the sea, the sleep of vegetables and animals, 
 the regularity of the menstrual and hsemorrhoidal discharges, are 
 each phenomena whose periodicity is as difficult of explanation as 
 that of diseases. This, then, should rather be attributed to the 
 weakness of human understanding than to the imperfection of the 
 science. 
 
 $ II. Diseases have been divided by authors into acute and 
 chronic, chiefly from their duration. We think, however, that 
 there is a certain number which are acute in their course, although 
 by their duration they belong to the chronic diseases ; as also there 
 are others, chronic in their course, but acute in duration. A dis- 
 ease is acute in its progress when the development, succession, and 
 intensity of its characteristic symptoms announce an affection 
 necessarily of short duration; on the contrary, when the symptoms 
 appear, increase and succeed one another slowly, its course is 
 essentially chronic. A typhoid fever which passes the fortieth and 
 even the sixtieth day, is still an acute disease; a tubercular affec- 
 tion is a chronic disease, although it prove fatal in a shorter time. 
 
 $ III. All authors have divided disease into a certain number of 
 periods * this is the name applied to each of its successive phases. 
 
 * HtQtudog, circuit} otfoj, path j 7it(u, around. 
 
 20* 
 
234 PROGRESS OF DISEASES. 
 
 The number of periods in disease has not been determined ; the 
 majority of authors recognise four or five ; others have enumerated 
 even eight in certain affections. With M. L. Beauvais, we shall 
 admit three only, each distinguished by an important and last- 
 ing condition, as the increase, persistence and diminution of the 
 symptoms, and we shall name them, according to universal usage, 
 period of increase or progress, static, and declining periods. The 
 invasion of the disease, being only its commencement, should not 
 be considered as a period ; if it be, the moment of its cessation 
 should be made one also. 
 
 A. The first period, that of increase, progress (incrementum), 
 extends from the invasion to the highest degree of intensity mani- 
 fested by the symptoms. 
 
 The invasion OY first appearance (invasio, initiummorbi), is the 
 moment at which the disease commences. It is never, or very 
 rarely, appreciable in chronic affections, and generally is recognised 
 with certainty in acute diseases alone; and even in them, is fre- 
 quently so indistinct that it is difficult, or even impossible, to sepa- 
 rate it from the time immediately preceding or following. This is 
 the case whenever the intensity of the precursory phenomena in- 
 creases gradually, so as to lead the system by degrees from a state 
 of health to disease ; or when an affection becomes manifest under 
 certain natural conditions which have materially modified the 
 functions, as for example, after parturition. Sometimes, it is true, 
 rigor, syncope or some other remarkable phenomenon supervenes 
 at such a time, which may be considered indicative of commencing 
 disease ; but uncertainty often exists. 
 
 The invasion of acute diseases, and especially those of a grave 
 nature, is usually announced by a chill, of variable duration and 
 severity ; this is succeeded by heat, and alternates with it tor an in- 
 definite period manifesting itself at one time suddenly, in persons 
 previously healthy, at another, after several days of indisposition ; 
 in most cases the patient is obliged to take his bed. 
 
 Invasion is accompanied by certain other phenomena ; such are, 
 a remarkable alteration of the countenance, tremor, convulsions, 
 syncope, fixed pain in a particular organ, delirium, retching, vo- 
 miting, dyspnoea, accelerated pulse, haemorrhage, etc. 
 
 The invasion of most diseases may happen at any hour of day 
 or night ; there are some which commence more particularly at 
 certain hours. For example, paroxysms of asthma occur most 
 frequently in the night ; those of intermittent fever, of the quoti- 
 dian type, in the morning; those of the tertian type, towards 
 noon ; of the quartan, in the latter part of the day ; of symptom- 
 atic intermittent fever, in the evening. This fact explains the ob- 
 servation of many physicians, that intermittent fevers, whose 
 paroxysms recur constantly at evening, usually resist the curative 
 action of quinine ; this remedy not acting in full force, except in 
 cases of essential intermittents. 
 
 The phenomena which announce the invasion of a disease are 
 
PROGRESS OF DISEASES. 235 
 
 occasionally characteristic of it ; they then persist through its sub- 
 sequent stages ; but, most frequently, they cease from the first day, 
 (as the chill which is common to all the acute affections,) and are 
 replaced by others. 
 
 The first period assumes various forms in different diseases. In 
 those of an acute nature, the functional disturbance becomes daily 
 more marked during the period of increase ; the color of the skin 
 is more decided ; the sensations and intellectual functions are 
 sometimes deranged, the thirst is increased, digestion becomes 
 completely depraved, the tongue is more or less coated, the pulse 
 more frequent, the heat of the body more elevated and nearly all 
 the evacuations are diminished or suspended. In chronic diseases, 
 this period is distinguished by the gradual development of the 
 principal symptoms. Its duration may be very short in some 
 acute diseases ; it is usually of some months' continuance in chronic 
 affections. 
 
 B. The second or static period (violence, status, a*^), is distin- 
 guished by the permanent intensity of the symptoms, and, occa- 
 sionally, by the appearance of new phenomena of greater or less 
 gravity. It commences when the aggravation of the symptoms 
 ceases, and terminates when their intensity diminishes, or when 
 the disease approaches a fatal termination. Its duration in acute 
 affections is usually shorter than that of the first period, in certain 
 cases, however, it is longer. 
 
 C. The third period, that of decline (decrementum), or termina- 
 tion, we now merely mention, intending to devote an entire chapter 
 to its consideration. 
 
 These three periods do not exist in every acute or chronic dis- 
 ease ; in certain fevers, the symptoms present, from the commence- 
 ment, their highest degree of intensity ; the period of increase is 
 not observed. In apoplexia fulminans there is but one period; in- 
 deed, it is often instantaneous. The same is true of some chronic 
 affections ; paralysis of any sense, deafness or amaurosis, for 
 instance, is sometimes, from the moment of its occurrence, as com- 
 plete as it will ever be in the lifetime of the patient; neither 
 increase nor decline is observed. In some inevitably fatal chronic 
 diseases, the symptoms gradually increase in severity from the 
 commencement to the termination ; there is, as it were, continual 
 aggravation : the division into periods is not applicable to these 
 cases ; in cancer of the stomach, for example, there are many de- 
 grees, biit properly speaking, no periods. 
 
 There are some affections, on the contrary, in which the three 
 periods are very manifest ; typhoid fever is an example, the exter- 
 nal appearance being usually sufficient for the diagnosis of the 
 disease and the appreciation of its period. 
 
 In diseases whose course is intermittent, each access presents a 
 succession of phenomena, somewhat analogous to the three periods 
 of an acute affection. Each of the component parts of the access, 
 
236 PROGRESS OF DISEASES. 
 
 viz., the chill, the flush and the sweating, is known by the name 
 stage (stadium). The chill has been considered as the period of 
 increase, the hot stage has been compared to the static period, and 
 the sweating stage to the termination. Independently of the three 
 stages presented by each paroxysm, the three periods of continued 
 disease may occasionally be distinguished in the aggregate of the 
 paroxysms. Thus, in the first week, the paroxysms progressively 
 acquire a higher degree of intensity ; then, for about the same 
 space of time, they maintain a uniform intensity ; a regular dimi- 
 nution, and finally, a spontaneous termination ensue. But in most 
 cases, after a few recurrences of the paroxysm, we arrest the pro- 
 gress of the disease, and consequently, can no longer observe these 
 modifications. 
 
 These periods are not observed exclusively in affections pro- 
 duced by internal causes, they are also evident in those resulting 
 from external causes. In superficial wounds we first observe the 
 divided parts becoming red, gradually swelling more and more, 
 and discharging a sero-sanguinolent fluid : when the inflammation 
 has become more intense, suppuration is established, and after some 
 days the phlogosis diminishes, while at the same time the edges of 
 the wound adhere, and the cicatrix is formed. In this series of 
 phenomena we clearly distinguish an incremental, a static, and a 
 declining, period ; something analogous takes place in fracture, 
 except that no purulent discharge exists, and that phosphate of 
 lime is deposited in the tissue, originally cellular, afterwards car- 
 tilaginous, which unites the fragments. 
 
 In terminating this paragraph, it should be remarked, that, 
 however distinct the periods may be, the transition from one to the 
 other is almost always gradual and imperceptible, and that it is 
 impossible to distinguish between the termination of one and the 
 commencement of another. 
 
 $ IV. The circumstances capable of modifying the progress of 
 diseases are very numerous. Youth and adult age, sanguineous 
 or bilious temperament, and a strong constitution, hasten that pro- 
 gress and awaken a more lively reaction. The diurnal revolutions 
 seem likewise to exert a very decided influence upon the course of 
 diseases. Some of the ancient physicians thought that the four 
 parts of the day might be compared to the four seasons of the year, 
 viz : the morning to spring, mid-day to summer, the evening to 
 autumn, the night to winter, and that each had an influence upon 
 the exercise of the functions in health and disease, analogous to 
 that of the seasons. Testa, who published a valuable work on 
 the periods, inclined to this opinion, which should be admitted 
 only with certain restrictions. Before sunrise, sweating is fre- 
 quently observed, in both acute and chronic affections ; at this pe- 
 riod, absorption appears to be somewhat increased ; redema, when 
 inconsiderable, disappears, and diminishes when excessive. It is 
 at this time, as we have previously said, that we should employ 
 absorbent remedies. Cruickshank assures us that venereal affec- 
 
PROGRESS OF DISEASES. 237 
 
 tions which resisted frictions em-ployed in the evening or night, 
 were cured by them when made in the morning. At sunrise, the 
 signs of plethora are more decided than at any other time ; the 
 body is then more unwieldy and the .head heavier : in some 
 persons the fingers are so swollen that they can with difficulty be 
 flexed ; the degree of heat is often uncomfortable ; at this time, 
 also, the symptoms of cutaneous inflammation are usually more 
 intense. The middle of the day induces a slight paroxysm in cer- 
 tain chronic affections, particularly in pulmonary phthisis, and 
 some periodical pains return constantly at this hour. The evening 
 is the most common season for exacerbations or paroxysms in most 
 acute or chronic diseases ; they persist and increase in intensity 
 during the night, which usually has an unfavorable influence 
 upon affections of a grave nature. Patients at this period, being 
 fatigued by the impressions received during the day, experience 
 more uneasiness; their pains, if any exist, become more severe; 
 their attention is not easily arrested, and their memory is less sure 
 than in the morning. It is almost always during the night that 
 disorder of the intellectual functions begins to manifest itself; in 
 some patients it reappears every evening, and ceases wholly during 
 the day ; in others, delirium, which is calm through the day, be- 
 comes furious in the night. During the night the countenance is 
 usually more animated, the thirst increased, the tongue less moist 
 or more parched, the respiration more accelerated, the pulse more 
 frequent, the heat of the skin more elevated, and the urine of a 
 deeper color. 
 
 Although the night may have an unfavorable influence upon the 
 majority of diseases, there are many in which this is far more de- 
 cided than in others ; among these are affections of the heart and 
 lungs (particularly emphysema, and pulmonary tubercle), rheu- 
 matic pains, etc. There are, indeed, certain affections, whose 
 symptoms wholly disappear during the day, and manifest them- 
 selves only in the night; such are certain syphilitic pains and 
 many eruptive diseases, as epinyctis. We have also seen a tnor- 
 billlform eruption reappear every night for nearly a month, in an 
 individual who retained no trace of it by day. 
 
 Some physicians have endeavored to discover the causes produc- 
 tive of these regular variations in the progress of diseases, which 
 correspond to the diurnal revolutions. M. Bally* asserts that 
 light, or its absence, different degrees of temperature, and the 
 unequal quantity of moisture diffused in the atmosphere, are the 
 principal circumstances which determine the changes observed by 
 day or night in the course of diseases. "Those manifesting 
 themselves by exaltation of the vital forces, become aggravated in 
 the daytime, those announced by prostration of the same forces, in 
 the evening and night." This writer adds, in support of his opin- 
 ion, that of eight cases of adynamic fever, seven terminated fatally 
 between sunset and sunrise. If his opinion be correct as regards 
 
 * De rinfluence de la Nuit, etc. Theses, 1807, No. 6. 
 
238 PROGRESS OF DISEASES. 
 
 affections of an adynamic type, it is far from being true in those of 
 an opposite nature ; daily experience will not allow us to admit 
 that the paroxysms of inflammatory fevers, and of the phlegma- 
 sise, take place in the daytime ; they are almost without excep- 
 tion observed in the night. Before concluding our remarks, in 
 regard to the influence of the latter period upon the progress of 
 diseases, we should draw attention to the fact that it is not always 
 injurious, and that frequently during its course, the gentle and 
 general sweats commence which announce the arrest (detente) of 
 the disease, according to the common expression, and lead us to 
 hope that a favorable termination is at hand. 
 
 The transient variations which occur in the temperature and 
 moisture of the atmosphere, and in the direction of the winds, have 
 but an uncertain influence upon the progress of chronic diseases, 
 and seem to exert none whatever upon that of acute affections. 
 A rapid change of temperature, however, especially sudden and 
 severe cold, hastens the termination of chronic diseases which have 
 attained their last stage. This is often observed in hospitals ; 
 when the temperature from having been for a long time mild, sud- 
 denly becomes very cold, the greater number of patients who, for 
 many days, have been struggling with death, will succumb in from 
 twenty-four to thirty hours. In hospitals allotted to old men, the 
 disastrous effect of cold upon the moribund is still more evident ; 
 but the time of the falling leaf, so dreaded by the lower classes, is 
 not generally more fatal to phthisical patients than the other 
 seasons of the year, when sudden changes of temperature occur. 
 
 Many patients, more particularly those laboring under rheumatic 
 and nervous affections, are persuaded that the intensity of their 
 pains augments or diminishes under the influence of certain atmos- 
 pheric conditions : many such persons believe they can accurately 
 foretell the changes about to take place in the atmosphere, by the 
 degree of severity of their pains ; but observation does not usually 
 confirm their assertions. 
 
 If the transitory changes supervening in the atmosphere have 
 but little influence upon the course of diseases, it is far otherwise 
 in regard to the important alterations arising from the succession 
 of the seasons : their influence is well established and cannot be 
 doubted. Thus, during winter, catarrhs and chronic discharges 
 become more severe, pulmonary phthisis advances with greater 
 rapidity, chronic rheumatism is more painful, dropsical effusion 
 increases more rapidly, and oedema of the lower limbs appears in 
 many patients who had never previously presented this symptom. 
 
 The influence of the heavenly bodies upon the course of diseases, 
 is, in our climate at any rate, quite as obscure as their action con- 
 sidered in the light of a morbific cause. The rising of the Pleiades, 
 the Dog-star and Arcturus. the equinoxes and solstices, in no de- 
 gree alarm the modern physician, however respectable in other 
 ways may be the authority which has pointed out the disastrous in- 
 fluence of these periods upon the course of diseases : this opinion, 
 however, had several advocates in the times immediately preceding 
 
PROGRESS OF DISEASES. 239 
 
 our own. Baillou. in the first book of his treatise on Epidemics, re- 
 lates the case of a patient who experienced, during an eclipse of 
 the sun, an attack of syncope, which continued until the reappear- 
 ance of that luminary. Ramazzini states, that in the night of the 
 twenty-first of January (this was during the prevalence of epidemic 
 petechial fever), when there was an eclipse of the moon, the greater 
 part of the patients died, and almost at the very hour when the 
 eclipse took place. " Facta per noctem lunari eclipsi, major pars 
 cegrotantium obiit, ac eadem pene hora qua nimirum luna labora- 
 bat." * Balfour, in Bengal, thought he could perceive that the 
 moon had a physical action upon the progress of various diseases.! 
 Bruce assures us that he has often noticed, in Sennaar, J the in- 
 fluence of this planet upon epileptics ; and the observations of 
 Fontana support this assertion ; but all that is known upon this 
 point would not serve as foundation for a sound opinion. The 
 same may be said in regard to the assertion of certain authors, 
 Daquin in particular, that the moon has a positive and constant 
 action upon the progress of insanity. M. Esquirol, indeed, has 
 also observed that the insane were more excited at the period of 
 full moon, but he convinced himself that this agitation was owing 
 to the penetration of lunar light into their chambers, for complete 
 exclusion of the light was sufficient to prevent the excitement. 
 
 Among those circumstances which influence the course of dis- 
 eases, we should bear in mind the greater or less degree of salubrity 
 of the patient's residence. Other things being equal, diseases are 
 less severe and of shorter duration among isolated individuals ; 
 the contrary is true in crowded hospitals. This difference is read- 
 ily perceived during an epidemic prevailing among all classes; the 
 influence of this cause may be equally well appreciated by a com- 
 parison of the success of operations done upon isolated and -upon 
 hospital patients. 
 
 Climate and the aspect of the dwelling, have also a certain in- 
 fluence upon the course of diseases: we refer to our previous 
 remarks upon climate and situation, considered as morbific causes. 
 
 The action of heat and cold upon the patient's body, the nature 
 and quantity of the food and liquids taken, exercise and rest, very 
 powerful sensations, agitation of mind, the passions, and nostalgia, 
 are all causes capable of modifying the course of diseases, but 
 productive of effects too various for general description. 
 
 In few diseases is the influence of these different agents so re- 
 markable as in those of the heart. In these affections, the gravest 
 symptoms, such as orthopncea and infiltration of the limbs, are 
 often observed to disappear several times before becoming per- 
 manently established : this retrograde course is more particularly 
 noticed among poor hospital patients ; in them, the development of 
 these symptoms is often determined by errors in diet, but particu- 
 larly by fatigue and watching, at a period when the organic lesion 
 
 * Opera. SYDENHAM, t. ii. p. 54. 
 
 f Journ. de Mtdecine, t. Ixvii. 
 
 ^ Voyage aux Sources du Nil. t. viii. p. 4. 
 
240 DURATION OF DISEASES. 
 
 alone would not have produced them. By the simple removal of 
 these causes, by rest and diet, the disease is reduced within its 
 appropriate bounds, and the premature phenomena to which acci- 
 dental circumstances had given rise, diminish and even disappear 
 for a certain time ; the affection returns to the second or even the 
 first stage, after having apparently attained the third. 
 
 There is another condition which has so remarkable an influence 
 upon the course of chronic diseases, that we cannot let it pass 
 unnoticed; we mean the state of pregnancy. It not only causes 
 the cessation of rheumatic and nervous affections, etc., but also 
 seems to suspend the progress of the gravest organic diseases, even 
 at an advanced stage. It is observed that phthisis often remains 
 stationary in pregnant women ; many of them survive the period 
 of parturition and die shortly after. 
 
 Before commencing another subject, we would remark that the 
 various circumstances which modify the course of diseases do not 
 prevent their exhibiting a striking resemblance, not only in times 
 and places nearly related, but also under very dissimilar condi- 
 tions. When we read attentively the descriptions of disease by 
 observing physicians of every age, from Hippocrates to our own 
 times, we must inevitably recognise a great similarity between 
 diseases observed in widely separated ages and countries ; and not- 
 withstanding the difference of climate, manners and other impor- 
 tant circumstances capable of modifying them. Baillou and Sy- 
 denham in particular, have noticed epidemic fevers similar to those 
 described by Hippocrates in the constitution of Thasus, and many 
 descriptions by Aretseus of Cappadocia seem models of the dis- 
 eases observed in our own times. M. 
 
 CHAPTER IX. 
 
 DURATION OF DISEASES. 
 
 THE duration of diseases (morbi mord) is the period of time 
 between their commencement and termination. 
 
 It is not always easy accurately to note the duration of a disease, 
 from the difficulty of distinguishing the moment of invasion, and 
 also the exact period of its termination ; if there be the least uncer- 
 tainty in respect to either of these two periods, the duration can 
 only be approximately determined. 
 
 There is still another circumstance which renders this point in 
 pathology still more obscure ; we refer to the various modes em- 
 ployed by physicians in reckoning the days. Some physicians, 
 with Hippocrates, reckoned the first day as terminating on the 
 night following the attack, at whatever hour it may have been, 
 and the following days as included between sunrise and sunset. 
 
DURATION OF DISEASES. 241 
 
 Others make the medical day to consist of twenty-four hours, each 
 day of the disease commencing and terminating at the hour when 
 the latter first made its appearance. 
 
 Diseases are extremely variable in their duration ; when lasting 
 but one, or, at most, two or three days, they are called ephemeral;* 
 they are termed acute, when their duration is not over forty or 
 sixty days ; chronic, when prolonged beyond that term. Ephe- 
 meral diseases have been divided into ephemeral, properly so called, 
 which last but one day, and prolonged ephemeral, which extend 
 to the second or third day. Acute diseases have been also sub- 
 divided into the very acute (morbi acutissimi), which present grave 
 symptoms, and terminate favorably or unfavorably in three or four 
 days ; tnorbi subacutissimi velperacuti, which continue seven days ; 
 acute diseases, properly so called (morbi acuti), whose duration is 
 fourteen days; and subacute diseases (morbi subacuti), which last 
 from twenty-one to forty days. Chronic diseases have not under- 
 gone similar subdivision. These scholastic distinctions are no 
 longer observed, and in the more modern schools are hardly under- 
 stood, having no practical utility; the division into acute and 
 chronic diseases is the only one generally admitted. 
 
 The duration of diseases varies from a few moments to many 
 years. Some fevers last but one day; the Asiatic cholera has 
 often terminated fatally in the course of a few hours ; there are 
 certain haemorrhages which last but a few minutes, and wounds 
 of the heart or a large artery may cause instant death. Certain 
 rheumatic affections terminate only with the life of the patient. 
 
 There are some diseases whose duration is fixed ; as rubeola, 
 scarlatina and variola discreta, when occurring in healthy individ- 
 uals ; the specific causes which produce them generally determine 
 similar phenomena, succeeding each other in a certain order, and 
 ceasing after a fixed time has elapsed. The duration of simple 
 wounds and fractures, may be approximately calculated before- 
 hand, according to the seat of the injury, age of the patient and 
 some other circumstances. The duration of affections produced 
 by internal causes is more variable ; that of pleurisy may termi- 
 nate in three or four days or be prolonged to thirty, and even 
 beyond, when it passes to the chronic state. 
 
 There are certain circumstances which exert a very marked influ- 
 ence upon the duration of diseases. Many affections continue longer 
 after their second, than after their first, attack. A second ophthalmia 
 commonly lasts longer than when it first appears; the same is often 
 true of blennorrhagia. This rule is by no means without exception, 
 as it is not rare to observe a second peripneumonia, or a second at- 
 tack of rheumatism, shorter than the first; in the successive attacks 
 of erysipelas, this disease diminishes in duration and severity. 
 
 The treatment and complications also exert a remarkable in- 
 fluence, as well upon the duration as the progress of diseases : these 
 two points will be hereafter considered. (J. 
 
 tQos; *7it, in j i^ttga, day. 
 
 21 
 
242 TERMINATION. OF DISEASES. 
 
 CHAPTER X. 
 
 TERMINATION OF DISEASES.* 
 
 ARTICLE FIRST. 
 Different Modes of Termination. (Morlorum eventus.) 
 
 THERE are some affections which continue through life and are 
 not fatal to the patient ; such are certain forms of paralysis and 
 chronic rheumatism. Properly speaking, these affections have no 
 termination ; but it is otherwise with the majority of diseases, 
 which terminate either in the return to health, in death, or in some 
 other disease. 
 
 A. The return to health, or the cure (morbi sanatio), consists in 
 the complete restoration of all the functions. Its accompanying 
 phenomena are exceedingly various, as are the diseases at whose 
 close they are observed. Our inability to enumerate them all at 
 present, compels us to review them generally, passing from the sim- 
 plest to the most complex cases. 
 
 1. Among the diseases confined to one portion of the body, 
 haemorrhages and nervous pains are the most simple in their ter- 
 mination : the flow of blood is gradually or instantaneously arrest- 
 ed, the pain ceases, and the disease is at an end. The case is 
 nearly the same in many other affections characterized by one 
 predominant symptom, as spasmodic vomiting or nyctalopia : the 
 gradual or rapid diminution of such a symptom, is the only phe- 
 nomenon presented by the return to health. In the cure of the 
 phlegmasiae, the changes are more varied and numerous. Inflam- 
 mation of the subcutaneous cellular tissue may serve as an exam- 
 ple ; in some cases, the pain, swelling, redness and heat disappear 
 by degrees, in succession or simultaneously, and the inflamed part 
 gradually regains its previous condition : this is called resolution. 
 In other cases, there is purulent secretion, constituting suppura- 
 tion ; the enveloping tissues become thin, and finally allow the 
 fluid to escape ; in some rare cases, the tumor, at whatever stage 
 of development it may be, not excepting that of evident fluctua- 
 tion, suddenly disappears, leaving no trace of its existence, except 
 flaccidity and wrinkling of the integuments : this is termed reper- 
 cussion (delitescence), and is a favorable mode of termination 
 in inflammations produced by evident external causes, as bums of 
 
 * We shall add some considerations upon critical phenomena and critical days, 
 to the account of the different terminations and principal forms of diseases. 
 
TERMINATION OF DISEASES. 243 
 
 the first degree, and contusions, but dangerous in those arising 
 from internal causes. The phlegmasise occasionally terminate in 
 gangrene, as is observed in furunculus and certain burns ; in the 
 former, a rounded eschar, the core, is discharged with the pus ; in 
 the latter, there is more or less extensive sloughing of the integu- 
 ments ; in both cases, the gangrenous portion is separated from the 
 living parts by the pus effused between the latter and the eschar. 
 Cicatrization gradually ensues, as in wounds with loss of sub- 
 stance. 
 
 2. In general constitutional affections, such as continued fever, 
 pestilential diseases, eruptive fevers, etc., the return to health is 
 rarely sudden : it is in some exceptional cases only, that in the 
 midst of the most violent symptoms, a calm suddenly supervenes, 
 which announces the approaching termination of the disease. The 
 return to health is most frequently progressive, the functions grad- 
 ually regain their healthy action, the countenance reassumes by 
 degrees its natural expression, the evacuations are re-established, 
 the skin becomes moist, the movements are more easily executed, 
 and the patient feels himself improving daily. When the cure 
 occurs by means of successive and distinct ameliorations, the 
 patient experiences in the space of a few hours, (and often after the 
 occurrence of phenomena which had not been previously observed, 
 as perspiration or alvine evacuation,) a relief which apparently 
 indicates incipient convalescence ; but the symptoms, after a degree 
 of mitigation, persist with the same intensity for several days, 
 until a new amelioration occurs : usually, the second amelioration 
 marks the commencement of actual convalescence ; diseases have 
 occasionally been observed to persist beyond this point with 
 slighter symptoms, and to disappear only after a third or fourth 
 effort. 
 
 General affections whose course is periodical, such as intermit- 
 tent fevers, and those diseases known by the term masked fevers, 
 sometimes terminate suddenly ; but more frequently their parox- 
 ysms become irregular and incomplete, and the disease disappears 
 gradually. 
 
 3. At the decline of local diseases which determine general 
 functional derangement, the same phenomena which are mani- 
 fested in local and general diseases are simultaneously observed. 
 On one hand, peculiar changes occur in the affected organ ; on the 
 other, in the functions, whose disturbance was sympathetic. Tn 
 pneumonia, for instance, the pain in the side ceases, the respiration 
 becomes freer, the cough less frequent; the sputa, which were 
 sanguinolent, are simply mucous, that part of the chest which 
 returned a dull sound on percussion, regains its natural resonance, 
 and instead of morbid sounds, we hear the gradually returning 
 vesicular murmur ; at the same time the face loses its flush, the 
 thirst and frequency of pulse diminish, the heat is moderated, the 
 skin is soft to the touch and often moist ; the flow of urine is in- 
 creased, appetite and strength return, etc. Such are the concomi- 
 tant phenomena of recovery in the principal forms of acute disease. 
 
244 TERMINATION OF DISEASES. 
 
 In chronic diseases this termination is almost always progres- 
 sive : the symptoms, after having increased for some time, diminish 
 gradually, so that the transition from disease to a state of health, 
 as well as its converse, is usually insensible : this is observed in 
 discharges and catarrhs of a chronic nature, in old ulcers, scorbu- 
 tus, etc. In certain cases, indeed, we observe chronic diseases come 
 to a sudden termination, as in the disappearance of herpetic eruptions 
 of long standing, the cessation of leucorrhea, the prompt cicatriza- 
 tion of ulcers ; but these rapid cures are very rare in chronic 
 disease, and render us anxious in regard to possible sequelae. 
 
 B. The termination in death takes place also in various ways, 
 both in acute and chronic diseases. In the former, it may some- 
 times occur suddenly, either from rapid sinking of the vital powers, 
 as in abundant haemorrhages, or before exhaustion has reached its 
 extreme point, as observed in certain typhoid fevers and in some 
 cases of confluent variola ; it may also happen by a kind of as- 
 phyxia, or with cerebral symptoms, as convulsions and coma. 
 Death may, at other times, be announced many days previously to 
 its occurrence, by a peculiar alteration of the countenance and an 
 extreme feebleness in the motions and in the voice ; the tongue 
 becomes clammy or dry, deglutition is noisy, difficult or impossi- 
 ble ; respiration frequent, unequal and rattling; the pulse small, 
 weak, intermittent or insensible ; the heat becomes gradually 
 extinct from the extremities towards the trunk of the body; the 
 body exhales a cadaverous odor, and is partially covered with a 
 viscid and cold sweat ; the excretions are involuntary, the sensa- 
 tions extinct; the patient differs only from a dead body by retain- 
 ing the respiratory movements, which take place at intervals, until 
 they cease entirely with life. This state, to which the term 
 agony * has been applied, may last for a few hours only, or be con- 
 tinued for many days, for one, or even several weeks ; its usual 
 duration is from twelve to twenty-four hours. In other cases death 
 is preceded and announced by many successive exacerbations in 
 the symptoms. This exacerbation of the symptoms in each suc- 
 cessive paroxysm, is particularly observed in malignant intermit- 
 tent fevers. 
 
 In chronic diseases, the termination in death is rarely sudden ; 
 sometimes, however, this has been observed in cardiac aneurism, 
 or in that of the larger arterial trunks, also in pulmonary phthisis 
 and scorbutus ; in all these cases death usually takes place by 
 syncope : in chronic pleurisy, when pus is suddenly and profusely 
 poured into the bronchial tubes, rapid death by asphyxia may 
 ensue. But in most cases, death occurs in chronic diseases by 
 progressive exhaustion of the vital energies, the patient being at 
 one time reduced to the last degree of marasmus, at another, swol- 
 len by serous infiltration into the subcutaneous cellular tissue and 
 effusion into the serous cavities. Many such patients retain their 
 
 v, a combat. 
 
TERMINATION OF DISEASES. 245 
 
 intellectual faculties and their appetite to the last ; some sink by 
 degrees, without pain or anxiety as to their fate ; others, in the 
 midst of the most excruciating bodily sufferings and the most 
 frightful despair. The majority present, three or four days before 
 death, a remarkable alteration of the countenance, a state of 
 collapse and a leaden hue, which announce to the physician the 
 approach of death. 
 
 C. Termination in another disease has been termed by the 
 Greek physicians, metaschematismus, * an expression almost bar- 
 barous to our ears. Peculiar denominations have also been pro- 
 posed. according to the actual transformation of the disease into 
 another, or to the mere change of seat or form. In the first case, 
 the change supervening in the kind or form of the disease, is called 
 diadoche (diadoxis)^ in the second, metastasis^ (metastasis), the 
 term metaptosis or metastosis$ has been employed in the former 
 sense by some, in the latter, by others. Metastasis is the only 
 term retained in our language, the others have become obsolete. 
 Every displacement or transformation of disease is now called 
 metastasis ; the epithets favorable or unfavorable are added, ac- 
 cording as the new affection is more or less severe than the former. 
 
 Metastasis takes place frequently in acute, but is more rare in 
 chronic, diseases. Rheumatism often terminates by forsaking its 
 original seat for an internal organ ; the same is the case with 
 haemorrhages : this is metastasis, properly so called, that is, a 
 simple change of seat or form, the disease remaining the same ; 
 while if a haemorrhage or a cutaneous eruption succeed inflamma- 
 tion of the stomach or lungs, the disease which replaces the first 
 is wholly different : this is the diadexis of the ancients. 
 
 Chronic affections are sometimes observed to cease on the ap- 
 pearance of a cutaneous eruption or of continued or intermittent 
 fever. M. Sabatier, in a very interesting thesis upon erysipelas, || 
 has shown by numerous cases collected at the Saint Louis Hospital, 
 that this exanthema is occasionally followed either by definitive 
 cure or by a very favorable change in the course of certain obsti- 
 nate eruptions which resist nearly all curative means, as im- 
 petiginous eczema, sycosis labialis, mentagra, lichen, and even 
 lupus and elephantiasis. 
 
 The transition of the same affection from the chronic to the 
 acute state, and vice versa, has been referred to this mode of ter- 
 mination. But is not this a simple change in the course of a dis- 
 ease, rather than its termination in another ? However this may 
 be, the substitution of the acute for the chronic character in disease, 
 sometimes effects a cure. It is not, indeed, uncommon to see 
 
 zuTiaiioc, transformation or change of form, from a^r t ua, form, and 
 ftrru, signifying a change. 
 
 t //ictcfo//,, succession ; diadixouai, I succeed. 
 t MtTuaTuntc, from utraaaw, to transfer. 
 
 MsTu/iTuxng, change of event; from TTTOW, to happen, and ur, signifying a 
 change. 
 || No. 209, 1831. 
 
 21* 
 
246 TERMINATION OF DISEASES. 
 
 urethral discharges persist for months and even years, resisting 
 every kind of treatment, and finally be wholly cured when the 
 blennorrhea is rendered acute by the influence of some excess or 
 by a new inoculation of the virus. 
 
 Diseases arising from internal or external causes, may terminate 
 either in death or recovery, but the termination in another disease 
 seems peculiar to those produced by internal causes; for the dis- 
 eases which are owing to external causes and exclusively surgical, 
 seem incapable of this mode of termination. 
 
 Such are the three modes of termination presented by diseases. 
 Upon this point all medical observers are agreed ; it is otherwise 
 in regard to understanding and explaining the transition from 
 disease to health. We here enter upon the domain of conjecture, 
 and, from that moment, must expect to encounter the greatest 
 diversity of opinion. 
 
 ARTICLE SECOND. 
 
 Doctrine of Crises. 
 
 $ I. THE term crisis * has not been employed in medical lan- 
 guage in a strictly uniform sense. Hippocrates declares crisis to 
 be present when there is marked increase or diminution of the dis- 
 ease, when it degenerates into another, or when it entirely ceases.f 
 Some authors apply this term only to the favorable or unfavorable 
 changes supervening during the static, or second period of the dis- 
 ease ; others make use of it to express a rapid and favorable 
 change observed in connection with some new evacuation, or other 
 remarkable phenomenon ; others, finally, have given this name to 
 the phenomena accompanying the change, and not to that change 
 itself. The majority of modern physicians understand the term 
 crisis in one of these latter acceptations, which is widely different 
 from that given to it by Hippocrates. 
 
 Several varieties of crisis have been admitted ; as salutary and 
 fatal, regular and irregular, complete and incomplete. The salu- 
 tary are those conducive of recovery ; when prompt and preceded 
 by exacerbation of the symptoms, they are crises properly so 
 named; they have been designated by the term lysis'^ (solutio), 
 when mild and unannounced by previous exacerbation. Regular 
 crises are those ushered in by precursory signs, which occur on 
 certain foreseen days, and are accompanied by critical phenomena ; 
 irregular crises do not present these conditions. Complete crises 
 
 * Est vox hcec, crisis, judicium, ano TOV xQtvioGat, desumpta a for o judicially 
 <juia inter spem vita metumque mortis ancipites tune agntrepidant, veluti rei coram 
 judice; incerti plane, utrum crimine absolcendi sint, an morte damnandi. (Pre- 
 lect. Ant. DEHAEN in Boerhaave. Inst. Path. t. ii. p 5287.) 
 Lib. de Affection. LINDEN, ii. p. 165. 
 ^t'<7i$, solution ; from *t'u>, I dissolve. 
 
TERMINATION OF DISEASES. 247 
 
 are those which decide the termination of the disease, by recovery 
 or death ; the incomplete leave the patient in a doubtful state. 
 
 The real object of discussion has been the existence of critical 
 phenomena, not that of crises. Every one admits changes of 
 favorable or unfavorable nature in disease, and the transformation 
 of one malady into another ; this we have seen to be the definition 
 of the term crisis as used by Hippocrates, but it is otherwise 
 with the accompanying phenomena of crisis; great difference of 
 opinion exists in regard to their frequency and influence upon the 
 termination of diseases. Before examining these two questions, 
 we must enumerate the phenomena themselves, and point out their 
 antecedent and accompanying signs and the circumstances favora- 
 ble to their production. 
 
 A. Critical phenomena may be manifested in various parts. 
 They are most frequently observed upon the mucous surfaces ; 
 next in frequency is the skin, thirdly the glands, afterwards the 
 cellular tissue and serous membranes; some of them may also oc- 
 cur in the nervous system.* 
 
 1. The mucous surfaces present certain critical exhalations and 
 eruptions. 
 
 The critical exhalations from the mucous surfaces are of several 
 varieties ; the natural exhalation may be increased, or may become 
 an accidental sanguineous or aqueous exhalation. The mucous 
 secretion of the nasal fossae, pharynx and bronchial tubes is some- 
 times augmented toward the close of diseases ; mucous stools, and, 
 occasionally, emesis of glairy matters have been observed at such 
 periods ; not unfrequently there is a similar deposit in the urine. 
 Sanguineous exhalations from the mucous surfaces, as epistaxis, 
 hasmorrhoidal flux and metrorrhagia have often been observed 
 under the above conditions, and considered as critical phenomena. 
 But few instances of aqueous exhalation from the mucous surfaces 
 have been recorded; aqueous emesis and catharsis have been 
 mentioned, as being apparently critical of dropsy. 
 
 One species only of critical eruption has been observed upon the 
 mucous surfaces ; this is the apthous eruption which occasionally 
 supervenes in the last stage of acute diseases, especially in children. 
 
 2. The skin likewise presents exhalations and eruptions re- 
 garded as critical. In the latter stage of many acute diseases, 
 pneumonia particularly, a general perspiration supervenes, which 
 is the more remarkable from the fact, that during the first two pe- 
 riods the skin often remains dry ; at other times there is only 
 slight moisture apparent. The eruptions observed upon the skin 
 toward the termination of acute or chronic diseases, are very nu- 
 merous. Erysipelas, furunculus, different species of erythema or 
 herpes are the principal ; the latter is most frequently seen upon. 
 
 * Dr. Copland differs from our author in his enumeration of critical phenomena, 
 in regard to their frequency of seat. He states them to occur, 1st, on the skin ; 
 2dly, in the cellular tissue ; 3clly, in the glands ; 4thly, on the mucous surfaces. 
 (Med. Diet. Art. Crisis ) TRANS. 
 
248 TERMINATION OF DISEASES. 
 
 the lips; pemphigus occasionally appears at the same period; 
 Storc/c* and Morgagni\ have related some very remarkable ex- 
 amples. The abundant purulent exhalation produced by vesica- 
 tion, and critical icterus, have been placed in the same category, 
 although the latter is more appropriately classed elsewhere. 
 
 3. The critical phenomena exhibited by the glandular organs 
 may consist in an increase of secretion, or in tumefaction of the 
 glands themselves. Salivation was noticed by Sydenham as a 
 critical evacuation in certain affections; bilious stools and abun- 
 dant flow of sedimentary urine are quite frequent phenomena at 
 the decline of diseases. The lacteal secretion, as we have pre- 
 viously seen, is critical of milk fever. Tumefaction of the parotids 
 sometimes supervenes on the decline of malignant fevers. Swelling 
 of the conglobate glands of the groin or axilla has been considered 
 as critical by many physicians who have observed and described 
 the plague ; but, in many of these cases, has not a tardily develop- 
 ed symptom been mistaken for a critical phenomenon ? 
 
 4. The same may be remarked of the oedematous swelling of 
 the cellular tissue, mentioned by Sydenham as a critical phenome- 
 non in intermittent fever. J Subcutaneous abscess has also 
 seemed critical of certain diseases. Simple inflammatory swelling 
 of the cellular tissue has been regarded as critical in certain cases, 
 although suppuration might not have taken place ; at the decline 
 of fevers a peculiar tumefaction of the extremities, the face and 
 even of the whole body, without evident signs of inflammation, 
 has been observed. Gangrene of the cellular tissue and integu- 
 ments has been ranked by some authors among the critical phe- 
 nomena of adynamic fevers. 
 
 5. The critical phenomena manifested by the serous membranes 
 are almost always unfavorable. Occasionally there is dropsy, 
 sometimes sanguineous effusion supervening on the decline of 
 another disease. The same is the case with synovial effusion into 
 articular cavities. 
 
 6. Finally, the nervous system has sometimes furnished critical 
 phenomena ; a sharp pain in the course of a nerve, paralysis, or 
 convulsion of a portion of the body, loss of a sense, as hearing, 
 sight or smell, and even disturbance of the intellectual functions 
 have been observed towards the termination of diseases,^ and re- 
 garded as critical. 
 
 B. Of the signs which precede and accompany critical phenom- 
 
 * Annus Medicus,ii, p. 112. " Unicus fuit teger in quo hac materies intra 
 scapulas colligebatur, et fiebat ibi tumor qui magnitudine caput virile excessit ; 
 aperto tumore, novem libra seriflavi viscidi effluxerunt." 
 
 f De Sedibus et Causis. Lib. iv. art. 7. 
 
 | Opera omnia, t. i. p. 60. 
 
 In certain circumstances, violent emotion has arrested the progress of an ob- 
 stinate disease, as an intermittent fever or a convulsive affection. Sleep has also 
 seemed to banish very severe pains which had continued for many hours. But ad- 
 mitting sleep to be a critical phenomenon, it is very certain that strong emotions, 
 disconnected with the disease, cannot be so considered. 
 
TERMINATION OF DISEASES. 249 
 
 en a, there are some which are common to all : there are others 
 peculiar to each. 
 
 The common precursory signs are pain, more or less severe, 
 often, simple pruritus, heat or a sense of weight in the organ about 
 to become the seat of the critical phenomena ; to these may be 
 added a notable increase of the general symptoms of the disease, 
 especially the force and frequency of the pulse. The usual con- 
 comitant signs of critical phenomena are a sensation of amend- 
 ment, more or less decided, and a perceptible diminution in most 
 of the symptoms. 
 
 Critical phenomena are not always announced by peculiar signs ; 
 those which present them most frequently, are the alvine evacua- 
 tions, haemorrhages, the urine and the sweat. 
 
 The signs preceding alvine discharges are borborygtni, colic, 
 distension of the abdomen, eructation and flatulence, a sense of 
 tension in the lumbar region, pains in the thighs and knees, and a 
 somewhat irregular pulse. The evacuation takes place without 
 pain ; it is copious, homogeneous, of a yellow or brownish color, 
 pultaceons and, sometimes, mucous. 
 
 Critical epistaxis is usually announced by redness, with slight 
 tumefaction of the face and eyes; occasionally the redness and 
 swelling are limited to one of the alee nasi, the one corresponding 
 to the nostril whence the blood will flow. A dull pain in the fore- 
 head, at the root of the nose or at the nape of the neck, throbbing 
 of the temporal arteries, tinnitus aurium, deafness, luminous 
 spectra, involuntary tears, and, in certain patients, slight delirium or 
 somnolency, precede epistaxis. A quick, hard pulse and frequent 
 respiration have sometimes announced this phenomenon ; epistaxis 
 should be copious to be termed critical. 
 
 Haemoptysis is preceded by a sensation of heat in the chest, and 
 by embarrassed respiration. 
 
 The signs indicative of haematemesis are praecordial anxiety, 
 eructations, and all the precursory phenomena of vomiting. Hae- 
 matemesis and haemoptysis, as also haernaturia, are almost always 
 unfavorable critical phenomena. 
 
 The haemorrhoidal flux is announced by pain and sense of 
 weight about the sacrum, tenesmus, and sometimes dysuria. The 
 same precursory signs belong to metrorrhagia, with occasional 
 augmentation or diminution in volume of the mammae, hypogas- 
 tric colic, and, for each female individually, the addition of the 
 phenomena usually preceding her menstrual periods ; these vary 
 in different persons. 
 
 Critical diuresis is preceded by a sense of weight in the hypo- 
 chondria, dull tension in the hypogastrium, titillation in the urinary 
 organs, and diminution of cutaneous exhalation ; frequent excretion 
 of urine afterwards takes place ; it is copious, usually high colored 
 when cool, and deposits a cohesive, homogeneous, white or rose 
 colored sediment. The addition of nitric acid sometimes throws 
 down a white, abundant, albuminous precipitate. 
 
 Sweating is frequently preceded by slight chills, diminished 
 
250 TERMINATION OF DISEASES. 
 
 urinary and faecal excretion, and occasionally By flushing of the 
 face; the elevation of the hypochondria and slight pruritus of the 
 cutaneous surface have been mentioned as signs of this phenome- 
 non. We have not enumerated, among these various signs, the 
 alterations in the pulse peculiar to each kind of crisis, because 
 experience has not confirmed the ingenious assertions of Solano 
 and his followers. Physicians have also been as prompt in aban- 
 doning, as they were ready to admit, the doctrine of critical pulse.* 
 
 * Bordeu, the most celebrated historian of critical pulse, divided the pulse into 
 irritative or non-critical, which is contracted, sharp, hard, dry and quick ; and into 
 critical pulse, which is bounding, full, strong, frequent and often unequal. The 
 latter is met with in the third period of diseases, the former in the first. The 
 critical pulse is divided into superior and inferior : the former indicates that the 
 crisis will take place by some organ situated above the diaphragm ; the latter, that 
 it will occur in one below it. 
 
 " The superior pulse is remarkable for a rapid reduplication of the arterial pul- 
 sations : this reduplication, which is its essential constituent, seems originally to 
 be but a single pulsation ; it is liable to intervals from time to time ; these are 
 longer or shorter, more or less frequent, according to the nature or degree of the 
 disease. Dilatation, usually effected in one, occupies two beats, and there are two 
 sensible efforts succeeding a natural contraction of the artery. 
 
 ' The inferior pulse is irregular, that is, its pulsations and intervals are unequal : 
 the intervals are sometimes so considerable as to constitute actual inter mittence, 
 according to the kind of inferior pulse and in proportion as it may be more or less 
 marked. A sort of leaping of the artery is sometimes noticed, which serves in 
 some degree to characterize this species of pulse. 
 
 "The superior and inferior pulse may be simple, compound or complicated : 
 they are simple when they indicate the approach of crisis by a single organ ; com- 
 pound, when the critical effort is about to be manifested in several at once ; compli- 
 cated, when they are united at intervals with the irritative pulse, during which 
 time the critical effort seems interrupted." 
 
 The different characteristics of the simple pulse are as follows : 
 
 SUPERIOR PULSE. 
 
 1. Pectoral. " This is soft, full, dilated ; its pulsations equal ; in each of them 
 a sort of undulation is noticed, that is, the dilatation of the artery takes place in 
 two beats, but with an ease, softness and gentle oscillatory force, which do not 
 allow us to confound this kind of pulse with the others." 
 
 2. Guttural. " Strong, with redoubling of each beat ; less soft and full, often 
 more frequent, than the pectoral, it is apparently intermediate between it and the 
 nasal pulse." 
 
 3. Nasal. "Redoubled beat like the guttural, but fuller and harder; much 
 stronger and quicker." 
 
 INFERIOR PULSE. 
 
 1. Stomachal. " Announces vomiting, and is the least developed of all the 
 varieties of critical pulse : it is less unequal than any of the kinds of inferior pulse ; 
 the artery seems to stiffen and tremble beneath the finger ; it is often somewhat 
 leaping in character ; the pulsations are frequent, and take place at moderately 
 equal intervals." 
 
 2. Intestinal. " More developed than the former; the pulsations quite strong, 
 as if rounded, and above all, unequal, as well in their force as in their interval, 
 which is very easily distinguished, since it happens almost constantly, that after 
 two or three quite equal and elevated pulsations, there occur two or three less de- 
 veloped, less prompt, nearer together, and as if communicating with each other ; 
 from this results a sort of leaping or convulsive effort (' explosion de Vart ere') 
 of the artery, of greater or less regularity : to the irregularities of this pulse very 
 
TERMINATION OF DISEASES. 251 
 
 The other critical phenomena have not, generally speaking, pe- 
 culiar precursory signs ; in those cases only where critical abscess 
 terminates a disease, the urine is sometimes observed to remain 
 clear, and transient chills and partial sweats are noticed at the 
 decline of the disease. * 
 
 At one time a single critical phenomenon only is observed, as 
 copious haemorrhage or profuse sweating ; at another, many are 
 
 remarkable intermittence is often added. It is never so full and developed as the 
 superior pulse : its intermittence does not necessarily follow a definite order, on the 
 contrary, its disorder renders it easy of recognition." 
 
 3. Uterine. " Usually more elevated and more developed than the natural 
 pulse : its pulsations unequal ; the rebounding character is, it is true, less constant, 
 less frequent and decided than in the nasal pulse, but is still sufficiently percepti- 
 ble." 
 
 4. Hepatic. "The most concentrated after the stomachal; neither hard nor 
 resistant ; unequal, its inequality consisting in the succession of three or four 
 unequal pulsations to the same number perfectly equal, and which often appear 
 natural." 
 
 5. Hamorrhoidal. " Unequal, like the other species of inferior pulse ; but the 
 inequality is peculiar to it. The pulsations have little similarity in force, and still 
 less as to interval. When less unequal, they seem almost always to belong to the 
 state of irritation : there are, however, occasionally, some which are fuller, and in 
 which the contracted character is not so perceptible : when more dilated, they are 
 soon followed by a rebounding pulse. Three or four rather concentrated pulsa- 
 tions, sharp, resistant and nearly equal, are succeeded by two or three somewhat 
 dilated, as if rounded and less equal ; the three or four following pulsations are 
 rebounding in their character; but these different pulsations have this in common, 
 that there constantly exists a sort of tremor, greater frequency and depth of con- 
 traction than in the other varieties of inferior pulse: a depth, so to speak, is per- 
 ceived in the pulsations, which, with the tremor, is the most distinguishing char- 
 acteristic between the uterine and haemorrhoidal pulse." 
 
 6. Urinal. " Unequal, with a sort of regularity : there are several pulsations 
 gradually diminishing in force even to the point, we might almost say, of disap- 
 pearing beneath the finger, and recurring in the same order from time to time : 
 the pulsations in the intervals are more developed, sufficiently equal and slightly 
 leaping in their character." 
 
 Sudatory. " When the pulse is full, pliant, developed, and strong; when in 
 addition to these modifications, the pulsations become unequal ; when they in- 
 crease to the last, which is distinguished by a dilatation and at the same time by a 
 more decided suppleness than in the other pulsations, a critical sweat should 
 always be expected." 
 
 * Hippocrates assures us that when the urine continues transparent and crude 
 for a long time, other signs being favorable, we should suspect abscess in some of 
 the organs below the diaphragm. (Praenot, No. 78, Foes). The case of Pithi- 
 on, related by Hippocrates in the third book of his Epidemics, is not the only one 
 confirmatory of this assertion, however extraordinary it may appear. Tissot has 
 given us another in his description of the bilious fever of Lausanne, and we have 
 ourselves seen a similar case in a patient at La Charite. He was affected with 
 peripneumonia, in the latter stage of which the urine remained constantly trans- 
 parent, after all the symptoms had completely disappeared. He seemed convales- 
 cent, when upon the seventeenth day there supervened severe pain in the left leg. 
 On the nineteenth day, this pain became throbbing in its character and remarkable 
 tumefaction and hardness were added. Afterwards, the pain and swelling in- 
 creased and extended to the thigh ; but on the fifth day, the urine, hitherto trans- 
 parent, became turbid and ammoniacal, and the inflammation, which threatened 
 suppuration, terminated promptly in resolution. 
 
252 TERMINATION OF DISEASES. 
 
 met with simultaneously ; in certain cases, all the colatoria seem 
 open at once; the skin is covered with sweat, there is profuse flow 
 of urine, the bowels become relaxed, the mucous secretion of the 
 nasal fossae and of the air passages is increased, etc. At other 
 times, various critical phenomena take place, but successively. 
 
 C. Critical phenomena are not in all circumstances equally evi- 
 dent. They are more distinct and frequent in youth and infancy, 
 in persons of strong constitution, in temperate climates, in elevated 
 situations, and in the spring of the year ; they are more obscure 
 in the diseases of the aged, in feeble constitutions, in moist situa- 
 tions, and under the influence of an active treatment Baglivi 
 asserted that they were less frequent among the inhabitants of 
 cities than among those of the country ; and others have noticed 
 their greater frequency in the higher classes. 
 
 There are certain circumstances favorable to the production of 
 particular critical phenomena. Critical haemorrhage is more fre- 
 quent in the spring and in dry summers, in fertile countries, and 
 in those of sanguine temperament who are subject, when in health, 
 to habitual haemorrhage ; it is chiefly observed from the age of 
 fifteen to thirty-five. Exhalation from the mucous surfaces takes 
 place especially in those of lymphatic temperament, in wet seasons, 
 as autumn and winter, and in low and marshy grounds. Critical 
 diarrho3a has seemed to be more frequent in adults of bilious tem- 
 perament, and in autumn ; critical diuresis, in the lymphatic, has 
 been more often noticed in winter and spring. 
 
 If the reports of some distinguished physicians may be credited, 
 it would seem that each country imparts to disease a peculiar ten- 
 dency to certain critical phenomena. Coray, in his erudite notes 
 to the treatise upon the atmosphere, water, and regions, assures us 
 that critical sweats are more frequent in Italy and in warm coun- 
 tries generally ; that in Holland and England, urinary deposits 
 are quite common ; that in western France the miliary eruption is 
 more frequently critical of diseases, while at Paris critical phe- 
 nomena would be more varied. 
 
 It has been thought that there are some critical phenomena 
 which more especially belong to diseases of certain cavities. M. 
 Voisin, in a thesis read before the Parisian Faculty of Medicine, 
 asserts that thoracic affections terminate most frequently by criti- 
 cal phenomena which are manifested upon the cutaneous surface, 
 while cerebral affections usually terminate by alvine evacuations. 
 This opinion, founded upon a certain number of observations and 
 upon the sympathy which exists between the lungs and the skin, 
 and between the head and the abdomen, demands the attention of 
 medical observers. 
 
 D. The duration of critical phenomena is variable ; the majority 
 persist for twelve or twenty-four hours only ; critical diaphoresis 
 and diuresis usually continue into convalescence, and their un- 
 seasonable suppression often induces recurrence of the disease. 
 
TERMINATION OF DISEASES. 
 
 Haemorrhages sometimes continue for a few minutes only, while 
 certain eruptions appearing at the decline of diseases, have per- 
 sisted, in some cases, for several months. 
 
 If, after the enumeration of these various phenomena, cited by 
 authors as critical, we would determine to what extent they de- 
 serve this appellation, we are compelled first to examine their 
 frequency, and afterwards their influence upon the course of dis- 
 eases. 
 
 There is great difference of opinion among writers upon this sub- 
 ject ; and, first, in regard to the frequency of critical phenomena ; 
 some asserting them to be exceedingly rare ; others, that they are 
 constantly present whenever treatment or a deteriorated constitu- 
 tion do not prevent. Authorities and arguments have been accu- 
 mulated on all sides, in order to solve a question which facts alone 
 can decide ; the numerous essays published upon this subject have 
 only rendered the proposed end more remote. We do not pretend to 
 decide a question so long disputed, but shall confine ourselves to the 
 simple exposition of the result of our observations and reflections. 
 
 We remark, in the first place, that this question does riot seem to 
 us so important as it has been considered, and the neglect into 
 which it has now fallen, confirms, to a certain extent, this opinion. 
 However this may be, the following is our opinion in reference to 
 the frequency of critical phenomena. In very many acute diseases, 
 and especially in inflammations of moderate intensity, we are not 
 in the habit of employing any of those active means which have 
 been regarded as peculiarly suited to prevent the development of 
 critical phenomena, and we are compelled to state that in an im- 
 mense majority of cases, we have seen these diseases cured with- 
 out any signification of their resolution by remarkable phenomena : 
 we cannot consider a slight moisture, more abundant or more 
 loaded urine, or certain alvine evacuations, as critical phenomena ; 
 we regard them as such only when they draw the attention by 
 something unusual in their nature or intensity, something, in short, 
 which distinguishes them from the common symptoms of these 
 diseases. It is, however, in exceptional cases only, that such phe- 
 nomena have been observed, and in a great majority of cases, 
 whatever may have been the treatment, the diseases have seemed 
 to us to terminate favorably or unfavorably without critical phe- 
 nomena of importance. 
 
 In regard to the second question, which refers to the influence 
 exerted by critical phenomena upon the result of diseases, a major- 
 ity of the old writers considered these phenomena the cause of the 
 re-establishment of the functions ; * that the morbific matter, prop- 
 erly elaborated, was excreted with the urine, the sweat, the faeces, 
 etc., and that the disease terminated in this manner by the elimi- 
 nation of its productive and continuing cause. This opinion has 
 
 * Critical phenomena may also correspond lo an exacerbation of symptoms, or 
 even to the death of the patients; but the term is usually employed in a favorable 
 sense. 
 
 22 
 
254 TERMINATION OF DISEASES. 
 
 been, latterly, disputed by very distinguished physicians, who 
 have considered the phenomena occurring at such times as the 
 simple effect of the re-establishment of functions previously dis- 
 turbed or suspended. We shall point out the principal reasons in 
 favor of these two conjectures. 
 
 Those who see in critical phenomena, and especially in critical 
 evacuations, the cause of re-established health, offer many argu- 
 ments in support of their opinion. 1. According to them, the epoch, 
 at which these phenomena appear, proves that they are the actual 
 cause of the return to health, since they often precede amendment, 
 and are, in many cases, announced by peculiar signs, while the 
 disease is yet at its height. 2. The relief which succeeds these 
 critical phenomena, and the reappearance of the disease when 
 they are unseasonably suppressed, favor the above opinion. 3. 
 These phenomena cannot be considered the effect of the re-estab- 
 lishment of the functions, if we remember that they differ very 
 much from those presented during health : the evacuations at the 
 termination of disease are never similar to those of health : the 
 urine contains sediment ; the copious and general sweats exhale a 
 peculiar odor ; the faeces are abundant and pultaceous, etc. 4. 
 Can haemorrhage, abscess, pustules and apthse, supervening on the 
 decline of acute diseases, be considered as the effect of the re-estab- 
 lishment of the functions alone ? Assuredly, there is here some- 
 thing more than the cessation of morbid phenomena. 5. If these 
 various proofs, united, were still insufficient, it cannot be denied 
 that the occurrence of the catamenia, during the fever preceding 
 their first appearance, and the secretion of milk, in that following 
 parturition, are, incontestibly, the causes which arrest the func- 
 tional disturbance. 6. If, in certain cases, the course of nature is 
 obscure, (add the partisans of this doctrine,) such are not the 
 circumstances suitable for its study : when the veil that shrouds 
 it is less impenetrable, the mechanism of its action may be detected. 
 
 Those who have considered the phenomena occurring at the 
 decline of diseases, as the effect, and not the cause of the return 
 to health, found their opinion upon arguments of considerable 
 plausibility : 1. The phenomena termed critical are generally 
 observed in one class of diseases only, viz. the acute diseases : 
 moreover, it most frequently happens that they are wanting, as is 
 proved by the statements of even Hippocrates and Forestus^ which 
 are cited by the partisans of crisis : but if these phenomena were 
 essential to the termination of the disease, would they not be of 
 constant occurrence ? 2. The so called critical phenomena do not 
 always appear previous to or at the same time with the amend- 
 ment ; they often succeed it, and must then be considered the effect, 
 and by no means the cause, of the change which has supervened. 
 The precursory signs which announce these phenomena, besides 
 being of very rare occurrence, do not prove them to be actually 
 critical : delirium, which is but a symptom of disease, has its own 
 precursory signs. 3. The same phenomenon which may be con- 
 sidered unfavorable or valueless in one case, is regarded as favor- 
 
TERMINATION OF DISEASES. 255 
 
 able in another, and this at different periods in the same indi- 
 vidual : the sweats, for example, which take place throughout 
 the disease, are considered unfavorable during the first, indifferent 
 during the second, and useful in the third stage ; is it not more 
 natural to admit that they are, in all the periods, but one of the 
 symptoms of the disease, and not a phenomenon distinct from the 
 others and capable of modifying its course ? 4. Most of the critical 
 evacuations differ very little from the natural : if some exhibit a 
 greater dissimilarity, the difference should doubtless be attributed 
 to the former malady, and to the still existing disturbance of the 
 functions, which only gradually recover their complete regularity. 
 5. In regard to diseases which appear at the instant when others 
 terminate, as unusual hsemorrhage, exanthemata, etc., it may hap- 
 pen, either that the appearance of the one class and the cessation 
 of the other are only a coincidence, or that the first of these phe- 
 nomena may be the cause of the second. Supposing the latter 
 proposition to be true, it would be proved that one disease might 
 suspend another ; but would that prove that the sweats, the sedi- 
 mentary urine, etc., produce a similar effect? 6. If relief follow 
 the appearance of critical evacuations, and if the exacerbation or 
 return of the symptoms be produced by their suppression, they 
 are not thereby proved to be the cause of this change. Suppres- 
 sion of natural evacuations, may excite in a healthy person the 
 development of any disease whatever ; is it surprising that the 
 same cause should produce analogous effects in one who is debili- 
 tated, and cause recurrence of an affection but just terminated 1 
 
 By an impartial examination of all the circumstances which 
 favor these two opposite opinions, we see how difficult it is, if we 
 would not decide hastily, to adopt the one and reject the other. 
 The partisans of critical phenomena will always cite, in support of 
 their doctrine, the lacteal secretion, which, in the newly delivered, 
 seems, indeed, the cause to which the cessation of the antecedent 
 fever must be ascribed; but if we afterwards consider the course 
 of reasoning, and the facts upon which the contrary opinion is 
 founded, its entire rejection will be found difficult. 
 
 The insufficiency of each of these theories might perhaps lead to 
 their reconciliation, although they are in complete opposition. If 
 we observe the various resources of nature, and how rarely she 
 is limited to an exactly uniform course, we might be induced to 
 think that the same phenomena are at one time the effect, and at 
 another, the cause, of the re-establishment of the functions. It is 
 even possible that the phenomena observed at the declining period 
 of diseases may have relations with those preceding and succeed- 
 ing them, which escape our observation. We should not be hasty 
 in drawing general conclusions, still less so, in assigning bounds 
 to the powers of nature. 
 
 Crises, in Hippocratic language, being only remarkable changes, 
 either favorable or unfavorable, supervening in the course of dis- 
 eises, their existence cannot be doubted. 
 
 This is not the case with critical phenomena, whose influence 
 
256 TERMINATION OF DISEASES. 
 
 upon the termination of the disease, is, and always will be, exceed- 
 ingly obscure. 
 
 in some few cases, these phenomena seem to play an active part 
 in the resolution of the disease ; analogy would lead us to suppose 
 that the same might be true in many other cases, where their in- 
 fluence is less evident. 
 
 The greater number of acute diseases, however, terminate with- 
 out critical phenomena, and the phenomena which have been dig- 
 nified with this name, are, for the most part, nothing but new 
 diseases, which have supervened upon the decline of the first, or 
 the tardily developed symptoms of the original disease, or lastly, 
 the simple effect of the re-establishment of previously suspended 
 secretions. 
 
 ARTICLE THIRD. 
 Doctrine of Critical Days. 
 
 Do crises, that is, the favorable or unfavorable alterations su- 
 pervening in the course of diseases, take place exclusively, or par- 
 ticularly, on certain days, or indifferently upon any? Are there, 
 or not, critical days ? 
 
 This doctrinal point has long been a permanent topic for contro- 
 versy in the schools. Its partisans and their opponents have been 
 drawn, as is almost always the case, by the heat of debate, beyond 
 the point which they wished to defend or attack. The former 
 have thus been led to assert that disease could not be terminated 
 except on certain days, while the latter maintain that no disease 
 whatever is restricted in its termination to any particular day. 
 
 The following is the doctrine of Hippocrates in reference to criti- 
 cal days. 
 
 He regarded the latter days of each week, or period of seven 
 days, as most favorable to the changes which occur in disease. 
 These days are the 7th, 14th, 20th, 27th, 34th, and 40th : he 
 termed them critical days. Counting in this manner, the third 
 septenary period commenced upon the last day of the second, that 
 is, the 14th day; the sixth week commenced upon the last day of 
 the fifth, or the 34th ; so that three periods, of seven days each, 
 consisted of only twenty days, and six periods comprised but forty 
 days. Hippocrates, therefore, reckoned twenty-one medical days in 
 twenty solar days. Chesneau, in his Treatise on Fever, proposed 
 a medical day of twenty- three hours ; but this would not be ex- 
 actly that of Hippocrates, which is somewhat shorter. 
 
 Hippocrates placed those days which occur in the middle of the 
 septenary periods, in the second rank, as the 4th, llth, and 17th; 
 he named them indicatory, because, in his opinion, the alterations 
 are rather indicated than declared, upon those days : they are in- 
 dicated either by some new phenomenon, or by diminished or aug- 
 mented intensity of the disease. 
 
TERMINATION OF DISEASES. 257 
 
 The remaining days were divided into intercalary, upon which 
 the crises happen less frequently, and are less complete than upon 
 the critical and indicatory days, and into vacant or non-decretory 
 days, upon which crisis rarely occurs. The days appertaining to 
 each of these four series are as follows : 
 
 Critical days, 7th, 14th, 20th, 27th, 34th, 40th, 60th, etc. 
 Indicatory days, 4th, llth, 17th, 24th, etc. 
 Intercalary days, 3d, 5th, 6th, 9th, etc. 
 Non-decretory days, 2d, 8th, 10th, 12th, 13th, 15th. 
 
 Our idea of the doctrine of Hippocrates upon critical days would 
 be incorrect did we consider it as exclusive. This great physi- 
 cian had the wisdom to offer nothing upon this subject as being of 
 constant occurrence ; he supposed that the course of diseases was 
 modified according to season and epidemics. The observations 
 recorded in his works are not always conformed to his general 
 axioms upon critical days, and this alone would prove that he ad- 
 mitted exceptions. He also thought that crises might be advanced 
 or retarded a day, taking place, for instance, upon the 6th, or even 
 the 8th, which is a non-decretory day, instead of on the seventh. 
 
 Galen and his followers were far from imitating the circum- 
 spection of the father of medicine ; they disfigured his theory by 
 asserting that certain days were constantly favorable, and others 
 always unfavorable ; so that no disease could terminate unfavora- 
 bly upon the 7th day, nor favorably upon the 6th. Upon this 
 subject Galen calls to witness the immortal gods, who, says he, 
 know the truth of my words ! 
 
 It is as easy to refute the exclusive assertions of Galen, as it is 
 difficult to combat the reserved doctrine of Hippocrates. If there 
 be a certain number of affections, which may terminate indifferently 
 at any period, there are many others whose cessation, in a fixed 
 time, is constant, and which have, as has been remarked, a kind 
 of maturity comparable to that of the vegetables; variola and 
 typhus, particularly, are of this class. Of forty-eight cases of grave 
 fever recorded by Forestus, thirty terminated upon critical days, 
 eight upon indicatory days, and ten only upon the vacant or inter- 
 calary days. By collecting all the observations scattered through 
 the works of Hippocrates, Dehaen has shown that in one hundred 
 and sixty-five cases of acute disease, one hundred and sixteen 
 complete or incomplete crises took place upon critical, or indica- 
 tory da*ys, and seventy-seven only, upon other days. Favorable 
 crises have occurred most frequently upon critical or indicatory 
 days, the unfavorable, upon intercalary, or vacant days.^ 
 
 This influence of the critical days is not evident in internal dis- 
 eases alone ; it would seem from the observations of Testa, that it 
 extends, in a certain degree, to surgical affections. According to 
 this author, it is usually upon the"4th, 7th, llth, 14th, or 2Uth 
 days that remarkable alterations take place in wounds, that ab- 
 
 * DEHAEN, Pralect : in Boerhaave. Inst. Path. t. ii. p. 276. 
 
 22* 
 
258 TERMINATION OF DISEASES. 
 
 scess discharges itself, that favorable evacuations, and the acci- 
 dents of disease, particularly convulsions, supervene. 
 
 The opponents of the doctrine of critical days have asserted that 
 it was not observation which led Hippocrates to its establishment, 
 but that he was prejudiced in favor of the numerical system of Py- 
 thagoras. CelsuSj in particular, thus indirectly reproaches Hippo- 
 crates, when he accuses the old physicians of having" referred the 
 periods of disease, and the critical days, to the power of numbers. 
 When we reflect upon the circumspection with which Hippocrates 
 expresses himself in regard to the influence of critical days, we 
 find it difficult to reconcile language so reserved with such a pre- 
 judice as has been mentioned. If we compare the numerical doc- 
 trine of Pythagoras with that of the critical days of Hippocrates, 
 we shall be still more convinced that the latter was not blinded by 
 Pytha gorism. The attentive perusal of the writings of Hippocrates 
 does not allow us to suppose that he attached so much importance 
 to numbers in general, and to unequal numbers in particular, as 
 has been generally believed. The doctrine of critical days, as pre- 
 sented in his authenticated works, is so different from that con- 
 tained in the books incorrectly attributed to him, that it becomes 
 concurrent proof in showing the slight foundation that exists for 
 the distinction which has been made. 
 
 We shall not go so far as to assert that the researches of Hippo- 
 crates upon critical days are wholly foreign to the system of 
 Pythagoras ; but it is another thing that this system suggested to 
 Hippocrates the idea of critical days, or that this physician was 
 led by that system to observe them ; if, therefore, it be proved that 
 the numerical doctrine, and that of critical days, although to a cer- 
 tain extent analogous, differ in many respects; if, as would be 
 easy to show, they are, in many points, in complete opposition, it 
 cannot be admitted that the doctrine of critical days is only the 
 application of the system of Pythagoras to the course of diseases, 
 and we are forced to the conclusion that Hippocrates relied mainly 
 upon his own observations in announcing a doctrine, the idea of 
 which might have been suggested to him by the numerical system. 
 
 Most of the discussions which have arisen concerning critical 
 days, might have been avoided if the point in debate had been 
 better understood, and each disputant had clearly expressed to what 
 extent he wished to question or defend this opinion. Almost all 
 these partisans willingly agreed that diseases did not undergo re- 
 solution in every case, without exception, upon critical, or fhdica- 
 tory days, and, very probably, the majority of their opponents 
 would have admitted that there are certain days upon which the 
 changes in diseases are somewhat more frequent ; from that mo- 
 ment the question would no longer have turned upon the relative 
 frequency, and the observations subsequently made, with the in- 
 tention of elucidating this latter point, would have had at least the 
 advantage of enriching the annals of science, even if they left this 
 question undecided ; for it is peculiar to exact observations, that, 
 even when they fail to attain the observer's object, they remain 
 
CONVALESCENCE. 259 
 
 forever, useful monuments for consultation, and suitable aids in the 
 solution of the questions daily arising by reason of the progress of 
 medicine. 
 
 Before terminating this article, we would remark that the doc- 
 trine of critical phenomena, and that of critical days, are, to a 
 certain extent, independent, and that one may be well founded, 
 and the other not. 
 
 In conclusion, we would add, that the doctrine of critical days, 
 like that of critical phenomena, does not possess the importance 
 which has been attributed to it ; that the difficulty of fixing the 
 days of the invasion and termination of diseases, renders it inap- 
 plicable in many cases, and that it allows both the adherents and 
 antagonists of this theory to interpret the same facts to their ad- 
 vantage. M. 
 
 CHAPTER XL 
 
 CONVALESCENCE. 
 
 CONVALESCENCE (convalescentia) is an intermediate state between 
 disease, which no longer exists, and health, still unrestored : it 
 commences when the characteristic symptoms of the disease have 
 disappeared, and terminates at the period when that free and 
 regular functional action, constituting health, is fully re-established. 
 
 The term convalescence consequently supposes a certain degree 
 of gravity in the antecedent disease. After simple indisposition, 
 or the cure of certain local affections, there is no convalescence. 
 
 Convalescence has been divided into the real and the fallacious : 
 this division cannot be admitted. If disease persist after a marked 
 remission, the individual is yet ill ; if it have ceased, he is conva- 
 lescent. Convalescence may be uncertain, but is never fallacious. 
 
 The phenomena of convalescence necessarily vary, like those of 
 the antecedent disease. They have, however, certain points in 
 common, both in acute and chronic affections. 
 
 In the latter, the slowness with which the re-establishment of 
 the functions takes place, constitutes the principal character of 
 convfcescence : the countenance long retains the impression of 
 disease ; the healthy standard, as regards flesh and strength, is not 
 regained for several months; the appetite languishes for a long 
 time, the stomach and intestines are inactive. An entire year 
 often elapses before complete recovery is attained ; and in certain 
 persons, especially those of advanced age, the system experiences, 
 for an indefinite period, the effects of the powerful shock it has 
 received. 
 
 The phenomena which accompany convalescence from acute 
 disease, are far more numerous and remarkable. One of the first 
 
260 CONVALESCENCE. 
 
 effects of the cessation of disease is a rapid emaciation of the 
 whole body, particularly of the face, which becomes paler. This 
 emaciation and pallor seem especially connected with the cessation 
 of the febrile action, and with the diminution of heat ; for even in 
 the living body, heat determines an increase of volume in its con- 
 stituent parts, an actual rarefaction of the solids and fluids ; the 
 re-establishment of the secretions during the third period, has also 
 a certain influence in diminishing the volume of the body. At the 
 same time that the convalescent experiences relief from the cessa- 
 tion of his pain or uneasiness, his loss of strength becomes more 
 evident : it is with tottering steps and great effort that he first 
 attempts to walk ; his voice remains for some time feeble, and 
 regains by degrees only, its natural tone. This prostration extends 
 likewise to the intellectual faculties: imagination, memory and 
 judgment, it is true, are freely exercised by the majority of indi- 
 viduals ; but violent mental exercise induces instant fatigue, head- 
 ache or other morbid phenomena. It is also observed that the 
 convalescent state is accompanied by remarkable increase of the 
 nervous susceptibility ; convalescents, although inclined to agree- 
 able thoughts, are impatient and irascible, and physical and moral 
 impressions often cause them a shock out of proportion to the 
 determining cause and the usual impressibility of the patients. 
 
 The regular action of the digestive functions is but gradually 
 resumed ; the tongue continues slightly coated, appetite does not 
 always return promptly ; wine often has a bitter taste, and bread 
 is tasteless ; thirst diminishes or ceases ; in the majority of cases, 
 appetite returns more quickly than the powers of digestion, and ; 
 this is the cause of the attacks of indigestion so frequent among 
 the convalescent : some persons, however, eat, and digest with 
 ease, a considerable amount of food, from the first day of conva- 
 lescence from grave disease. We have observed two convalescents 
 from typhus fever take, without injury and at one meal, upon the 
 very day of the cessation of the disease, more than half a pound 
 of solid food. Hildenbrand has made analogous observations : he 
 relates that the appetite often amounts to actual voracity. * Cos- 
 tiveness is usually noticed during convalescence from acute disease ; 
 sometimes, on the contrary, there is diarrhoea. Respiration is easy 
 while the person is at rest, but exercise and conversation cause 
 dyspnoBa. The pulse often remains frequent for many days ; but 
 if all the other signs are favorable, this frequency need not alarm 
 us ; it should not deter the physician from allowing the con^les- 
 cent the food they request. In certain persons the pulse becomes 
 slower than in the healthy state, owing, doubtless, to the rest and 
 long continued diet required by the disease : there may be but 
 fifty, or even fewer pulsations in a minute. Most convalescents 
 experience palpitations, even from the slightest causes, as walking, 
 or from the effect of a lively sensation or emotion ; these are, how- 
 ever, by no means alarming; in the anaemic, a bellows' sound is 
 
 * Typh. Contag. Trad, de Gasc. p. 86. 
 
CONVALESCENCE. 261 
 
 usually heard in the heart and large arteries : in almost all cases 
 the lower limbs swell readily, when the upright position is long 
 maintained, and in the evening slight oedema is perceived around 
 the ankles. Convalescents are habitually cold, even in the warm 
 season, either because their natural heat is diminished, or because 
 a prolonged continuance in their apartments, and in bed, has ren- 
 dered them more susceptible to external cold. In very many, the 
 cutaneous transpiration is abundant during sleep, and the secretion 
 of urine is also increased. The grayish color of the faeces, often 
 noticed, and the infrequency of their discharge, lead us to suppose 
 that the biliary secretion is diminished at the commencement of 
 convalescence. 
 
 One of the most remarkable phenomena of convalescence, is the 
 excitement of the generative organs, causing strong venereal desire, 
 lascivious dreams, and nocturnal pollutions. Many authors relate 
 that old men who had not had any ejaculation for years, have 
 experienced it during convalescence. The menstrual discharge 
 frequently does not recur for many months after the cessation of 
 the disease. 
 
 To the above phenomena, we shall add the desquamation of the 
 cuticle and the loss of the hair, which occur in many individuals 
 at a very advanced stage of convalescence. These phenomena 
 are often observed after grave diseases, and especially after those 
 accompanied by an eruption upon the skin, even if obscure, as in 
 typhoid fever. The hair, when renewed, has not its original color 
 or form, and from this arises its peculiar appearance in convales- 
 cents from severe disease. 
 
 To finish the picture of convalescence, we should mention the 
 feeling of comfort, which is more and more lively in proportion to 
 the completeness of the restoration, and those new delights tasted 
 by the convalescent in the simple performance of the most ordinary 
 acts of life ; delights unknown to one who has never been ill. " No 
 one," said Hildenbrand, " has experienced pleasure in perfection, 
 if he has not felt that which arises during convalescence ..." 
 Indeed, it is only when we have been deprived of health, as of any 
 other enjoyment, that we can really appreciate it. 
 
 The duration of convalescence is often uncertain, because the 
 epoch of its commencement and termination are not well defined. 
 It can hardly ever be accurately determined; its proximate duration, 
 only, can be known. 
 
 Ma% conditions, moreover, may prolong or abridge convales- 
 cence. The age and constitution of the individual, the nature and 
 duration of the affection, the treatment, dwelling, season and reg- 
 imen, are those most influential in determining the time which will 
 elapse between the termination of the disease, and the complete re- 
 covery of health. Other things being equal, convalescence is shorter 
 in infancy and youth ; it is longer in persons habitually feeble and 
 indisposed ; in damp situations, in those where the houses are 
 below the level of the ground, and in hospitals, than in opposite 
 circumstances. The ingestion of unwholesome food, too rigorous 
 
262 CONSECUTIVE PHENOMENA. 
 
 diet, or the opposite extreme, prolong the period of convalescence. 
 It has likewise been observed to be shorter in spring than in 
 autumn and winter. Finally, it is of very constant occurrence, 
 that it is generally shorter after inflammatory diseases, than after 
 those accompanied by great prostration. Excessive evacuations, 
 (especially the sanguineous,) either spontaneous or artificial, occur- 
 ring in the course of a disease, prolong convalescence. 
 
 When we attentively observe the changes which supervene dur- 
 ing convalescence, we generally remark a daily increase in the 
 regularity of action and freedom of the various functions ; but we 
 notice that the recovery does not take place with like uniformity 
 and promptitude in the different organs. Not only are those which 
 were primarily and principally affected generally the last to 
 recover their energy, but among those secondarily affected, a 
 certain number do not regain their normal state for some time 
 after the others. Convalescence is a complex phenomenon ; it is 
 composed of the partial re-establishment of each of our organs : it 
 may be complete in one patient, while it has hardly commenced in 
 another. 
 
 Established convalescence does not always lead to an immedi- 
 ate and complete recovery of health : it may be impeded in its 
 course by certain phenomena which are not of sufficient severity 
 to constitute a morbid condition ; it may be interrupted by the 
 recurrence of the disease which preceded it. These two points in 
 the history of disease will be examined in the two following chap- 
 ters. M. 
 
 CHAPTER XII. 
 
 CONSECUTIVE PHENOMENA. 
 
 BY the words consecutive phenomena, are denoted those various 
 disturbances of the functions which continue, or make their first 
 appearance, after the natural termination of diseases. They are 
 sometimes confounded with the phenomena of a prolonged conva- 
 lescence, but, in general, are widely different, not only in degree, 
 but because, for the most part, they affect a single functiorr^only, 
 while convalescence is distinguished by a general debility affecting 
 alike all the organs of the economy. 
 
 One of the most familiar examples of a consecutive phenome- 
 non, is the yellow color of the integuments which sometimes con- 
 tinues after the causes, which have produced any obstruction to the 
 secretion or excretion of bile, have ceased to act, as is apparent 
 from the entire re-establishment of the digestive functions, the 
 normal color of the urine and fasces, and the perfect regularity of 
 all the functions ; the icterus, in these cases, is no longer a symp- 
 
CONSECUTIVE PHENOMENA. 263 
 
 torn, since 'there is no disease. The impregnation of the integu- 
 ments by the coloring matter of the bile, is the persistent effect of 
 a morbid condition which has ceased to exist ; it is not the sign 
 of a present disease, but only the consequence of a disease already 
 terminated ; and this icterus, which, at the time of its first appear- 
 ance, was included among the symptoms, properly so called, is now 
 but a consecutive phenomenon. 
 
 Of these consecutive phenomena, some are contemporaneous 
 with the disease, as for example, pain in the side in cases of pneu- 
 monia ; others appear a certain number of days after the com- 
 mencement, but a considerable time before the termination, of the 
 disease. An instance of the latter, is the yellow color of the skin, 
 which shows itself after seven or eight paroxysms of intermittent 
 fevers, and which continues for a greater or less time after conva- 
 lescence. There are others which make their appearance when 
 the disease begins to abate, and on this account have been consid- 
 ered by many physicians as critical phenomena ; and, finally, there 
 is still another class of these phenomena which are only known to 
 exist after complete recovery, as the oedema which follows a great 
 number of diseases. 
 
 It is apparent from this brief classification, that the consecutive 
 phenomena of diseases are very numerous and of various descrip- 
 tions ; we only propose, however, in the following pages, to give an 
 enumeration of the principal ones that come under our observation. 
 
 Many persons experience, after sickness, a remarkable dimi- 
 nution or increase in the size of the body. In the first case, 
 instead of recovering their natural embonpoint, they continue to 
 lose flesh, in the same manner as during sickness ; in the latter, of 
 which Tissot saw many examples, they discover an alarming ten- 
 dency to obesity. In other cases of convalescence, the patient is 
 left with a debility which affects the movements of the whole body, 
 or particular parts of it, and sometimes with a trembling, more or 
 less general. Hoarseness of the voice continues after some cases 
 of angina and certain nervous affections. Pains are very common 
 consecutive phenomena after herpes zoster and other phlegmasiae. 
 The organs of sense, particularly those of sight and hearing, re- 
 main oftentimes enfeebled after the other functions are completely 
 re-established. Delirium was observed by Hippocrates, and Piquer 
 saw two examples of it. We have also ourself observed it. Entire 
 sleeplessness is also a common consecutive phenomenon. Tissot 
 thinks* that this may be owing, in some cases, to the loss of habit. 
 Sometimes we see various disorders of the digestive functions, 
 such as loss of appetite, weakness of the stomachic digestion, and 
 constipation so obstinate as to resist the most energetic treatment. 
 Cough, hiccup, and frequency of the pulse, sometimes remain after 
 the other functions have recovered their natural exercise. Exces- 
 sive perspiration and abundant flow of the urine, are two phenom- 
 ena that often appear after acute diseases, and one or the other 
 almost invariably. Sometimes they occur alternately until the 
 health is completely re-established. Their suppression is liable to 
 
264 RELAPSE AND RECURRENCE. 
 
 be followed by an increased exhalation in the cellular tissue, and 
 the supervention of anasarca. 
 
 To the consecutive phenomena above enumerated, may be added, 
 abscesses, gangrene and hectic fever resembling phthisis. These, 
 however, are rather diseases, than simple consecutive phenomena. 
 
 Consecutive phenomena may increase or diminish in intensity, 
 or remain stationary. They are various, also, in as far as they 
 possess sometimes a continuous and sometimes a periodic charac- 
 ter. The pains which follow herpes zoster, the dyspnoea which 
 follows pneumonia, are continuous like those affections. On the 
 other hand, the phenomena which remain or make their appear- 
 ance after periodical diseases, have the same periodical character. 
 Thus after intermittent fevers, we observe phenomena differing 
 with regard to form and duration, and making their appearance at 
 intervals corresponding to the* attacks of the fever, as a momentary 
 chill of the whole, or any part of the body, transient heat, a pain 
 or spasm, and a brick colored sediment in the urine. Phenomena 
 are sometimes observed, however, after diseases of this sort, which 
 have not this periodical character. Of this class, are the swelling 
 of the spleen, ascites, and the oedema of the lower extremities, 
 which continue for a greater or less time after intermittent fever. 
 
 We can lay down no general rule with respect to the duration 
 of consecutive phenomena. Generally speaking, however, they 
 do not continue above two or three weeks, though sometimes 
 longer. The weakness or stiffness of limbs, which sometimes fol- 
 lows rheumatic affections, has been known to continue during 
 life. O. 
 
 CHAPTER XIII. 
 
 RELAPSE AND RECURRENCE. 
 
 BY the term relapse is signified the renewal of a disease during 
 the period of convalscence ; by recurrence (morbus recidivus), is 
 understood the reappearance of a disease after the complete restor- 
 ation of health. 
 
 Relapse is commonly produced by some occasional cause : ex- 
 posure to cold, an error in diet, excessive exercise, a violent emo- 
 tion, immoderate use of medicine, are the most frequent causes 
 of the return of a disease. 
 
 Relapse is not of equal frequency in all affections; there are 
 some diseases, as the contagious eruptive fevers, in which it 
 never takes place; there are others, as peripneumonia and pleu- 
 risy, in which it rarely occurs ; and finally, still others, as inter- 
 mittent fevers, in which it is of frequent occurrence. The fre- 
 quency of relapse in the latter affection has been attributed to the 
 
RELAPSE AND RECURRENCE. 265 
 
 course of these fevers, which have a marked tendency to repro- 
 duce themselves, and to the kind of habit the economy seems to 
 have contracted, when the paroxysms have been many times re- 
 peated. A remarkable circumstance connected with the relapse of 
 intermittent fevers, is their almost uniform occurrence at the day 
 and at the hour, when the fever should have appeared, had not 
 the paroxysms been suspended. Strack remarked that he had 
 sometimes seen this regularity in the recurrence of fevers, after the 
 lapse of several months and even a year ; but the latter cases are 
 very rare, and may admit of doubt ; for however little the parox- 
 ysm be advanced or retarded, how can the application of the cal- 
 culation to so considerable a lapse of time hold good ? 
 
 The symptoms accompanying relapses are nearly the same with 
 those of the primary affection. There is generally, however, more 
 debility, which may increase the danger. Their duration is ordi- 
 narily longer, and when the life of the patient is spared, they 
 generally leave him in a state of debility, from which he recovers 
 but slowly, and, in some cases, never regains his strength. But 
 to this assertion there are numerous exceptions ; thus, the reappear- 
 ance of erysipelas after a lapse of seven or eight days from the ter- 
 mination of the first attack, and in the part previously affected, is 
 rarely so violent as at first, being of shorter duration, and, in some 
 cases, only ephemeral. 
 
 Relapse should not be confounded with the new diseases which 
 sometimes attack the convalescent, nor with recurrence. 
 
 The latter is occasioned sometimes by a peculiar predisposi- 
 tion, and sometimes by a fresh exposure to the occasional or spe- 
 cific causes of the disease. So great is the tendency of rheumatism 
 to recur, that but few cases have been cited of persons who have 
 suffered but once in their lives from this disease ; the recurrence 
 in such cases appears to be owing to predisposition. So with 
 erysipelas of the face, which frequently reappears in some individ- 
 uals at longer or shorter, and sometimes determinate, intervals, 
 many examples of which are related by Lorry and Franck. The 
 case is otherwise in the yearly recurrences of intermittent fevers in 
 marshy places ; these are owing to a fresh exposure to the specific 
 cause of the disease. 
 
 The affections in which relapse never occurs, are also exempt 
 from recurrence, with some few exceptions ; yellow fever and 
 typhus, for example, are never developed twice in succession, but 
 may reappear after a greater or less period. In rheumatic affec- 
 tions, relapse is, perhaps, less frequent than recurrence. 
 
 The symptoms of recurrence present nothing remarkable ; they 
 are not constantly more violent, or lighter, than in the primary 
 affection. A second, a third pneumonia is sometimes more violent 
 than the first ; but the contrary is often observed. We saw a man 
 at La Charite, who was suffering from peripneumonia for the 
 tenth time; the first inflammation had been severer than those 
 that followed. In the first attack of erysipelas of the face this dis- 
 ease has been so violent as to endanger the patient's life, after- 
 23 
 
266 GENERA, SPECIES AND 
 
 wards diminishing in severity in proportion to the number of times 
 it reappeared, becoming at last so slight as to produce but little 
 functional disturbance, and to last but a short time. What we 
 have said of erysipelas, equally applies to many other diseases, 
 particularly angina tonsillaris. O. 
 
 CHAPTER XIY. 
 
 THE number of diseases to which man is liable is very great, 
 and would be infinite, if we considered, as distinct diseases, the in- 
 numerable varieties of the same disease that come under our obser- 
 vation. The same affection is, perhaps, never presented twice 
 under the same form. 
 
 If facts had been considered isolated from each other, and those 
 among them which are analogous had not been distinguished, 
 science would never have existed. The relation of facts to each 
 other, the resemblance observed between many of them, and their 
 union under a common name, indicate the commencement of med- 
 ical science, and it is only at this stage that we can arrive at any 
 knowledge of the course of diseases and the means of treating them 
 with success. 
 
 It is natural to suppose that the genera of diseases recognized 
 by the earliest observers, were very different from those of the 
 present day, particularly as regards internal diseases. Doubtless 
 they often mistook the symptom for the disease, considering as dif- 
 ferent affections what are merely different phases of the same 
 affection, and confounding under the same denomination diseases 
 totally distinct in their nature. 
 
 In proportion, however, as physicians have become enlightened 
 by experience and observation, numerous modifications have been 
 successively made of the genera originally admitted. Considered 
 merely in this aspect, the study of pathological anatomy has ef- 
 fected an entire revolution in medicine. Physicians of the present 
 day, however, are far from having arrived at the same conclusion 
 with regard to the genera of diseases, and in fact have not even 
 attempted to establish principles upon which this division can be 
 founded. We shall endeavor to supply this deficiency. 
 
 Among diseases, there are those that consist in a material and 
 perceptible lesion of the solids or fluids that enter into the compo- 
 sition of the human body ; there are others in which we can dis- 
 cover no perceptible alteration, and still a third class in which 
 there are only variable lesions. 
 
 Well defined lesions of an organ, as a fracture of a bone, a 
 wound of an integument, a burn, etc., constitute diseases of a well 
 
VARIETIES OF DISEASE. 267 
 
 marked character. The same remark may be made with regard 
 to some other lesions, the development of which is spontaneous, 
 such as inflammations, cancer, tubercles, etc. It is true, that in 
 each of these affections the material lesion is not precisely the same 
 in every stage of the disease, but the changes which it undergoes 
 are the same, and repeated observation only proves their regular 
 succession and invariable connection. The redness of skin, which 
 marks the commencement of many of the eruptive diseases, is a 
 very different lesion from the pustules that are developed at a 
 later period, and these differ no less, in their turn, from the thick 
 crusts by which they are succeeded. Here, however, and still 
 more clearly than before, there is but one disease. In typhoid 
 fever, the anatomical lesions are different in each of the three 
 periods of the disease. At its commencement the patches are hard 
 or soft, prominent, and of a rosy white color ; afterwards eschars 
 and ulcerations make their appearance, and still later in the pro- 
 gress of the disease, the surface of these ulcers becomes clean, 
 their edges become depressed, and they cicatrize and present a slate 
 color. Here, again, there is but one disease, because these lesions 
 depend upon one cause, and succeed each other in a determinate 
 order. 
 
 The presence of foreign bodies in the interior of the organs, 
 whether inanimate, as calculi of different kinds, or living, as 
 cysts which participate in the general vitality, or parasitical ani- 
 mals, which have an entirely independent existence, constitutes 
 many distinct genera of disease. 
 
 Collections of fluid in the interior of the organs, attended with no 
 perceptible lesion of the solid tissues, form well denned genera of 
 disease. Such are the effusions of serum and blood in the serous 
 membranes and the cellular tissue. These effusions, it is true, 
 often follow lesions of the solids, but since the accumulation is 
 oftentimes the only material alteration which is perceptible, the 
 accumulation must in such cases constitute the disease. The same 
 remark extends to those cases in which certain fluids are excreted 
 in excessive quantities, and often with some change in their quali- 
 ties, as, for example, the urine in diabetes and Bright' s disease. 
 In certain haemorrhages, the effusion of blood from the vessels 
 which naturally retain it, is equally a single perceptible lesion. 
 
 Sanguineous plethora and anemia may also be classed among 
 diseases in which there exists a material .perceptible lesion. The 
 diminution in the quantity of the blood in anemia has been meas- 
 ured with great exactness, and its increase in cases where there 
 are symptoms of general plethora can hardly be called in question. 
 
 Diseases arising from specific causes form also distinct genera. 
 The sting of the bee, the cutaneous affection that follows contact 
 with the nettle, the bite of the viper, the virus of variola, vaccinia, 
 rubeola and scarlatina, syphilis and glanders, and poisons of every 
 kind, give rise to a distinct class of affections, in which the mate- 
 rial lesion, whatever it may be, is only a secondary phenomenon. 
 It is. in fact, in these cases, the cause that constitutes the disease. 
 
268 GENERA, SPECIES AND 
 
 Intermittent fevers, in the production of which malaria plays so 
 important a part, are, as a general rule, a well defined class of dis- 
 eases. If their symptoms, type, and the specific action of quinine 
 in their treatment, evidently distinguish them from other diseases, 
 should we not refer this resemblance of their phenomena to the 
 identity of their cause 7 
 
 With regard to those diseases in which there is no material 
 lesion of the organs, and which arise from no specific cause, as the 
 nervous diseases, we can only establish their genera from an exam- 
 ination of their symptoms. Upon this subject the greatest differ- 
 ence of opinion has existed among physicians down to the present 
 time, and we cannot safely form conclusions in regard to it, until 
 we have a more thorough knowledge of the causes which produce 
 these affections and the lesions of which they consist. A great 
 number of them have already been found to be connected with 
 organic lesions upon the existence of which they evidently depend. 
 
 But whatever the genus of a disease may be, it is not always 
 developed with the same symptoms, attended with the same suc- 
 cession of phenomena, protracted to the same duration, or inclined 
 to the same termination. Variola, for example, is always accom- 
 panied by an eruption sid generis, which cannot be mistaken ; but 
 the general phenomena of this affection, and the number and form 
 of the pustules, are exceedingly various. In one case, the pulse is 
 full, the temperature of the body increased, the pustules round, 
 distended and surrounded by a red areola; in another, on the 
 contrary, the pulse is feeble, the skin almost cold, the eruptions 
 feeble, of a brownish color, and with a pale or livid areola. In 
 some cases, the eruption is rare and scattered nearly uniformly 
 over the whole skin ; in others, the pustules run together over the 
 whole, or are collected in great numbers on some part, of the body. 
 Sometimes the disease is attended with no danger ; at other times 
 the danger is imminent, and in a third class of cases death is almost 
 inevitable. Now would it be possible to acquire a correct idea of 
 variola by studying it only under one of the numerous forms 
 which it assumes? Undoubtedly not; and we may apply the 
 same remark to the study of every disease. 
 
 It is then essential in pathology to understand thoroughly the 
 different modifications of each disease. These modifications, how- 
 ever, are not all equally important. Some of them are so slight 
 that they may be entirely disregarded, while others, it is useful, 
 and even indispensable, to distinguish. These latter have been 
 divided into two classes ; in the first class have been placed those 
 of, apparently, a greater, and in the second, those of a less, degree 
 of importance. To the former class the term species has been ap- 
 plied, and to the latter, the term varieties, although even at the pres- 
 ent day no fixed rule has been established for distinguishing the one 
 from the other. The word species has not the same signification 
 in pathology, as in botany and zoology. In these sciences, it 
 designates the assemblage or class of individuals that perpetuate 
 themselves by reproduction ; while the word varieties comprises 
 
VARIETIES OF DISEASE. 269 
 
 those individuals which, though differing somewhat in appearance, 
 can reproduce, under given circumstances, individuals resembling 
 those from which the variety derives its origin. In pathology, the 
 word species expresses a mere abstraction. Its distinction is so 
 vague and indefinite, that some have admitted twice, and even 
 four times, the number that have been admitted by others. Sau- 
 vages carries the number as high as eighteen hundred ; Sagar, to 
 two thousand five hundred; while Cullen admitted only six hun- 
 dred. There is hardly an instance, as Bayle * has remarked, in 
 which the same author has published several editions of his works 
 without modifying, in some respects, the species that he had for- 
 merly admitted. 
 
 If it is impossible, as we have reason to believe it is, after the 
 fruitless efforts of nosologists, to obtain a definition of species 
 which shall be a uniform rule applicable to all diseases, we should, 
 nevertheless, in making such a distinction as we can, have regard 
 to the objects of the greatest utility, and determine the species of 
 the disease from the circumstances that exercise the greatest in- 
 fluence on its treatment. In all the acute phlegmasice, there is, 
 according to us, the inflammatory, bilious, adynamic and ataxic 
 character, which ought to determine their species, because the 
 character of a disease, considered with reference to its treatment, 
 is as important as, and sometimes more so than, its genus. What- 
 ever the genus of a disease may be, if it is attended with the gen- 
 eral symptoms of inflammatory fever, we resort to blood-letting 
 and the antiphlogistic regimen; if it has an adynamic character, 
 we must have recourse to stimulants and tonics ; if it is legitimate, 
 that is to say, if it is accompanied with the general phenomena, 
 only, which are peculiar to it, without any of the features which 
 characterize inflammatory or adynamic fevers, &c., repose and 
 a slender diet are most generally the only conditions necessary to 
 its cure : even these are not always indispensable, as in some cases 
 of erysipelas, chronic catarrh, etc. The division of the inflam- 
 mations into the acute and chronic species is no less important,- 
 considered with reference to their treatment, than the preceding. 
 With regard to haemorrhages, their division into two species, the 
 active and passive, has the advantage of the same practical char- 
 acter; but since there are many haemorrhages that belong to neither 
 of these species, it is necessary to recognize a third species which 
 can hardly be confounded with the others. This division is also 
 applicable to fluxes, effusions, and particularly dropsy, and may be 
 extended with advantage to certain nervous affections. The 
 happy effect of tonics, which have been used for a long time, seem 
 sufficient to prove the existence of passive neurosis ; and the 
 extraordinary cures that have been effected in other cases by a 
 totally opposite course of treatment, in addition to other circum- 
 stances, would induce us to recognise the existence of active neu- 
 
 * Theses de.la Faculti, Annee, 1801, No. 71. 
 23* 
 
270 COMPLICATIONS. 
 
 rosis. There are, doubtless, cases, however, which belong to 
 neither of these two classes. 
 
 The modifications that take place in the symptoms of those 
 diseases termed organic, with the consequent changes of treatment, 
 are unimportant, and constitute rather varieties than species unless 
 they are connected with some peculiar diathesis, as a scrofulous, 
 scorbutic or syphilitic taint.^ 
 
 Varieties of disease are the result of a multitude of circumstan- 
 ces some of which are of practical importance, as, for example, 
 the general severity of the disease, the predominance of any par- 
 ticular symptom, or the appearance of any remarkable epiphenom- 
 enon, and also the various peculiarities relative to seat, extent, 
 cause, type, etc. The number and form of the pustules in variola, 
 the seat of the exanthema in erysipelas, the severity of the pain 
 in pleuropneumonia or of the delirium in typhoid fever, constitute 
 varieties. The same may be said of the continuous or remittent 
 progress of continuous diseases ; of the quotidian, tertian or quar- 
 tan type of periodic diseases, etc. We recognise varieties, also, in 
 diseases according as they arise from external causes, or are pro- 
 duced by an internal disposition, as they are fixed or movable, as 
 they affect external or internal parts, the limbs and trunk, or the 
 organs more or less essential to life. Varieties of diseases are 
 sometimes referable, also, to the manner in which they terminate, 
 to their regular or irregular return, etc., and they frequently result 
 from complication. O. 
 
 CHAPTER XV. 
 
 COMPLICATIONS. 
 
 THE word complication, in its most extended meaning, expresses 
 the mingling together of many different things, of which it may 
 be important to ascertain the presence and determine the nature. 
 In pathology, we understand by complication, the concurrence or 
 simultaneous existence of many diseases capable of exerting a 
 mutual influence on each other. The coexistence of many entirely 
 independent diseases, as, for example, cataract, calculus in the 
 bladder, and an external injury, is not a complication. Some phy- 
 sicians f have proposed to limit still farther the meaning of this 
 
 * The division of diseases into false (morbi spurii, nothi), and true (morbi 
 exquisite, legilimi), has been properly rejected by physicians of the present day. 
 The classification into these species has been entirely exploded by recent nosology. 
 
 fFernel and Plempius, two physicians of the sixteenth and seventeenth cen- 
 turies, divided diseases into solitary and multiple (morbi solitarii et multiplices}. 
 They subdivided solitary diseases into simple and compound. They termed a 
 disease simple, which affects one or more parts of the body in the same manner ; 
 as, for example, pneumonia confined to a single viscus, and gout which attacks at 
 
COMPLICATIONS. 271 
 
 word, and to apply it only to diseases which exist simultaneously 
 in the same organ, and concurrently produce a disturbance of the 
 same function ; but their opinion does not carry with it the weight 
 of authority. 
 
 Some authors have fancied that they traced the influence of 
 complication even in the most trifling cases of disease, while others 
 have been almost wholly unwilling to recognize its existence. It 
 becomes important, then, to establish some principles by which we 
 may be guided with regard to a subject, which, though not of the 
 greatest importance, is certainly not destitute of interest. 
 
 1. The simultaneous development or consecutive extension of the 
 same disease, of a phlegmasia, for example, or an organic lesion 
 in continuous or contiguous parts, is not sufficient to constitute a 
 complication. The simultaneous inflammation of the pleura, the 
 parenchyma of the lungs and the bronchial membrane, is obviously 
 the extension of one disease to different tissues, and not three 
 diseases. So in surgery, the injury of the integuments that cover 
 the seat of a fracture is never regarded as a complication. A 
 cancerous affection of the pyloric extremity of the stomach is also 
 a simple disease, although the disease extends to the lymphatic 
 glands, the epiploon, the pancreas or the liver. 
 
 2. The simultaneous existence of similar lesions in organs, more 
 or less remotely situated from each other, does not constitute a 
 complication, when these lesions result from the same cause. 
 Thus the tubercular or cancerous affection of different organs in 
 different parts of the economy is a simple disease, because one 
 cause, however latent, has given rise to these multiple lesions. 
 
 3. The simultaneous existence in different parts of the body of 
 lesions differing entirely from each other, is insufficient to constitute 
 a complication, when these lesions are owing to the influence of 
 one ascertained cause. We may mention, as examples of this, the 
 sore throat which sometimes accompanies variola, the swelling of 
 the lymphatic glands of the neck incases of tinea, and the develop- 
 ment of ulcers, excrescences, exostoses and buboes, in cases of 
 syphilis. 
 
 4. Neither is a complication the coexistence of two diseases, 
 one of which is a necessary consequence of the other. Of this 
 
 the same time different articulations, but which arises from one cause, and is fol- 
 lowed by the same results. They termed those diseases compound which, though 
 possessing the characteristics of single diseases, arise from a concurrence of dif- 
 ferent causes ; such are the adynamic or bilious phlegmasiae. 
 
 They recognized three sorts of multiple diseases. 1. Complicated diseases, 
 (morbi impliciti^ complicati), those that exist at the same time in the same organ, 
 and concurrently produce a disturbance in the same function, as, for example, 
 pneumonia and phthisis. 2. Connected diseases (morbi connexi v el consequentes} , 
 those cases in which one disease concurs in the production of another ; such are 
 peritonitis accompanying inflammation of the uteius, and gangrene developed in 
 the integuments in severe cases of fever. 3. Distinct or separate diseases (morbi 
 disjuncti vel separati), those that do not affect the same function, and exert no in- 
 fluence in the production of each other; two wounds, one of the thigh, the other 
 of the head, the simultaneous existence of gout in the feet and hpoma in the 
 thorax, or of ulcers in the leg and pneumonia, are obvious examples. 
 
272 COMPLICATIONS. 
 
 class of cases is peritonitis, resulting from a perforation of the 
 intestines or stomach, and rarer examples of it are those cases of 
 pleurisy which follow the ulceration of the pleura in consequence 
 of the softening of a pulmonary tubercle. 
 
 5. Lastly, the general phenomena that accompany the affection 
 of certain organs, do not constitute a complication. In cases of 
 this sort there is but one affection, although the general disposition 
 of the patient gives the local disease a peculiar modification, as 
 for example, in bilious or adynamic pneumonia. 
 
 It follows, in the first place, that a complication cannot exist 
 except when there is a coexistence of diseases entirely distinct from 
 each other, either as regards their origin and the mode of treatment 
 proper for their cure, or their seat and the anatomical lesions of 
 which they consist ; and, in the second place, it is also a necessary 
 condition, as we have before remarked, that these diseases be not 
 entirely independent, but capable of exerting a mutual influence 
 on each other. 
 
 The number of diseases that may exist at once in the same in- 
 dividual and form a complication is unlimited. It is rare, how- 
 ever, to see more than two. We sometimes meet with cases where 
 an individual is affected with five or six different diseases ; but 
 these cases are very uncommon, and, besides, in a greater part of 
 them the diseases have an entirely independent existence, and con- 
 sequently come under the head of coexistence, and not of compli- 
 cation. 
 
 The causes of complication are very various. Sometimes each 
 disease arises from a specific cause, as in a complication of two 
 eruptive fevers. Sometimes the same occasional cause develops 
 two distinct affections. Thus, the effect of cold may give rise, in 
 the same individual, to a rheumatic affection and a pulmonary 
 catarrh, although, in cases of this sort, there is reason to suspect 
 the concurrent influence of predisposition. Complications are not 
 equally common in all conditions of life. They appear to be of 
 more frequent occurrence in infancy and mature age, than during 
 the intermediate period, and in the inhabitants of cities, rather 
 than those of the country. 
 
 The most important point to consider, in the examination of this 
 subject, is the influence which complicated diseases exercise on 
 each other. In some cases, the supervening disease diminishes 
 or increases the severity of the primary affection, and in others 
 has the speedy effect of, either temporarily or permanently, sus- 
 pending its symptoms. Acute diseases are sometimes observed 
 to affect in this manner chronic complaints, to arrest which, all 
 the resources of art have been in vain resorted to. Incipient 
 variola has been known to be suspended by the development of 
 rubeola and on the termination of the latter, to make its reappear- 
 ance. A visceral phlegmasia that follows an injury almost inva- 
 riably modifies the symptoms of the external wound, and the nature 
 of the fluid which it exhales. Erysipelas, which is developed in 
 osdematous limbs, often terminates in the suppuration of the cellular 
 
DIAGNOSIS. 273 
 
 tissue and the gangrene of the integuments. In another class of 
 cases, the supervening disease does not influence the one that 
 precedes it but is influenced by it. Examples of this are cases of 
 accidental wounds and fractures in persons afflicted with scurvy. 
 The scorbutic affection undergoes no perceptible change, but the 
 fractures do not unite, and the wounds assume the appearance 
 peculiar to scorbutic ulcers. 
 
 We conclude, that wherever many diseases exist simultane- 
 ously; 1. they may either have no influence upon each other; 2. 
 the second disease may modify, suspend or terminate the first ; or 
 3. the first, may aggravate the character of the supervening, dis- 
 ease. O. 
 
 CHAPTER XVI. 
 
 DIAGNOSIS, 
 
 DIAGNOSIS* is that part of pathology whose object is the discrim- 
 ination of diseases. To discriminate a disease is to recognize it 
 whenever it exists, whatever be the form it assumes ; and also to 
 decide that it does not exist, whenever other diseases appear with 
 symptoms similar to its own. 
 
 " The science of diagnosis " says Louis, in his Memoir upon 
 fungous tumors of the dura mater, " is the most important, most 
 useful, and most difficult of all the divisions of medical science. 
 The discrimination of the peculiar nature of each kind of disease, 
 and of its different species, is the source of curative indications. 
 Without an accurate and precise diagnosis, theory is ever at fault 
 and practice often unfaithful." 
 
 There are two different modes of considering diagnosis ; succes- 
 sively, in single diseases, or by abstraction of particular cases, as 
 a branch of general pathology. The latter only will occupy us at 
 this time ; the former belongs to the special description of disease. 
 
 Diagnosis, thus generally considered, presents many points of 
 importance; of these the principal are, 1. the signs upon which 
 it should be founded ; 2. the conditions necessary for its formation, 
 both on the part of the patient and the physician ; 3. the proper 
 mode of examination and interrogation of the sick, in order to 
 acquire a knowledge of the affections under which they labor ; 4. 
 the component elements of diagnosis, viz. the seat and nature of ana- 
 tomical lesions, and the form and type of symptomatic phenomena ; 
 5. the circumstances rendering diagnosis difficult or uncertain. 
 
 I. Diagnostic Signs. The term diagnostic signs comprises 
 
 * Jidyvooig, discernment; <Jia, through (thoroughly,) yivuxTxto, to know. 
 
274 DIAGNOSIS. 
 
 all those circumstances which enlighten us in regard to the genus 
 or species of a disease ; the principal are, past or present symp- 
 toms, the predisposing or determining causes of the disease, its 
 mode of access and progress up to the moment of examination, and 
 the effect of remedial measures. Diagnostic signs are not all of 
 equal importance ; those termed characteristic, are such as either 
 alone, or united, are sufficient for the recognition of the disease ; for 
 example, the sense of tension, pain in the abdomen, vomiting, 
 etc., attending peritoneal inflammation. These signs have also 
 been called true, essential, sufficient, univocal, because they leave 
 no doubt in regard to the existence of the disease. Among these 
 latter signs there are some known as pathognomonic* it being 
 affirmed that the disease never exists without them, and that they 
 are never present except the disease exist. Characteristic, differ 
 from pathognomonic, signs, in this respect, that the disease may be 
 manifested without the former, but never without the latter. But, 
 as has been correctly remarked, if the term pathognomonic be em- 
 ployed in so rigorous a sense, no sign would deserve the appella- 
 tion. The mobility of the fragments in fracture of the bones, and 
 the flow of blood in hemorrhage, are not pathognomonic signs, 
 because both fracture and haemorrhage may occur without these 
 symptoms. For this reason most modern authors have employed 
 the terms pathognomonic and characteristic without any distinction, 
 to designate the signs clearly indicating the existence of disease. 
 Other signs, known as common, equivocal, insufficient, are those 
 met with in many diseases, but appertaining especially to none ; 
 such are frequency of the pulse, elevation of temperature and 
 thirst. These signs are not indifferent in diagnosis, but are less 
 important than the preceding. 
 
 The signs perceived by the physician's own senses have an en- 
 tirely different value from those derived from the account of the 
 patient and his attendants. It is mainly by the aid of the former 
 that he should form his opinion ; the latter will often mislead him 
 if he yield them his entire confidence. 
 
 Finally, there are positive and negative signs in disease, that is, 
 the absence of certain phenomena and the existence of others, may 
 concur in deciding the physician's opinion. Negative signs, how- 
 ever, are of far less value than those which are positive ; thus, fine 
 and dry crepitus, sanguinolent sputa, vomiting of dark colored 
 matters and epigastric tumor, are signs of pneumonia and cancer 
 of the stomach ; the absence of these signs does not prove that the 
 lung is not inflamed, nor that the stomach is free from scirrhus. 
 
 We consider it needless to enlarge farther upon the diagnostic 
 signs of diseases ; it has already been our duty in various parts of 
 this work, and particularly in the long chapter devoted to symp- 
 tomatology, to point out the diagnostic value of very many; we 
 shall again find it necessary to notice them at a future time, when 
 speaking of the different modes of exploration necessary for the 
 
 * Ilu&og, disease ; yvwjuovixoj, pertaining to discrimination ; yivoxrxo), to know. 
 
DIAGNOSIS. 275 
 
 formation of diagnosis, of the form and type of symptomatic phe- 
 nomena, or, finally, of the conditions which render diagnosis diffi- 
 cult. Whatever we might add in this connection would belong to 
 the particular history of disease. 
 
 $ II. Necessary Conditions for the Formation of Diagnosis 
 on the part of the Patient and Physician. There are many 
 conditions on the part of the patient, which, if not indispensable 
 in forming a diagnosis, are, at any rate, well suited to render it 
 more easy and exact. The first is, sufficient intelligence to 
 understand the questions proposed by the physician, and to 
 answer them with precision. We see how difficult it is to form 
 a decided opinion in regard to a patient, when his intellectual fac- 
 ulties are naturally obtuse or accidentally disturbed, when he is too 
 young to express himself verbally, or when we do not understand 
 his language. Another important condition is the absence of all 
 attempts at deception on the part of the patient, either by conceal- 
 ing certain circumstances relating to his disease, or by stating 
 symptoms which he does not experience. There are some patients 
 whose intelligence is sufficient, and who do not intend to deceive 
 the physician, but who render their examination very embarrass- 
 ing by the manner in which they describe their sensations and 
 answer the questions proposed to them. Instead of simply stating 
 their sufferings, and replying directly to questions, they give their 
 opinion of the peculiar nature of their disease; one is tormented 
 by mucous discharges, bile, the blood, or by an acrimonious state 
 of the humors; another has irritation, tension, or relaxation of 
 the nerves, etc. It is easy to conceive that when a patient has 
 expatiated for an hour or more upon his sensations, constantly 
 dwelling upon the biliary and mucous secretions, the acrimonies, 
 and the nerves, the physician will have made no progress in the 
 diagnosis. We might suppose that by requesting patients not to 
 use such language, but only to tell what they actually feel, we 
 could induce them to speak more intelligibly; but we are en- 
 tirely mistaken ; the greater number do not change their language 
 in the least. The physician needs all his patience to enable him 
 to listen ; and in certain cases he is obliged to form his opinion 
 solely by what he sees, almost entire abstraction being made of all 
 that he has heard. 
 
 The necessary conditions for accurate diagnosis on the part of 
 the physician, are numerous. The first, and indispensable condi- 
 tion, is a thorough knowledge of pathology. He who is not fa- 
 miliar with the signs of all diseases is not fit to give an opinion of 
 any one in particular. Another condition, no less important than 
 the theoretical knowledge of disease, is long and careful observa- 
 tion, and ability, by means of frequent dissections, to confirm 
 or rectify a diagnosis made during the progress of disease. The 
 physician who has not for a long time applied his knowledge at 
 the bedside and assisted at many post-mortem examinations, is 
 certainly unfit to form a correct opinion of the diseases he observes. 
 
276 DIAGNOSIS. 
 
 Supposing his diagnosis to be correct in some cases, it would be 
 the opposite in a great number, and in all, it would be formed 
 slowly and doubtfully. Skill in diagnosis, which constitutes, in 
 connection with a readiness to perceive indications, that quality 
 known as medical tact, can only be acquired gradually ; it implies 
 the union of all the qualities necessary to the observer ; integrity of 
 the senses, which thus distinctly transmit every modification of the 
 phenomena within their jurisdiction, a firm and penetrating mind, 
 capable of properly collating, comparing with discernment, and de- 
 ducing from facts the inferences and consequences which they fur- 
 nish, and which, uniting boldness and prudence in due propor- 
 tions, dares at times to obey the dictates of a seeming inspiration, 
 which is really an accurate, although a rapid, appreciation of the 
 most expressive phenomena of the disease. These precious quali- 
 ties are rarely combined in one individual, and the number of phy- 
 sicians remarkable for great skill in diagnosis is always very 
 limited. 
 
 There is still another condition, which, if not indispensable, is at 
 least of great service to the physician in the diagnosis of diseases ; 
 this is a knowledge of the normal state of the various functions of 
 the patient to whom he is called. The modifications made by dis- 
 ease in the physiognomy, gait, voice, mental disposition, circula- 
 tion and respiration, are often hardly appreciable by the physician 
 who has not seen the patient when in health, while they would 
 be very manifest to him who can make this comparison. On this 
 account we must approve the wise forethought of those persons 
 who wish to be known during health by the physician who is to 
 attend them when ill. In order to respond properly to the confi- 
 dence of these individuals, the physician should thoroughly ex- 
 amine the condition of all the functions as he would do in one 
 .laboring under disease. 
 
 Not only is it necessary for the physician to have exercised his 
 senses for the detection of every modification of morbid phenome- 
 na, and his mind in determining their value, but he should also 
 have acquired by practice, and as far as possible by instruction 
 from others, the habit of employing the different modes of explo- 
 ration, by the aid of which he attains a knowledge of certain 
 phenomena, likely to escape ordinary observation, or at any rate, 
 to be far less accurately appreciated. These modes of exploration 
 are pressure, palpation, touch, succussion, mensuration, percus- 
 sion, auscultation, examination with various kinds of sounds, spec- 
 ula, magnifying glasses, the microscope, and chemical reagents. 
 
 1. Pressure. Pressure made with the hands or fingers, and 
 which should not be confounded with palpation, is doubtless a 
 very simple mode of exploration, but one that furnishes, notwith- 
 standing, numerous and important signs. In the first place, it 
 enables us to recognise the various changes in the resistance of 
 diseased parts, as the hardness of the cellular tissue in phlegmon - 
 ous inflammation, the tension of the abdomen in tympanitis, its 
 simple resistance in chronic peritonitis, the elasticity of tumors 
 
DIAGNOSIS. 277 
 
 containing pus, the flaccidity of parts whose volume has rapidly 
 diminished, as the abdomen after the employment of the trocar, 
 or after parturition, or that of an inflammatory tumor after the 
 natural or artificial evacuation of its purulent contents. 
 
 When, by equable and simultaneous pressure made on both 
 sides of the abdomen, with both hands, and over exactly corres- 
 ponding regions, a decided and constant difference is perceived in 
 regard to the extent to which each hand penetrates, we should 
 suspect some deep-seated lesion of the least depressible side of the 
 abdomen, even when the hand does not distinguish any alteration 
 in the consistence of the tissues. It should not be forgotten that 
 an abnormal direction of the dorsal or lumbar portion of the spinal 
 column might cause the same sensation, without furnishing the 
 same inference. 
 
 When air or serum is infiltrated into the subcutaneous cellular 
 tissue, pressure, by displacing the infiltrated fluid, causes, first, a 
 sensation of crepitation ; secondly, it conveys the impression of 
 penetration by the finger into the compressed part ; and if two 
 fingers be used to pinch up a fold of the skin, upon the thigh, for 
 instance, they approach each other, and a transient pitting of the 
 infiltrated part succeeds this action of the fingers. In typhoid 
 fever, when pressure is made in the right iliac fossa, a remarkable 
 gurgling is produced, which occurs also, from similar pressure, in 
 abscesses into which air has penetrated. 
 
 When a liquid is contained in a cavity which has no outlet, and 
 whose parietes are elastic, as the knee or abdomen, rapid pressure 
 furnishes us with important signs ; the shock of the patella against 
 the opposite surfaces of the femur and tibia, shows a synovial 
 effusion which recedes before the finger. When the abdomen is 
 simultaneously the seat of moderate effusion, without evident 
 fluctuation, and of a tumor so deeply seated as to be inaccessible 
 to common palpation, we find a valuable mode of exploration, as 
 yet very little known by physicians, in rapid pressure practised 
 with the extremities of the fingers. By means of this, we discover, 
 often at considerable depth, something resistant against which the 
 abdominal parietes strike ; and the sensation of a body which re- 
 treats before the fingers and returns immediately on the cessation of 
 pressure, indicates that there is liquid interposed between the 
 tumor and the integuments, the sound on percussion of the abdo- 
 men, as is noticed in these cases, being entirely flat. 
 
 Pressure, also, furnishes certain signs relative to the change it 
 effects in the coloration of the parts. 
 
 Certain kinds of erythema, are characterized by the disappear- 
 ance of their redness under the pressure of the finger, as erysipelas, 
 scarlatina, and roseola ; others by its persistence, notwithstanding 
 pressure, or even by its increase, as purpura hamorrhagica ; the 
 reason of this doubtless is, that the surrounding skin becomes 
 whiter by pressure, and makes the darkness of the heemorrhagic 
 spot more intense by contrast. 
 
 In cases of very slight rubefaction, as that which is diffused 
 24 
 
278 DIAGNOSIS. 
 
 over the entire surface of the body in sanguineous plethora, or 
 around certain joints affected with rheumatism, pressure, made 
 with a single ringer, causes a discoloration of the compressed point, 
 and renders the slight redness of the neighboring parts more man- 
 ifest. 
 
 Finally, certain pains, particularly those of an inflammatory 
 nature, are aggravated by pressure ; others are not influenced by 
 it, as is observed in some cases of sciatic neuralgia ; the intensity 
 of others is diminished, as the abdominal pain of lead colic j others, 
 still, are momentarily suspended by strong pressure upon the af- 
 fected point, as certain varieties of hemicrania. Lastly, entire ab- 
 sence of sensation under pressure sufficiently strong to give pain, 
 as that made with the extremities of the ringers, or even with the 
 nails, shows complete loss of sensibility. 
 
 2. Palpation. Palpation, or the act of feeling, is one of the 
 most useful and most frequently employed means of exploration. 
 It consists in the methodical application of the physician's hand to 
 the affected parts, for the purpose of appreciating the various alter- 
 ations which may have taken place. It requires much circum- 
 spection, dexterity and practice united, in order to derive from it 
 all the advantage it possesses, to avoid the dangers which it some- 
 times occasions and the errors to which it may give rise. The 
 following is the best mode of procedure. 
 
 The parts upon which palpation is to be practised, should be so 
 placed as that their enveloping muscles may be, as nearly as pos- 
 sible, in a state of complete relaxation ; muscular contraction 
 would have the double disadvantage of withdrawing the parts 
 from the hand of the examiner, arid sometimes even of simulating 
 tumors, as is particularly the case in regions occupied by inter- 
 secting muscles, as the recti abdorriinis. It is often useful to vary 
 the attitude of the patients ; by a comparison of the results Ob- 
 tained in different positions, we complete, and sometimes rectify, 
 the ideas suggested by the first examination. 
 
 It is generally preferable that the parts to be examined should 
 be uncovered : delicate linen, however, does not interfere with 
 palpation, indeed, it often facilitates it, especially in sensitive per- 
 sons, in whom the coldness of the hand employed in palpation, or 
 the disagreeable sensations caused by exposure of the person, 
 excite involuntary muscular contraction, which ceases with the 
 removal of its exciting cause. 
 
 In practising palpation, the whole hand, or even both hands, 
 should be used, according to the extent of the parts, and riot one 
 or more fingers only, except in cases where the volume of the 
 affected part will admit of no other mode of exploration. Usually, 
 the whole hand should be at once applied to the diseased part, 
 instead of pressing perpendicularly, or even obliquely, with the 
 extremities of the fingers, as is often done by inexperienced per- 
 sons. We should commence by palpation of the neighboring 
 parts, or of those similar in kind to the one we wish to examine, 
 as for example, the healthy limb, breast, testicle, or side of the 
 
DIAGNOSIS. 279 
 
 abdomen, previously to those affected, so that we may, by a 
 knowledge of the normal condition, better appreciate the altera- 
 tions, sometimes slight, produced by disease in the unhealthy 
 parts. The hand should at first be simply applied to these 
 parts ; if it encounter no resistance and produce no pain, we 
 should gradually exert more pressure, directly, at first, afterwards, 
 with slight lateral movements. When we discover an enlarge- 
 ment or swelling, we should endeavor to circumscribe it completely, 
 by surrounding it on all sides with the fingers, sufficiently flexed 
 and separated from each other, to be applied to the whole of the 
 resisting or swollen surface, and thus ascertain its limits. Fre- 
 quently, one of the hands should be so placed as to favor the exam- 
 ination which is particularly conducted by the other : thus, in order 
 to verify an obscure fluctuation, we press back the fluid with one 
 hand towards the place where the other hand is applied : in exam- 
 inations of the abdomen, one hand, applied to the right lumbar 
 region, pushes the liver forward, so that the other hand can better 
 appreciate its volume and its consistence. Tn order that the hand 
 placed upon the hypogastrium may ascertain the condition of the 
 uterus, it is often requisite to raise the os tincse with the index 
 finger of the other hand. In the examination of inflammatory 
 tumors, abscess, certain species of hypertrophy, various kinds of 
 organic degeneration, and arterial aneurism, palpation furnishes 
 signs of peculiar value, especially when uniformly identical results 
 are obtained on repeated trials at different intervals. It enables 
 us to discover the number, size, form and consistence of the above 
 tumors, to judge whether their surface be smooth or uneven, 
 whether they are soft or hard, and if these qualities characterize 
 them throughout or only partially ; whether they are elastic or 
 fluctuating, unique or multiple, fixed or movable : if they exhibit 
 internal movements or pulsations ; if these pulsations be isochro- 
 nous, or not, with those of the heart or arteries, if they are the 
 effect of simple displacement, or of an actual expansion, if they 
 may be referred to that undulatory thrill observed in many dis- 
 eases of the circulatory system, especially in certain alterations of 
 the cardiac orifices and in varicose aneurism, etc. 
 
 Palpation, moreover, repeated at suitable intervals, enables the 
 physician to judge of certain changes which time and remedies 
 effect in the course of diseases ; diminished or increased volume of 
 parts already examined becomes in this way the most certain of 
 signs, and is suggestive of the most positive ideas. We should, 
 however, remember that various modifications, taking place either 
 in the situation of the tumor or in the surrounding parts, may 
 sometimes deceive the practitioner. A cancerous tumor, developed 
 in the greater curvature of the stomach, is more or less apparent 
 according to the state of vacuity or repletion of that viscus, and 
 in proportion to the amount of gas contained in the neighboring 
 intestines. We have so frequently observed, in cases of this de- 
 scription, and in others analogous, the difficulty of reaching the 
 tumor lead to the supposition of its decrease, or even its disap- 
 
280 DIAGNOSIS. 
 
 pearance, that we have thought proper particularly to notice this 
 source of error. 
 
 The simple changes wrought by disease in the natural solidity 
 of the organs, are, moreover, important phenomena to establish, 
 and can only be appreciated by means of palpation. Not to men- 
 tion that relaxation of the integuments and muscles, which is, as 
 it were, the first stage of emaciation, and which in some instances 
 furnishes us with an important sign, we would notice that cir- 
 cumscribed hardness and the consecutive engorgement of a certain 
 portion of the integuments, where deep-seated inflammation is 
 developed, or purulent matter collected; finally, we would call to 
 mind that resistant state of the abdomen so precious in the diag- 
 nosis of certain cases of chronic peritonitis. 
 
 3. Examination by the Touch. Touch * is a species of palpation 
 made by one or more of the fingers, introduced into parts naturally 
 inaccessible to the eye, as the vagina and rectum, with the design 
 of verifying different physiological and morbid conditions, either 
 of these passages, or of neighboring organs. 
 
 The index finger of either hand is usually the only one employed 
 in vaginal and rectal examinations ; it is very rare that diagnosis 
 is assisted by the introduction of two fingers into the same pas- 
 sage ; but in some circumstances, when we wish to examine the 
 recto-vaginal parietes, we introduce, simultaneously, the thumb 
 into the vagina, and the index finger of the same hand into the rec- 
 tum. The nail of the finger which is used in such examinations 
 should be short, and smooth, so that the pulp of the finger may be 
 more accurately applied to the parts, and no pain or laceration be 
 produced. Previously to such an examination, the bladder, and 
 especially the rectum, should be evacuated. These preliminaries 
 being fulfilled, and the finger being covered with cerate or some 
 other unctuous or mucilaginous substance, we proceed as follows, 
 for vaginal and rectal examinations. 
 
 If we intend to examine the vagina and uterus, the woman may 
 be either recumbent or erect. If the former position be adopted, 
 she should assume the dorsal decubitus, the body being somewhat 
 inclined upon the pelvis, so as to relax the muscles as completely 
 as possible, the thighs being slightly separated and flexed. The 
 physician should stand, by preference, at the right side of the bed, 
 so that he may use the index finger of the right hand. If the pa- 
 tient be in the upright posture, she should be requested to lean 
 upon some firm support, separating the thighs slightly, and the ex- 
 aminer should be before her, upon a low seat, or resting upon one 
 knee. Whatever be the position, we should avoid exposure of the 
 patient under an examination more or less trying to nearly all 
 females. With the thumb and middle finger of the hand em- 
 
 * The term " toucher," which we have rendered by the English word touch, 
 is used in a medical sense, by the French, to express explorative examination by 
 the finger, usually, the index finger of the right hand ; in some rare cases, two 
 fingers are used, as is mentioned in the text. The term is employed, in the vast 
 majority of cases, to indicate vaginal exploration with the finger. TRANS. 
 
DIAGNOSIS. 281 
 
 ployed, we slightly separate the labia majora of the vulva, the 
 index finger is readily introduced into the vagina, while the other 
 fingers are strongly flexed upon the palm of the hand. The finger 
 should enter the vagina slowly, in order to avoid the pain which 
 might be occasioned by a rapid introduction, and to appreciate 
 more thoroughly either the changes which may be detected in the 
 parietes of the passage, as regards heat, sensibility, consistence, 
 form, and moisture, or, in certain cases, to ascertain the formation 
 of the pelvic cavity. When the finger has reached the os tincae, 
 which will be recognized by its form, consistence, and by the 
 central depression which distinguishes its orifice, we ascertain 
 if it be in its normal position, if depressed or inclined to the 
 right or left, forward, or backward ; the sensibility, length and 
 volume of the neck, whether it be hard, or soft, sometimes the in- 
 equalities of its surface, the relative size of the two labia oris 
 tineas, the degree of dilatation of its orifice, as well as its form, ele- 
 vation and direction, should each be the objects of attentive exam- 
 ination. We next proceed to the examination of the uterus. For 
 this purpose, raising the finger, as if to elevate the organ, and 
 carry it backwards, towards the brim of the pelvis, we judge of its 
 weight and mobility, and if the woman be pregnant, we may thus 
 determine and perceive the repercussion (ballottemenf] of the foetus. 
 When the patient is in a horizontal position, the unoccupied hand 
 should be placed upon the hypogastrium, in order to appreciate the 
 volume of the uterus, and accurately determine its elevation ; by 
 this means, we may, in certain cases of abdominal tumors of diffi- 
 cult diagnosis, gain a more accurate knowledge of their seat and 
 connections ; by alternate pressure of the hand, applied to the ab- 
 domen, and of the finger resting upon the uterus, we can generally 
 ascertain whether the tumor under examination be formed by the 
 uterus itself, merely attached to it, or distinct from it. 
 
 In order to derive all the advantage possible from this mode of 
 exploration, it is often necessary to change the position of the pa- 
 tients, and to place them alternately in the horizontal and upright 
 position. The latter is particularly useful when we wish to ascer- 
 tain with accuracy certain deviations of the uterus, especially pro- 
 lapsus, or to verify the phenomenon of repercussion of the ifoetus. 
 
 In all cases where morbid changes in the vagina, or the neck of 
 the uterus, are discovered by the touch, the physician should ex- 
 amine ocularly, and by the sense of smell, the finger which has 
 been employed, in order to judge of the changes which may have 
 occurred in the vaginal mucus, or any other matters remaining 
 upon the finger. 
 
 In rectal examinations, the horizontal posture will generally be 
 convenient, the body being inclined to one side, with the corres- 
 ponding limb extended, the other slightly flexed. The index finger 
 should be introduced more slowly than in vaginal examinations; 
 and in case of strong contraction of the sphincter, we should wait 
 for its relaxation. Still greater caution is requisite when the margin 
 of the anus is the seat of hsemorrhoidal tumors, or of fissure. The 
 24* 
 
282 DIAGNOSIS. 
 
 finger thus introduced into the intestine should be moved gradually 
 over the whole internal surface, in order to appreciate the various 
 modifications which may exist, in its sensibility, tension, heat and 
 consistence, or, as regards any inequalities it may present, such as 
 granulations, wrinkles, ulcerations, tumors, with, or without a pedi- 
 cle, fraena, strictures, or dilatation of this portion of the rectum. 
 The rectal touch may moreover discover, in the male, through the 
 recto-vesical parietes, calculi, engaged in the inferior extremities of 
 the ureters, or occupying the base of the bladder, or tumefaction 
 arid induration of the prostate, which is a frequent cause of reten- 
 tion of urine. In the female, we may by this means detect aug- 
 mented volume of the uterus, its deviation from the normal posi- 
 tion in retro version, and certain fibrous tumors developed in its 
 posterior parietes, near its external surface ; it also furnishes valu- 
 able signs in certain forms of extra-uterine pregnancy, and, in 
 some very rare cases, reveals the absence of the uterus. 
 
 Vaginal or rectal touch is also indispensable for the diagnosis of 
 diseases which have their seat in the pelvic cavity, exteriorly to 
 these passages and the organs with which they are immediately 
 connected ; such as that kind of abscess which often occurs 
 after parturition, and scirrhous tumors and exostoses developed 
 within the pelvis, which would remain unknown in most cases, if 
 this mode of exploration did not enable the physician to seek for 
 and discover them. 
 
 The thorough exploration of the posterior fauces, by means of 
 the finger, may be considered analogous to the above, its purpose 
 being to examine the most remote portion of the nasal fossae above, 
 and the various alterations of the epiglottis, arytenoid folds, and 
 middle portion of the pharynx, below. This examination, in 
 which we are sometimes obliged to keep the maxillae separated 
 by means of some resistant body placed between the molar teeth, 
 may suffice of itself, in some cases, to establish the diagnosis of 
 certain very obscure diseases, as polypi developed in the nasal fos- 
 sae, oedema of the glottis, abscess and foreign bodies in the pharynx. 
 
 In concluding our remarks upon this mode of exploration, we 
 deem it necesary to repeat an opinion daily expressed in our clini- 
 cal lectures, viz., that this kind of examination is too much neg- 
 lected, that most physicians are not aware how much information 
 it supplies, nor how many errors may be avoided or rectified by its 
 aid ; and that consequently, it is an imperative duty to have re- 
 course to it whenever any circumstance draws our attention to 
 those organs where its application is possible. 
 
 4. Siiccussion. Succussion consists in shaking the patient's 
 body with sufficient force to agitate the fluids and gases contained 
 in one and the same cavity, and to cause more or less distinct 
 gurgling. 
 
 A lateral shock given to the body, and frequently repeated, by 
 means of the two hands placed upon the lower part of the chest, 
 one on the right, the other on the left side, usually enables us to 
 detect this species of gurgling, without the necessity of ausculta- 
 
DIAGNOSIS. 283 
 
 tion ; in most patients the sound is sufficiently distinct to be per- 
 ceived at a considerable distance. 
 
 Succussion is applicable to but a small number of diseases. We 
 cannot, indeed, produce the sound above-mentioned, except in cases 
 where gas and liquids are contained in the same natural or acci- 
 dental cavity, and such affections are rare ; the principal are hy- 
 dro-pneumothorax, (an affection almost always consecutive upon 
 the ulceration of pulmonary tubercles, with perforation of the 
 pleura,) and certain affections of the stomach, among which the 
 dilatation consequent on scirrhus of the pylorus is the most fre- 
 quent. In the latter case, the gurgling is produced in the abdo- 
 men ; in the former it takes place in the thorax. A fold of intes- 
 tine, considerably dilated, may also present this phenomenon, if 
 succussion be practised. We detected it upon one occasion, in a 
 cyst of the ovary, which contained, as was discovered at the post- 
 mortem dissection, pus of creamy appearance and very fetid gases, 
 which, as it seemed to us, were probably produced by the putrefac- 
 tion of this liquid. We should add that there are certain persons, 
 whose digestion seems regular, in whom stomachal gurgling occurs 
 on succussion, after the ingestion of liquid aliment. 
 
 5. Mensuration. Mensuration, as the word imports, is that 
 mode of examination, by which we endeavor to determine with 
 more accuracy than is attainable by either sight or touch, the 
 volume or length of certain diseased, or healthy parts. For this 
 purpose we employ, according to the form of the parts, either an 
 inelastic band, or a pair of callipers (compas d* epaisseur), with a 
 scale divided into centimetres or lines ; in many cases, the physi- 
 cian will find his fingers the most natural and available instrument 
 for mensuration. 
 
 Certain precautions are necessary in the application of this 
 method of exploration, so as to give to its results the accuracy 
 which constitutes their utility. The first is a uniform degree of 
 pressure in all the successive measurements ; the second, a like 
 uniformity and precision in regard to the posture of the patient, 
 and particularly the position of the parts to be examined : the 
 position should, if possible, be rectilinear, so that future examina- 
 tions, made in exactly the same manner, may accurately exhibit 
 the alterations, if any have supervened. If mensuration be ap- 
 plied to the head or the thorax, the patient should be either sitting 
 or erect ; his posture should be the horizontal, when the limbs arid 
 abdomen are to be measured. Another point of equal importance 
 is to apply the instruments upon exactly the same points ; the 
 nipple and the umbilicus, in mensuration of the abdomen and 
 thorax, may serve as limits (jalons). 
 
 Mensuration may be very advantageously applied in diseases 
 which change the direction or the relations of one or more portions 
 of the osseous system. It proves the existence of disorders which 
 the eye would only lead us to suspect, and enables us to determine 
 their extent and to trace their changes; on this account it is fre- 
 quently employed by orthopedic surgeons. We cannot, however, 
 
284 DIAGNOSIS. 
 
 too often repeat how important it is in these cases, as well as in 
 moulding in plaster, to maintain strict uniformity of attitude, in 
 order that each ulterior examination may be conducted under pre- 
 cisely similar conditions. 
 
 In estimating the length of the lower limbs, mensuration pre- 
 sents some difficulties with which we should be familiar ; lateral 
 inclination of the pelvis might erroneously lead us to suppose elon- 
 gation- or shortening of a limb, did we not possess, in the ingenious 
 process proposed by Professor Sanson, a sure means of ascertaining 
 the direction of the pelvis, * and consequently of rectifying the 
 error. 
 
 More difficulty is encountered in mensuration of the chest, than 
 in that of any other portion of the body, on account of its alter- 
 nate movements of dilatation and contraction and its frequent 
 faulty conformation. The object of thoracic mensuration is, to 
 determine whether there exist enlargement or diminution in the 
 volume of either side. The following is the mode of procedure. 
 
 The patient should be seated, the arms separated from the body, 
 and the hands clasped upon the head. The spinal processes of 
 the dorsal vertebrae distinguish the median line posteriorly; a cord 
 drawn from the superior extremity of the sternum to the ensiform 
 cartilage marks it anteriorly. A graduated riband passed from 
 one of these points to the other, across each side of the thorax, to 
 the level of the nipple in the male, and just beneath the mamma in 
 the female, enables us to ascertain accurately the comparative size 
 of the two sides of the chest, in the alternate movements of in- 
 spiration and expiration. Tn aid of this process, which should be 
 repeated at suitable intervals, the physician should follow out the 
 changes induced by certain diseases in the volume of the chest, 
 particularly by pleurisy with eifusion. 
 
 This kind of mensuration, however, is not always sufficient for 
 the appreciation of alterations in the volume, and, particularly, the 
 capacity of the thorax. In some cases, indeed, where circular 
 mensuration detects no difference in the extent of surface, simple 
 inspection will show considerable antero-posterior depression of one 
 side, and by means of the graduated callipers, and particularly 
 the instrument which we have constructed for this purpose, f a 
 difference of from an inch to fifteen lines in the antero-posterior 
 diameter of the two sides may be detected, and, what is of more 
 
 * This process consists in letting fall, from the upper part of the body to the 
 pubis, a vertical line represented by a cord reaching from the superior notch of the 
 sternum, to the symphysis pubis, and crossing another cord extending from one 
 anterior superior spinous process of the ilium to the other. Before measuring 
 the limbs, we should so place the pelvis, as that the cords shall cross at right 
 angles. 
 
 f This instrument, which is very similar to that used by shoemakers for meas- 
 uring the foot, differs from it in having upon each of its branches, a movable 
 plate ten or twelve lines in breadth, which, resting with a broad surface upon the 
 chest, cannot, like the branch of the instrument, be alternately placed upon an 
 intercostal space and a prominent rib, which condition would alter the results of 
 mensuration and might lead to erroneous conclusions. 
 
DIAGNOSIS. 285 
 
 importance, it reveals a far greater change in the capacity of the 
 thorax, than that occurring in cases where the extent of surface, 
 only, is diminished. These two modes of exploration have ena- 
 bled us to ascertain two facts, of considerable interest in the his- 
 tory of pleuritic effusions : first, that the chest, although much 
 contracted after chronic pleurisy, may regain, in the course of 
 years, its original dimensions ; secondly, that in those cases where 
 one side becomes contracted by reason of the compression and 
 atrophy of the lung therein contained, the other side is enlarged, 
 as if to supply the loss of power in its companion, in conformity 
 with the known laws of pathological physiology. We shall men- 
 tion a single fact, only, in support of each of these observations. 
 
 Dr. D., member of the Faculty of Paris, in the course of a 
 chronic pleurisy of the left side, had dilatation of the side and 
 subsequent contraction, as is observed in the majority of patients ; 
 by means of often repeated circular and an tero- posterior mensura- 
 tion, the various modifications of the conformation of the thorax 
 were followed and appreciated. After several years, it was desir- 
 able to examine anew, in order to judge of the changes gradually 
 wrought by time in the respiratory murmur, which had remained 
 feeble, and also in the conformation of the left side, which, after 
 seven or eight months of disease, was still much contracted. This 
 last examination, made three or four years after the apparent cure of 
 the disease, convinced us that the respiratory murmur had regained 
 its normal type, and what was yet more surprising, that the left 
 side had not only re-attained a size equal to that of the right, but 
 that it had become larger, both in regard to its superficies, circu- 
 larly measured by a riband, and in its antero-posterior diameter, 
 measured by the instrument above mentioned. It is possible that 
 this side may have been originally larger than the right. 
 
 The second fact relates to a phthisical young girl, who was 
 brought to the clinical wards of La Charite with all the signs of 
 pneumo-thorax upon the left side, and in whom suffocation seemed 
 imminent. Liquid effusion succeeded to that of gaseous nature, 
 and its absorption was very gradual; mensuration, at intervals of 
 eight or ten days, established that the right side was progressively 
 dilated, in proportion to the contraction of the left, although the 
 contraction of the latter must have opposed the enlargement of the 
 former. This patient survived the attack of pneumo-thorax, and 
 died two years after, from the gradual progress of phthisis. 
 
 Mensuration of the abdomen is performed with a graduated 
 riband, or with a plain one, upon which the result of each meas- 
 urement is marked with ink. This exploration is particularly 
 useful in abdominal dropsy, where it enables us to appreciate even 
 the slightest modifications in the volume of the abdomen, and to 
 deduce from thence our inferences as to the effect of the treatment 
 employed. It is important, however, to remember that the volume 
 of the abdomen depends both upon the quantity of liquid con- 
 tained in the peritoneum or in a cyst, and upon that of gases and 
 other matters confined in the intestines. The alterations which 
 
286 DIAGNOSIS. 
 
 supervene in the volume of the abdomen, do not, then, give us the 
 exact measure of the existing modifications in the quantity of 
 liquid contained in the abdomen : percussion must concur with 
 mensuration in forming the opinion of the physician in such cases. 
 
 Mensuration is still farther applicable to certain tumors, which 
 are sufficiently superficial to allow of being included between the 
 branches of the callipers ; although little employed, there are cer- 
 tain cases where it may be useful ; a greater degree of precision in 
 the appreciation of the changes which supervene in the volume of 
 these tumors, furnishes prognostic and therapeutical indications 
 which should not be neglected. 
 
 Finally, mensuration becomes a valuable means in the appreci- 
 ation of the pelvic diameters, especially the antero-posterior, whose 
 extent it is very important accurately to ascertain, with reference 
 to parturition, particularly in deformed females. Several instru- 
 ments invented for this purpose and called pelvimeters,* have 
 been abandoned; the index finger is to be preferred, introduced to 
 a sufficient depth into the vagina, to reach with its extremity the 
 sacro-vertebral angle, while its base rests beneath the symphysis 
 pubis ; we can thus estimate this diameter within one or two lines. 
 
 6. Percussion. Percussion is that mode of exploration whose 
 special purpose is to ascertain the degree of resonance presented 
 by various parts of the body. It is by a species of percussion, 
 likewise, that we obtain that internal impulse, caused by a sudden 
 shock communicated to a liquid confined in a natural or accidental 
 cavity {fluctuation), or to a mass of hydatids enclosed in a cyst 
 (hydatic fremitus) ; but it is the first kind of percussion only, 
 which will be here considered. 
 
 From the earliest times of medicine, percussion seems to have 
 been employed in examinations of the abdomen : the term tympa- 
 nitis, applied by the Greek physicians to considerable gaseous 
 distension of the abdomen, puts it beyond a doubt that they had 
 noticed, by means of percussion, the increase of resonance in this 
 region. The utility of percussion, however, was then but limited : 
 it barely sufficed to distinguish between dropsy and tympanitis. 
 For this reason, Avenbrugger has very generally and justly been 
 considered the inventor of this mode of exploration, which he was 
 the first to apply to the study of thoracic diseases. Since the pub- 
 lication of his work, in 1763, and especially since its translation 
 into French by the celebrated Corvisart (1808), percussion has 
 become one of the most employed and most useful of diagnostic 
 means : every day has added to its importance, either because it 
 
 * A new and very simple pelvimeter has been contrived, consisting of two pieces 
 of wood, each one eighth of an inch square and eight inches long, fastened 
 together in the centre by a pivot, so as to form a cross with equal legs. The 
 lower extremity of one of these legs has a graduated transverse bar attached, 
 upon which the other leg traverses. Thus, whatever space is ascertained by the 
 expansion of the upper legs of this double compress, is marked by the separation 
 of the lower. All that is required, therefore, is to introduce the upper end, 
 closed with the finger, and to open it when in the pelvic cavity. (Medical 
 Gazette, Oct. 30, 1846). TRANS. 
 
DIAGNOSIS. 287 
 
 has been more carefully studied and more extensively applied, 
 or because the discovery of auscultation has given more precision 
 to the value of the signs furnished by percussion. Finally, by the 
 recent labors of many physicians, and particularly of M. Piorry, 
 percussion, applied to the observation of abdominal disease, has 
 furnished a new series of very useful diagnostic signs. (See 
 page 151). 
 
 In order thoroughly to appreciate the changes wrought by dis- 
 ease in the resonance of the thorax, the physician should be aware 
 that there is great variation in regard to the degree of resonance 
 in different individuals, and that, in the same individual, percus- 
 sion furnishes different results, according to the parts of the chest 
 upon which it is practised. Broad chests, clothed with voluminous 
 muscles, give, most generally, an obscure sound on percussion, 
 whatever portion may be examined. In very thin persons, on 
 the contrary, the chest resounds clearly, and is almost tympanitic 
 throughout. In all cases the resonance of the thorax varies ac- 
 cording to the regions : it is more clear beneath the clavicles, in 
 the axillary regions and in the lateral portions ; less so over the 
 scapulae and in the prgecordial region ; the latter returns an obscure 
 sound, over a surface of from one and a half to two square inches, 
 which indicates the space where the heart remains uncovered by 
 the lungs ; but in some persons, the heart, deeply situated in the 
 mediastinum, has its anterior surface entirely covered by the lung, 
 and percussion, practised upon the cartilages of the fifth and sixth 
 ribs and the lower part of the sternum, gives an entirely clear 
 sound. Below the heart, the thoracic resonance usually becomes 
 clearer than anywhere else, which is owing to the presence of the 
 stomach and its gaseous contents ; on the right side, in a corres- 
 ponding point, the sound is dull, which is referable to the liver. 
 It has been said that the resonance of the right side was of deeper 
 tone by reason of the greater volume of the lung ; but we do not 
 consider this difference sufficiently established. 
 
 Percussion has long been practised, directly, with the palm of 
 the hand, or with the extremities of the fingers. This mode of 
 percussion has the disadvantage of causing some pain, particularly 
 in the mammary and abdominal regions, and it has become the 
 practice to interpose some substance between the hand used in 
 percussion and the part percussed, thus diminishing the pain, 
 while the degree of resonance is the same or even increased. The 
 latter kind of percussion is called mediate, the former immediate. 
 Many instruments have been devised for mediate percussion. An 
 ivory plate with projections, so that it may be firmly held (plezi- 
 meter), a piece of silver, or of caoutchouc, have all been proposed; 
 but we prefer the index finger of the hand not used in percussion, 
 (and this is usually the left,) because it can be better applied to the 
 chest, and causes less noise than either ivory or metal, and also, 
 because, as a general rule, the physician should not have recourse 
 to instrumental aid, except in cases where the hand is insufficient. 
 It has been suggested that the finger which serves as an interme- 
 
288 DIAGNOSIS. 
 
 diate body, be placed in supination, in order to percuss upon the 
 softer palmar portion, which is less sonorous than the dorsal por- 
 tion : we regard this modification as of little consequence, and 
 employ the ringer either in supination or pronation, according to 
 the patient's position, without remarking any appreciable differ- 
 ence in the results obtained. 
 
 Whatever mode of percussion be preferred, certain rules should 
 be observed in its practice. 
 
 It is a precept of general application in all modes of exploration, 
 to commence by an examination of parts somewhat remote from 
 the supposed seat of disease ; this rule is equally applicable to 
 pressure, palpation, percussion arid auscultation : a previous exam- 
 ination of healthy parts admits of more accurate appreciation of 
 the alterations, sometimes but slight, which take place in diseased 
 parts. There are, however, some exceptions, and if the patient 
 submitted to percussion or auscultation of the chest, be so feeble that 
 he can with difficulty assume a sitting posture, even for a few 
 seconds, it is preferable to examine the affected side first, lest syn- 
 cope might prevent a more extended examination. 
 
 When either percussion or auscultation are practised, the patient 
 should be in a quiet room, and those -present should remain mo- 
 tionless and silent. 
 
 The parts subjected to percussion should be bare, or only very 
 thinly clothed. The patient should be in a sitting posture during 
 percussion of the thorax ; the dorsal decubitus is suitable in percus- 
 sion of the abdomen, and is admissible, also, for the front chest. 
 The arms should be maintained in similar positions, hanging by 
 the sides of the body, when we percuss in front or behind ; raised, and 
 the hands clasped upon the head, when the lateral regions are per- 
 cussed. The physician may stand indifferently on the right or left 
 of the patient for percussion of the abdomen ; for that of the thorax, 
 his position should be such as will enable the ringers of the most 
 practised hand, which is usually the right, to strike at right angles 
 and with uniform force upon corresponding points of the chest, on 
 each side, either anteriorly or posteriorly ; this is one reason for 
 desiring persons who are not ill enough to be confined to bed, to 
 sit on a chair when examined. If the results are at all doubt- 
 ful, we should percuss comparatively, standing alternately at the 
 right and left of the patient, and employing both mediate and im- 
 mediate percussion. 
 
 It is generally best, in children and thin persons, to employ medi- 
 ate percussion, with a single finger : the medius is preferable, which, 
 by its greater length, naturally extends beyond the others. If the 
 thoracic integuments are of considerable thickness, and especially 
 if there be much adipose tissue, a greater degree of force will gen- 
 erally be necessary, and two fingers, as the medius and index 
 united, should be employed, and sometimes, even all the fingers joined 
 together and forming a line. Percussion should be gentle at first, 
 being thus less painful and disagreeable to the patient, and also 
 because, in this way, the sound caused by the percussing finger 
 
DIAGNOSIS. 289 
 
 is nearly null, and the internal resonance more easily appre- 
 ciated. The force with which we percuss, may gradually be 
 augmented, until we attain that degree which gives the most 
 marked results. 
 
 Should nothing indicate existing lesions within the thorax, we 
 limit our percussion of its several regions to three or four points ; if 
 we have any reason to fear concealed lesion, we should percuss 
 much more frequently, and not renounce the idea of discovering 
 some disorder, until we have examined, not only by percussion, but 
 by auscultation, nearly every point of the thoracic surface. 
 
 Abdominal percussion is generally practised by tapping with 
 the medius of the right hand upon the index finger of the left, 
 which is made to glide successively from above downwards over 
 the abdominal parietes, from the ensiform cartilage to the pubis. 
 and from the margin of the ribs, on each side, to the ossa ilia. 
 The resonance of the abdomen, like that of the chest, varies, in 
 health, according to the thickness of the integuments and the flesh 
 of the patients, and also according to the amount of gas contained 
 in the alimentary canal, which may vary very much without consti- 
 tuting a morbid condition. The resonance of each abdominal 
 region is generally proportionate to the diameter of the organs 
 containing the gaseous fluid : in the normal state, the stomach 
 gives the clearest sound on percussion, and the large, are more re- 
 sonant than the small, intestines. 
 
 Abdominal percussion, in disease, conjointly with palpation 
 and pressure, furnishes a great number of important signs. In 
 cases of general distention of the abdomen, it assists us in ascer- 
 taining whether the swelling be owing to an accumulation of gas 
 in the intestinal canal, to liquid effusion, or to a large, solid tumor 
 entirely filling the cavity. In the first case, there is increased, in 
 the two others, diminished, resonance : in one of the latter cases, 
 fluctuation reveals liquid effusion ; in the other, the absence of 
 fluctuation and the greater resistance to pressure declare the exist- 
 ence of a solid abdominal tumor. 
 
 In cases where the abdomen presents only a partial tumefaction, 
 percussion upon such a point, when a clear sound is returned, indi- 
 cates that the swelling is owing to gaseous distention of a portion 
 of the intestinal tube : when the sound is flat, the presence of a 
 solid tumor or liquid effusion may be suspected as the cause, and 
 in certain cases where there is a medium and variable resonance, 
 a fold of intestine may be contained in the tumor, without consti- 
 tuting it entirely. Percussion, in conjunction with other modes of 
 exploration, assists the diagnosis of peritoneal effusions, of tumors 
 formed by the uterus and ovaries in females, by the bladder, 
 spleen and liver in both sexes, and reveals the alterations effected 
 by time and remedies in the course of these diseases. 
 
 Percussion, while it allows the ear to distinguish important mod- 
 ifications in the degree of resonance of diseased parts, imparts, 
 also, a peculiar sensation to the finger, which may be valuable in 
 certain cases. Thus, according to the observations of M. Piorry. 
 25 
 
290 DIAGNOSIS. 
 
 when a multilocular ovarian cyst exists in the abdomen, whose 
 compartments contain various substances, each of them may pre- 
 sent a different degree of resistance to the ringer, and this phenom- 
 enon concurs with pressure and palpation in the determination of 
 the seat and nature of the tumor. 
 
 7. Auscultation. Auscultation is that mode of exploration whose 
 purpose is to ascertain, by the mediate or immediate application of 
 the ear to different parts of the healthy or diseased body, the 
 various sounds which may be produced, and to appreciate their 
 semeiological value. 
 
 Auscultation was at first applied by its inventor to the study of 
 thoracic affections only, and we have previously seen (pp. 138, 166), 
 what a number of important signs it has furnished in the diag- 
 nosis of diseases of the lungs, heart, and their respective envelopes. 
 But Laennec himself was aware that it might be extended to 
 other affections, especially to certain diseases of the middle ear, 
 the Eustachian tube and the mastoid cells. Subsequently, a number 
 of English physicians declared its utility in certain cases of peri- 
 tonitis with formation of false membranes. MM. Mayor of Ge- 
 neva, Kergaradec, and afterwards M. Paul Dubois and the younger 
 Noegele, have published interesting researches upon the application 
 of auscultation to the study of pregjnancy, and of certain condi- 
 tions of the foetus during intra-uterine life. Finally, some sur- 
 geons have declared, that in those deep-seated fractures where 
 crepitation was doubtful, and in cases of urinary calculi where 
 the shock of the sound against the foreign body communicated 
 only an obscure and doubtful sensation, they could, by means of 
 auscultation, distinctly hear the collision of the bony fragments and 
 the light touch (frolemenf) of the catheter against the surface of 
 the calculus. * 
 
 Auscultation may be practised in two ways : either by the in- 
 tervention of the acoustic instrument known as the stethoscope 
 (mediate auscultation) ; or by the direct application of the unassist- 
 ed ear to the parts we would examine (immediate auscultation). 
 
 Mediate auscultation was the only method advised and practised 
 by Laennec, who found inconveniences in immediate auscultation 
 
 * The application of auscultation to the diagnosis of cerebral disease, was first 
 introduced to the profession in 1834, by Dr. Fisher, of Boston. Subsequent and 
 more extended researches led him to announce the existence of an encephalic 
 bellows murmur in many cases of apoplexy and fracture of the skull, in addition 
 to the diseases wherein it was first declared to be evident, viz., acute and chronic 
 meningitis, encephalitis, during the accidents of dentition and in pertussis. The 
 conclusions drawn by Dr. Fisher from his researches are the following : 1. The 
 encephalic bellows murmur does not exist in the normal state of the encephalon. 
 2. It may be easily distinguished from the other sounds heard while ausculting the 
 head, as the sound produced by the passage of air through the nares, by degluti- 
 tion, locution, and the cardiac pulsations. 3. Its seat is the arterial trunks at the 
 base of the skull, when they are compressed by the brain ; as occurs in effusion, 
 or in inflammatory increase of volume of the organ. The calibre of the arteries 
 being diminished, the circulation is impeded, and this, in addition to the resulting 
 increase of friction, is the source of the bellows murmur. (See American Jour- 
 nal of the Mtdical Sciences. August, 1838.) TRANS. 
 
DIAGNOSIS. 291 
 
 which seem to us fictitious.* In the last edition of this work, we 
 asserted, that in our own experience, immediate auscultation had 
 presented the same exactitude, in its revelations of the various 
 auscultatory phenomena, as that by means of the stethoscope, even 
 when employed by the most skilful. Fifteen years of observation 
 have confirmed this opinion more and more, and it is entirely 
 proved, that all the modifications of the respiratory murmur, and 
 all the rales and abnormal sounds of which the lungs, heart and 
 their enveloping membranes may be the seat, are as appreciable by 
 the unassisted ear, as by the aid of the stethoscope. A certain de- 
 gree of practice is requisite in both these methods of exploration ; 
 but skill is far more easily acquired in immediate than mediate 
 auscultation. One who accustoms himself to the stethoscope, hears 
 with more difficulty when he uses the unaided ear ; another, (and 
 this is our experience) more familiar with immediate auscultation, 
 appreciates far better, by its means, the phenomena arising from 
 the respiration, voice, and movements of the heart. But, supposing 
 these two methods to be the same, should we not prefer the most 
 simple 1 
 
 Immediate auscultation presents still other advantages : 1. It 
 requires less time, which, indeed, is of little importance in ordinary 
 cases, but is not to be disregarded in those where the debility of 
 the patient barely allows him to retain, even for a few minutes, the 
 sitting posture, a circumstance of frequent occurrence. 2. The atten- 
 tion of the physician is not divided between maintaining the stetho- 
 scope in exact application to the parts he is examining, and the 
 appreciation of the phenomena which he studies ; it is not impossi- 
 ble, especially in the case of those who have not acquired great skill 
 in the use of the stethoscope, that this instrument, being improperly 
 applied, may lead the observer into error in regard to the phenom- 
 ena which he is desirous of studying, while immediate ausculta- 
 tion would present no such difficulties. 
 
 * Immediate auscultation is equally inconvenient for the physician and the pa- 
 tient ; disgust, alone, renders it impracticable in hospitals ; it is hardly to be 
 thought of with the majority of females, and in some, the size of the mammae is 
 a physical obstacle to its employment ; these are Laennec's objections 
 
 To this we reply : 1. Immediate auscultation is less inconvenient for the phy- 
 sician than mediate, by reason of the firm support which the patient's chest affords 
 the head ; it is less painful for the patient, for the pressure of the ear is softer 
 than that of a wooden instrument ; 2. Disgust does not render any mode of ex- 
 ploration impracticable; it is also completely conquered by habit. 3. Immediate 
 auscultation may be practised with such propriety that no reasonable female would 
 object to it. 4. Considerable volume of the mammae is quite as great a hindrance 
 to the employment of the cylinder, as to that of the ear. 5. Lastly, to a final 
 objection offered by Laennec, viz. " that all the parts of the observer's head, 
 which touch the thorax, becoming so many conductors of sound, might cause the 
 respiratory murmur to be heard in cases where it did not exist in the part situated 
 directly beneath the ear, which might occasion serious error," we reply, that in 
 no case have we seen this supposition realized, and that the most circumscribed 
 lesions of the lungs have seemed to us as easily distinguished by the unaided ear, 
 as by means of the stethoscope. In conclusion, we add, as confirmatory of our 
 opinion, that, at present, the great majority of practitioners only use the stetho- 
 scope in those cases where there exists an obstacle to immediate auscultation. 
 (See p. 292 ) 
 
292 DIAGNOSIS. 
 
 There are, however, some cases where mediate auscultation is 
 preferable. In the examination of an cedematous chest, the pres- 
 sure of the stethoscope displaces the serosity and enables us better 
 to appreciate the phenomena of auscultation. At other times, the 
 form of the parts prevents the accurate application of the ear, and 
 renders immediate auscultation impracticable. In some phthisical 
 patients, for instance, where the emaciation is excessive, the con- 
 siderable prominence of the clavicle and acromion process of the 
 scapula does not admit the application of the ear to the thoracic 
 parietes in the hollow circumscribed by these bones. The same is 
 true in certain cases of rachitis, where, by reason of deformity of 
 the thorax, the stethoscope alone can be employed ; such is also 
 the case, and for analogous reasons, in auscultation of the arteries ; 
 for if we except the cceliac axis and the arch of the aorta, to 
 which the ear can, if necessary, be directly applied, we must use 
 the stethoscope for all the others, either with or without its sup- 
 plementary portion, or plug (enbout). Too strong pressure upon 
 the artery with this instrument should be avoided ; its effect would 
 be to produce a bellows murmur in the vessel, which would 
 simulate a morbid sound. 
 
 Mediate or immediate auscultation is practised as follows : 
 
 In the first place it is more convenient entirely to uncover the 
 part about to be examined ; the interposition of linen alone is not, 
 usually, any obstacle to this sort of exploration ; indeed, we some- 
 times observe that certain thick articles of clothing, and those 
 doubled, do not always prevent the perception of auscultatory 
 phenomena. We have often appreciated these phenomena with 
 great accuracy through the thick garments worn in the cold season, 
 and also, through linseed cataplasms entirely enveloping the tho- 
 rax in children. On other occasions, the contrary is observed, 
 and very thin clothing, as the corsets in females, or the starched 
 shirt-bosom in males, almost wholly prevents the perception of 
 phenomena afforded by auscultation. As a general rule, when 
 nothing opposes, it is better to auscult the bare surface. 
 
 It is equally necessary, in order to the exact perception of aus- 
 cultatory phenomena, that the muscles, interposed between the part 
 examined and the ear of the observer, be entirely relaxed ; their 
 contraction might have the double disadvantage of altering the 
 transmission of the sounds we wish to study, and of mingling with 
 them other sounds arising from the muscular contraction itself. 
 
 In mediate auscultation, the stethoscope should be held like a 
 pen, the hand being placed very near the part to be examined, in 
 order to be sure that the instrument is accurately applied. If the 
 patient be in bed, he should lie upon the back or assume a sitting 
 posture, and the anterior parts of the chest should be examined in 
 this position, the auscultator standing alternately upon each side 
 of the bed ; in the examination of the lateral portions and axillary 
 regions, the patient should be inclined to the opposite side ; in that 
 of the back, he should sit up in bed, the body slightly bent for- 
 ward, the arms folded, and the back turned toward the examiner. 
 
DIAGNOSIS. 293 
 
 If the patient be sitting up, it is better to rest upon one knee than 
 to stoop, in the examination of the anterior and lateral parts of the 
 chest. 
 
 Tn immediate auscultation, the patient should be sitting, either 
 in bed, or upon a chair ; the physician, standing beside him, applies 
 the same ear successively over the whole anterior thoracic region, 
 to the right and left, at corresponding altitudes ; the right ear 
 should be employed if he stand on the patient's left hand, the left, 
 if on his right, so that the slightest difference presented by the aus- 
 cultatory phenomena in corresponding points of the lungs or pleu- 
 rae may not escape observation. The patient's arm being next 
 held in an elevated position, the physician applies his ear to the 
 axillary space of the same side and to different parts of the lateral 
 thoracic region ; he passses to the other side to examine the dor- 
 sal region, the opposite axilla and corresponding side of the chest. 
 
 Acuteness of the sense of hearing is an important condition in 
 the practice of auscultation, and the inequality of this sense, in the 
 two ears, may be very troublesome to the auscultator, especially 
 when the phenomena are indistinct. On this account, when both 
 ears are not equally sensible of sound, (and this is perhaps the 
 most common case,) the physician should employ exclusively the 
 most acute in auscultation, and for this purpose he should stand 
 successively on the right and left of the patient, so that he may 
 examine with the same ear the anterior and posterior thoracic re- 
 gions. 
 
 Whatever be the mode of auscultation employed, the respiration, 
 cough and voice are successively examined, in all the points to 
 which the ear or the stethoscope is applied. We generally com- 
 mence by listening to the natural respiratory murmur, that is, the 
 patient respiring in his usual manner and with no more than ordi- 
 nary muscular force and rapidity. We thus ascertain the strength 
 or feebleness of the respiratory sound, whether it be soft, or rude 
 in character, and the rales by which it is accompanied in the alter- 
 nate movements of inspiration and expiration, whose duration also 
 is observed. If we do not distinctly perceive the respiratory 
 murmur, we desire the patient to breathe more fully or rapidly^ 
 as if sighing; also, to cough, for, in certain cases, it is only during 
 the long inspirations which precede, or follow the cough, that we 
 distinguish the fine, dry crepitus, or the bronchial respiration of 
 pneumonia. One or two questions should be asked him, that we 
 may ascertain whether the voice have a ringing character. In 
 auscultation of the anterior thoracic region, the patient should be 
 desired to turn the head away from the auscultator. This pre- 
 caution always has the advantage of avoiding the inhalation of his 
 breath, and facilitates auscultation of the voice. It is absolutely 
 necessary in immediate auscultation of the anterior and superior 
 thoracic regions, it being very inconvenient to apply the head to 
 those parts, except the patient turn his own in the opposite direc- 
 tion. 
 
 8. Exploration with Sounds and Probes. Sounds and probes 
 25* 
 
294 DIAGNOSIS. 
 
 have always been employed in tracing the course of fistulous 
 ulcers, and the lesions of parts situated beneath these fistulas, par- 
 ticularly the bones and cartilages; it is by means of metallic 
 sounds, also, introduced into the bladder, that we discover the pres- 
 ence of calculi, a shock being transmitted, by means of the instru- 
 ment, to the hand which directs it. For the purpose of ascertain- 
 ing the form, degree, and exact seat of strictures in the urethra, 
 soft bougies have been introduced, capable of receiving and retain- 
 ing the form of the parts with which they are for a time kept in 
 contact, and it has been supposed that the resulting impressions 
 represent accurately the lesions existing in the urethra. But expe- 
 rience has shown that this mode of exploration does not merit all 
 the confidence which some surgeons have too hastily ascribed to 
 it. Flexible sounds are still employed in certain diseases of the 
 rectum and oesophagus, for the discovery of foreign bodies or stric- 
 tures not within reach of the finger. But the signs which may be 
 deduced from tfie difficulty experienced in passing these instru- 
 ments, have less value than those furnished by the introduction of 
 the finger. 
 
 9. Exploration by Specula. Various instruments have been 
 imagined for the examination of deep-seated organs, to which the 
 name speculum * has been given : their purpose is to enable the 
 physician, bbth to discover, by the eye, the many alterations which 
 without their aid would be inaccessible to vision, and also to ap- 
 ply to the diseased parts the different remedies required. 
 
 Specula generally consist of hollow cylinders, with or without 
 the central shaft intended to render their introduction more 
 easy, and which is removed after the instrument itself is intro- 
 duced. This shaft is indispensable when the speculum is used 
 for the examination of a passage closed by a sphincter, as the rec- 
 tum; it has hardly any advantage in the contrary case, especially 
 in examinations of the vagina and uterus. The form of specula 
 has been almost infinitely varied, but these numerous varieties 
 depend upon two principal conditions; one class are made entire, 
 and represent a conic cylinder, others consist of several pieces, 
 tvhich glide upon one another so that the instrument may be as 
 small as possible when introduced, and that after its introduction 
 it may be so far expanded as is compatible with the construction 
 of the parts to be examined, and as much as the examination de- 
 mands. The four-bladed speculum seems to us far preferable to 
 all the others in examinations of the uterus, and even of the rec- 
 tum ; it has. moreover, this advantage, that we can, if necessary, 
 detach one or two blades, for the better inspection of one side of 
 the passage we examine. The two-bladed speculum is nearly ex- 
 clusively used for the auditory canal. It is of great service in the 
 diagnosis of various affections of which the tympanum is the seat. 
 It has the advantage of straightening the curves of the meatus au- 
 ditorius externus, and rendering more easy and complete an 
 
 * Mirror. 
 
DIAGNOSIS. 295 
 
 examination, which might, it is true, be made without the instru- 
 ment. 
 
 The speculum intended for exploration of the rectum (speculum 
 ani), is but rarely employed ; its introduction is generally painful, 
 and the impossibility of giving a sufficiently large diameter for 
 the requisite admission of light to the parts exposed, without caus- 
 ing too severe suffering to the patient, restricts the number of cases 
 in which it is useful, to those in which the disease is near the 
 anus ; the vegetations, fissures or perforations so often occurring 
 in this portion of the intestine, can be observed by means of this 
 instrument. 
 
 In uterine affections the speculum is far more frequently used, 
 and its application is much more advantageous. The diagnosis of 
 diseases of the cervix uteri has been much facilitated by its em- 
 ployment; lesions of this part can thus be appreciated by the eye, 
 arid their progress traced as readily as that of external affections. 
 Granular nietritis, a very frequent and unimportant disease, ranked 
 by some surgeons (quite improperly, as we think) among the 
 most dangerous of uterine diseases, under the term ulcer at ions, 
 remained nearly unknown until the period when the speculum 
 was employed. By means of this instrument, certain small, red 
 agglomerated elevations have been discovered around the margin 
 of the uterine orifice, forming by their union a circular or oval 
 patch, well circumscribed, resembling the raspberry in color and 
 inequality of surface, and very easily distinguished by these two 
 conditions from the healthy portion of the os tincae. Since the dis- 
 covery of this affection by the speculum, the touch, previously un- 
 able to appreciate it, has furnished us with a sign by which, at 
 present, we succeed in recognizing, or at least, are led to suspect 
 it. If, when examining the surface of the os tincae with the ex- 
 tremity of the finger, we find, within and around the uterine 
 orifice, a soft and somewhat uneven surface, imparting a sensa- 
 tion comparable to that occasioned by touching the fabric known 
 by the name of Utrecht velvet, while the eccentric portion of the 
 os tincse is firm and smooth, the existence of this granular affec- 
 tion can hardly be doubted, and we should immediately ha^e 
 recourse to the speculum to verify the diagnosis. The speculum 
 enables us, moreover, to ascertain the nature of the liquid, fre- 
 quently viscous and transparent, which escapes from the uterine 
 orifice; we can also perceive, (especially it' the instrument be 
 slowly withdrawn and sufficiently expanded,) the alterations in 
 the color, surface, and secretions of the vaginal mucous membrane. 
 
 The introduction of the speculum into the rectum and vagina, 
 requires certain precautions. Previous examination of the parts 
 should be made with the finger, and in those cases only where 
 this first examination has revealed, or led us to suspect certain 
 lesions, and no obstacle to the introduction of the speculum exists, 
 is it advisable to proceed to one which is yet more repugnant to 
 the patient. The cerate carried by the finger into the rectum or 
 vagina, renders the introduction of the speculum more easy, and 
 
296 DIAGNOSIS. 
 
 this instrument is guided more accurately and carefully towards 
 the diseased part when the finger has already ascertained the seat, 
 and, in some instances, the nature, of the affection. It is hardly 
 necessary to add, that a considerable contraction of the vagina or 
 rectum would be an obstacle, and sometimes a complete one, to 
 this sort of exploration. In the examination of the uterus, the po- 
 sition of the cervix being ascertained and sometimes rectified by 
 means of the finger, the physician is more confident in regard to 
 the direction which should be given to the speculum. If the touch 
 discover cancerous degeneration of the vaginal or rectal parietes, 
 we should abstain from introducing the speculum, or should use it 
 with great circumspection ; for there are cases in which the dis- 
 eased parts are so softened or attenuated, that the introduction of 
 the instrument, and particularly the development of its valves, 
 might cause a rupture whose consequences would be exceedingly 
 serious. 
 
 In all cases, even when the touch has not revealed any serious 
 lesion of the parts into which the speculum is introduced, we should 
 proceed to this examination methodically and carefully. The ex- 
 ternal surface of the instrument, and above all, its extremity, as 
 well as the central shaft, if thought necessary, must be covered 
 with a thick coating of cerate or some other unctuous substance. 
 In examination of the rectum, the patient should lie upon the side : 
 care should be taken in the introduction of the speculum that it be 
 effected slowly and at a moment when the sphincter is relaxed. 
 
 In uterine examinations, the dorsal decubitus is preferable, the 
 thighs should be flexed and separated, and the feet should rest 
 upon a support some inches lower than the pelvis. In introducing 
 the speculum, we should press moderately against the perinatal 
 surface of the vagina, until it passes the pubic arch ; the trans- 
 verse line formed by the contact of the two vaginal parietes, which 
 are seen in front of the instrument, indicates the direction which 
 should be given to it. This line, receding before the instrument, 
 conducts it to the os tincse, which is easily recognized by its rounded 
 form and the absence of the rugae presented by the vaginal pa- 
 rjptes. The blades of the speculum should then be gradually ex- 
 panded, taking care that they do not touch the os tincae, whose 
 surface might be lacerated by them, and this organ comes fully 
 into view at the extremity of the vagina. The mucus which fre- 
 quently covers it may then be removed with pledgets of lint, 
 applied by means of long forceps, and its color, form and volume, 
 readily ascertained. If the day be dark, a candle may be placed 
 before a teaspoon, whose concave surface will act as a reflector. 
 
 Exploration of far more deeply seated parts, has been attempted 
 by means of very complicated specula : among these are the in- 
 strument proposed by Bambolzini, for the examination of deep 
 cavities, particularly the stomach, and that invented by a mechan- 
 ician affected with ulceratioii of the larynx, to enable his physi- 
 cian, M. Trousseau, to inspect the cavity of this organ; that 
 proposed by M. Segalas for the urethra and bladder, to ascertain 
 
DIAGNOSIS. 297 
 
 the state of the mucous membrane and the actual existence of 
 calculus, is of the same description. Hitherto, however, these 
 ingenious inventions have remained nearly inapplicable. 
 
 10. Examinations with the Microscope and Magnifying Glass. 
 Although the unassisted eye suffices, in most cases, for the observa- 
 tion of pathological phenomena we cannot doubt that the aid of 
 those instruments, intended either to magnify very small objects, 
 or to render visible, bodies wholly imperceptible to ordinary vision, 
 possesses in all cases a certain degree of interest, and must, in 
 some instances, furnish useful results. 
 
 We have previously seen that the microscope was necessary for 
 the discovery of certain substances contained in urinary deposits, 
 and for the determination of their nature. It may be equally 
 useful in appreciating certain alterations of the milk or of the 
 blood corpuscles, and, especially, the presence of pus in the latter 
 liquid, when the precaution has been taken to prevent its coagula- 
 tion by depriving it of its fibrine. But it should be remembered that 
 the microscope requires long practice ; this explains the often con- 
 tradictory results obtained by different observers. For this reason 
 we should not admit any observations as exact, unless they are 
 verified a certain number of times ; and by various persons accus- 
 tomed to these researches. 
 
 The magnifying glass (loupe) is more easily and generally 
 employed : it enlarges objects sufficiently to enable us to recognise 
 the presence of the acarus scabiei, and, of course, the head of the 
 tape worm. With this instrument, also, certain superficial erosions 
 of the cornea may be perceived, and the species of some cutaneous 
 affections, about to declare themselves, be determined at their 
 commencement, etc. 
 
 11. Employment of Chemical Reagents in the Diagnosis of 
 Disease. There are some affections whose diagnosis is impossible 
 without the aid of chemical agents : such is diabetes mellitus ; and, 
 also, that disease of the kidneys, in which the urine becomes albu- 
 minous. The assistance of chemistry is necessary in these cases, 
 not only to determine the nature of the disease, but also to follow 
 it in its progress, and appreciate the changes effected in its inten^ 
 sity by time and remedies, and finally, to verify, in some cases, 
 the complete disappearance of a malady too often rebellious under 
 every kind of treatment. 
 
 Among the diagnostic aids borrowed by medicine from chem- 
 istry, there are some easily employed, and whose application should 
 be familiar to every physician : such are tournesol * and turmeric 
 paper, for determining the acid or alkaline quality of liquids, and 
 nitric acid for detecting the presence of albumen in the urine, or 
 for precipitating the coloring matter held in suspension by the bile. 
 When, on the contrary, it becomes necessary to undertake a series 
 of experiments which require much time and great experience, it is 
 both proper and indispensable to entrust such researches to persons 
 who have paid particular attention to these branches. 
 
 * Heliotropium Europaeum. TRANS. 
 
298 DIAGNOSIS. 
 
 Having stated the principal means of exploration which the 
 physician should thoroughly understand in order to diagnose dis- 
 ease, we shall in the next place describe the proper mode of exam- 
 ining patients. 
 
 $ III. Proper Manner of examining and interrogating Patients, 
 for the purpose of Diagnosis. When visiting a patient for the 
 first time, the physician should commence by a rapid general 
 examination. If the patient be up, his attitude and gait are the 
 first objects of attention ; if he be in bed and nothing prevent, it 
 is of service to uncover him completely, in order better to appreci- 
 ate his strength, flesh, stature, and the various phenomena afforded 
 by external appearance, such as certain eruptions, mutilations and 
 deformities. This first examination is almost always sufficient for 
 the recognition of recent or chronic diseases, and, in some cases, 
 even for concluding that an acute has supervened upon a chronic 
 affection. If, for example, we visit a patient at mid-day and ob- 
 serve that redness of the face, increased heat, frequent pulse and 
 prostration which belong to acute disease, the existence of this 
 complication is, at any rate, very probable. 
 
 Successive examination of the various regions of the body may 
 furnish very important signs, not only in external, but also in in- 
 ternal affections. In external diseases, simple inspection of the 
 affected part is often sufficient to establish the diagnosis. In 
 certain general affections, as scorbutus, syphilis, etc., the ecchy- 
 moses, pustules, maculae and exostoses inform us, at a glance, of 
 the nature of the disease. Cicatrices, also, deserve special atten- 
 tion, particularly when they occupy the superior cervical and the 
 inguinal regions. The former are almost always the result of 
 scrofulous tumors : the latter of a syphilitic bubo which has sup- 
 purated. The existing disease may have some connection with 
 one or other of these affections, and it is so much the more impor- 
 tant that the physician be aware of their former existence, because 
 many patients neglect or voluntarily refrain from mentioning 
 them. * 
 
 If the patient have lost a limb, a finger or one of the phalanges, 
 me physician should never neglect to inquire the cause which 
 rendered the loss of the part necessary. If it were white swelling 
 which required amputation, this circumstance may have great 
 weight in diagnosing an internal affection : if, for instance, the 
 individual who has undergone this operation, present the symp- 
 toms of chronic pulmonary catarrh with emaciation, we should 
 fear the existence of tubercles in the lungs ; if his abdomen be 
 
 * The cicatrix resulting from a burn, a blister or an ulcer of long standing, 
 deserves also the physician's attention, less, perhaps, in a diagnostic than in a 
 therapeutic point of view. It is well known that the suppression of an issue and 
 the healing of a chronic ulcer are often followed by the development of some 
 grave affection, which does not yield except on there-establishment, natural or 
 artificial, of these discharges ; the same is true of the maculae which succeed 
 certain herpetic eruptions. 
 
DIAGNOSIS. 299 
 
 harder and more voluminous than common, if the stools are fre- 
 quent and liquid, it is to be feared that the mensenteric glands are 
 the seat of incurable degeneration. Deformity of a limb or of the 
 nose, etc., require the same questions. The physician should 
 always know whether these deformities are congenital or acquired, 
 and, in the latter case, what is the productive cause. 
 
 When disease of very different character from those ordinarily 
 manifested makes its appearance in an individual with congenital 
 malformation, we should ascertain if this disease existed from 
 birth, or whether it appeared a long time afterwards. In the 
 former case, we may reasonably suppose that the unusual symp- 
 toms complained of by the patient are owing to internal deformity, 
 because observation has taught us that any deformity rarely exists 
 alone : almost always there are several coexistent, and very often 
 a faulty internal organization corresponds to that manifested ex- 
 ternally. 
 
 External appearance, moreover, supplies us with certain other 
 valuable diagnostic signs, in those who work the metals. It is 
 not very uncommon to see patients brought to the hospitals with 
 convulsions, delirium or coma, and consequently unable to give 
 any information relative to the causes of such affections, and in 
 whom the red color of the hair, beard and eyebrows, or the pres- 
 ence of a white powder at the root of the nails, make it almost 
 certain that the illness is caused, in the former, by minium ; in the 
 latter, by carbonate of lead. 
 
 This hasty examination of the exterior of the body,* as we 
 perceive, furnishes valuable diagnostic signs, especially when the 
 physician wholly uncovers the patient. This we never fail to do, 
 after the example of Corvisart and Bayle, in the male wards of 
 the hospitals ; and also in private practice, whenever it is possible. 
 Every one perceives, in part, at least, the advantages resulting 
 from this mode of examining patients ; but in order thoroughly to 
 appreciate them, it must be individually practised for a certain 
 time. We have ascertained that it often enables us to dispense with 
 a multitude of useless questions, and leads, in many cases, to a 
 knowledge of circumstances, which, without its aid, would have 
 remained undiscovered. 
 
 * A new means of diagnosis of the tuberculous diathesis, has been lately an- 
 nounced, derived from the external appearance (habitude exterieure). " When a 
 child is observed with dark irides, colorless cheeks and darkish hair (the eyes 
 often full and large, the eyelashes very long and close together), the forehead cov- 
 ered with close-lying hair, sometimes almost down to the eyebrows, its arms and 
 back from the hair of the head down between the scapulae, quite hairy, the hairs 
 often being very thickly placed and dark in color, cachexia often being coexistent ; 
 in nine cases out often, such a child is tuberculous; either having tubercles 
 already deposited, or liable to have them, in almost every organ of the body, the 
 lungs especially. This hairy condition in a cachectic or unhealthy looking child, 
 is a sign, generally speaking, of a constitution miserable in the extreme, saturated 
 with scrofula." (Dr. Wilshire. Med. Times, April 10, 1847.) Does not the 
 confessedly existing cachexia, detract from the value of the concomitant alleged 
 diagnostic sign, being in itself sufficient evidence of the tuberculous diathesis? 
 Were these " hairy " children always stuffed with tubercles, when not cachectic in 
 external appearance, the above would be an indubitable diagnostic sign. TRA.NS. 
 
300 DIAGNOSIS. 
 
 Simultaneously with this rapid, but still careful external exami- 
 nation, the physician commences his questions. Two important 
 points here present themselves : the mode of questioning, and the 
 order in which questions should be asked. 
 
 When interrogating a patient, the physician should employ those 
 terms only which are easily understood ; he should assure himself, 
 if doubtful, that he has been well comprehended, by repeating a 
 second and even a third time, if necessary, the same question in 
 different terms from those first employed. He should so manage 
 that the patient shall state of his own accord, as far as may be, 
 all that is necessary to learn from him, and, for this purpose, his 
 questions should be such that they cannot be answered by simple 
 affirmation and negation. Without this precaution, the physician 
 renders the patient liable to state his case far otherwise than if 
 he had told it without restraint. 
 
 It is equally necessary for the physician to pursue a regular 
 course in questioning his patients ; otherwise, he exposes himself 
 to forget important questions and to repeat others, at any rate, 
 needlessly, sometimes, injuriously to the patient,* and always to his 
 own disadvantage. We say to his disadvantage ; for the patient 
 who notices this, will think his attention distracted, and from that 
 moment his confidence in him is impaired. The number of ques- 
 tions necessarily varies according to the case. Generally, they 
 should neither be too many nor too few ; it is nearly as important 
 to omit those which can be of no service, as not to neglect those 
 that are necessary ; the physician who wishes to know the minutest 
 details, is more exposed, than another, to neglect essential points, or 
 to forget them after having ascertained them. It is hardly neces- 
 sary to add, that he who has not acquired the habit of seeing and 
 interrogating patients needs to ask a great number of questions in 
 order to form his opinion, while the experienced practitioner often 
 attains this result, by the aid of signs furnished by the external 
 appearance, and from limited information given by the patient or 
 the assistants. So much the more important is it for the physi- 
 cian, on account of his reputation, to proceed methodically in the 
 examination of his patients, because his fellow-physicians form 
 their opinion of him from such grounds. " A physician who listens 
 to the interrogations made by another to a patient, judges imme- 
 diately whether he is well informed ; and if so, he readily sees the 
 reason of each question, why he passes from one to the other and 
 the order in which they are asked. The most thoroughly informed 
 physician," we should rather say, the most skilful, "is he who 
 asks the fewest questions in diagnosing disease." f 
 
 The following has seemed to us the best order to follow in 
 questioning a patient seen for the first time. 
 
 * The patient's interest sometimes requires that the number of questions should 
 be very restricted : in diseases where silence is necessary, and particularly in in- 
 flammations of the respiratory and vocal organs, as in haemoptysis, many ques- 
 tions would always prove injurious. 
 
 f Theses, 1808, No. 138. M. Falvard- Mont-Luc. 
 
DIAGNOSIS. 301 
 
 1. We commence by asking his age, occupation, place of resi- 
 dence, customary diet and usual habits of life ; whether he is 
 habitually in good health or otherwise, and what illness he may 
 have had. These questions are not always useful in diagnosis, 
 but it is sufficient that they may be so in certain cases, to induce 
 us never to neglect them. 
 
 2. We next ascertain the period of commencement of the exist- 
 ing disease ; this should be determined with the greatest possible 
 precision, especially in acute diseases : on this account the physi- 
 cian should rarely content himself with the patient's first replies, 
 particularly in hospital practice. Indeed, the lower classes disre- 
 gard the functional disturbance which occurs during the first days 
 of the disease, and do not consider themselves ill, except from the 
 moment when they have left their work, or abstained from food, 
 or from the day when they experienced severe pain. We must, 
 then, if we would be exact, review all the functions from the day 
 when the slightest disturbance occurred, to the moment of exam- 
 ination. 
 
 In chronic diseases, as we have elsewhere seen, the transition 
 from health to sickness is almost always insensible, and it is often 
 difficult to determine, even approximatively, the period when the 
 disease commences. The external appearance of the patient is 
 then often at variance with his replies ; it announces a disease 
 already of long standing, while he complains only of some days 
 or weeks of indisposition. It is generally easy to form a cor- 
 rect opinion, by asking the patient himself, or those who reside 
 with him, whether previously to the period to which he refers the 
 commencement of his disease, he did not experience some indispo- 
 sition, some diminution of appetite, strength or flesh. 
 
 By the following questions, we endeavor to ascertain if the pro- 
 gress of the disease has been slow or rapid ; if there have been 
 sudden exasperations or gradual increase; if the symptoms have 
 been the same from the invasion; if they have persisted without 
 interruption, or have been manifested at intervals ; whether some 
 of those originally observed have disappeared, and whether others 
 have supervened. When the patient is confined to his bed. we 
 should not forget to inquire since when, and how soon after the first 
 appearance of the symptoms, he has been obliged to keep his bed. 
 
 All commemorative circumstances are highly important in diag- 
 nosis : in many diseases, indeed, and particularly in those whose 
 diagnosis is somewhat obscure, it is quite as much upon the suc- 
 cession of antecedent symptoms, as upon the concurrence of those 
 actually present, that the physician's opinion may be founded. 
 Unfortunately, many patients are not in a condition to give a clear 
 statement of previous occurrences, and the physician is deprived 
 of the information which might have been supplied by an accu- 
 rate relation. When the patient's age or the disturbance of his 
 intellectual faculties unfit him for replying to our questions, we 
 must rely upon the attendants. 
 
 3. When all the preceding details are known, we pass to the 
 26 
 
302 DIAGNOSIS. 
 
 examination of the existing symptoms, which generally supply the 
 most important diagnostic signs. 
 
 We first inquire if the patient has any pain ; if so, we ascertain 
 its situation. We should not rest satisfied with knowing that it is 
 seated in the stomach or in the cardiac region, etc. ; the vague sense 
 of these expressions, as employed by persons unacquainted with 
 medicine is too well known : we request the patient to point out 
 with his hand the place where the pain is seated, and also, if it 
 extend over a considerable surface, to circumscribe it and trace its 
 course ; we inquire if it is superficial or deep-seated, continued, pe- 
 riodical or transient ; if its intensity be uniform, or if it increase and 
 diminish at intervals, and under what influences ; if it be accom- 
 panied by a sensation of heat or cold, of weight, etc. ; we ascer- 
 tain thoroughly the effect of pressure upon this pain, and ask the 
 patient to what it may be compared. 
 
 We next notice whether there is any change in the color, vol- 
 ume, form and consistence of the affected part. This examination 
 often requires the concurrence of the sight and touch ; it should be 
 made with the most scrupulous attention, and can never be omit- 
 ted without disadvantage. We also ascertain if any unusual pul- 
 sation or fremitus exist in the painful part, and, in certain cases, 
 whether the natural resonance on percussion is preserved. 
 
 The three great splanchnic cavities present very different condi- 
 tions in regard to exploration, relative to the various degrees of re- 
 sistance offered by their envelopes, and also to the number and 
 importance of their contained viscera. The cranial cavity being 
 entirely surrounded by osseous walls, the enclosed parts are, as we 
 may say, removed from our explorative means, and protected also 
 from the action of external objects likely to prove injurious. It is 
 in early infancy only, or from the results of diseases which have 
 retarded ossification, or more or less completely destroyed a por- 
 tion of the bony parietes of the encephalon, either suddenly or 
 gradually, that the physician can see and touch the organs within, 
 naturally inaccessible to direct explorative means, and whose dis- 
 eases we can only appreciate from the supervening functional dis- 
 turbance; the difficult diagnosis of cerebral disease is thus ex- 
 plained, a diagnosis so difficult, that notwithstanding the very 
 remarkable works published upon this subject during the last 
 twenty years, the physician who does not wish to hazard his opin- 
 ion, is frequently obliged to be extremely reserved in regard to the 
 diagnosis of a cerebral affection, given at the patient's bedside. 
 This uncertainty, however, does not ordinarily regard the existence 
 of the lesion, but its peculiar form; the cranium, containing but a 
 single viscus and its enveloping membranes, presents in this re- 
 spect favorable conditions for diagnosis, which compensate, in some 
 measure, for the difficulties resulting from the arrangement of the 
 investing tissues. 
 
 The thoracic parietes, formed both of osseous and soft parts, are 
 so disposed, that while they prevent the application of some of our 
 direct means of exploration to their contained organs, they still 
 
DIAGNOSIS. 303 
 
 admit many, by whose aid we can appreciate, and, as it were, touch, 
 the greater part of the material organic lesions : they are suscepti- 
 ble of dilatation and contraction, either complete or limited, and 
 these changes of volume afford us some valuable signs. But while 
 exploration of this region meets with fewer obstacles, the greater 
 number of contained organs renders it more difficult to determine 
 the seat of the disease. 
 
 Lastly, the nature of the abdominal parietes which are formed 
 posteriorly by the bony column which supports the trunk of the body, 
 and elsewhere by fleshy tissues, renders every kind of exploration 
 possible. But the number of organs contained in this cavity is far 
 greater than in the two others : many among them concur in the 
 same function, and from this very fact, the determination of the 
 seat of disease presents more difficulties and is more frequently un- 
 certain. We shall summarily state the proper method of examin- 
 ing each of these three great cavities, either as a whole or in re- 
 gard to any of their component parts. 
 
 A. If the head be affected, it is sometimes useful to examine that 
 portion of the cranium where the pain is felt, to ascertain if there 
 be any partial tumefaction, and particularly, oedema and tender- 
 ness of the scalp, characteristic signs of erysipelas of this part; 
 also if the bony parietes be intact, if the sutures are in their natural 
 condition, etc. 
 
 We shall not attempt, in this place, to review all the symptoms 
 which may be presented by the numerous organs enclosed within 
 the cranium or situated upon the face. We shall restrict ourselves 
 to the statement, that pain in the head and certain grave functional 
 disorders of the encephalon, as delirium and convulsions, are far 
 more frequently the indication of lesions in organs more or less re- 
 mote, or the effect of certain deleterious agents, among which 
 should be mentioned the virus of eruptive fevers, than the result 
 of actual cerebral disease. We shall hereafter reconsider this point 
 when treating of sympathetic phenomena, considered in their rela- 
 tion to diagnosis. 
 
 At present we merely observe, that pain, when confined to the 
 right or left side of the head, hemicrania, properly so called, is 
 almost constantly owing, either to a lesion of the corresponding 
 cerebral hemisphere, or of its membranes, or, far more frequently, 
 to disease of some of the parts included in the same half of the 
 face, particularly the nasal fossas. the frontal and maxillary sinu- 
 ses, the teeth, the ear, or the eye. 
 
 B. When the vertebral column is the seat of pain, or when re- 
 markable disturbance of the nervous action of the spinal marrow 
 directs attention to that point, the spinal region should be exam- 
 ined, the patient either standing, or lying upon the abdomen. We 
 are thus enabled to discover the various deviations and curvatures 
 of which the spine may be the seat, the projection of one or more 
 vertebrae accompanying Pott's disease, etc. Great importance has, 
 
304 DIAGNOSIS. 
 
 of late, been attached to the pain (more or less severe) produced in 
 a limited portion of the vertebral column by pressure, made suc- 
 cessively, with one or two fingers from the atlas to the sacrum, and 
 this phenomenon has been cited as capable of revealing the ex- 
 istence of a lesion of the spinal marrow, or of its membranes, in the 
 part corresponding to the seat of pain. The thickness of the parts 
 comprised between the spinous processes and the spinal marrow, 
 the slight depression 1 ity of the vertebrae, and the unequal projec- 
 tion of the different spinous processes, lead us to suppose that the 
 importance of this sign has been much exaggerated, and that new 
 facts are necessary in order to determine its value. The same 
 may be said of the hot sponge which Copeland * has proposed to 
 pass along the spine, and which, it is asserted, would cause a 
 burning sensation in that point only where the medulla was af- 
 fected. 
 
 C. If the ear be painful, or if any remarkable lesion of the audi- 
 tory sense arrest the physician's attention, the meatus auditorius 
 externus should be examined, and in certain cases, it should be 
 ascertained whether the meatus auditorius internus be permeable. 
 
 The examination of the meatus auditorius externus is not very 
 difficult ; it is often sufficient to straighten the passage by draw- 
 ing the concha upwards and outwards, and thus gain a complete 
 view of the whole internal surface, and even distinguish with suf- 
 ficient precision the membrane of the tympanum, especially if 
 direct solar light be introduced. If simple traction of the concha 
 be not sufficient to bring the interior of the auditory canal properly 
 into view, we employ the small instrument called speculum auris, 
 whose two movable blades, separating after their introduction, 
 straighten and enlarge the passage, and allow the eye to distinguish 
 the different changes occasioned by disease, either in the mem- 
 brane itself, or in the matter secreted by it ; ulcerations and perfo- 
 rations of the tympanum are equally easy of discovery by means of 
 this instrument. 
 
 Exploration of the meatus auditorius internus, which has been 
 icvived by the exertions of Dr. Deleau, presents considerable dif- 
 ficulty; on this account it is hardly ever employed, except by the 
 small number of physicians who make the diseases of the ear, and 
 their treatment, the object of special study. This exploration is 
 performed by means of a small sound of metal, or preferably, of 
 gum elastic, introduced into the nasal fossae and directed so as to 
 penetrate into the Eustachian tube. The obliteration of this canal 
 is a frequent cause of deafness. 
 
 D. Certain peculiar phenomena, as the nasal alteration of the 
 voice, difficulty of breathing through the nose, discharge of puru- 
 lent or sanious matter from the anterior or posterior openings of 
 
 * Observations on the Symptoms and Treatment of Diseases of the Spine. Lon- 
 don, 1815. 
 
DIAGNOSIS. 305 
 
 the nasal fossae, or a fetid odor proceeding from these cavities, may 
 require an examination which is managed as follows : the patient 
 is turned towards the light, the head thrown backwards, one of the 
 examiner's fingers pressed upon the lobe of the nose for the pur- 
 pose of expanding the nostrils, or, preferably, a pair of dressing 
 forceps is introduced, the separation of whose branches allows of 
 a more complete inspection of these anfractuous cavities. We 
 may, moreover, by means of an elastic sound, or of Belloc's instru- 
 ment, sometimes ascertain the presence of a foreign body not dis- 
 cernible by the eye. 
 
 E. If the disease occupy the isthmus of the fauces, or the supe- 
 rior opening of the larynx or oesophagus, the following is the mode 
 of examination. 
 
 1. For the examination of the isthmus of the fauces, we cause 
 the patient to open the mouth widely : we depress the tongue with 
 the index finger, with the handle of a spoon, a spatula or the in- 
 strument called tongue depressor * whose concave surface is 
 accurately adapted to the convexity of this organ, and we expose 
 the velum palati and its pillars, the uvula, tonsils and posterior 
 part of the pharynx. In some persons, the epiglottis itself may be 
 seen behind the base of the tongue, and, when inflamed, may come 
 entirely into view, resembling a cherry with a median fissure. 
 
 We ascertain the alterations in these various organs, in respect to 
 color, volume, moisture or dryness, the nature of their secretions, 
 the coats or false membranes, granulations, liberations, and perfo- 
 rations which they may present. Certain individuals have the 
 faculty of lowering the base of the tongue sufficiently, by muscular 
 action alone, to expose completely those parts not visible in the 
 majority of persons except by powerful depression of that organ; 
 in them the inspection of the posterior fauces is as easy as that 
 of the gums and tongue. 
 
 Some diseases, as angina tonsillaris and mercurial stomatitis, 
 when at their height, entirely prevent the depression of the lower 
 jaw, and, consequently, completely frustrate this kind of explora- 
 tion. In these cases, where the lesions cannot be seen, we some- 
 times succeed in ascertaining, although with difficulty, by means 
 of the index finger introduced into the mouth, between the slightly 
 separated teeth, or in a space where they are wanting, increased 
 volume of the tonsils, and their consistence, and occasionally to dis- 
 
 * The speculum oris (lately constructed by the French instrument^makers) com- 
 bines the speculum with the depressor lingua. ; it consists of the latter, projecting 
 from a hoop of the same metal, (usually the German silver, or the amalgam 
 called " maillechort,") which is pierced with two or three apertures correspond- 
 ing to the sams number of buttons for retaining it at different graduations of its 
 circumference, thus adapting it to the various sizes of the mouth in different indi- 
 viduals, and maintaining it permanently expanded during its insertion, thereby 
 avoiding the signal inconveniences experienced when a spatula or the handle of a 
 spoon are used for depressing the tongue. A far better view of the buccal cavity 
 and posterior fauces is also obtained. TRANS. 
 
 26* 
 
306 DIAGNOSIS. 
 
 cover an abscess, which has in some instances been ruptured by 
 simple pressure of the finger. 
 
 By means of the finger introduced as far as possible into the 
 mouth, in certain cases of angina cedematosa [oedema, of the glot- 
 tis\, we discover the tumefaction of the membranous folds extend- 
 ing from the epiglottis to the arytenoid cartilages and circumscrib- 
 ing the superior opening of the larynx. This examination excites 
 in some patients so strong contraction of the pharyngeal muscles 
 and so much retching, that it is wholly useless. 
 
 Exploration of the oesophagus and of that portion of the pharynx 
 not attainable by the finger, must be practised with the cesopha- 
 geal tube, which is introduced through the nasal fossae, or prefera- 
 bly, by the mouth. We thus discover or suspect, in some cases, 
 from the degree of resistance encountered, the existence of stricture 
 or the presence of a foreign body, and determine their situation. 
 
 F. When local symptoms are manifested in the chest, we should 
 endeavor to determine whether the disease occupies the parietes of 
 the thorax, or the organs contained within it, and in the latter case, 
 whether it be seated in the organs of respiration or circulation. 
 To obtain this result, the conformation of the chest should be ex- 
 amined (p. 91), and percussion and auscultation employed, to ascer- 
 tain whether the functional disturbance is connected with some 
 material alteration of the organs contained in this cavity, and if 
 necessary, to these results should be added those obtained by men- 
 suration. We have previously mentioned the signs furnished by 
 each of these modes of exploration ; we will here enumerate, very 
 briefly, the diagnostic signs acquired by the comparison of these 
 three orders of phenomena. 
 
 The diminution or permanent absence of the respiratory mur- 
 mur, without alteration either of the conformation or resonance of 
 the chest, usually indicates that some internal or external body 
 closes or compresses the trachea, and prevents the passage of air 
 into the pulmonary vesicles. According as these phenomena man- 
 ifest themselves in a limited portion, or over the entire surface 
 of one side of the chest, or even of both, we conclude that the 
 obstruction to the passage of air, occupies, in the first case, one of 
 the bronchial divisions ; in the second, the principal bronchus ; in 
 the third, the trachea or larynx. 
 
 If the diminution in the strength of the respiratory murmur be 
 accompanied by increased resonance and dilatation of the thoracic 
 parietes ; if these phenomena are particularly manifest in the 
 space included between the clavicle arid the mamma, their con- 
 currence reveals the existence of pulmonary emphysema. 
 
 Entire absence of the respiratory murmur over one side of the 
 chest, with tympanitic resonance and dilatation of the parietes, 
 generally indicates the existence of pneumo-thorax. If amphoric 
 respiration and voice be added to the three previously mentioned 
 phenomena, we can no longer doubt that there is a communication 
 between the pleural cavity and some bronchial branch, from which 
 
DIAGNOSIS. 307 
 
 communication pneumo-thorax results. If metallic tinkling and 
 gurgling on succussion be added to the former symptoms, and if 
 the sound become flat at the base of the chest, over a space grad- 
 ually extending upwards, hydro-pnenmo-thorax undoubtedly ex- 
 ists. 
 
 If we find simultaneous diminution of resonance and feebleness 
 or absence of the respiratory murmur, there is, necessarily, either 
 alteration of the pulmonary parenchyma, rendering it less per- 
 meable to the air, or interposition of some solid or fluid body, 
 which prevents both the transmission of the respiratory murmur, 
 and also the penetration of air into the compressed lung. 
 
 If the sound be flat over one entire side of the chest, if the res- 
 piratory murmur and the resonance of the voice be null in that 
 part, there is certainly liquid effusion into the pleural cavity, par- 
 ticularly if mensuration discloses a remarkable increase or dimi- 
 nution of volume in the affected side ; in the latter case, absorption 
 of the fluid is taking place. If the sound be obscure or flat in one 
 part of the chest only, the corresponding changes are generally 
 less marked, and, when present, almost always imply an organic 
 lesion of a chronic nature. If this obscurity of sound be at the 
 superior part of the chest, and in the sub-clavicular region espe- 
 cially, if there be a depression in that point more readily appreci- 
 able by the eye than by mensuration, if the respiratory murmur 
 be feeble, expiration prolonged and somewhat rude, and particu- 
 larly if some moist crepitus be heard, if the voice is more resonant 
 there than on the opposite side, we must conclude that tubercular 
 affection of the lungs exists. The flat sound, accompanied by 
 bronchial respiration and resonant voice, may depend upon pul- 
 monary induration or slight pleuritic effusion. In these two cases, 
 mensuration is of no service, but generally, the resonance of the 
 voice has a jerking character in pleurisy ; the contrary is the case 
 in pneumonia. In the latter affection, some crepitus is nearly 
 always caused by the cough, in certain points where bronchial 
 respiration is heard, and this constitutes a valuable diagnostic 
 sign. Partial pleuritic effusion constantly occupies the lowest part 
 of the chest ; pneumonia may be manifested in any portion. 
 
 Dulness on percussion, with absence of respiratory murmur and 
 resonance of voice, when limited to any part of the chest except 
 the praecordial region, almost always denotes a circumscribed 
 pleuritic effusion, the fluid being in moderate quantity (d* une 
 ccrtaine epaisseur) ; sometimes, a tumor or partial splenization of 
 the lung. 
 
 Circumscribed and chronic effusion, and tumors, may cause a 
 partial protrusion or prominence of the thoracic parietes, which is 
 never produced by splenization. Tumors are almost always seated 
 in the superior portion of the chest; most frequently they are 
 formed by the dilatation of the large vessels ; they then present 
 pulsations isochronous with those of the heart, abnormal sounds 
 and other characteristic signs. The distinction between circum- 
 scribed effusion and pulmonary splenization is often difficult : but 
 
308 DIAGNOSIS. 
 
 in one case, the possibility of changing certain conditions relating 
 to the effusion by varying the attitude of the patient, and the 
 moderate intensity of the dyspnoea and febrile action ; in the other, 
 (splenization,) the presence of pneumonic sputa and the gravity 
 of the general symptoms are phenomena, which, in most cases, will 
 supply the deficiency of signs furnished by exploration of the 
 chest ; effusion, moreover, constantly occupies the base of the chest ; 
 splenization may occur in any portion. 
 
 A flat sound on percussion, when confined to the cardiac region, 
 indicates an affection of the heart, or of its envelopes. We should 
 suspect pericarditis, if the affection be recent, if the dulness has 
 been rapidly developed, if the sounds of the heart are deep and 
 obscure; if opposite phenomena are observed, our diagnosis should 
 be hypertrophy, particularly if there be also considerable promi- 
 nence of the prsecordial region, strong impulse and very distinct 
 bellows murmur. 
 
 G. When the symptoms are referred by the patient to the ab- 
 domen, that part should be thus examined. The patient should 
 assume the dorsal decubitus, the head be raised by a pillow, the 
 thighs flexed upon the pelvis, the legs upon the thighs, and the 
 knees slightly separated. We ascertain by ocular inspection, or 
 by means of the hand, the changes of form and volume which 
 may be presented, either over the entire surface of the abdomen, 
 or in one or more points, especially in those where hernia or simple 
 dilatation of herniary apertures may exist. Pressure and palpa- 
 tion are next resorted to, conformably to the foregoing rules ; we 
 percuss, and if necessary, employ mensuration and touch, should 
 any circumstance indicate the utility of these explorative means. 
 In those cases where the abdomen is distended by an enormous 
 quantity of serous fluid, it often happens that we cannot exactly 
 judge of the condition of the viscera, or discover the lesion which 
 causes the dropsical effusion until after the evacuation of the fluid 
 by tapping. 
 
 Many important diagnostic signs are furnished by abdominal 
 exploration. It alone, enables us to ascertain the accumulation of 
 serous fluid in the peritoneum, of gas in the intestines, and the 
 various tumors resulting from hypertrophy or degeneration of the 
 abdominal viscera. The latter are characterized by certain con- 
 ditions with which we should be acquainted, because they consti- 
 tute actual pathognomonic signs ; thus, the liver arid spleen almost 
 constantly preserve their original form in the different diseases 
 which augment their volume, and no other part, when morbidly 
 enlarged, assumes the form of the liver or spleen; consequently, 
 whenever we discover in the abdomen, a tumor occupying the 
 right hypochondriac and the epigastric region, extending upwards 
 beneath the ribs, and whose inferior border is firm, angular, run- 
 ning transversely, but more often obliquely, from left to right, and 
 from above downwards, we may be sure that it is formed by the 
 liver. A tumor which occupies the left side, extending somewhat 
 
DIAGNOSIS. 309 
 
 beyond the false ribs, whose form is a segment of an ovoid, whose 
 internal border is rounded and angular, and vertical in its direc- 
 tion, must be formed by the spleen, particularly if no general 
 transposition of the viscera exist, of which an examination of the 
 praecordial region may convince us : if the heart be in its usual 
 situation, we may, as a general rule, conclude that the liver and 
 the spleen are so, likewise. The bladder in both sexes, the uterus, 
 and, to a certain extent, the ovary in the female, present in their 
 development, certain peculiarities of form and position, which 
 admit of easy recognition, at least in the majority of cases. Tu- 
 mors formed by masses of faecal matter in the large intestines, 
 have a form similar to a string of beads {forme de chapelet), 
 which generally renders their diagnosis easy. Those formed by 
 the kidneys have no peculiar shape, and the depth at which they 
 are seated, does not allow us to reach them, except they have 
 acquired considerable volume. We may discover these tumors by 
 seizing the sub-costal region with the whole hand, the thumb 
 resting upon the lumbar portion, and the fingers upon the side. 
 Tumors developed in the stomach and intestines are never uniform 
 in volume, form or seat, and are frequently movable. Those 
 of the pylorus are found, in certain patients, very far from the 
 region commonly occupied by this extremity of the stomach ; they 
 have occasionally been discovered near the umbilicus, and even in 
 the right iliac fossa, nearly in contact with the anterior, superior 
 spinous process of the ilium. The iliac fossae are very frequently 
 the seat of phlegmonous tumors, to which the attention of physi- 
 cians has been particularly directed by the researches of Dance, 
 and MM. Melier, Meniere and Grisolle. Lastly, the abdomen is 
 sometimes the seat of pulsative tumors, some of which are formed 
 by aneurismal arteries, others derive their pulsation from a neighbor- 
 ing artery. Auscultation should be practised in these cases, as well 
 as in those where there is doubt as to the existence of pregnancy. 
 It is also interesting (as is evident from the researches of many 
 English physicians, particularly Bright, Corrigan, Beatty and 
 Stokes ) in certain forms of peritonitis, especially in those where 
 the abdomen contains a more or less resistant tumor; in these 
 cases a slight friction sound is heard, indicative of the develop- 
 ment of false membranes upon the internal surface of the peri- 
 toneum. 
 
 H. In scrotal examinations, it is important to ascertain whether 
 the disease, whatever be its nature, occupies the envelope or the 
 contained organs, and among the latter, whether the epididymis, 
 testicle or tunica vaginalis are affected ; to pressure and palpation, 
 should be added the weight [act of weighing, " ponderation" ] of 
 the tumor, and we should ascertain particularly, whether it be 
 transparent, by placing it before a bright light ; tumors of the 
 testicle are heavy and opaque, hydrocele is light and transparent; 
 an explorative puncture (as it is called) is sometimes indispensa- 
 ble, to render the diagnosis positive, when examination of the 
 
310 DIAGNOSIS. 
 
 tumor will not justify us in asserting that its contents are fluid. 
 In certain cases of scrotal enterocele, percussion elicits a clear 
 sound, and assists our diagnosis. 
 
 I. In cases where the rectum is the seat of the local symptoms, 
 in either sex, or the organs of generation in the female, ocular 
 inspection is necessary ; when the disease is external, the anus or 
 vulva should thus be examined, the soft parts which surround each 
 orifice being separated as far as is necessary; when internal, the 
 finger or speculum should be introduced into the rectum or vagina, 
 according to the rules and precautions previously indicated. 
 
 J. The examination of the limbs is not always so simple as 
 we might, at first, suppose. Not to mention the difficulty of diag- 
 nosis, in certain cases of fracture without displacement of the 
 fragments, and of some chronic dislocations, we would point out, 
 as worthy the attention of the physician, the frequently trifling 
 difference in the volume of the limbs, in their length, contractility, 
 sensibility, heat, freedom and extent of motion, and in the volume 
 and direction of the bones which support them. Partial or general 
 swelling of the limbs, the various tumors of which they are the 
 seat, either in their continuity or contiguity, and the external lesions 
 to which they are even more exposed than the body, supply the 
 physician with numerous phenomena to be discovered only by 
 examination of the affected part. 
 
 Having finished the examination of the region to which the pain 
 is referred, we should ascertain the functional condition of the 
 corresponding parts. For example, if the patient complain of 
 pain in the chest, we examine the respiration in regard to its fre- 
 quency, its equality and the mode of dilatation presented by the 
 thorax; we learn whether there be cough ; and if there be sputa, 
 we examine them. Before passing to general symptoms, which 
 are less interesting, we should ascertain the functional condition of 
 those organs more particularly sympathizing with the affected 
 parts. Thus, when an acute pain in the lumbar region and along 
 the course of the ureters, with suppression or alteration of the 
 urine, leads us to suspect inflammation of the kidney, the local 
 symptoms having been examined, we should inquire if there be 
 retraction of the testicles and vomiting, because these two sympa- 
 thetic phenomena are important signs of nephritis. The same is 
 true of vomiting in peritonitis, etc. 
 
 If the patient experience no local pain, and complain only 
 of some functional disturbance, as cough, diarrhoea, partial debil- 
 ity, etc., we first examine everything in any way connected with 
 the function principally involved; the general symptoms are after- 
 wards considered. 
 
 In those cases were the patient complains only of general indis- 
 position without particular pain, of universal derangement of the 
 functions without any marked disturbance of any one in particu- 
 lar, we examine them all in the order we have followed in the 
 general account of symptoms. 
 
DIAGNOSIS. 311 
 
 The physician should at first direct his attention to the expres- 
 sion of the patient's physiognomy, and to his attitude. He should 
 then endeavor to appreciate the muscular force, either by questions 
 or by certain movements required of the patient. If the voice 
 seem unnatural, he learns from the assistants what changes it 
 may have undergone; he afterwards inquires into the condition of 
 the various sensations, the moral affections, the character of the 
 patient, his intellectual faculties, and his sleep; after which he 
 examines, successively, the nutritive functions. 
 
 The interior of the mouth, and particularly the tongue, is next 
 examined ; the patient is asked if he is hungry or thirsty, if degluti- 
 tion be free, if he experience nausea or eructations ; if he still takes 
 food, and in what quantity, if digestion be easy, if uncomfortable 
 sensations, oppression or somnolency occur after eating ; if there 
 are borborygmi ; the physician should ascertain whether the ab- 
 domen be supple, the alvine evacuations regular, and what is the 
 nature of the excretions. He next notices the respiration and the 
 different respiratory acts, then the circulation, heat, exhalations, 
 and secretions, and finally, if it be necessary, inquires into the 
 state of the generative functions. 
 
 In this complete review of the functions, the physician should 
 endeavor to fix the period at which each symptom appeared, and 
 the successive changes it has manifested from its appearance to 
 the moment of examination. 
 
 To the examination of symptoms, the difficult, and often un- 
 fruitful, search for the productive causes of disease should always 
 be added. The knowledge of causes, when it can be gained, con- 
 firms or rectifies diagnosis in obscure cases, and is not without 
 interest in others. Consequently, we should not neglect to ask 
 whether the affection whose nature we endeavor to determine, be 
 hereditary or acquired ; if this be the first attack or otherwise ; if 
 it be owing to specific causes whose action is manifest, or to pre- 
 disposing causes, whose action is uncertain ; if it have any con- 
 nection with previous diseases, and what those diseases have been. 
 
 The effect of remedial measures may also contribute to decide 
 our opinion, particularly when the disease under consideration is 
 of that limited number arising from specific causes ; the specific 
 remedy employed, becomes, in such cases, a sort of touch-stone 
 which reveals their nature. This is particularly observed in 
 syphilitic affections, and in some obscure forms of intermittent dis- 
 eases. In these cases, arid in certain others also, diagnosis is 
 almost entirely founded upon the knowledge of the cause which 
 has produced the disease. 
 
 $ IV. Principal component Elements of Diagnosis. If there are 
 certain diseases whose nature is simple and whose effects are limited 
 to the parts they occupy, as wounds, or fractures not presenting 
 those conditions to which surgeons have quite improperly applied 
 the term complication, it is otherwise in most affections, especially in 
 those constituting the domain of medical pathology. Here, indeed, 
 
312 DIAGNOSIS. 
 
 the disease is nearly always complex ; there is predominant lesion 
 of one organ, simultaneously with lesions of all the others, or at 
 least of those more particularly connected with the one principally 
 affected. This more or less general disturbance of the organism 
 sometimes precedes the local lesion, announces it and perhaps con- 
 curs in preparing its development ; in other cases it is associated 
 with it; both may appear simultaneously. In all these cases the 
 disease is by no means simple, and the physician who sees in ery- 
 sipelas or pneumonia, only the material lesion of the skin or pul- 
 monary parenchyma, would not have an accurate idea or a thorough 
 knowledge of either disease ; for such knowledge necessarily com- 
 prehends, on the one hand, the seat and nature of the lesion, its 
 extent and degree of intensity, and on the other, the accompany- 
 ing symptomatic phenomena, local and general, their form, whether 
 acute or chronic, the presence or absence of febrile reaction, the 
 energy of that reaction, the period attained by the disease, the pe- 
 culiar type it assumes, etc. ; these are, indisputably, so many con- 
 ditions constituting indispensable elements of diagnosis, arid should 
 be carefully examined in this connection. 
 
 When diagnosis is thus thoroughly considered, we see how in- 
 complete and restricted was the opinion of certain physicians of the 
 anatomico-pathological school, who founded their diagnosis of dis- 
 ease entirely upon material organic lesions, so that, in their opinion, 
 every thing depended upon determining what organ was affected, 
 and in what manner. The ancients were more excusable, when, 
 strangers as they were to the knowledge afforded by necroscopy, 
 they saw, in disease, only the apparent functional disturbance, 
 which, indeed, they observed with admirable sagacity. 
 
 A. Determination of the Seat of Disease. This includes several 
 questions which will be successively considered. 
 
 1. W hich is the diseased organ. 2. To what extent is it affected. 
 3. In certain cases, which of its elementary tissues is particularly 
 diseased. 
 
 1. Which is the diseased Organ? The senses alone are suffi- 
 cient, in a certain number of diseases, to inform us which is the 
 affected organ ; in others this knowledge cannot be acquired, except 
 by the aid of those signs which reason deduces from the phenom- 
 ena furnished by the senses; in still other cases, the seat of disease 
 remains obscure through life, and sometimes even after the ne- 
 cropsy has afforded us the most complete investigation, and one 
 seemingly the most likely to dispel every doubt. 
 
 When the disease is external, as herpes zoster or erysipelas, its 
 seat is so evident, that unprofessional individuals can perceive it 
 equally with the physician. The same is true of the numerous 
 diseases of the skin, and of the majority of those seated near the 
 point of union of the skin and mucous membranes ; conjunctivitis 
 is recognised at sight, as also ulceration and puffiness of the lining 
 membrane of the mouth, swelling of the tonsils, excrescences de- 
 veloped near the nostrils, upon the glans penis, the vulva and 
 
DIAGNOSIS. 313 
 
 around the amis. We may, moreover, as regards the ascertain- 
 ing their seat by means of our senses, compare these diseases with 
 certain affections in which the diseased organ, originally out of 
 sight in one of the splanchnic cavities, as the thorax or even the 
 cranium, causes absorption of their parietes by reason of its subse- 
 quent morbid growth, and shows itself beneath the skin. Fungus 
 of the dura mater and aneurism of the arch of the aorta, become, 
 in this way, external diseases. Certain diseases of the abdominal 
 viscera, may also be subjected to the touch, especially when they 
 occupy the liver or spleen, which organs, as we have previously 
 observed, almost always retain their form, whatever may be their 
 increase of volume. As we have elsewhere remarked, by the in- 
 troduction of the finger into the vagina or rectum we ascertain the 
 seat of various affections, and, by the use of the speculum, vision 
 assists the sense of touch. In nearly all cases of fracture, the de- 
 formity of the limb, the mobility of the fragments and the distinct 
 crepitation, are all phenomena clearly indicative of the seat of 
 injury. 
 
 There are. however, many diseases, particularly among those ap- 
 pertaining to internal pathology, where the senses alone are insuf- 
 ficient to determine what organ is affected. If the disease be one 
 of that class which are of sufficient severity to terminate occasion- 
 ally in death, and which present constant lesions on dissection, the 
 comparison of the phenomena observed during life with the lesions 
 discovered, after death, in analogous cases, generally enables the 
 physician to declare without hesitation its seat, and the kind of 
 alteration presented by the affected organ. When, therefore, in an 
 unlimited number of cases, after a determinate series of symptoms, 
 post-mortem examination reveals, in the same parts of the body, a 
 lesion of constant occurrence, we reasonably conclude, that when- 
 ever the same phenomena reappear, we shall find the same organ 
 similarly affected. 
 
 There are, however, certain diseases, some of which are severe 
 and others of slight importance, for whose elucidation pathological 
 anatomy furnishes us far less assistance. If the individuals affect- 
 ed by them die, either from the actual disease or some coexistent 
 affection, nothing is discovered explanatory of the previously ob- 
 served phenomena, either because the accompanying lesions are 
 not appreciable by our senses, or because the requisite attention 
 has not, thus far, been devoted to researches of so delicate a nature. 
 Many individuals die instantaneously, or in a very short time, with 
 apoplectic symptoms, tetanic convulsions, and hydrophobic spasms ; 
 some even die paralytic, and no lesion whatever is discovered at 
 the necroscopy. If an individual affected with acute rheumatism, 
 or some nervous disease, be attacked by another and a fatal mala- 
 dy, in the majority of cases, no appreciable alteration is met with 
 in the parts to which the pain was referred. Necroscopy has hith- 
 erto proved insufficient to determine the seat of these diseases, and 
 certain notions upon this point have been derived solely from the 
 often contestable laws of physiology. 
 27 
 
314 DIAGNOSIS. 
 
 Physiology acquaints us with the functions proper to each of our 
 organs. Disorder of a function leads us to admit a certain lesion 
 in the organ to which that function belongs. Thus, when severe 
 pain occurs without swelling, redness, or any other appreciable 
 change in the affected part, we judge that the disease is seated in 
 the nerves or brain, because they are the organs of sensibility. 
 If this pain increase on motion, and diminish or cease by rest, if 
 its intensity is constantly proportionate to the force of muscular 
 contraction, we conclude that the affection is seated in the organs 
 of motion, that is, the muscles. But here there is no absolute 
 proof; the concurrence of the nerves and muscles being necessary 
 to motion, it is difficult to distinguish whether the disturbing cause 
 be in the muscular or nervous system, or in both together. This 
 distinction is equally difficult in convulsive diseases, of which the 
 muscles are the immediate agents, and in which the nervous sys- 
 tem plays, incontestably, a great part. Our previous and future 
 remarks upon sympathy will prove more clearly into what error 
 we should be led, if we attempted, in all cases, to determine exactly 
 which is the affected organ, from functional disturbance alone. 
 
 The difficulty of fixing the seat of diseases becomes still greater in 
 those characterized by general functional disturbance, without pri- 
 mary local affection. We mean fevers, and especially intermittent 
 fevers ; for if there still exist conflicting opinions among physicians 
 in regard to the constancy and value of lesions in continued fevers, 
 they are agreed in regard to the impossibility of determining the seat 
 of disease in intermittent fevers. The external appearance is 
 changed, the circulation, heat, digestion, secretions, sensations, 
 sometimes even the intellectual functions, respiration, locomotion 
 and the voice, are simultaneously affected for a certain number of 
 hours, the disturbance ceasing with the paroxysm. Where in such 
 a case is the seat of disease ? Is it in the spleen, as some assert ? In 
 the stomach, the intestines, or the mesentery ? Is it in the nervous 
 system generally, or in one of its divisions ? In the blood or some 
 other of the fluids which enter into the composition of the human 
 body? All these opinions have had or still have their partisans, 
 but none of them has been established upon a basis sufficiently 
 firm to convince us of its truth. The interesting researches in 
 pathological anatomy, made some years since by Dr. Bailly (too 
 soon removed from science and society), in a country where inter- 
 mittent fevers are sufficiently severe to terminate frequently in 
 death, have left the question of the seat of intermittent fever unde- 
 cided ; a disease in all other respects so well understood, that not- 
 withstanding the obscurity which prevails in regard to this point 
 of their history, it is, at present, of all th^ diseases to which man is 
 subject, the one whose diagnosis is generally most easy, and whose 
 treatment shows most incontestably the power of our art. So true 
 is it that the most important thing in medicine, and even in diag- 
 nosis, is not always, as has been asserted, to determine which is the 
 affected organ, and how it is affected. 
 
 2. The Seat of the Disease being known> what is its Extent ? 
 
DIAGNOSIS. 315 
 
 In those cases where the physician succeeds in discovering which 
 is the diseased organ, it is desirable to determine to what extent it 
 is affected. If we consider how much its extent influences the 
 gravity of the disease ; what difference there is, for instance, be- 
 tween erysipelas limited to one cheek, and that which occupies 
 the face, and simultaneously the entire scalp ; between partial pem- 
 phigus, and that which is nearly general ; between variola discreta 
 and variola confluens (for in the latter, it is, as it were, a simple 
 difference in the extent of the affection, measured by the number of 
 pustules); between inflammation limited to a single point in one 
 lung, and double pneumonia; between partial peritonitis, a disease 
 generally attended with little danger, and general peritonitis, which 
 is most frequently mortal, we cannot misunderstand all the impor- 
 tance which the question of extent should have, in deciding our 
 opinion of a disease. 
 
 The extent of those diseases which are seated at the surface of 
 the body is easily perceived. In these cases, however, the affec- 
 tion is not always confined to the skin. Many affections styled 
 cutaneous, and particularly those depending upon a contagious 
 principle, attack the skin and certain of the mucous membranes 
 simultaneously, and. by the febrile action they excite, often produce 
 lesions of considerable severity in the viscera themselves. 
 
 It is generally difficult to determine the extent of the disease in 
 internal affections ; this difficulty, however, is not always insur- 
 mountable. Thus the exploration of the abdomen often enables 
 us to determine whether the liver is diseased throughout, or in one 
 lobe only, also, to what extent the spleen is enlarged ; examination 
 of the chest enables us to distinguish whether pleuritic effusion 
 occupies a part or the whole of the pleura ; if pneumonia, limited 
 at first to a portion of the pulmonary parenchyma, invade daily 
 a greater extent, and whether at a more advanced period it be- 
 comes limited in its seat, and diminishes in intensity at the same 
 time. Finally, there are certain cerebral affections, haemorrhage 
 in particular, in which we can, to a certain extent, estimate the 
 volume of the apoplectic clot, from the intensity of the symptoms, 
 and consequently the extent of the rupture of the cerebral pa- 
 renchyma. There is, then, a certain number of internal diseases, 
 in which we can judge, approximatlvely at least, of the extent 
 occupied by the material lesion. 
 
 3. The study of the seat of diseases sometimes extends to de- 
 termining which of the elementary tissues is primarily affected. 
 But we should remember that this sort of research belongs to that 
 molecular anatomy, in which imagination too often supplies the 
 insufficiency of the senses, and whose results must be received 
 with great circumspection. 
 
 There are, however, some diseases of the skin whose special seat, 
 whether in the mucous layer, or in the follicles, is now scarcely 
 contested ; among these are acne, which seems to occupy the fol- 
 licles exclusively, and those affections known by the name of ma- 
 culce and ephelides, which, being characterized by alterations in th 
 
316 DIAGNOSIS. 
 
 color of the skin, can hardly occupy any other part than the mu- 
 cous layer, in which the secretion of coloring matter takes place. 
 Every one, at the present day, is aware that in typhoid fever it is 
 not the intestinal mucous membrane which is affected, but the 
 follicles, either agminated or isolated, which lie between this mem- 
 brane and the cellular coat, and which occupy particularly that 
 portion of the ileum nearest to the caecum. But if we pass from 
 the skin and mucous membranes to certain other organs in which 
 the elementary tissues are less distinct, as the liver, the kidney, 
 and even the lung; if we wish to determine, in this latter organ, 
 the tissue in which tubercle is formed ; if we attempt to discover 
 in a liver affected with cirrhosis, or in a kidney affected with 
 Bright's disease, the hypertrophy of one element of these organs 
 and the atrophy of the other, we are liable to leave the domain of 
 positive anatomy, and to enter upon a class of questions which 
 are hardly susceptible of a definite solution. * 
 
 B. Determination of the Lesion. Having explained in what 
 way the physician succeeds in discovering which is the affected 
 organ, and to what extent it is affected, we will now consider the 
 second point, viz. the manner in which it is affected, which compre- 
 hends both the nature of the lesion and the progress it has made. 
 
 * The correctness of this remark may be questioned, if we rightly understand 
 the author's assertion. Can we avoid the conclusion that many lesions of the 
 kidneys have been so accurately described by different authors, that in respect to 
 them, we are in "the domain of positive anatomy," and that many questions 
 have received that ** definite solution " of which they are declared " insusceptible " 
 in the text ? The elaborate researches of Dr. Bright upon the pathological lesions 
 exhibited by the kidneys, when affected by the disease that bears his name, 
 surely announce to us many points within " the domain of positive anatomy." Dr. 
 Prout, in his valuable work on Stomach and Renal Diseases, declares that " the 
 post-mortem phenomena, when studied in connection with the condition of the 
 urine and the constitutional symptoms, are quite sufficient, in a practical point of 
 view, to regulate our proceedings and to show us in general, what we can and 
 what we cannot accomplish." (p. 178, 4th English edition.) The admirable 
 work of M. Rayer, from which large quotations are made by Dr. Prout, (loc. 
 supra cit.) may be mentioned in proof of how much " positive anatomy " can be 
 claimed at the present time, in regard to renal lesions : (Traite des Maladies des 
 Reins. Atlas.) Nothing can be more minute, but at the same time, what can be 
 more accurate, than the description of the morbid appearances of the kidney affect- 
 ed with granular degeneration. 1 (Prout. Op. cit. pp. 180, 181. Rayer's Post 
 Mortem Classification.) The hypertrophied and atrophied tissues are clearly de- 
 
 'This term, which originated with DR. CHRISTISON, has, of late, been objected to by 
 some authors. Dr. WATSON, in his Lectures on the Principles and Practice of Physic, 
 (Vol. II. p. 572, 2d Eng. edit.) says, " some call it (Bright's disease) granular degenera- 
 tion of the kidney, but the epithet granular is not always applicable." DR. COPLAND 
 describes it under the name of Cachectic Nephritis (Med. Diet.). DR. BRIGHT himself 
 termed it granular disease of the kidneys. DHS. Q.UAIN and WILLIAMS, however, in their 
 late descriptions of the renal lesions observed in this disease, give, as the second of their 
 three divisions, " the truly granular or atrophied kidney. (WILLIAMS, Lond. Med. Gaz. 
 1845. QUAIN, Lond. Lancet, Feb. 1846.) DR. GEORGE JOHNSON has lately maintained 
 that the so-called granular, is, in fact, a "fatty," degeneration of the kidney, analogous to 
 that of the liver." (Lond. Lancet, Jan. 1846.) GLUGE, in his " Atlas der Pathologischen 
 
 ventured to employ the term " granular degeneration. 
 
DIAGNOSIS. 317 
 
 1. Here, as in the former case, the disease may be upon the sur- 
 face of the body, and then, by the direct use of the senses, partic- 
 ularly of sight and touch, we can often recognise at once, both the 
 seat of disease in the skin, in the subcutaneous cellular tissue, in 
 the superficial lymphatic ganglia, in the mammary gland or in the 
 testicle, and its inflammatory, scirrhous or tuberculous nature. If 
 the affection be internal, it is in like manner by the comparison of 
 all the symptoms of the actual disease, and of the lesions observed 
 at necropsies, in analogous cases, that we succeed in discovering the 
 nature, as well as the seat, of the lesion. In the examination of a 
 patient affected with pneumonia or peritonitis, for instance, the 
 physician cannot isolate these two questions, he perceives the seat 
 and nature of the lesion simultaneously. This is generally the 
 case ; the same modes of investigation lead to the solution of both 
 questions, and the solution of one often implies that of the other. 
 There are, however, frequent occasions when these two questions 
 become, at the bedside, entirely distinct ; so that in certain cases, 
 the seat of the lesion is evident and its nature uncertain, and vice 
 versa. It is quite common, for instance, to recognise satisfactorily by 
 the peculiar form of a tumor developed in one of the hypochondria, 
 the existence of an affection of the liver or of the spleen, and not 
 be able to determine the kind of alteration of which those organs 
 are the seat. At other times, the nature of the lesion is manifest 
 and its seat obscure ; thus, in some cases, one of the iliac regions, 
 the right, for instance, becomes, in a short time, the seat of an 
 acute pain which is exasperated by pressure ; by palpation, a 
 resisting, ill-defined tumor is discovered ; fever, nausea and vomit- 
 fined, as also are the periods when these changes occur ; and although, with Dr. 
 Proul, we may consider the practical aid derived from the precise knowledge of post- 
 mortem phenomena as exhibited in the kidneys, of but little imponance, still they 
 are far from valueless, and can by no means be said to constitute " an order of 
 questions insusceptible of definite solution." 
 
 The discoveries of Kiernan, while they add so much to our knowledge of the 
 anatomy of the healthy liver, have also tended to give more minuteness and accu- 
 racy to the details of the pathological lesions it displays. In cirrhosis (which 
 is mentioned by M. Chomel as a disease in which there can be no precision in 
 regard to the seat of lesions observed after death) , the minute descriptions of pathol- 
 ogists seem to be founded upon " positive anatomy," and if not so, are worthless. 
 The conclusions drawn by Dr. Budd (Diseases of the Liver, Cirrhosis, p. 113, 
 Eng. edit.) in regard to the appearances generally presented in cirrhosis, are val 
 uable in support of our position. He remarks, " The ordinary appearances in 
 cirrhosis, and the changes just described, (atrophy and diminished weight of the 
 liver, notwithstanding the existence of an adventitious tissue, formed of coagula- 
 ble lymph ; and nodular formations composed of a yellow matter, seen by the 
 microscope to consist of the original lobular substance of the liver, drawn into 
 these round nodules by the previously mentioned tissue,) seem the consequence of 
 adhesive inflammation in the areolar tissue about the small twigs of the portal 
 vein, by which serum and coagulable lymph are poured out ; " etc. etc. The em- 
 ployment of the microscope in these examinations, often explains problems pre- 
 viously " insoluble" (as is seen in the above statement) and gives the highest im- 
 portance and daily increasing accuracy to that " molecular anatomy where the 
 insufficiency of our senses is too often supplied by the imagination." (Vide 
 p. 315). TRANS. 
 
318 DIAGNOSIS. 
 
 ing supervene ; the inflammatory nature of the tumor is evident, 
 but where is its peculiar seat ? Is it developed in the cellular tissue 
 of the iliac fossa? Did it originate in the coecum? Might it not, if 
 the patient be a female, be seated in the ovary, rare as are acute 
 inflammations of that organ ? One more example may be cited. 
 A hard, unequal tumor, of irregular form, is distinguished through 
 the abdominal parietes, near the umbilicus; it has supervened 
 gradually, and its development has been accompanied by progres- 
 sive loss of flesh in the patient, whose hue is of that straw color, 
 which appertains to a particular class of organic diseases ; no one 
 can doubt the scirrhous nature of the tumor; but how great is the 
 difficulty, in many cases, of determining its seat. Does it occupy 
 the epiploon, or certain mesenteric glands, or the greater curvature 
 of the stomach, or some part of the intestinal canal? All physi- 
 cians know how embarrassing, in these circumstances, is the deter- 
 mination of its seat. In a large proportion of cases, the uncertainty 
 in regard to the precise seat of the disease is less dangerous than 
 doubt as to its nature ; for the nature of the lesion, more generally 
 than its special seat, constitutes the basis of therapeutical indica- 
 tions. The treatment of pneumonia, for example, differs generally 
 but very little from that of acute pleurisy, but very much from that 
 of pulmonary tubercle : in the former case, the two affections are 
 identical in their nature, and different in their seat ; in the latter, 
 the seat is the same, but the nature of the lesion different. 
 
 2. At the same time that the physician endeavors to determine 
 the kind of alteration presented by the affected part, it is equally 
 important for him to know the degree attained by the disease. 
 An inflammation which has hitherto occasioned simple turgescence 
 of the diseased part, is quite unlike that which has already mod- 
 ified the tissues to a great extent ; and this extensive modifica- 
 tion is itself different from suppuration ; scirrhous induration dif- 
 fers from ulcerated cancer, and tubercle exhibits quite as marked 
 dissimilarity in the successive stages of its development. It is, then, 
 highly important that the physician endeavor to appreciate this 
 diagnostic point, the importance of which is acknowledged by all. 
 In external inflammations, in cancerous affections of the skin, and 
 in tubercle of the subcutaneous ganglia, the physician can easily 
 determine the degree the disease has acquired ; in internal diseases 
 there frequently exist great difficulties. By the assistance, how- 
 ever, of the progress made, especially of late, by semeiology, a 
 progress in which French medicine has had the largest share, the 
 physician can appreciate during life, in a considerable number of 
 visceral diseases, the different phases presented by the material 
 alterations, and determine, more or less accurately, the degree 
 they have attained. Enlightened by the signs supplied by the 
 various modes of exploration of the chest, he is able to ascer- 
 tain, in those, cases where the disease is not limited to the deep 
 seated portions of the lung, (and these cases are the most com- 
 mon,) whether the lung is affected with simple inflammatory 
 engorgement, or whether it is indurated ; whether the tubercles 
 
DIAGNOSIS. 319 
 
 developed in this organ are in a crude or softened state ; he will 
 sometimes appreciate, approximatively, the extent of cavities, and 
 will easily recognise those cases where perforation of a tuberculous 
 lung opens a communication between the bronchi and the cavity 
 of the pleura. 
 
 In affections of the abdominal organs, but more particularly of 
 those contained within the cranium, the determination of the degree 
 attained by the disease is far more difficult ; often it is wholly 
 impossible. There are, however, some diseases in which the 
 physician may judge with probability of the changes which super- 
 vene in the affected parts, from the duration of the disease and the 
 intensity of the symptoms which reveal it. In typhoid fever, for 
 instance, we can, generally, indicate at the different periods of the 
 disease, the principal conditions of color, tumefaction, and ulcera- 
 tion presented by the intestinal follicles and mesenteric glands, 
 without being able, however, to determine over what extent of the 
 intestine and mesentery these lesions exist. In cerebral haemor- 
 rhage, not sufficiently severe to cause death, it is not impossible for 
 the physician to judge nearly of the changes which take place in 
 the cerebral mass around the effused blood, and of its definitive 
 absorption, by the time which has elapsed, and from the re-estab- 
 lishment of the locomotive function in those parts which had been 
 deprived of it. But in the greater number of diseases which are 
 seated in the abdomen and cranium, and especially in organic 
 disease, we cannot determine the existing degree of lesion, the 
 favorable or unfavorable changes which supervene in the inten- 
 sity of the symptoms being equally dependent upon the modifica- 
 tions presented by the disease, either as regards its extent, or on 
 account of its intensity. 
 
 C. Symptomatic Phenomena considered in relation to Diagno- 
 sis. We cannot doubt the necessity of admitting local and general 
 functional disorder, as elements of diagnosis. This necessity is 
 very evident in those diseases where the physician cannot distin- 
 guish during life, nor ascertain after death, the anatomical lesion 
 which might account for the symptoms ; here the disease reveals 
 itself only by functional disturbance ; it is in the latter, alone, that 
 the physician can find the elements of diagnosis. But in those 
 cases, even, where anatomical lesion exists, the symptomatic phe- 
 nomena are still of great importance in the appreciation of the 
 disease. Compare pneumonia, occurring in a young and robust 
 subject, and accompanied by that form of febrile action, known 
 by the name of inflammatory fever, with the pneumonia which 
 attacks an infirm and worn-out old man, which appears with 
 adynamic symptoms, and we have, necessarily, two very different 
 diseases, although the anatomical lesion may be nearly the same. 
 Compare acute with chronic inflammation of the stomach ; there 
 are, in many cases, in an anatomical point of view, but very slight, 
 and oftentimes even uncertain differences, while, by their symp- 
 toms, they constitute two entirely distinct diseases. 
 
320 DIAGNOSIS. 
 
 If, then, in diagnosis, we did not bear in mind the acute or 
 chronic form of a disease, its character, or. as was formerly said, 
 the inflammatory or adynamic nature which it assumes, we 
 should form an inaccurate idea of it, and our diagnosis would be 
 very incomplete. 
 
 The absence or presence of febrile action are conditions of some 
 value in the diagnosis of many diseases. The complete absence of 
 fever is an important sign in lead colic, and in many nervous affec- 
 tions, as also, in other cases, the presence of fever becomes an 
 important diagnostic sign, in pneumonia, for example, and in 
 typhoid fever. 
 
 Independently of the semeiological value of fever, in determining 
 the seat arid nature of the lesion, its existence, is, moreover, of 
 great importance in any single affection, as a test of its intensity. 
 Acute bronchitis, for instance, is of slight importance when entirely 
 apyretic ; it becomes more serious, if every evening there be ac- 
 celerated pulse and elevated temperature ; it may finally disturb 
 the economy almost as much as pneumonia, when it is associated, 
 as is not rare, with very intense febrile movement. In this latter 
 case, if the patient be advanced in years, it becomes a very dan- 
 gerous disease. The febrile state is. then, an indispensable condi- 
 tion in the appreciation of certain diseases, and should form one 
 of the elements of diagnosis. 
 
 The period at which the disease has arrived, is likewise an 
 indispensable condition in forming a medical opinion. In each 
 phase of the disease, the anatomical lesion and functional disor- 
 ders are modified daily, and he would be unworthy the name of 
 physician, who, in his appreciation of a disease, should disregard 
 the time already elapsed, and for whom pneumonia, at the stage of 
 resolution, would not be different from the same disease at its stage 
 of increase : the increase of the symptoms during the first days, 
 is constant and regular ; but when after the sixth, and much more 
 after the eight or ninth day, the symptoms continue to become 
 aggravated, the character of the disease is entirely changed, and 
 the opinion formed upon the actual and future state of things, is 
 far more serious. 
 
 Finally, the type of the disease becomes, in certain circumstan- 
 ces, not only an important, but the principal element of diagnosis. 
 When a certain affection, inflammatory, hsemorrhagic or nervous, 
 instead of appearing with a continued type, which is, as it were, the 
 natural type for most of these affections, assumes one regularly in- 
 termittent, as the quotidian, tertian or quartan ; when its character- 
 istic phenomena appear and disappear alternately, as would be the 
 case in regular intermittent fever, with that form of paroxysm, 
 whose continuance is generally restricted to the limits peculiar to fe- 
 brile paroxysms, the disease then becomes quite a different thing from 
 inflammation, haemorrhage, or nervous disease ; it differs from them 
 by its nature even, for it has a different cause, progress and treat- 
 ment, and it was not without reason that those who preceded us, 
 when describing these affections under the ingenious and expressive 
 
DIAGNOSIS. 321 
 
 name of masked fevers* compared them with, and at the same 
 time distinguished them from, normal intermittent fevers. In such 
 a case, as will be evident, the type becomes in reality the most im- 
 portant diagnostic condition. 
 
 $V. Circumstances which may render Diagnosis difficult and 
 even, uncertain. In the preceding sections we have spoken of diag- 
 nostic signs, modes of exploration, the proper manner of examin- 
 ing patients, and the principal elements of diagnosis. It remains 
 for us to glance at those circumstances which render diagnosis 
 difficult and uncertain, and to indicate, summarily, the course 
 which should be pursued in order to surmount these obstacles, 
 and, according to circumstances, pronounce or delay our opinion. 
 These obstacles relate principally to the epoch at which the phy- 
 sician is called to the patient, to the predominance of general or 
 sympathetic, over local phenomena, to the absence, even, of the 
 latter, to the infrequency of the disease observed, to the complica- 
 tions, and to deception on the part of the patient. 
 
 1. Difficult Diagnosis on account of the Period at which the Phy- 
 sician is summoned. When the physician is called at the com- 
 mencement of an acute disease, it is often difficult, sometimes im- 
 possible, for him to know what it will be. The invasion of certain 
 thoracic inflammations, is marked by phenomena of which the 
 stomach and brain are the seat, as vomiting and delirium, and some- 
 times the first disturbance of the respiratory functions does not 
 commence until the second or third day. The physician is doubt- 
 less excusable in these cases, when he fails to distinguish pneumonia 
 which is not manifested by any symptom peculiar to that affection. 
 Even in these circumstances, when the disease has commenced 
 with that intense chill which belongs to pneumonia more particu- 
 larly than to most other inflammations, if the invasion be sudden 
 and spontaneous, without previous change of residence, or power- 
 ful moral impression ; if both the country and season be remarka- 
 ble for the frequent occurrence of pneumonia, the physician should 
 be on his guard against the previously mentioned gastric and cere- 
 bral disorders, and while he delays giving a decided opinion, should 
 suspect and even announce the possibility of commencing pneu- 
 
 * The diseases spoken of as " masked fevers " (filvres larvees) are, properly, 
 irregular intermittents, styled by Dr. Copland "simulating- intermittents." (Med. 
 Diet. art. Int. Fever. ) He states their assumption of very diversified forms ; or 
 rather, that various affections, and chiefly those of the nervous system, may assume 
 an intermittent form. The rheumatic and neuralgic forms are the most common. 
 The type of ** masked ague " is generally quotidian, double tertian or tertian ; 
 sometimes quartan, or double quartan. The disease is most common in spring 
 and autumn, especially the former, and during the prevalence of easterly winds ; 
 it is usually attended by more or less disorder of the digestive, biliary and excret- 
 ing organs, and its successful treatment depends mainly upon attention to this 
 circumstance. (Op. Cit. p. 1088. Am. Ed.) "The intermittents that occur in 
 the United States, are chiefly of the simple form, although in some districts they 
 often assume one or more of the complications above pointed out, when they are 
 called congestive or pernicious." (Dr. Lee. Loc. Cit.). TRANS. 
 
322 DIAGNOSIS. 
 
 monia. But in this, as in other cases, we cannot give a definite 
 diagnosis, except at the period when the local and characteristic 
 signs of the disease are distinctly manifested, and this is not, in 
 most instances, until the second or third day. and sometimes still 
 later. In typhoid fever, we can rarely form a positive diagnosis 
 until the last half of the first week. In chronic diseases, whose in- 
 vasion is gradual, several weeks, sometimes many months, elapse, 
 before we can determine their nature, seat, and other essential con- 
 ditions. 
 
 In all cases, the physician should be on his guard against the 
 desire he may have of forming an opinion upon the sort of disease 
 which is about to commence, and also against the very natural 
 impatience of the patient's friends. The danger attending a pre- 
 mature diagnosis cannot be too strongly insisted on ; not only 4oes 
 it expose us to error, but, moreover, we are placed in such a con- 
 dition, that either through confidence in our first opinion, or fear of 
 appearing undecided, we find it difficult to forsake the wrong path 
 upon which we have entered. 
 
 It is not alone when summoned at the commencement of an 
 acute or chronic disease, and prior to the development of those 
 phenomena which characterize it at a later period, that the phy- 
 sician meets with difficulties and finds himself obliged to delay 
 giving an opinion. In the opposite cases, that is, in those where 
 an acute or chronic disease is about to terminate, either favorably 
 or unfavorably, the diagnosis is often very difficult. The transi- 
 tion from disease to convalescence is similar in a great number of 
 cases, and the features of the last struggle are uniform in both 
 acute and chronic affections. It should be remembered that diag- 
 nosis is of far less value when the disease approaches its termina- 
 tion. There are cases, however, in which it is useful to know 
 what the disease is which has proved fatal to the patient : not to 
 mention facts appertaining to legal medicine, it is interesting to 
 know, when the father of a family dies, whether the disease which 
 proved fatal to him be capable of hereditary transmission ; and if, 
 contrary to custom, the physician was not summoned until the 
 latter hours of the patient's life, and the information he acquires, to- 
 gether with the examination of the actual symptoms, be insufficient 
 to decide his opinion, the extreme weakness of the patient forbid- 
 ding the methodical examination of the different organs, examina- 
 tion after death can alone furnish the desired solution. When a dis- 
 ease terminates favorably, its exact diagnosis is generally of but 
 little consequence. There are, however, exceptions ; thus, when a 
 patient is near the termination of an eruptive fever, it is of some 
 importance to know whether it has been scarlatina or rubeola ; not 
 only because the first requires more strict and prolonged precau- 
 tions during convalescence, on acccount of the anasarca which 
 may supervene, but also because in after life, the individual who 
 knows with which of these diseases he has been affected, will 
 avoid the double inconvenience of either taking superfluous pro- 
 phylactic precautions, or of neglecting those which are necessary. 
 
DIAGNOSIS. 323 
 
 The manner in which desquamation takes place, furnishes, in 
 this case, an unequivocal diagnostic sign : it comes on more 
 quickly, and the scales are small after rubeola ; it is slower after 
 scarlatina, the epidermis is smooth and shining, the fingers look as 
 though covered with dried serous membrane [peau de baudruche, 
 q. v.] the epidermis comes off in long strips, and sometimes even 
 in the form of gloves. 
 
 When a disease, not yet in its last stage, has already gone 
 through the greater part of its course, the diagnosis may also pre- 
 sent certain difficulties to the physician who is then called for the 
 first time, and for the reason that he has not witnessed the primary 
 evolution of the antecedent phenomena. From this arises the in- 
 dispensable necessity of ascertaining as accurately as possible, 
 from the patient and those about him, and especially from the 
 physician previously in attendance, the series of phenomena succes- 
 sively observed, from the invasion of the disease to the time of 
 examination. Failure to obtain a part of this information might 
 sometimes render it impossible for the physician to give a precise 
 opinion in regard to the case in question. 
 
 2. Difficult Diagnosis arising from the Predominance of the 
 general or sympathetic Phenomena, or from the obscurity or ab- 
 sence of local Phenomena. When an important organ is the seat 
 of serious lesion, sympathetic phenomena are manifested by the 
 others, and particularly by the heart and brain, which, of all the 
 viscera, are those most actively associated with the others when 
 diseased ; the digestive and respiratory organs are by no means 
 strangers to these sympathetic influences. In many cases, and in 
 acute inflammations particularly, this sympathy extends, simuU 
 taneously, but in different degrees, to all the functions of the 
 economy, as is observed in the various forms of febrile action, to 
 which an entire article will be devoted. 
 
 When the general and sympathetic phenomena are only of me- 
 dium intensity, they do not mask the local symptoms, and their 
 presence constitutes no obstacle to diagnosis, but it is otherwise in 
 those cases where they become predominant ; they then demand, 
 and sometimes even absorb, the observer's attention, who. if he be 
 not aware of the errors to which this unusual intensity of sympa- 
 thetic phenomena may give rise, would be exposed to frequent de- 
 ception in his diagnosis. This point seems to us so important, that 
 we think it requisite, in this place, to glance at the principal sym- 
 pathetic phenomena, and point out their value. 
 
 It should be noticed, in the first place, that the two organs which 
 are the most common seat of sympathetic phenomena, are far less 
 frequently the actual seat of disease, than the other important 
 viscera. Thus the functional disorders of the brain and heart, as 
 cephalalgia, delirium arid even convulsions, accelerated circulation, 
 palpitations and syncope, in the great majority of cases, especially 
 in acute affections, have their source in other organs ; while the 
 serious disorders supervening in the digestive and respiratory or- 
 gans belong, most frequently, to certain diseases of these organs 
 
324 DIAGNOSIS. 
 
 themselves, or of the parts which assist them in the performance 
 of the same functions. When therefore we visit a patient with 
 delirium, convulsions, or severe headache, we are induced to seek 
 for its cause in the remoter organs rather than in the brain ; as also 
 we look for the source of severe fever in almost any other organ 
 than the heart. 
 
 Cephalalgia may depend upon local sanguineous plethora, in- 
 flammation of the organs contained within the cranium, tumors 
 developed in the same parts, or softening of the cerebral pulp, all 
 which diseases, if we except the first, are rare in comparison with 
 those which, being seated elsewhere than in the brain, produce 
 sympathetic cephalalgia. Among the latter we shall cite only the 
 different kinds of dyspepsia, so frequently productive of those 
 attacks of frontal pain, improperly called hemicrania ; acute bron- 
 chitis, in which the cough rings so painfully through the head 
 that it seems ready to burst ; prolonged constipation, typhoid fever, 
 eruptive fevers during their first period, the paroxysms of inter- 
 mittent fever, and almost all the visceral inflammations, which, in 
 some patients, may be accompanied by more or less intense cephal- 
 algia.* What has been said of cephalalgia is equally applicable to 
 delirium, which will occur twenty times perhaps as a sympathetic, 
 where it does once as an idiopathic phenomenon, that is, one de- 
 pendent upon disease of the brain itself, at least in acute affections. 
 This opinion we formerly communicated to Dr. Esquirol, and 
 asked of him, as the most competent judge in such cases, if the 
 observations that he had been enabled to make upon the delirium 
 of the insane, had led him to similar or different results. He replied 
 that he was convinced that in the insane, as well as in those affect- 
 ed with acute disease, delirium is most frequently sympathetic, and 
 consequently subordinate to disease of some other organ than the 
 brain. Cephalalgia and delirium have no very precise value in the 
 diagnosis of cerebral affections, except when rigidity or paralysis of 
 one part of the body, debility or loss of general sensibility, either 
 of one or several senses, are added to one or both of these two 
 symptoms. 
 
 What has been said of delirium, is equally applicable to convul- 
 sions and the coma which succeeds them ; those observed in chil- 
 dren in the first period of eruptive fevers, and during dentition, 
 those occurring in puerperal women, those noticed in hysteria, in 
 certain forms of malignant fever, or in persons under the influence 
 
 *Some instructive remarks upon the different forms and causes of cephalalgia, 
 are quoted from Dr. Wright's Clinical Lectures, (published in the Med Times, 
 Dec. 19, 1846,) by Dr. Ranking in his Half Yearly Abstract of the Medical Sci- 
 ences, (January to July 1847, p. 33, art. 8.) The principal varieties mentioned, 
 are those arising from the habit of masturbation, from dyspepsia, rheumatism of 
 the cranial integuments, (an affection requiring great attention, as metastasis to 
 the meninges may occur,) syphilitic taint and derangements of the menstrual func- 
 tion. The various causes which give rise to headache show the correctness of 
 our author's rule of practice, viz. "to seek for its cause in remote organs, before 
 referring it to the brain ; " (p. 324). Several of the causes of sympathetic head- 
 ache, enumerated by Dr. Wright, are not noticed by Chomel. TRANS. 
 
DIAGNOSIS. 325 
 
 of certain poisons, are independent of any cerebral disease, prop- 
 erly so called. 
 
 Paralysis of motion and sensation is, of all cerebral disorders, 
 the most valuable in the diagnosis of affections of the brain or its 
 appendages ; hemiplegia is a sign almost pathognomonic of some 
 lesion of the opposite cerebral hemisphere ; paraplegia generally 
 reveals the existence of disease of the spinal marrow. There are, 
 however, sufficiently numerous examples of paralysis of the lower 
 limbs, in which, on post-mortem examination, no lesion whatever 
 has been discovered ; there are even certain cases of hemiplegia, 
 in which the brain, examined with the most scrupulous attention, 
 has exhibited no material lesion. We have also seen certain indi- 
 viduals in whom intestinal disorder has for some hours been ac- 
 companied by torpor of the entire lateral half of the body, which 
 disappeared completely under the influence of abundant alvine 
 evacuations, natural or artificial. But paralysis is no less the most 
 certain sign of material lesion of the nervous centres, especially 
 when it is permanent, and very pronounced, and occupies either 
 the lateral half, or the lower portions of the body. 
 
 Disturbance of the cardiac functions, especially in acute dis- 
 eases, but also in many of a chronic nature, appertains, in the 
 great majority of cases, to the sympathetic phenomena. When 
 the physician discovers in the patient to whom he is called, an in- 
 tense febrile action, the idea that acute inflammation of the heart 
 is the cause of the acceleration of the pulse would be the last 
 which would occur to his mind. Syncope itself belongs much 
 more frequently to certain forms of abdominal pain, to the indis- 
 position which precedes vomiting and alvine evacuations, to certain 
 moral affections, to some varieties of intermittent fever, or to the 
 invasion of certain acute diseases, than to diseases of the heart 
 and its envelopes. Irregularity in the pulsations of the heart, 
 which seems to belong more particularly to material lesion of this 
 organ, and which, in reality, constitutes one of its most important 
 signs when permanent, (when, for example, they persist for one 
 or more weeks, and more particularly when they last for many 
 months,) is sometimes transient, like the sympathetic phenomena, 
 in the same conditions which cause syncope ; and in certain cases, 
 even for a considerable time, when the same causes are in continu- 
 al action, as in the case reported by Morgagni, arid previously cited, 
 (p. 175.) Excessive sanguineous evacuations effect changes in the 
 force, frequency, and rhythm of the pulse, and even in the sounds 
 perceived by auscultation (p. 167), which might simulate the 
 existence of cardiac lesions, if the signs furnished by percussion 
 and the examination of the different circumstances of the disease 
 did not aid us in the diagnosis. 
 
 Haemorrhage and dropsy belong to the secondary phenomena 
 furnished by disorder of the circulatory organs. Both appear, in 
 certain circumstances, with great intensity ; they predominate so 
 much over the other symptoms, which are frequently very ob- 
 scure, that they seem to constitute the entire disease, and in many 
 28 
 
326 DIAGNOSIS. 
 
 instances it is really very difficult, sometimes even impossible, 
 for a considerable period, to determine accurately whether the 
 hgemorrhage or the dropsy we observe, be essential or symp- 
 tomatic. 
 
 Haemorrhage occurring during the course of diseases * is, as we 
 have elsewhere seen, general or partial (p. 201). The former is of 
 easy diagnosis ; it furnishes an additional sign in scorbutus and 
 pestilential diseases, and renders the disease more manifest. It is 
 chiefly when hsemorrhage takes place from a single organ, that 
 the diagnosis is obscure. Two conditions here present themselves ; 
 in the first, the organ which is the seat of the haemorrhage has 
 previously shown indubitable signs of being in a morbid condition, 
 and in that case, the occurrence of haemorrhage assists, rather 
 than hinders, diagnosis. This is observed in individuals, who, 
 with equivocal signs of pulmonary tubercle, cancer of the stomach, 
 or typhoid fever, suddenly discharge blood, either from the bron- 
 chia, the stomach, nares or intestines : in these cases, the haemor- 
 rhage evidently confirms the diagnosis. In the second condition, 
 the haemorrhage appears in those apparently in health, manifesting 
 itself as a primary and unique phenomenon ; the patient and those 
 habitually with him, assert that no functional alteration, nor 
 change in his usual appearance preceded the haemorrhage, and the 
 examination of the cavity whence the blood is discharged, although 
 often repeated, and by all the known modes of exploration, reveals 
 no lesion. In such a case the physician remains in great doubt ; 
 the extreme rarity of essential haemorrhage should lead him to 
 fear that that which he observes is symptomatic, still the absence 
 of the peculiar characteristic signs of material lesion does not allow 
 him to affirm its existence ; he must, then, defer giving his opinion 
 until new signs come to his assistance. Recovery after profuse 
 haemorrhage is often very uncertain, and we cannot be entirely 
 confident of it for many months or even years. This is particu- 
 larly applicable to haemoptysis, which is often indicative of latent 
 tubercle, and to hasmatemesis and haematuria, which are sometimes 
 the first signs of lesion in the stomach or urinary organs. Uterine 
 haemorrhage is generally more easily distinguished, because the ex- 
 ploration of the uterus is far more direct and complete than that of 
 the lungs, stomach, and kidneys can be : but, on the other hand, 
 those affections to which this kind of haemorrhage appertains, are 
 more varied and their distinction frequently obscure. Although 
 the uterus is the seat, during several years of life, of a normal san- 
 guineous discharge, and essential haemorrhage is more rare from 
 this organ, than from the others which have just been named, 
 considerable uterine haemorrhage is, notwithstanding, in a great 
 majority of cases, a symptomatic phenomenon, and whenever the 
 
 * Hsemorrhage belongs, at one time, to general phenomena, at another, to the 
 local symptoms of diseases : the first alone should have here been considered, but 
 we thought it useful to add a few words upon the latter, in their relation to diagno- 
 sis ; an entire article seemed unnecessary. 
 
DIAGNOSIS. 327 
 
 physician meets with a case of this nature, either in the old or 
 young, married or single, his first reflection should be that the 
 existing haemorrhage arises from disturbed pregnancy, threatened 
 abortion, the presence of some foreign body in the uterus, a can- 
 cerous affection, granular inflammation or some other less frequent 
 disease of this organ. 
 
 We cannot conclude this article, devoted to the semeiological 
 value of haemorrhage, without reminding the reader, that that 
 succeeding the suppression of the menstrual, or of some other 
 constitutional or periodical sanguineous discharge, has the least 
 importance in regard to prognosis, and is most frequently uncon- 
 nected with material lesion of the parts where it is manifested. 
 
 Finally, it should be remembered that the suspension of consti- 
 tutional haemorrhage, particularly of the menses, unless occurring 
 with the natural conditions, is almost always the effect of disease, 
 either latent or manifest, developed sometimes in the uterus, but 
 more frequently in a distant organ, as the stomach, and particu- 
 larly the lungs, or even affecting the entire system. 
 
 We class dropsy among the disorders of the organs of circula- 
 tion, because, in a very great majority of cases, it arises from an 
 obstruction in the course of the blood, either in the heart, in which 
 case dropsy progressively pervades the whole system, commencing 
 at the extremities ; or in some point of the venous system, the 
 effusion being then confined to the parts from which the branches 
 of the compressed or obliterated vein arise. General dropsy, which 
 has supervened gradually, is one of the most certain signs of or- 
 ganic affection of the heart, or of a more or less serious change in 
 the composition of the blood, or, finally, of that disease of the 
 kidney described by Dr. Bright, of which the presence of albumen 
 in the urine is the pathognomonic sign. General dropsy, mani- 
 festing itself rapidly in an acute disease, becomes a valuable sign 
 in the frequently obscure diagnosis of pericarditis and endocarditis. 
 In 1826, we pointed out the importance of this phenomenon in acute 
 pericarditis,* and in the course of the same year, at the Clinique 
 of the Hotel Dieu, this sign led us to suspect endocarditis in 
 a young female, which proved fatal. Finally, when an individual 
 is attacked with acute anasarca, we should always ascertain if he 
 have not been recantly affected with some eruptive disease : ana- 
 sarca, indeed, is observed quite often in convalescents from scarla- 
 tina, the material cause of the effusion not being, as yet, accurately 
 determined. 
 
 The diagnostic signs furnished by partial dropsy, are equally 
 important. When confined to a single limb, it indicates compres- 
 sion or obliteration of its veins. The examination of the infiltrated 
 limb, enables us sometimes to recognise in the course of the vein, 
 near the trunk of the body, a very firm cylinder, formed by the 
 inflamed and indurated vessel. But in the greater number of cases, 
 this partial oedema of a limb results from compression made upon 
 
 * Diet, de Medecine, En 21 vol. Art. Pericardite. 
 
328 DIAGNOSIS. 
 
 the principal vein, by a tumor developed either in one of the iliac 
 fossae, or within the thorax, according as the infiltration occupies 
 the thigh or the arm : in certain cases, this infiltration is the first 
 and even the only sign which indicates the existence of the tumor 
 or leads us to suspect it, and can alone enable us to form a correct 
 diagnosis. When dropsy occupies the two lower limbs simultane- 
 ously, it may depend upon compression of the vena cava abdomi- 
 nalis ; but most usually, this form of oedema is only the first 
 degree of general dropsy, which begins at the most depending 
 parts, where the difficulty with which the blood rises in opposition 
 to the laws of gravity, concurs with the lesion of the heart, or the 
 change in the blood, in the production of serous infiltration. It is 
 otherwise in very rare cases, where dropsical effusion occupies the 
 superior half of the body : we then cannot doubt the existence of 
 a considerable obstacle to the circulation of the blood in the vena 
 cava superior. A case of this nature occurred the present year at 
 the Medical Clinique of the Hotel Dieu. A man was admitted, whose 
 face, neck, upper half of the chest, and both arms, presented enor- 
 mous serous distention which contrasted singularly with the exces- 
 sive emaciation of the inferior three fourths of the body. The 
 necropsy disclosed a cancerous tumor, developed in the mediasti- 
 num, by which the vena cava superior was, as it were, strangula- 
 ted, confirming, at least as far as regarded the existence of a tumor, 
 the diagnosis which had been made; nothing had indicated that 
 this tumor was necessarily cancerous, and the relative frequency 
 of aneurismal tumors of the aorta would more particularly have 
 aroused suspicions of the latter cause of compression. 
 
 Among the partial dropsical effusions, we shall enumerate ascites, 
 the most important diagnostic sign of cirrhosis of the liver ; * also 
 the serous infiltration which supervenes in prolonged intermittent 
 fevers, arid which is distinguished by the dull yellow tinge of the 
 skin and congestion of the spleen, which, like the dropsy, are the 
 consequence of these fevers. We would also mention the serous 
 infiltration developed in the vicinity of certain deep-seated abscess- 
 es, and which is, in some cases, almost their only sign ; and the 
 serous infiltration of one half of the face, a phenomenon which 
 alone, in certain cases, leads us to seek and discover an abscess 
 formed near the alveolar border of one of the maxillae, and arising 
 almost always from a carious tooth. 
 
 3. The secondary or sympathetic phenomena furnished by the 
 digestive and respiratory organs, are, as we have remarked, of far 
 less importance, and rarely embarrass diagnosis. The anorexia 
 
 * In ascites dependent on lesion of the liver, the urine is always more or less 
 deeply colored, whilst in renal ascites (Bright's disease or otherwise), it is white 
 or colorless (Rayer). This characteristic condition of the urine was known to 
 the Arabian physicians. (Monthly Journal of Med Science, Dec. 1847, quoted 
 by Dr. Ranking, Med. Abst. Jan. to July, 1847.) Dr. Budd declares the urine 
 in cirrhosis to be almost always scanty and high colored, depositing lithate of am- 
 monia. (Diseases of the Liver. Cirrhosis.) This, being constant, will always 
 assist in the differential diagnosis of ascites. TRANS. 
 
DIAGNOSIS. 329 
 
 accompanying the greater number of diseases, and the acceleration 
 of respiration in all cases where the circulation is quickened, hardly 
 ever lead the physician to suppose the stomach or lungs the seat 
 of a disease which might be situated in any other part of the body. 
 The contrary is true of vomiting, cough, and dyspnoea. 
 
 Vomiting does not always depend upon disease of the stom- 
 ach; its productive cause may be elsewhere seated. We have 
 previously stated the numerous and various conditions which may 
 cause vomiting, and lead to the supposition of an acute or chronic 
 affection of the stomach. We shall, at present, only call to mind 
 the difficulty presented by certain cases of misunderstood or sim- 
 ulated pregnancy, and of epiploic or intestinal hernia, so small, or 
 so far concealed by obesity, that they are not discovered until they 
 have been suspected, and after a most attentive search. The ob- 
 stinate vomiting, which, in certain instances, is the predominant 
 symptom in hepatic and nephritic colic, and which may mask the 
 local symptoms, should also be mentioned. We would particularly 
 mention those cases, as yet too little known by most physicians, 
 of accidental occlusion of the intestine, of which vomiting is the 
 most apparent sign ; a disease confounded with the peritonitis con- 
 sequent upon it, and in which energetic purgatives, assisted by the 
 external and internal use of ice, often produce most wonderful 
 effects. 
 
 Cough and dyspnoea are two phenomena sometimes determin- 
 ed sympathetically by an affection of remote organs, and may 
 render diagnosis difficult or erroneous. We have previously men- 
 tioned the principal forms of sympathetic cough (p. 153), we need 
 not re-enumerate them : we shall only remark that sympathetic 
 cough is habitually dry, if we except that called gastric, which is 
 often accompanied by a glairy exhalation from the posterior fauces. 
 Sympathetic cough, also, is not accompanied with those ausculta- 
 tory and percussory phenomena belonging to pulmonary diseases, 
 and which manifest themselves almost constantly with idiopathic 
 cough. Dyspnoea rarely occurs as a sympathetic phenomenon ; 
 it belongs almost exclusively to affections of the pulmonary or 
 circulatory organs, which are intimately associated, or to material 
 lesions of the nerves, which preside over respiration and circula- 
 tion ; in all these cases, it is idiopathic, or may be so considered. 
 That form of dyspnoea observed in cases of enormous distention 
 of the abdomen in ascites, tympanitis, and encysted dropsy, is 
 entirely mechanical, and its source cannot escape the most unprac- 
 tised eye. 
 
 Sympathetic dyspnoea is hardly ever observed, except under 
 the influence of certain moral affections, whose effects extend, in 
 some persons, to the entire nervous system, as in females affected 
 with so called hysteria, while in others they are concentrated in 
 the respiratory organs. Certain stomachal affections, character- 
 ized by an acute pain or a kind of spasm in the epigastric region, 
 sometimes occasion dyspnoea so intense, that the patient appre- 
 hends suffocation. In all these cases, the cause of the dyspnoea, 
 28* 
 
330 DIAGNOSIS. 
 
 the diagnostic signs and remedial indications, are to be sought 
 elsewhere than in the respiratory organs or their appendages. 
 
 Having reviewed the sympathetic phenomena which may be 
 presented by each of the four great functions, and pointed out the 
 difficulties of diagnosis resulting from the intensity of these phe- 
 nomena, we shall now examine febrile action, which comprises all 
 functional disorde^ when considered in regard to the obstacles it 
 places in the way of the diagnosis of disease, on the one hand, 
 when by its predominance it masks the local symptoms, or when 
 these symptoms are entirely wanting ; on the other, when it is so 
 slight in itself as to remain almost unperceived : for we should not 
 forget that if the violence of the fever be a frequent obstacle to 
 diagnosis, its presence is sometimes one of its necessary elements. 
 
 Febrile action is observed with either the intermittent or continu- 
 ed type, and with an acute or chronic form. It is particularly in 1 
 these two points of view that it should be examined, when the 
 diagnosis is difficult. The degree of intensity and the inflamma- 
 tory, adynamic or ataxic forms of fever have, in this connection, 
 only a secondary interest. 
 
 Febrile action which manifests itself with the intermittent type, 
 is generally considered as exclusively appertaining to essential in- 
 termittent fevers, and as requiring to be treated, in consequence of 
 this opinion, by the specific remedy usually employed in these dis- 
 eases. This opinion, which is mainly true in regard to those 
 febrile affections whose paroxysms are widely separated, as in the 
 quartan and even the tertian type, is no longer so, when we arrive 
 at the quotidian, and more especially the double quotidian. Pro- 
 portionally, indeed, to the proximity of the paroxysms, the num- 
 ber of cases in which the fever is symptomatic becomes greater, 
 so that, by referring to the results of our own observation, which 
 extends over a space of more than thirty years constantly passed 
 in the hospitals, the double quotidian fever is always symptomatic ; 
 the quotidian is so in more than half the cases ; the tertian rarely ; 
 the quartan never. We consider this result as more important, 
 from the fact that many physicians, otherwise well informed, are 
 not sufficiently aware of the frequency of symptomatic intermit- 
 tent fevers, and how necessary it is to guard against the too gen- 
 eral tendency to declare the existence of essential intermittent 
 fevers wherever the intermittent type is perceived. Here, as we 
 have seen, the duration of the intermission is highly important, 
 since the farthest removed paroxysms belong constantly to essen- 
 tial iritermittents, which are the nearest allied to the symptomatic 
 fevers. It is, then, in the intermediate types that difficulties may 
 occur in diagnosis ; to these, consequently, our attention should be 
 chiefly directed. 
 
 The tertian type, whose paroxysms occur generally at intervals 
 of about thirty-six hours, does not, as we have said, belong, except 
 very rarely and as if accidentally, to symptomatic fevers. \V e 
 have had, in the clinical wards of the Hotel Dieu, an individual af- 
 fected with gastro-enteritis of medium severity, with tertian febrile 
 
DIAGNOSIS. 331 
 
 paroxysms, evidently under the control of the regimen adopted by 
 the patient. In fact, during the eight or ten days which preceded 
 his admission, this man had alternately tried, on the one day, food 
 whose ingestion was followed by a febrile paroxysm, and on the 
 following day, abstinence; simple abstinence from food prevented 
 the return of these paroxysms, which may be termed artificial, 
 and the use of certain antiphlogistic remedies subdued the gastro- 
 intestinal inflammation in a short time. Evidently, in this case, 
 the febrile paroxysms were the result of inflammation of the diges- 
 tive passages, exasperated every two days by the unseasonable use 
 of food. The repeated action of cold may produce effects in 
 bronchitis, analogous to those determined by food in gastritis, and 
 accidentally give to the disease the appearance of tertian intermit- 
 tent fever ; but these cases are very rare, and the tertian type must 
 be regarded as appertaining to essential intermittent fevers. 
 
 It is otherwise with the quotidian type, as we have previously 
 remarked; the greater number of diseases presenting this type, 
 and perhaps all those of the double tertian, belong to symptomatic 
 fevers. When, therefore, a disease manifests itself with the quo- 
 tidian type, our whole attention, in examining the case, should be 
 given to the determination of the essential or the symptomatic 
 nature of the fever. In the solution of this question, which is so 
 often presented in the practice of medicine, it is interesting to know 
 the affections in which the symptomatic quotidian type has been 
 particularly observed. There is, perhaps, no inflammation, acute 
 or chronic, no suppuration, either manifest or concealed, which 
 has not been accompanied during a certain part of its course, by 
 quotidian paroxysms. But it is chiefly in inflammations of the 
 bronchial, digestive, and urinary mucous membranes, in the sec- 
 ond stage of tuberculous affections, and in cases of deep-seated or 
 superficial ulceration, that this febrile type occurs. Thus, when 
 we are observing a quotidian intermittent, we should endeavor to 
 ascertain, by the examination of the patient, whether the parox- 
 ysms do not depend upon some one of these affections. In many- 
 cases the diagnosis is easy : on one hand, the primary disease mani- 
 fests itself by signs peculiarly its own ; on the other, the febrile 
 paroxysms, instead of commencing in the morning or at mid-day, 
 at precise hours, or at least with uniform intervals of twenty-two, 
 or twenty-six hours, for instance, begin almost constantly towards 
 evening, that is, at the time when the paroxysms of the phlegma- 
 siae, and of almost all diseases of continued type, occur. But 
 there is not always this distinctness. In certain cases, the local 
 symptoms of the inflammation, the abscess, or the tuberculous 
 affection, are obscure, easily escaping the notice of the physician 
 who does not search for them ; sometimes even, they are not evi- 
 dent to the one who suspects them, and who employs all the known 
 explorative means for their discovery ; in certain cases, finally, the 
 febrile paroxysms become so intense, that they might be considered 
 as pertaining to the pernicious form of intermittent fever, and this 
 disproportion between the general phenomena and the local lesion 
 
332 DIAGNOSIS. 
 
 renders the diagnosis very difficult, sometimes even impossible, 
 until new signs come to our assistance. These paroxysms of a 
 pernicious nature are especially observed in diseases of the urinary 
 passages, and in ruptures of the canals and reservoirs of this fluid ; 
 and their origin is unknown until the moment when gangrenous 
 inflammation of the tissues infiltrated with urine, reveals the cause 
 of all the disorder. Generally, also, in these very rare cases, the 
 febrile action assumes rather the remittent than the intermittent 
 type : by carefully questioning the patient and the assistants, we 
 sometimes succeed in learning tfyat previously to the existing 
 affection, there was some disorder in the urinary passages, that the 
 first chills came on after violent efforts to pass urine, etc. But the 
 following important fact, above all others, may enlighten the phy- 
 sician in the midst of the difficulties with which the severity of the 
 paroxysms surrounds the diagnosis, viz. that in a healthy coun- 
 try (at Paris for instance), nothing is more rare than essential 
 pernicious fever, therefore, unless it has been elsewhere con- 
 tracted, we must suspect a symptomatic fever in the paroxysms 
 which are observed of this pernicious nature, and, by an 
 attentive and methodical exploration of all the organs and func- 
 tions, endeavor to discover the source of those alarming symp- 
 toms, which are, in reality, but the shadow of the disease. 
 
 Lastly, it frequently happens that the paroxysms of certain acute 
 affections, particularly those of typhoid fever, are distinguished, for 
 several consecutive days, by chills, which may occur at the same 
 hour, and give to the disease the appearance of the intermittent, or 
 remittent type ; but this is only the exceptional course, and after 
 some days the disease resumes the continued type peculiar to itself. 
 The same thing occurs, either in the first period of certain acute 
 inflammations, in which every exacerbation of the disease may be 
 marked, as was its invasion, by successive chills ; or in an ad- 
 vanced stage of certain acute diseases, when metastatic abscess is 
 formed. In these various conditions we observe the great impor- 
 tance of quotidian chills, in a diagnostic point of view. 
 
 Before concluding our remarks upon the diagnosis of intermit- 
 tent affections, we would add, that, if in many cases the predomi- 
 nance of the febrile action masks the original disease, in some 
 cases of essential intermittent fever, on the contrary, the paroxysms 
 are so feebly marked, that they easily escape the superficial ob- 
 server, who would see only, in the patient he attends, a want of 
 power in the digestive organs, oedema of the lower limbs, and en- 
 largement of the spleen. It is particularly in those places where 
 essential intermittent fevers prevail, and in those individuals who 
 have exhibited their manifest access, that the obscure paroxysms, 
 we have thought it important to notice, are observed. 
 
 Continued febrile action may be either acute or chronic ; in the 
 latter form, it is called hectic fever ; in the former, it is divided 
 into ephemeral and synochal, according as it only attains or con- 
 tinues beyond the third day. These are not useless distinctions, 
 when continued febrile action is considered in regard to diagnosis. 
 
DIAGNOSIS. 333 
 
 Ephemeral fever is often the symptom of slight inflammation, as 
 coryza, or cynanche tonsillaris, whose symptoms are sometimes 
 prolonged, with diminishing intensity, after the cessation of the 
 febrile action. But often, likewise, ephemeral fever, particularly 
 in children, is a primary or essential disease; in some individuals 
 it results from certain causes which reproduce it whenever they 
 are in action ; unusual exercise, exposure to cold or heat, strong 
 emotion, or errors in diet, are sometimes sufficient to determine a 
 very intense febrile action accompanied by alarming symptoms, 
 but ceasing after twenty-four or forty-eight hours, without any 
 remedial aid. 
 
 When a disease commences with continued febrile action, it is 
 generally difficult and often impossible to determine its duration, 
 whether it will remain within or go beyond the limits of ephemeral 
 fever. This uncertainty exists, indeed, at the commencement of 
 many acute affections, whose diagnosis, as we have said, cannot 
 be pronounced until the second or third day. Most frequently, it 
 is not until after the cessation of ephemeral fever, that the diag- 
 nosis is entirely clear. The uncertainty is not of long duration, 
 and not seriously injurious. But when the continued febrile action 
 exceeds the period of ephemeral fever, and especially, when it con- 
 tinues beyond the fifth or the sixth day, and there are no manifest 
 signs of a local affection, the diagnosis may be very difficult, and 
 the uncertainty, a serious inconvenience. The principal affections 
 with which it is connected are latent visceral inflammations, and 
 eruptive affections of abnormal course, inflammation of the veins 
 or lymphatics, and typhoid fever. 
 
 There are but few visceral inflammations sufficiently grave to 
 produce febrile action persisting with considerable intensity until 
 the fifth day, without its existence being revealed by local signs. 
 There have been cases, however, where inflammation of the uterus 
 and its appendages, or of some portion of the peritoneum or neigh- 
 boring cellular tissue, especially after parturition, has occasioned 
 febrile action, whose source it is difficult to determine, although the 
 patient's peculiar state calls attention particularly to the affected 
 point. An attentive exploration of the uterus and pelvic cavity, 
 by vaginal and rectal examination, and by palpation of the abdo- 
 men, does not always enable us to establish an immediate diag- 
 nosis, and in some cases many weeks elapse before the characteristic 
 signs begin to appear. With the exception of these particular 
 cases, the chest is the most frequent seat of those latent inflamma- 
 tions, which febrile action leads us to suspect, although not de- 
 clared by any local symptom. Not to mention certain cases of 
 pericarditis without effusion, of interlobular pleurisy, or that con- 
 fined to the diaphragmatic and mediastinal regions, where auscul- 
 tation and percussion would be almost unavailable, we would par- 
 ticularly notice that deep-seated pneumonia, equally inaccessible 
 to our means of exploration, and which, sometimes occurring with- 
 out pain in the side or sputa, almost defies discovery. In these 
 obscure cases, however, the intensity of the invading chill, whose 
 
334 DIAGNOSIS. 
 
 value we have already mentioned, the persistence of febrile action 
 for a longer period than four or five days, particularly in a patient 
 beyond the age exposed to typhoidal affections, and in a season 
 when pneumonia is prevalent, should suffice, not wholly to con- 
 vince the physician, but to lead him to a confident presumption, 
 that the febrile action observed arises from pneumonia. 
 
 In the eruptive affections, the febrile action usually precedes the 
 exanthema by a few days only ; it is, then, in entirely exceptional 
 cases, that the fever of invasion persists until the fourth or fifth 
 day, before the appearance of the eruption ; and it is even more 
 unusual that the contagious principle of variola, rubeola, or scar- 
 latina, causes a febrile action, which is not followed by an erup- 
 tion, (variola sine variolis, morbilli sine morbillis, scarlatina sine 
 scarlatina.) In cases where the fever persists, and no eruption 
 appears, the diagnosis may be elucidated to a certain extent, by 
 considering the prevailing diseases, by the symptoms peculiar to 
 the period of invasion of each of the eruptive fevers, as the coryza, 
 epiphora and cough in rubeola, the sore throat in scarlatina, and 
 the lumbar pain in variola ; and in each of them by the appear- 
 ance of an eruption upon the mucous membrane of the mouth, 
 similar to that which should have been manifested upon the skin, 
 and, finally, by the inaptitude to contract the same disease in future. 
 
 Inflammation of the veins or lymphatics causes intense and 
 permanent febrile action, whose source is sometimes very obscure. 
 A slight wound, the contact of putnfied matter with a simple ex- 
 coriation, sometimes a mere contusion upon the surface of the 
 body in a part where the veins rest upon a bone, as the cranium 
 and the front of the tibia, have been the occasion of latent phle- 
 bitis, the sole symptom of which has been intense fever for a 
 period of from eight to ten days, until the appearance of multiple 
 abscess beneath the skin established the diagnosis. In these dif- 
 ficult cases, the necessity of tracing the febrile action to its cause, 
 should lead the physician to put his questions with a view to all 
 those circumstances likely to induce phlebitis ; and when this in- 
 quest has given the proper direction to our search, the attentive 
 examination of the region where the disease commenced some- 
 times reveals modifications in the consistence, volume, and sensi- 
 bility of its vessels, which, although slight, become very valuable 
 diagnostic signs. 
 
 But of all the affections where continued and prolonged febrile 
 action is observed, without local phenomena clearly indicative of 
 its source, typhoid fever is indisputably the most common. The 
 greater part of those affections described by writers of former ages 
 under the name of essential fevers are, evidently, as we have 
 proved,* only various forms of typhoidal disease, since post-mor- 
 tem examination reveals identical lesions in all these fevers, which 
 are not met with in any other disease. From this fact it follows, 
 that typhoid fever is one of the most frequent affections noticed in 
 
 * Logons de Clinique Medicale sur la Maladie Typhoi'de. 
 
DIAGNOSIS. 335 
 
 our climate, and if we consider that the general symptoms which 
 accompany it are often very grave, while the local phenomena 
 connected with the anatomical changes are most frequently ob- 
 scure, and sometimes almost null, we shall, by a comparison of 
 these two conditions, have the natural explanation of the opinion 
 often expressed in our clinical instructions, viz. that an acute fever 
 persisting beyond the eighth day, and presenting, up to that period, 
 after methodical and repeated explorations, no indication of local 
 inflammation sufficiently intense to explain the fever, should be 
 considered typhoidal, at least in our climate, and in our usual san- 
 itary condition.* Certain rare exceptions to this practical axiom 
 do not invalidate it. 
 
 Hectic fever, or the chronic form of continued febrile action, is 
 also of great importance in the diagnosis of disease, whether, as is 
 quite often the case, the hectic fever being apparent, the lesion which 
 produces it remains concealed ; or whether this affection is itself 
 obscure and uncertain in its manifestation. If we except the very 
 rare cases where it is the direct result, either of a profound moral 
 affection, of excesses or of considerable evacuations, hectic fever is 
 almost always the effect, and consequently, the sign, of chronic sup- 
 puration, itself arising from essential or symptomatic inflammation; 
 caries of the bones, for instance, or the tuberculous affection. In 
 a considerable number of cases, it is difficult to determine to which 
 of these lesions the hectic fever should be ascribed : certain forms 
 of chronic abscess are unaccompanied by any local sign whatever ; 
 some chronic inflammations, likewise, occasion only a progressive 
 and apparently inexplicable marasmus, and the tuberculous affec- 
 tion, the most frequent of all the diseases productive of hectic 
 fever, is at the same time one of those whose local symptoms may 
 longest remain obscure. Thus the existence of hectic fever, with- 
 out local lesion to explain it, is a sign almost pathognomonic of 
 tubercular disease, as an acute fever, whose source is not evident 
 after seven or eight days' continuance, is almost characteristic of 
 typhoidal affection. 
 
 Before approaching another subject, we would add that in the 
 continued, as well as in the intermittent, type, the difficulties of 
 diagnosis do not always depend upon the predominance of the 
 febrile action and the obscurity of the local symptoms. In certain 
 cases, on the contrary, the local symptoms are sufficiently well 
 marked, but the slight intensity of the febrile action might lead us 
 to suppose that it was entirely absent, and thus communicate an 
 uncertainty to the diagnosis of certain affections where the febrile 
 condition is an important sign. Thus, individuals are met with, 
 aged persons particularly, in whom the examination of the chest 
 and the character of the sputa announce the existence of pneumo- 
 nia ; but the state of the pulse, the slight heat of the skin, especially 
 
 *That is to say, abstraction being made of the times and places in which epi- 
 demic or pestilential diseases are prevalent ; such as contagious typhus, the plague, 
 yellow fever, certain kinds of puerperal fever, etc. 
 
336 DIAGNOSIS. 
 
 if we examine the patient in the morning, seem to indicate an 
 apyrectic state which little harmonizes with such an affection. In 
 such cases, by ascertaining the state of the healthy pulse in these 
 individuals, by examining the degree of heat elsewhere than at 
 the wrist, upon parts constantly covered by the bedclothes, as the 
 chest or abdomen, by observation of the patient at different parts 
 of the day, we are enabled to ascertain the existence of a febrile 
 action, which becomes manifest in its exacerbations and is discov- 
 erable even in its remissions. The same is true of that scarcely 
 noticeable febrile action which accompanies typhoid fever during 
 the first week, and sometimes even through its entire course, when 
 it assumes its mildest form. 
 
 The phenomena of hectic fever, in certain cases, (and almost 
 always at its commencement,) are for a considerable time obscure 
 and of difficult appreciation. It does not cause that disorder in 
 the system which belongs to acute febrile action. The latter in- 
 stantly produces general indisposition, loss of appetite, and con- 
 fines the patient to bed ; while hectic fever, especially during its 
 first period, does not at all affect the habits of life ; the strength and 
 flesh, it is true, diminish gradually, but most frequently the patient 
 pursues his occupations, eats and digests nearly as usual ; some- 
 times even, he does not perceive the slightest change in his health. 
 This is particularly observed in the course of certain diseases of 
 the chest, when the pulse begins to be accelerated, the thirst to 
 increase, and the sleep to be accompanied by morning perspira- 
 tions. In these cases, the knowledge of the existence of com- 
 mencing hectic fever, is frequently the most important point in 
 establishing the diagnosis of a tuberculous affection.* 
 
 3. Difficult Diagnosis resulting from the Infrequency of the Dis- 
 ease. If those diseases be excepted which are seated upon the 
 external surface, or in parts which, although situated somewhat 
 profoundly, may yet be directly examined by the aid of our ex- 
 plorative means; we repeat, if these diseases, whose diagnosis is 
 
 * Although hectic fever is connected with tuberculous affections in so great a 
 majority of cases, that its mention, alone, suffices most frequently to bring to mind 
 its formidable companion, (or, more properly speaking, its cause, considering hectic 
 fever as a symptom or assemblage of symptoms;) yet it should be remembered 
 that many other affections or practices induce a species of hectic fever. Authors 
 have enumerated several varieties ; as Gastric, Pectoral, Genital, Hamorrhagic, 
 Cutaneous, Moral, eic. (Broussais) : Inflammatory, Putrid, Nervous, Gastric, 
 Atrabilious, Piluitous, Verminous, Enter o-mesenteric, and Suppurative. (Hilden- 
 brand.) To these, puerperal hectic is added by Dr. Copland. (Med. Diet. 
 Hectic Fever.) Of these various forms, the genital, hamorrhagic and moral seem 
 most constantly inclined to merge, finally, in the pectoral, which deservedly occu- 
 pies the first rank in point of frequency. The other varieties, depending upon 
 special and evident causes, disappear with their removal, and rarely terminate in 
 the pectoral, which may, (if we may hazard the opinion,) be considered the only 
 incurable variety, depending as it does, nearly always, upon causes incapable of 
 removal. The suppurative form may be considered as next in point of fatality, 
 but cannot compare with the pectoral. The gastric disorder accompanying pecto- 
 ral hectic can hardly be considered as indicating the termination of the gastric in 
 the pectoral variety. TRANS. 
 
DIAGNOSIS. 337 
 
 generally quite easy, because they are evident to our senses, be set 
 aside, we must admit that, generally, the more rare a disease is, 
 the less it is understood, and consequently its diagnosis is more 
 obscure. This proposition needs no proof. The most highly edu- 
 cated physician, when confronting a disease he has never observed 
 or heard described, and of which, perhaps, there exists no example 
 in the annals of the science, will often experience insurmountable 
 difficulties in its diagnosis. Such was the position of Boerhaave* 
 when called to visit Admiral Wassenar, laboring under the dread- 
 ful symptoms of transverse rupture of the oesophagus. Post-mor- 
 tem examination alone revealed the material lesion productive of 
 symptoms equally frightful and unusual. 
 
 It is not only in cases where the signs of a disease and its very 
 existence are unknown, that diagnosis is difficult or impossible ; 
 these difficulties, this almost impossibility, exist in certain very rare 
 affections, whose anatomical nature and symptoms, however, are 
 recognised when they have signs in common with another disease 
 daily observed by the physician. In fact, when a group of symp- 
 toms belongs to two affections, one of which is very frequent, and 
 the other as rare, the physician will, and naturally should, be led 
 to apply these symptoms, whenever presented, to the most common 
 disease. If, for example, in a case of chronic disease, one side of 
 the thorax present, in a limited space, (which is constantly the 
 same whatever be the attitude of the patient,) a flat sound and 
 entire absence of the respiratory murmur, without fever, and with 
 medium loss of flesh, we may suspect two different lesions : either 
 there is pleuritic effusion circumscribed by adhesions, which is of 
 daily occurrence, or a solid tumor developed in the pleura or in 
 the pulmonary parenchyma, some examples of which are con- 
 tained in the records of the science. The latter does not, perhaps, 
 occur in greater proportion to the former, than one to one hundred 
 thousand ; therefore when the exceptional case presents itself, it 
 will almost inevitably become the source of error in diagnosis, 
 especially if the physician have not been summoned at the com- 
 mencement of the disease, or if the exploration of the chest was 
 not scientifically made. The unequal frequency of diseases neces- 
 sarily constitutes one of the elements of diagnosis ; it sometimes 
 renders it more obscure, but in most cases it. is highly serviceable to 
 the physician, when the inductions furnished by it are employed 
 with proper reserve. 
 
 4. Complications generally embarrass diagnosis, either because 
 the symptoms of one disease encumber or obscure those of the other, 
 or because the mingling of these phenomena changes simultaneously 
 the physiognomy of both affections, so that neither of them exhibits 
 its usual characteristics. There is rarely error in regard to both 
 diseases at once ; but it often happens that one of them is misun- 
 derstood, and that the phenomena appertaining to the other disease 
 are referred to sympathetic disturbance of the functions. This 
 error may usually be avoided, by recollecting, that in order to 
 form an accurate diagnosis, we must not only ascertain the actual 
 29 
 
338 DIAGNOSIS. 
 
 disease, but also be sure that no other exists. By such a method 
 of examining patients, obscure complications will frequently be 
 detected, and sometimes even, we may be led to perceive in that at 
 first regarded as the unique and essential disease but a symptom 
 or consecutive lesion of one subsequently distinguished. 
 
 5. There is still another condition which greatly enhances the 
 difficulties of diagnosis : this is deception on the part of individuals 
 *vho wish either to conceal the diseases under which they labor 
 (maladies dissimuttes), or to induce the physician to suppose others, 
 really non-existent (maladies simulees). 
 
 It is quite common for individuals to seek to conceal from the 
 physician the diseases which affect them : a false modesty, fear of 
 blame, or a wish to retain or obtain employment, are the most 
 usual causes of such dissimulation. But it far more frequently 
 happens that individuals complain of diseases which they have 
 not, for the purpose of obtaining something desired, or avoiding 
 something apprehended. The talented author of Guzman d'Al- 
 farache has exposed the greater part of the tricks practised by 
 mendicants to excite the public commiseration. The wish to avoid 
 military service often leads young men to feign various diseases. 
 Many persons indicted for criminal offences have feigned derange- 
 ment in order to escape impending condemnation. 
 
 Some of these simulated diseases may take place without the 
 slightest disturbance of the health; an individual in perfect health 
 may feign paroxysms of intermittent fever with general tremor and 
 chattering of the teeth, rheumatic or nervous pains, loss of one of 
 the senses, as hearing or sight, apoplexy, epilepsy, hysteria, mania 
 and incontinence of urine. There are other affections which can- 
 not be simulated except by determining a disease resembling them, 
 but which is very slight : such is the kind of fever produced by 
 the internal use of excitants, by the introduction of garlic or to- 
 bacco into the rectum, etc: cutaneous diseases are simulated by 
 the application of rubefacients, elephantiasis by insufflation of air 
 into the cellular tissue, cancer of the mammae by the use of certain 
 topical irritants, etc. 
 
 Jt is very difficult to ascertain a concealed disease, except it de- 
 termine a remarkable change in the external appearance, or that 
 the friends of the patient oblige him to consult a physician. If 
 the disease present external signs, the successive examination of 
 the various parts may lead to its detection. If those signs be 
 wanting, if, for instance, concealed grief be the cause of settled 
 decline, the diagnosis is very difficult so long as the patient obsti- 
 nately refuses to reveal his ailment. 
 
 The sagacity of physicians, however, has on many occasions 
 surmounted these obstacles. We even now admire the penetration 
 of Erasistratus in discovering the secret cause of the illness of 
 Antiochus, and the address with which he succeeded, contrary to 
 all expectations, in restoring him to health, by obtaining for him 
 the hand of Stratonice. 
 
 The distinction is usually more easy in simulated diseases. The 
 
DIAGNOSIS. 339 
 
 peculiar situation of the individuals, the knowledge of those things 
 which they necessarily fear or desire, and their relations to those 
 around them, often communicate the first suspicion to the physi- 
 cian, and, most frequently, when he is deceived, it is because the 
 fraud has not been suspected. In some cases, however, the diffi- 
 culty is very great, especially when he who wishes to deceive 
 perfectly understands the part he is to play, and has great interest 
 in sustaining it. Mahon has related a very striking example o 
 this sort.* A young soldier, with the intention of quitting the 
 service, feigned total loss of vision. The fraud was suspected ; 
 he was consequently subjected to the most painful treatment, 
 while every means were put in requisition to expose the deception. 
 Various attempts having proved useless, the following was tried 
 as the last resort. He was stationed at a few paces distance from 
 a deep river and ordered to walk straight forward ; this he did 
 without hesitation and allowed himself to fall into the river. After 
 this trial, he was still retained, with a promise of release on confess- 
 ing the truth ; he refused for a long time, but finally, convinced of 
 the sincerity of those who promised, he took up a book and read. 
 
 The means employed for distinguishing simulated diseases 
 vary according to circumstances. The very attentive examina- 
 tion of all the phenomena usually leads to the detection of the 
 fraud ; most simulated diseases, indeed, have but an imperfect 
 resemblance to the real affections ; there is always something un- 
 usual which does not escape the practised eye. Feigned diseases 
 very closely resemble flowers and fruit attached to trees which 
 do not produce them: ordinary observers may be deceived, but 
 the expert botanist is not the dupe of such an artifice. 
 
 An individual who endeavors to feign a disease, rarely foresees all 
 the questions that may be addressed to him upon the course and 
 succession of the phenomena which he has experienced ; taken 
 unawares on many points, he hesitates in his first replies ; if inter- 
 rogated a second time in regard to the same things, his memory 
 fails him, especially when the questions have been numerous : if 
 he do not betray himself in his answers, he can, in most cases, 
 be led to say things in regard to the progress of his complaints, 
 which are in such complete opposition to daily observation, that 
 they expose the deceit in the surest manner. 
 
 If all this should prove insufficient, the individual suspected of 
 feigning disease might be submitted, for one or more days, to rigid 
 diet. This plan, which is wonderfully efficacious with children, is 
 likewise of great service in hospitals, especially where active su- 
 pervision prevents the individuals submitted to such a kind of 
 proof from procuring food, which is far more difficult than is gen- 
 erally supposed. We might, however, announce to the patients 
 that it will be requisite, if the disease persist, to resort, without de- 
 lay, to painful measures, as blisters, setons, and moxas ; the incon- 
 veniences of these means might be exaggerated, and we might 
 
 * MAHON, Medecine-legale, torn. i. 
 
340 
 
 DIAGNOSIS. 
 
 even proceed to apply them, because they are indicated if the 
 disease really exist, and because, if the disease be feigned, the 
 patient will not submit to their use, especially if it be necessary to 
 repeat them. Finally, one means, nearly always successful with 
 females who simulate hysterical attacks, is the prescription of a 
 large blister over parts which are habitually uncovered, as the 
 nape of the neck, or even the throat and chest : the pandiculation 
 ind yawning which usually terminate the attack immediately 
 take place, and the patient recovers herself before the prescription 
 can be executed. If simulated diseases are more frequent in fe- 
 males than in males, as Morgagni * has remarked, the vanity 
 peculiar to their sex supplies the physician with additional means 
 of discovering the deception. 
 
 * Sexus ad fallendum pronus. 
 
 [Feigning of Disease. This subject, which must always be of very great in- 
 terest to the physician, is somewhat differently considered, as to its divisions, by 
 various authors. The distinction drawn by Chomel between concealed and simu- 
 lated diseases (Maladies Dissimulees, Maladies Simulees, p. 338), seems well 
 founded and desirable. Nysten and Dunglison consider the terms as synonymous, 
 and the latter groups all diseases of the deceptive class, under the appellation 
 " Feigned Diseases," of which he gives a very complete list, with the mode of 
 imposture and means of detection : this list, which is far more complete than the 
 enumeration of our author, should be referred to in this connection. (Dunglison, 
 Med. Diet Feigned Diseases.) l A highly interesting and complete account of 
 Feigned Diseases and the ingenious methods adopted for their detection, etc., is 
 contained in Copland's Med. Dictionary, art. F. Diseases. Soldiers, who are 
 also termed " malingerers," and sailors, known as " skulkers," with mendicants 
 and prisoners, constitute the larger number of such impostors. But names of 
 greater note " grace" (to use the expression of Dr. Copland) that class of " ma- 
 lingerers " who wish to accomplish, by such procedures, any object of private or 
 political ambition, or to compass any particular end. Among these are mentioned 
 Amnon the son of David, Ulysses, Solon, the elder Brutus, etc. ; and in later 
 times, Northumberland, the Earl of Essex, and Raleigh. In addition to the de- 
 scription in " Guzman d'Alfarache," the ingenious devices employed by the 
 Parisian mendicants to obtain the means of existence are graphically described by 
 Victor Hugo in his Notre Damede Paris, chap. vi. : the revelations of the " Cour 
 des Miracles " are at once astonishing, ludicrous and thrilling. Feigning has 
 been suspected, when actual disease existed, as was proved by post-mortem exami- 
 nation (Copland.) This should render the physician scrupulous in regard to a 
 hasty verdict. Hysteria may be real, although sternutatories, as recommended by 
 Dunglison, produce their usual effect. "Detection is by no means easy." (Cop- 
 land.) The "concise rules for the detection of feigned and factitious diseases, 
 from Guy's Forensic Medicine," (Copland, Op. Cit. Dr. Lee,} should be familiar 
 to the practitioner. External, are more frequently feigned than internal, diseases, 
 for the obvious reasons that they are more constantly manifest and more easily 
 simulated. 
 
 We now possess an agent of unlimited power, as it would seem, in the detec- 
 tion of feigned diseases ; viz. the inhalation of the vapor of sulphuric ether ; whether 
 its efficacy be shown as a revealer of external alterations, by enabling the physi- 
 cian to examine the body more carefully and easily, the patient being in a state of 
 insensibility, or in removing, as if by magic, the factitious deformities of the body 
 itself, which, by long practice, the patient is enabled to produce at will and pre- 
 serve for an indefinite period. The only cases which we have as yet noticed of 
 
 1 Synonymes : Simulated Diseases ; Pretended Diseases ; Feigned Diseases ; Excited 
 Diseases. (Fr.) Maladies dissimulees. M. simulees. M. feintes. M. supposees. (Dun- 
 glison.) M. dissimulees. M. simulees. (Nysten. Diet. Med.) 
 
PROGNOSIS. 341 
 
 CHAPTER XVII. 
 
 PROGNOSIS.* 
 
 PROGNOSIS is the previously expressed opinion in regard to the 
 changes about to supervene in the course of a disease. 
 
 It is that part of medical science which gains most reputation 
 for a physician among a large class, who, not capable of appre- 
 ciating accuracy of diagnosis, are always able to verify an opinion 
 given as to the duration and result of a disease. On this account 
 nothing is better suited to win the confidence of the patient and 
 his attendants, than a confirmation of the prognosis by after events, 
 and nothing injures the physician's reputation more than error in 
 this respect. 
 
 Prognosis does not consist alone in foretelling that a disease will, 
 or will not, prove fatal ; it enables us to recognize, among affections 
 which are not fatal, those which will terminate in complete restor- 
 ation to health, those which will remain stationary, and those 
 which will diminish or increase gradually during life, at periods 
 which we can sometimes determine. Prognosis is also applicable 
 to the accidental symptoms which may supervene, such as deliri- 
 um and convulsions ; likewise to the period when the disease will 
 terminate, sometimes even to the critical and consecutive phenom- 
 ena and the danger of relapse and recurrence. 
 
 I. The necessary conditions on the part of both physician and 
 patient, in order to the greatest accuracy in prognosis, are the same 
 that have been mentioned in regard to diagnosis, (p. 275.) 
 
 When we notice, from the earliest days of medicine, (a time when 
 the diagnosis of most diseases was incomplete or erroneous.) that 
 rules for prognosis were established by observers, which are cited 
 as models in our times; and likewise that persons almost wholly 
 unacquainted with medical knowledge, especially those who devote 
 their time to attendance upon the sick, exhibit daily a certain skill 
 in foreseeing the issue of diseases, we might be led to conclude that 
 diagnosis possesses only a secondary utility in forming prognosis, 
 but we should be greatly deceived. 
 
 this application of ethereal inhalation, are reported from M. Baudens in the Medical 
 Gazette for March 19th, 1847. These were cases of conscripts suspected of 
 feigning diseases for the purpose of avoiding service. One of them had, appa- 
 rently, outward curvature of the spine in a marked degree. Inhalation produced 
 total disappearance of the deformity. The other case illustrates the advantage to 
 be derived from the use of ethereal inhalation where feigning is suspected but 
 disease actually exists, as has been previously noticed. The person was supposed 
 to feign anchylosis of the hip-joint. Relaxation of the muscles was the result of 
 inhalation, but the reality of the anchylosed slate was proved by thorough exami- 
 nation. TRANS.] 
 
 * HooyviaOig ; 7156, before ; yu'wGxo), I know. 
 
 29* 
 
342 PROGNOSIS. 
 
 There are, it is true, certain cases in which the first glance at 
 the patient enables us to judge immediately of his danger, even 
 before we ascertain the disease by which he is attacked ; but in 
 the first place, these cases are not the most common, and even in 
 these, where prognosis seems so clear, a thorough examination of 
 the patient is by no means superfluous. Oftentimes, when the 
 diagnosis has been established, it is discovered that the original 
 gpinion in regard to the gravity of the disease must be rectified. 
 Certain fatal affections declare themselves by their diagnostic signs 
 a long time before the face presents any indicative impression, and 
 some affections not dangerous in their nature, as for example, 
 anaemia, and certain intestinal pains, alter very much the color of 
 the skin, and also the features, while the prognosis is far from un- 
 favorable. A thorough knowledge of diseases is to the physician 
 an indispensable condition in properly establishing his prognosis; 
 we may even add, that in order to acquire great skill in prognosis, 
 more time and experience are requisite than for accurate diagnosis. 
 Prognosis, indeed, often presents great difficulties in cases where 
 diagnosis has none, and in those where diagnosis is obscure, prog- 
 nosis is likewise necessarily so. If we except those cases where 
 there can be but one termination, (and these are the rarest cases,) 
 prognosis is always a delicate question in diseases of a certain 
 degree of gravity, and especially in acute diseases. In order 
 to form it. the physician is obliged to compare the case he is 
 actually observing, with all the analogous cases he has pre- 
 viously observed ; if the result has been constantly either favorable 
 or unfavorable in all, the prognosis cannot be doubtful ; but if it 
 has been at one time favorable, at another the contrary, it is, then, 
 necessary to compare the various conditions which have accom- 
 panied a disease apparently similar both in those who have recov- 
 ered and those who have died, and to ascertain to which of these 
 two groups the case in question should be assigned. But this 
 comparison of cases is only valuable when the physician has pre- 
 viously made many and careful observations. Much time is 
 required in order to understand fully all the forms of a single dis- 
 ease, all their tendencies, and all the accidents which may disturb 
 its course, and this practical knowledge is a necessary element in 
 prognosis. A few years devoted to clinical study may suffice to 
 enable one to form a correct diagnosis ; but to acquire excellence 
 in prognosis, which does not consist, like diagnosis, in the appreci- 
 ation of existing facts, but in foreseeing future events, an entire life 
 devoted to observation scarcely suffices to accumulate the mass of 
 facts necessary for the solution of the complex problems which are 
 daily presented to the physician ; in many cases, moreover, even 
 the longest and most enlightened experience only enables us to 
 avoid an erroneous opinion, and to establish with more precision 
 the various chances appertaining to each particular case. 
 
 II. Under the term prognostic signs is comprised all which 
 may enlighten the judgment of the physician upon the future course 
 
PROGNOSIS. 343 
 
 of the disease ; they are to be discovered in the most exact appre- 
 ciation possible of the actual state of the patient, and, consequently, 
 of what has preceded, while forming the diagnosis. Diagnosis isj 
 in fact, the original and chief basis of prognosis. If diagnosis be 
 obscure, prognosis is uncertain. It is only when diagnosis is clear 
 and complete, that is to say, when it comprehends all its con- 
 stituent elements (p. 311), that prognosis can and should be estab- 
 lished, according to the cases, at one time positively, at another, 
 with reserve, and with a methodical appreciation of the various 
 chances presented by the disease. Independently of the prognostic 
 signs afforded by the seat and nature of the disease, the physician 
 will find still others in its natural tendency towards various termi- 
 nations, in the degree of efficacy of remedial measures, in the pe- 
 culiar conditions relative to age, sex, constitution, causes of the 
 disease, antecedent phenomena, mode of attack, course, duration, 
 effect of remedies first employed, and, in certain cases, complica- 
 tions and epidemics. Finally, without attaching so much impor- 
 tance to particular symptoms as most authors on semeiology have 
 done, we still think it our duty to glance rapidly at the prognostic 
 value of the principal symptoms. 
 
 1. It is hardly necessary to enlarge upon the proposition already 
 stated, viz., that prognosis is based upon diagnosis, understanding 
 diagnosis to be the exact knowledge of the disease in regard to its 
 material lesions and symptomatic phenomena. 
 
 The character of the lesion, when one exists, and the degree of 
 its development, are, in connection with the extent of such lesion, 
 the primary conditions of prognosis. A lesion inflammatory in its 
 nature, is not, in general, at all serious, when it occupies an organ 
 of minor importance and for a limited extent ; it becomes more 
 serious when its extent, both superficial and profound, is increased, 
 and when seated in a part whose functions are more important. 
 In herpes zoster, which is wholly exempt from danger; in general 
 peritonitis, which is almost constantly fatal, the prognosis is easy. 
 In visceral inflammations, whose termination is most frequently 
 favorable, though sometimes the contrary, the prognosis should be 
 formed with great reserve, in order equally to avoid inspiring the 
 patient's attendants with too great security, or excessive anxiety. 
 The prognosis is still more difficult and delicate in certain affec- 
 tions, as the eruptive fevers, in which a deleterious agent, existing 
 in the system, may at any moment occasion formidable accidents, 
 which nothing seemed to indicate, and which, in many cases, are in 
 no wise explained on post-mortem examination. But of all acute 
 affections, typhoid fever presents the most difficulty in regard to 
 prognosis ; in this disease, we at one time behold the most formida- 
 ble accidents terminate favorably, and again, the mildest symptoms 
 in appearance, become suddenly exasperated and terminate in 
 deatli. This sudden exacerbation is sometimes caused by perfo- 
 ration of the intestine. 
 
 In those diseases called organic, the prognosis is generally easy ; 
 when once the disease is ascertained, there can remain no doubt as 
 
344 PROGNOSIS. 
 
 to its future course, and its definitive termination. Tubercle and 
 cancer never retrograde, and their progressive extension most fre- 
 quently induces marasmus and death. The difficulty of prognosis 
 in this case consists only in the appreciation of the time during 
 which the struggle will continue. 
 
 The degree of development attained by the lesion is likewise 
 highly important in prognosis. Pneumonia in its third stage is 
 generally fatal; and necessarily so, if it occupy a considerable 
 portion of the pulmonary parenchyma. Softened tubercles and 
 ulcerated cancer cause more immediate anxiety than crude tuber- 
 cle arid scirrhus. 
 
 The seat of the disease has likewise great value in prognosis. 
 The lesion being the same, the danger is necessarily subordinate 
 to the importance of the affected part and the extent to which it is 
 affected. 
 
 The local and general symptomatic phenomena, which, as we 
 have seen, are very valuable in a diagnostic point of view, furnish, 
 moreover, very important signs for prognosis. Excessive dyspnoea 
 in thoracic inflammations, considerable irregularity in the pulse in 
 pericarditis, and frequent vomiting in gastritis, add greatly to the 
 gravity of the prognosis. In every acute disease, general phenom- 
 ena of a grave, adynamic or ataxic nature are replete with danger. 
 
 2. The powers of nature, and of our science, are to be well con- 
 sidered in prognosis. A large number of chronic diseases, con- 
 nected with deep-seated organic lesion, resist every effort of nature 
 or art : of this number are organic affections. There are other 
 diseases in which nature alone is almost constantly powerless, as 
 cataract, vesical calculi and syphilis, and in which the interference 
 of art can secure recovery. In some cases, as in malignant inter- 
 mittent fevers, death is the inevitable and prompt termination of 
 the disease, if artificial means are not resorted to. The efficacy 
 of quinine in intermittent diseases greatly diminishes the gravity 
 of the prognosis in affections presenting this type. Lastly, there 
 are other diseases, where the concurrence of natural and artificial 
 means can, in most cases, (although not in all,) lead to the recov- 
 ery of health, as is observed in severe fevers and in visceral in- 
 flammations. 
 
 3. The peculiar conditions of sex and constitution must not be 
 neglected in a prognostic point of view ; but the age, the previous 
 good or bad health, and the physical and moral causes which have 
 affected the organization, furnish far more important prognostic 
 signs. 
 
 Other things being equal, an acute disease, and especially an 
 inflammation supervening in a strong and well constituted indi- 
 vidual, who had previously enjoyed good health, is far more likely 
 to terminate favorably than when it appears under opposite condi- 
 tions. 
 
 In similar circumstances, age presents results no less remarka- 
 ble. Diseases are generally more severe and more frequently 
 fatal at the extreme periods of life, with this difference, that in 
 
PROGNOSIS. 345 
 
 early infancy, the most violent affections are never entirely hope- 
 less ; infancy is the age of resurrections ; the well known adage 
 ubi vita, ibi spes, is applicable to infancy; while in the aged, acute 
 diseases, when they assume a grave form, almost inevitably termi- 
 nate in death. In adult age, the changes are more favorable, and 
 still more so in youth and early manhood. Pneumonia is one of 
 the most remarkable examples of this fact. According to the 
 clinical records of the Hotel Dieu, the mortality in this disease is 
 less than one twentieth in those from fifteen to twenty years of age, 
 it is about one fourth in adult age, and one half in patients of 
 sixty years and upwards. There are, however, certain diseases 
 to which these considerations are not applicable. The eruptive 
 fevers, for example, are less dangerous in infancy, and some or- 
 ganic affections, as scirrhus and tubercle, most frequently remain 
 stationary, or, at least, progress more slowly in the aged. 
 
 There is an hereditary condition which renders certain diseases 
 much more grave, or even constantly fatal, in nearly all the mem- 
 bers of the same family. This remark, made by Meara, is con- 
 firmed by the observations of Morton, who has seen variola * 
 quite as dangerous in certain families as the plague. 
 
 The diseases developed in females at the period of menstrua- 
 tion, and especially during pregnancy, are, in general, more severe. 
 In the first case, suppression of the menstrual discharge, or uterine 
 haemorrhage, often supervenes; in the second, abortion frequently 
 takes place, and this circumstance, which nearly always proves 
 fatal to the child, aggravates in every way the condition of the 
 mother, and frequently results in her death. 
 
 The puerperal state adds very much to the danger of those 
 acute diseases which supervene dtfring its continuance; serous 
 arid parenchymatous inflammations pass rapidly into the suppura- 
 tive stage, and the eruptive fevers often appear accompanied by 
 ataxic or adynamic symptoms. The diseases developed under 
 these conditions are the more serious in proportion to their prox- 
 imity to the moment when delivery took place. Observation has 
 shown that a severe chill, supervening immediately after delivery, 
 denotes the invasion of an acute disease, whose termination will 
 almost always be unfavorable and sudden. If the disease does 
 not appear for several days, the prognosis will be far less serious, 
 and still less so, if one or two weeks elapse between the labor and 
 the onset of the disease. 
 
 Habitual intemperance adds infinitely to the unfavorable circum- 
 stances of disease. Many physicians have observed that the acute 
 affections which supervene in the intemperate are almost con- 
 stantly fatal. Habitual excess in eating adds likewise to the 
 danger, but in a less degree. Those diseases which succeed a 
 long famine, or the nearly exclusive use of food of a bad quality, 
 or not sufficiently nutritive, usually terminate unfavorably. Asce- 
 tics, who use a diet almost entirely vegetable during Lent, incur 
 
 *MORTON, de VarioUs, chap. vi. 
 
346 PROGNOSIS. 
 
 far more danger in those acute diseases with which they may be 
 attacked, after this long abstinence. 
 
 Excessive evacuations, considerable and prolonged fatigue, ex- 
 cessive venereal indulgence, the practice of masturbation, watch- 
 ings, unremitting mental labor, and long continued grief, are all 
 circumstances nearly always rendering the course of diseases unfa- 
 vorable. We have observed quite a number of grave affections 
 developed in individuals who had recently lost an employment 
 upon which their means of existence depended : all of them died. 
 
 Habitual ill health, and chronic disease preceding an acute affec- 
 tion, in like manner render prognosis more unfavorable. If a 
 circumscribed inflammation, as erysipelas, even of slight intensity 
 and limited extent, be developed under these conditions, we most 
 frequently see the patients sink into a state of extreme prostration 
 and die in a few days. The same observation is applicable to 
 patients just recovering from an acute affection which has greatly 
 debilitated them, and in whom a new disease supervenes. 
 
 Climate and season, which modify the course and duration of 
 certain affections, are also capable of varying the prognosis. For 
 this reason, dysentery is not only more frequent, but also far more 
 severe, in hot than temperate climates, while syphilis, which 
 among us often exhibits grave and obstinate symptoms, is in 
 southern climates, on the contrary, generally mild and easily 
 treated. 
 
 4. Precursory phenomena are of little value in prognosis : when, 
 however, a disease is preceded by loss of flesh, which has increased 
 progressively for several months, grave symptoms and a fatal ter- 
 mination may be apprehended. 
 
 5. The manner in which diseases commence merits also some 
 attention : those whose invasion takes place by violent alternate 
 chills and heat, which continue for one or more days, those which 
 begin by syncope, violent delirium, arid sudden prostration, most 
 frequently terminate unfavorably and suddenly. 
 
 It should, however, be remembered, that prognosis can rarely 
 be positively established at the commencement of diseases. The 
 successive development of symptoms is quite as necessary in de- 
 ciding the opinion of the physician upon the ulterior course of the 
 disease, as upon its seat and nature. Even at the period when 
 diagnosis is no longer doubtful, prognosis will often still remain so, 
 and this uncertainty may be prolonged even to the last period of 
 the disease, sometimes' even to the moment when death dispels all 
 doubt and destroys the latest hope. In the midst of this violent 
 disturbance of the organism, where the danger is only too evident, 
 prognosis varies necessarily with the varying disease. The skill 
 of the physician consists, at such times, in carefully appreciating 
 the different elements presented to his observation, in calmly ana- 
 lyzing the favorable and unfavorable chances in the daily modifi- 
 cations of the disease, and, lastly, in being on his guard, in view of 
 the great changes presented by the symptoms, against a deceptive 
 security and a premature discouragement. 
 
PROGNOSIS. 347 
 
 6. The progress of the disease is of some importance in prog- 
 nosis, especially when it is regular. When the symptoms increase 
 gradually in intensity beyond the ordinary limits of the period of 
 increase, the prognosis is unfavorable: it is favorable, on the other 
 hand, if their violence diminish from day to day ; it is almost 
 always uncertain when the course of the disease is irregular. A 
 sudden change, either favorable or unfavorable, is far less impor- 
 tant in regard to the prognosis than one which takes place slowly. 
 The latter almost always announces, with certainty, the favorable 
 or unfavorable termination of the disease ; while a sudden ame- 
 lioration is always suspicious, as likewise a sudden aggravation, 
 without appreciable cause, is generally more alarming than dan- 
 gerous. 
 
 7. The duration of the disease is also one of the elements of 
 prognosis : neuralgia of many years' continuance, old arid uncon- 
 solidated fracture, and dislocation of many months' standing, are 
 affections nearly always incurable ; when recent, on the contrary, 
 they generally yield to the treatment employed. 
 
 8. The influence of previous treatment deserves much attention : 
 if the use of remedies, properly or improperly administered, has 
 been followed by marked improvement, the prognosis is favorable, 
 but if, notwithstanding the treatment, especially when most dis- 
 tinctly indicated, the disease continues to progress beyond the usual 
 limits of its period of increase, it is, at any rate, very grave, 
 although it may not necessarily be, on that account, incurable or 
 fatal. 
 
 9. Complications greatly increase the gravity of the prognosis ; in 
 the first place, because there are, at once, many sources of danger, 
 and many enemies to resist, and also because, in many cases, each 
 of the diseases adds to the gravity of the other : thus, when acute 
 dysentery is complicated with cancer of the large intestines, it is 
 more dangerous, because developed in an individual already ill, 
 and sometimes exhausted, and the progress of the cancer will be 
 hastened by the acute affection of the intestine. We have pre- 
 viously indicated the gravity of erysipelas when it supervenes 
 upon another disease, while simple erysipelas is almost always 
 without danger. 
 
 10. When a disease attacks many persons simultaneously, the 
 prognosis in regard to each particular case is more or less grave, 
 in proportion as the actual general mortality is greater. There 
 are certain epidemics in which the inhabitants are less severely 
 affected than strangers, females less so than males, infants than 
 adults, feeble than robust persons, and vice versa. In every epi- 
 demic, there is a period of increase, during which the number of 
 patients augments daily, and the disease becomes more grave in 
 most of the cases ; a period of violence, during which the number 
 of patients and the severity of the disease are at their maximum ; a 
 period of decline, when both diminish simultaneously. It has 
 likewise been observed in certain epidemics, that there was, as it 
 were, a focus, where the disease appeared in all its energy, and 
 
348 PROGNOSIS. 
 
 that in proportion to the distance from this spot, a smaller number 
 of individuals were attacked, and each with less intensity. These 
 different circumstances should be taken into consideration when 
 pronouncing an opinion upon each patient during an epidemic. 
 
 11. In the writings of the ancients, particularly in those of 
 Hippocrates, the symptoms, either isolated or grouped together, 
 furnished, in themselves, the elements of prognosis. At this day, 
 when the diagnosis of diseases has acquired a degree of accuracy 
 to them unknown, the importance of those signs furnished by the 
 symptoms has doubtless much diminished ; but it is still of suffi- 
 cient power to make it impossible for the physician to neglect 
 noticing these signs, when forming his opinion upon the ulterior 
 course of a disease. 
 
 It is unnecessary to enumerate here, as in treatises upon semeiol- 
 ogy, the unfavorable or favorable signs which are observed in the 
 course of each particular disease : we shall confine ourselves to 
 the presentation of those which may be exhibited in most of them, 
 and which, for this reason, belong to the domain of general pathol- 
 ogy- 
 External appearance furnishes many prognostic signs of con- 
 siderable importance. Constant change of position awakens no 
 apprehension at the commencement of acute diseases ; but it is 
 otherwise when it continues for many days. It is a still more un- 
 favorable sign, when the patient maintains unceasingly the same 
 position, as, for example, the dorsal decubitus, as is seen in typhoid 
 fever of adynamic form ; it is likewise a grave sign if he be obliged 
 to remain constantly in a sitting posture, as occurs in certain tho- 
 racic affections. When jactitation succeeds immobility in the latter 
 period of an acute affection, it is generally a fatal sign, especially 
 if the patient uncover himself, and if he make unavailing efforts 
 to rise.* 
 
 The progressive loss of flesh which supervenes in acute diseases, 
 is but of slight importance, but in chronic diseases we should ap- 
 prehend from it a fatal termination, which is nearer at hand in 
 proportion as the marasmus is more rapid. The oedematous infil- 
 tration which is manifested during the course of chronic diseases, 
 is likewise a most unfavorable sign. This is not the case in re- 
 spect to partial oedema, confined to the malleoii, which is observed 
 towards the close of acute diseases, and is connected with the state 
 of prostration and languor of most of the functions ; this, in general, 
 is not at all serious. The eschars which are formed in different 
 
 * Among other prognostic signs, one which is always considered grave, may 
 be appropriately added to those here mentioned, viz. the sliding down in bed, 
 noticed particularly in typhoid fever ; the patient's lower extremities often protrud- 
 ing to some distance from the foot of the bed ; this doubtless arises from exces- 
 sive debility, and although the state in which it is observed is attended with more 
 or less danger, it is not incompatible with recovery, except, indeed, there be con- 
 currence of a great number of unfavorable signs, as subsultus tendinum, coma, 
 hiccough, involuntary evacuations, rapid and fluttering pulse, labored respiration, 
 etc. etc. TRANS. 
 
PROGNOSIS. 349 
 
 parts of the body, and particularly upon those where the 
 bones are near the integuments, are unfavorable signs in chronic 
 diseases: they are also nearly always so in acute diseases, and 
 particularly in typhoid fever and affections of the spinal chord ; 
 not only because their appearance adds to the original disease a 
 phenomenon which fully reveals its gravity, but still farther, be- 
 cause the eschar becomes in certain cases, when the primary affec- 
 tion has disappeared, a source of debility and death by the abun- 
 dant suppuration which it furnishes, the denudation of the bones, 
 the purulent absorption, and, in certain cases, by the exposure of 
 the rectum in the pelvic cavity. 
 
 The physiognomy is very important in prognosis ; but it ad- 
 dresses itself, if we may so express ourselves, only to the practised 
 eye. "W hen the natural expression is preserved, the prognosis is 
 very favorable. A remarkable change in the countenance, from the 
 first of an acute disease, should lead us to apprehend, that at a later 
 period, as from the fifth to the ninth day, adynamic or ataxic 
 symptoms may supervene. At an advanced period of either acute 
 or chronic affections, a marked and sadden alteration of the coun- 
 tenance announces the approach of death. If this change of 
 countenance take place at a time when death seems still distant, 
 we should suspect the development of some acute inflammation, 
 which, in the state of prostration to which the patient is reduced, 
 most frequently does not give rise to any of the local symptoms 
 which ordinarily reveal it, and only determines a sudden aggrava- 
 tion of the general condition.* Those in whom this is observed 
 rarely survive more than three days ; most frequently they die in 
 a still shorter time. The rapid increase of stature, which takes 
 place in young patients during acute diseases, is also a sign almost 
 constantly unfavorable. 
 
 Tremor, stiffness and subsultus tendinum always indicate dan- 
 ger ; picking of the bedclothes, and particularly epileptiform or te- 
 tanic convulsions and rigidity of the limbs, are usually fatal in fever, 
 when they supervene at an advanced period ; convulsions occur- 
 ring at the commencement of diseases, particularly in children and 
 in the eruptive affections, are not so serious. The irregular move- 
 ments of the limbs, which the patient seeks to uncover, although 
 they are cold, are of equal value with convulsions as regards prog- 
 nosis ; trismus. the sardonic grin and strabismus, are of like signifi- 
 cance. Another sign, still more unfavorable, is the almost auto- 
 matic movement by which the patient strives unceasingly to bring 
 his arm to his side, while the physician detains it outside the bed 
 in examining the pulse; we have always observed these cases ter- 
 minate fatally, but very few authors have mentioned this sign. 
 
 Aphonia is one of the most unfavorable signs that can be observed 
 in acute diseases. Many of the patients, however, who presented 
 
 * We should not confound this change of countenance with pallor of the face, 
 which denotes the cessation of the fever and the commencement of convalescence ; 
 the two differ very much in themselves and the opposite phenomena which ac- 
 company them. 
 
 30 
 
350 PROGNOSIS. 
 
 this symptom in the epidemic typhus observed at Presburg, in J683, 
 and described by Lsew, recovered. We have seen recovery take 
 place in patients with typhoid fever, who had been aphonic for 
 many days. 
 
 Aphonia supervening during a chronic affection of the chest, and 
 persisting, is always a grave sign, because it leads us to fear the 
 development of tubercles in the larynx, and also to conclude that 
 they exist in the lungs. 
 
 The intensity of pain in disease is not generally in proportion to 
 the danger: the most serious diseases are not usually accompanied 
 with more than moderate pain, many indeed are entirely free from 
 it, and those affections in which pain causes cries, as hepatic, ne- 
 phritic and lead colic, neuralgia, rheumatism, etc. rarely terminate 
 unfavorably. In certain chronic affections, however, prolonged 
 and intense pain, preventing sleep, concurs in exhausting the 
 strength, and renders the prognosis less favorable, independently 
 of the disease. 
 
 Other things being equal, deep-seated pain is more unfavorable 
 than that which is superficial, and fixed pain, than that which is 
 moveable. Very severe pains in the limbs at the commencement 
 of a disease indicate its future severity ; those occurring at the de- 
 cline of an acute affection are favorable. In the phlegmasiae, the 
 sudden cessation of pain, joined to a marked change of the counte- 
 nance, indicates the approach of death ; the gangrene announced 
 by most authors, is rarely discovered, in these cases, on post-mor- 
 tem examination ; the inflamed part is most commonly in a state 
 of suppuration, as all those physicians who make frequent dissec- 
 tions must be convinced. 
 
 The various disturbances to which the organs of sense are ex- 
 posed, rarely supply us with prognostic signs of much importance 
 in regard to the termination of the disease ; in some cases, how- 
 ever, they are the forerunners of delirium, coma, or some other 
 accident. Most authors have supposed that deafness was of cer- 
 tain value as respects prognosis : but some have considered it a 
 favorable, others an unfavorable, sign ; several have regarded the 
 deafness occurring towards the close of the disease as favorable, 
 and that noticed at the commencement as unfavorable. In our 
 opinion, the deafness which is independent of any material lesion 
 of the ear, and which appears as a sympathetic phenomenon in 
 various acute diseases, always indicates serious danger : it is not 
 observed in mild diseases ; it is noticed only in those which exhibit 
 more or less of the ataxic character, and particularly in typhoid 
 fever. By a comparison of the fatal cases, both among individuals 
 who had been affected with deafness during the course of this dis- 
 ease, and among those who were exempt, we have been led to the 
 conclusion that in the former the mortality has been nearly double 
 that of the latter class. 
 
 The mild and moderate passions, as hope and gaiety, are gen- 
 erally favorable signs in disease. The depressing passions, on the 
 contrary, as hatred, jealousy, discouragement and despair, are of 
 the most ominous presage. It is rare that patients recover from an 
 
PROGNOSIS. 351 
 
 acute affection, with which they are persuaded they shall die, un- 
 less they are hypochondriacs ; depression is then not so unfavora- 
 ble a sign. We have had various opportunities of being convinced 
 of this, particularly in the case of a young man of melancholic 
 temperament, whom we attended during an attack of typhus fever. 
 From the first of his illness he had arranged his affairs, and written 
 a very pathetic letter to his father ; the apprehension of death fol- 
 lowed him unceasingly until delirium appeared. During this 
 period, when asked how he was, he promptly replied very well, 
 which is noted by Tissot as constantly a fatal sign ; the disease, 
 however, terminated favorably on the fourteenth day, and the re- 
 covery was complete. 
 
 We should not mistake for safety, either the affected calm of 
 some patients, nor that prostration of the intellectual faculties 
 which deprives the individual of the knowledge of his situation, 
 and consequently of the danger which threatens him ; this absolute 
 indifference is a grave sign, and appertains in a special manner to 
 one of the most dangerous forms of typhoid fever. A certain 
 degree of uneasiness, in proportion to the gravity of the disease, is 
 the ordinary condition of the patient, complete security is unnat- 
 ural, and consequently does not encourage the physician ; in acute 
 diseases it should cause him to fear commencing delirium; in 
 chronic diseases, and especially in pulmonary phthisis, the feeling 
 of security in the patient does not at all dimmish the gravity of the 
 prognosis. 
 
 The prognostic signs furnished by delirium are subordinate to its 
 intensity, persistence, and the conditions in which it appears. Quiet 
 and transient delirium, which consists in a simple wandering from 
 which the patient may be easily recalled, is not very serious; 
 when permanent, especially if violent, and if the strait waistcoat be 
 necessary, it is always a bad sign ; it becomes still more so, if the 
 individual be advanced in years. There are, however, individuals 
 even among adults, who are delirious during the course of almost 
 all the diseases with which they are affected, even in ephemeral 
 fever, and simple angina ; a knowledge of this idiosyncrasy in 
 patients is sufficient for the appreciation of the value of this 
 symptom. 
 
 Prolonged sleep need cause no alarm in fevers when the patients 
 awake easily to take liquids, and answer the questions addressed 
 to them ; but when it becomes necessary to shake them, or to shout 
 aloud in order to wake them, the prognosis is serious. 
 
 When the sleep is not quite so profound, we must, according 
 to the recommendation of Piquer* regard the other symptoms, 
 in order to judge of the value of this sign; if they be dangerous, 
 the sleep is so likewise, and vice versa. 
 
 Prolonged sleep may, in certain cases, be a good omen; in 
 the delirium which succeeds capital surgical operations and in 
 delirium tremens, if the patients sleep calmly for a certain number 
 
 * Traite des Fievres } p. 285. 
 
352 PROGNOSIS. 
 
 of hours, on awaking, they most frequently have completely re- 
 covered their intelligence, and do not remember their delirium. 
 Coma and sopor caroticus are very grave signs, and are almost 
 always fatal when intense and continued. There is more hope 
 when they take place at the commencement of disease, in cases, 
 for instance, of haemorrhage or concussion of the brain, than when 
 they succeed delirium or convulsions, as occurs in inflammations of 
 the brain. 
 
 Anorexia is not at all unfavorable in acute, any more than 
 the diminution of appetite in chronic diseases ; but in the latter, 
 disgust at food is a bad sign. A voracious appetite, which super- 
 venes suddenly in the violent stage of an acute or even a chronic 
 disease, without diminution of the other symptoms, accordng to 
 Baglivi, announces death in tweniy-four hours ; we have 
 seen death succeed this irregular hunger almost constantly, as 
 this physician has remarked, but some of the patients lived until 
 the second, and even the third day. Pneumonia, in our ex- 
 perience, has furnished the most instances of this sign.* 
 
 Slight thirst is generally a phenomenon of little value in a prog- 
 nostic point of view ; but extreme thirst, supervening in an indi- 
 vidual apparently healthy, always arrests the attention of the 
 physician : it is frequently the first sign of commencing diabetes, 
 and sometimes of pulmonary phthisis. We shall always vividly 
 remember the death of two men, in mature age, with this latter 
 disease, both remarkable for their strong constitution and embon- 
 point, in whom the same phenomenon, a thirst so violent, that 
 every evening, for nearly a year, they were obliged to drink one or 
 two pints of water, preceded the manifestation of tuberculous 
 disease, which rapidly destroyed them. 
 
 Observation has shown the exaggerated importance which has 
 been attributed to the different modifications presented by the 
 tongue in disease, in reference to the diagnosis of stomachal and 
 intestinal affections; it has confirmed, on the other hand, the value 
 of the prognostic signs furnished by this organ. The dryness, 
 ligneous hardness, shrinking and tremulousness of the tongue, and 
 the difficulty of protruding it, are, at present, as in the days of 
 Hippocrates, very grave signs, and indicate great danger. The va- 
 rious coats which, in the forms of apthse, pellicle and pulp, cover 
 the mucous membrane of the mouth, especially when they consti- 
 tute a thick layer, and become renewed immediately after they are 
 detached, are prognostic signs of great value in acute, and still 
 more so, in chronic, diseases ; in the latter they announce a termi- 
 nation almost inevitably fatal, in the former they increase the 
 
 * This has also been noticed in the last stage of phthisis. The case of a young 
 man in this stage of the disease recurs strongly to our recollection at this time, 
 whose craving for food was so irresistible as to lead him, while travelling by rail- 
 way, to snatch from the hands of a cliild some cake it was eating, much to the as- 
 tonishment of his fellow passengers ; for some time his whole attention had been 
 directed to satifying this unnatural appetite : this individual, however, lived for a 
 fortnight after the above occurrence, making the voyage from England to this 
 country, and dying on the day of his arrival home. TRANS. 
 
PROGNOSIS. 353 
 
 gravity of the prognosis, without being so constantly the indication 
 of an unfavorable termination. 
 
 Difficult deglutition, but more particularly, inability to swallow, 
 are signs of most unfavorable augury in cerebral diseases and in 
 those acute affections in which the examination of the fauces does 
 not show the cause of the dysphagia. Hydrophobia or horror of 
 liquids, with spasmodic contraction of the pharynx, is a still worse 
 sign, with the exception of those cases of pregnancy, hysteria and 
 inflammation of the stomach, in which this phenomenon has fre- 
 quently been observed. That alteration of deglutition in which 
 liquids pass through the oesophagus as through an inert tube, and 
 fall noisily into the stomach, has for a long time been noticed as 
 announcing the approach of death. 
 
 The continual nausea observed in certain acute diseases is a 
 grave sign; it is frequently the prelude of that obstinate bilious 
 vomiting which generally resists all remedies, and finishes, in the 
 greater number of cases, by causing death, the cadaveric examina- 
 tion not always accounting for the intensity of the symptom. 
 
 In the last stage of certain diseases, as peritonitis and intestinal 
 occlusion, regurgitation takes the place of vomiting; death is then 
 imminent. 
 
 The danger arising from haematemesis, and stercoraceous, puru- 
 lent, or rice-water vomiting (Asiatic cholera), is subordinate to 
 the intensity and persistence of the symptom, but more particularly 
 to the kind of disease which causes it. Here, as in all cases, the 
 prognosis is in a great degree the consequence of the diagnosis. 
 
 Meteorism, when considerable, is always a serious sign, both in 
 acute diseases, as adynamic fevers and the various forms of peri- 
 tonitis and in chronic diseases, where its occurrence should lead 
 us to fear complete occlusion of the intestines or some other dan- 
 gerous lesion. 
 
 Constipation does not become a serious sign, except when it 
 resists remedies, arid is accompanied with vomiting, as in the 
 different kinds of ileus, a complex phenomenon, which always 
 depends upon a material lesion interrupting the course of the faecal 
 matter through the intestines. 
 
 Diarrhoea, especially when it resists diet, suitable remedial 
 means, and time, and when the discharges are both numerous and 
 liquid, is a grave symptom, both in acute and chronic affections; 
 it leads us to fear the existence of ulcerations or softening of the 
 internal tunic of the intestine. Obstinate diarrhoea, accompanied 
 by hectic fever and morning sweats, is nearly always a fatal sign ; 
 it is an almost certain indication of a tuberculous affection, even in 
 those who do not cough, and in whom the various modes of explor- 
 ation of the chest reveal no lesion of the contained organs. A black 
 color and cadaverous odor of the faecal matter are unfavorable 
 signs. Intestinal haemorrhage, supervening in the course of an 
 acute disease, is a grave symptom, observation having shown that 
 this haemorrhage hardly ever occurs except in typhoid fever, and 
 that it is followed by death in at least one half of the cases. 
 30* 
 
354 PROGNOSIS. 
 
 Involuntary evacuation of the faeces and urine is, moreover, a 
 very grave sign in acute diseases, especially when the patient is 
 unconscious of it ; we should apprehend from this symptom the 
 near approach of death. It is not a sign of equal gravity when 
 the intellectual faculties are disordered; but even then, it adds to 
 the seriousness of the prognosis. 
 
 The signs furnished by the respiration should be ranked among 
 the least deceptive. When respiration is uniform, free, not accel- 
 erated, exempt from pain and oppression, when the interval be- 
 tween inspiration and expiration is not too long, and the patient 
 respires well in all positions, we may hope for a favorable termi- 
 nation. On the contrary, very frequent respiration indicates great 
 danger ; the elevation of the respiration to fifty in a minute is a 
 sign nearly always fatal. Stertorous respiration and tracheal 
 rattle are most usually the phenomena of the agony, particularly 
 when they supervene in the latter period of cerebral diseases ; 
 stertorous respiration, however, is not so grave in pulmonary in- 
 flammations when expectoration is not interrupted. 
 
 " Short and accelerated respiration, that is, respiration made up 
 of small inspirations and expirations, which succeed each other 
 rapidly, is a very bad sign, even when all the other signs seem 
 favorable;" "for this reason," says Rtoll, "whenever I do not 
 observe this sort of respiration in putrid or malignant fevers, and 
 even in inflammations of the thoracic organs, I never despair ; but 
 I have never seen any patient who had this symptom, recover." * 
 
 Embarrassed respiration occurring in paroxysms, although not 
 without gravity, is far less dangerous than permanent dyspnoea. 
 In pulmonary emphysema, paroxysms are often noticed in which 
 the oppression almost amounts to asphyxia, and nothing is more 
 unusual than the death of patients during these paroxysms. 
 
 Hiccough is a very unfavorable sign towards the close of dis- 
 eases, when unaccompanied with marked amelioration of the 
 symptoms. 
 
 The sputa furnish important prognostic signs. In peripneumo- 
 nia, when they are serous, red, or like the juice of liquorice or 
 prunes, and slightly frothy, the disease constantly terminates 
 fatally, even when, in other respects, it seems mild in its character. 
 In phthisical patients, when the sputa, from having been a long 
 time mingled with diffluent mucus, become entirely purulent, or 
 when they are of a dirty gray color, and exhale a fetid odor, death 
 is generally not far distant. A brown color and gangrenous odor 
 of the sputa announce a fatal result. 
 
 The pulse, considered in regard to prognosis, supplies us with 
 few, but important, signs, especially in acute affections. It is 
 always encouraging when the pulse presents a moderate frequency 
 and a certain degree of development in these diseases. Considera- 
 ble frequency of the pulse constantly denotes a serious disease. 
 If the pulse, in an adult, rise to one hundred and fifty pulsations 
 in a minute, and more especially, if beyond that, the prognosis is 
 
 * STOLL, Rat. Med., torn. iii. p. 62. 
 
PROGNOSIS. 355 
 
 unfavorable ; * if, at an advanced period, the pulse become irreg- 
 ular, unequal, intermittent and imperceptible, death is imminent. 
 Moderate irregularity of the pulse, without any other aggravation 
 of the disease, sometimes precedes and announces a favorable 
 change. 
 
 Faintness and syncope are often more alarming than dangerous, 
 especially when they supervene in persons who are not, as yet, 
 much debilitated ; it is quite otherwise, when they occur in the 
 opposite conditions ; they should then cause the most serious and 
 instant anxiety. 
 
 A considerable increase of heat generally denotes a grave dis- 
 ease, especially when the heat is dry. Coldness of the extremities, 
 extending afterwards to the rest of the body, supervening during 
 the course of a disease, together with diminution of the strength, 
 and aggravation of most of the symptoms, should cause apprehen- 
 sion of an approaching fatal termination. This is not the case 
 with that coldness which takes place at the commencement of dis- 
 ease, and which is not equally grave, although in some of its forms 
 (p. 346), it may be an unfavorable prognostic sign. The irregular 
 chills which supervene at an advanced period of the disease, 
 should excite suspicion, either of the formation of pus in inflam- 
 matory affections, or of its absorption when there already exists a 
 purulent collection, as after extensive injuries and particularly 
 solutions of continuity. 
 
 Suppression of the cutaneous exhalation, which is known by the 
 dryness of the skin, is, generally, if not a dangerous, at least an 
 unfavorable sign ; suppleness of the skin, accompanied by a gentle 
 perspiration, is, on the contrary, a favorable circumstance. 
 
 Abundant sweats are generally injurious, or at least useless, at 
 the commencement of diseases ; they are often favorable at their 
 decline. Continual sweating, in the course of an acute affection, 
 often produces destructive prostration, as was observed by Cotugno 
 in the hectic fever at Naples. The cold sweats which supervene 
 at the decline of diseases are nearly always unfavorable ; we 
 have, nevertheless, seen them establish a favorable crisis in a child 
 
 * " In most grave diseases, a pulse which at all hours exceeds one hundred and 
 twenty indicates serious morbid affection, and a pulse of one hundred and forty, 
 if long-continued and feeble, is indicative of danger." (American Editors of 
 Marshall Hall's Theory and Practice of Medicine, p. 49.) According to our au- 
 thor, also, a pulse of one hundred and fifty and over, in the minute, renders the 
 prognosis unfavorable ; we remember hearing him remark, that he had never 
 known a patient to recover who presented the above frequency of pulse, for any 
 considerable time, in acute disease. The case which elicited the remark was one 
 of typhoid fever, where the pulse was so rapid that it could not be counted; death 
 ensued in a few hours. According to Dr. Copland, (prognostic signs furnished by 
 the pulse in continued fever,) " the pulse, to the experienced physician, furnishes 
 the chief indications of danger, as well as of treatment; if it reach one hundred 
 and twenty, the danger is very great, if it amount to one hundred and thirty, 
 recovery seldom or never occurs, unless in cases of hysterical and irritable females, 
 or those in the puerperal state." (Med. Diet. Am. Ed. p. 1135.) Dr. Graves 
 has remarked, that where the respirations are very numerous (forty, for example), 
 with a comparatively infrequent pulse (eighty or ninety), a fatal result may gen- 
 erally be anticipated. TRANS. 
 
356 PROGNOSIS. 
 
 six years of age, on the seventh day of very grave peripneumonia ; 
 a prompt amelioration of the local and general symptoms suc- 
 ceeded the cold sweat, by which the parents had been exceedingly 
 alarmed. 
 
 Haemorrhage occurring at the commencement of a disease gen- 
 erally announces its future severity; that which supervenes in the 
 last period is rarely indifferent; it is most commonly followed by 
 a marked increase or diminution in the pre-existent symptoms. 
 Epistaxis, hsemorrhoidal discharge and metrorrhagia, are gen- 
 erally favorable in those who are subject to them during health ; 
 pulmonary and intestinal haemorrhage are generally unfavorable ; 
 that from the urinary passages is almost constantly fatal, as has 
 been observed in variola (Sydenham), in the plague (Diemer- 
 broeck), and also in yellow fever. 
 
 The old physicians asserted that transparent and crude urine 
 indicated a lengthy disease; that substances remaining suspended in 
 it when cool, announced the termination of the disease at a period 
 more or less distant; sedimentary deposit, an approaching termina- 
 tion, etc. There is nothing certain in these various signs. The 
 involuntary excretion or retention of urine supervening in the 
 course of febrile affections, or in those of the medulla spinalis and 
 the brain, most frequently indicate great danger. 
 
 The state of the vital forces is also highly important in prognosis. 
 Every affection where their diminution is considerable is always 
 very dangerous; their perversion is equally so. 
 
 Certain epi-phenomena appearing in the course of diseases, 
 may be of some importance in prognosis ; the parotiditis noticed in 
 grave fevers and in typhus is particularly of this class. The 
 development of the parotids in acute diseases, has been regarded as 
 favorable by some and dangerous by others. Hildenbrand was 
 led, from a great number of observations, to regard inflammation 
 of the parotids, supervening at the decline of disease, as favorable, 
 and that occurring at the commencement as unfavorable. In our 
 opinion, the appearance of parotiditis in an acute disease has 
 always a gravity which increases the anxiety the disease may 
 already have inspired. At whatever stage of the disease this 
 swelling occurs, it is allowed by all to be a bad omen when 
 it attains to the degree of embarrassing deglutition, and above all, 
 respiration. 
 
 The aspect of wounds and of surfaces to which blisters and 
 rubefacients have been applied, supplies us also with prognostic 
 signs. When wounds are of a bright color, and furnish thick and 
 homogeneous pus, it is a favorable sign; the contrary is the 
 case when they are brown, livid, black, dry, or pour out putrid or 
 sanious matter. It is a very unfavorable, and nearly always a 
 fatal, sign,* when blisters and sinapisms produce no effect upon 
 
 * It often happens that sinapisms and blisters produce no effect, even in patients 
 who are not dangerously ill, on account of the bad quality of the materials em- 
 ployed. It is important to be on one's guard against the false inductions which 
 might be drawn from their slight action. 
 
NECROSCOPY. 357 
 
 the part to which they are applied. It is also a bad sign when the 
 dermis peels off from the subjacent parts in places where leeches 
 have been applied ; we have constantly observed death to succeed 
 this sign, seemingly of such slight importance. 
 
 Such are the principal signs by whose aid we are enabled to 
 pronounce an opinion upon the changes which will supervene in the 
 course of diseases. These signs, we repeat, are valueless, except 
 by reason of the reciprocal support they yield one another. A single 
 sign, however important in itself, has no weight except by the 
 concurrence of many others. The most unfavorable sign, if iso- 
 lated, as is seen in certain nervous affections, indicates no danger : 
 convulsions, picking of the bedclothes, general insensibility, horror 
 of liquids, meteorism, involuntary excretions, aphonia, etc., are 
 signs of almost no importance in hysterical attacks, and almost 
 always fatal in febrile affections. It is, then, only by a comparison 
 of all the signs, that the physician can obtain a knowledge of 
 future events. M. 
 
 CHAPTER XVIII. 
 
 THE ALTERATIONS PRESENTED BY THE ORGANS AFTER DEATH. 
 
 THE numerous alterations caused by disease, in the structure of 
 our organs, have of late years greatly attracted the attention of 
 physicians, who have based upon them, at it were, a new sci- 
 ence which they have named Pathological Anatomy, but which 
 ought rather to be considered a branch of pathology. The history 
 of diseases is necessarily incomplete, when considered indepen- 
 dently of the structural alterations effected by them, and the 
 study of these alterations is almost without interest when discon- 
 nected from the history of the disease. 
 
 We are surprised, with Senac,* that for so long a period physi- 
 cians showed so little zeal in obtaining the light that necroscopy f 
 would have furnished them ; but it is still more astonishing that at 
 the time when the anatomy of man in health was cultivated 
 with most success, the lesions which disease had effected in his 
 various organs should have scarcely attracted attention. Fallo- 
 pius, Vesallus and Eustachius, who made such great advances in 
 anatomy, and Harvey, who discovered the circulation of the blood, 
 lived not far from a century before the first physicians who engaged 
 in the study of pathological anatomy. The example of Bartholin 
 and Theophilus Bonet was followed by but few, as Morgagni, 
 Lieutaud and Portal^ and it was not until the end of the last cen- 
 
 * De recondita Febr Natura, pag. 194 ; " Mirum est sane eos qui de morbis 
 scripserunt, non majori studio investigasse quid morleipsd edeoceamur." 
 t NexQog, dead body ; oxo/recu, I examine. 
 
358 NECROSCOPY. 
 
 tury that this branch of pathology was generally studied. Since 
 then, all educated physicians take every opportunity to ascertain 
 after death the nature of the lesion which caused or accompanied 
 the phenomena observed during life ; and many treatises and im- 
 portant memoirs have been published upon this subject by the 
 most distinguished physicians of our age ; among whom may be 
 mentioned, Bayle, Baillie, Laennec, Dupuytren ; and still later, 
 Brcschet, Cruveilhier, Louis, Andral, Bouillaud, Rayer, Carswell, 
 &c. &c. 
 
 The advantages derived from the study of pathological anatomy 
 are now so generally appreciated, that it is unnecessary to enu- 
 merate them. When we consider the numerous errors corrected 
 by post-mortem examinations, the positive information they furnish 
 respecting the seat of many diseases, and how important they 
 always are in confirming or rectifying our diagnosis, it cannot be 
 denied that these investigations have greatly conduced to the ad- 
 vance of our art, and must still continue to do so to an indefinite 
 extent. 
 
 In order to discover and appreciate the lesion produced by dis- 
 ease, we must first have a clear idea of the conformation and 
 structure of the organ in health. A knowledge therefore of nor- 
 mal, should precede the study of pathological anatomy.* 
 
 It is also necessary that he who devotes himself to these re- 
 searches, should follow, in his investigations, some convenient 
 method, that nothing essential be omitted, and that the examina- 
 tion of parts first exposed may not interfere with that of others. 
 
 Lastly, it is very useful, if not indispensable, to have a previous 
 knowledge, from accurate descriptions, or rather from actual obser- 
 vation, of the various alterations to which the organs are liable. 
 
 ARTICLE FIRST. 
 Mode of Conducting Post-mortem Examinations. 
 
 THE terms " post-mortem examination," "autopsy,"t and " ne- 
 cropsy, "J are synonymous, and express both the operation by which 
 the internal organs of a dead body are exposed to view, and the 
 record of the appearances exhibited by them. 
 
 $ I. We should always begin the examination of a dead body by 
 observing its external aspect : the degree of fleshiness or emaciation 
 should be noted with as great precision as possible. The general or 
 partial tumescence produced by air or serum should also be carefully 
 ascertained. It is sometimes necessary, particularly in examinations 
 made for judicial purposes, to observe with great attention the atti- 
 
 *It is desirable that the varieties of form, color, consistence, &c. which the 
 organs may present in health should be better determined and more accurately de- 
 scribed than they have been, hitherto, in order that we may distinguish with more 
 precision what is caused by disease, and what is only a variety of the healthy state. 
 
 t Avri)\iua ; from uvro?, himself; and onrouai, 1 see. 
 
 t Ntxqog, dead body j oTirojucu, 1 see. 
 
NECROSCOPY. 359 
 
 tude of the corpse and its relation to surrounding objects, the state 
 of the clothes, &c. &c. Circumstances, apparently very trifling, 
 may become important in the further development of facts. The 
 expression of the countenance, which is often that of fear, despair, 
 &c., ought not to be neglected. The flaccidity or rigidity of the 
 limbs should be particularly noted ; the rigidity always commences 
 with the jaws, the neck, the trunk, afterwards extending to the 
 upper extremities, and lastly to the lower ; it generally comes on as 
 soon as the animal heat has passed off; in those who have died of 
 an acute disease, it is greater and more durable than in those who 
 have died of a chronic affection; wounds, contusions, ecchymoses, 
 excoriations, marks of ligatures, eruptions, tumors, ulcerations, 
 gangrene of the integuments, are circumstances which should 
 always be noted. Attention should also be given to the reddish and 
 livid spots caused by the stagnation of the blood in the subcuta- 
 neous cellular tissue, and sometimes in the skin itself; these are 
 generally found on the posterior part of the trunk when the body 
 has lain upon the back since death ; they may exist, however, even 
 upon parts of the body which have not been dependent ; but in 
 such cases they are almost exclusively found in the neighborhood 
 of large veins, and seem to be caused by an exudation from them. 
 Sometimes these spots are diversified with lines, furrows and marks, 
 in which the skin still remains white ; these are caused by the 
 folds of clothing, or by inequalities on the surface upon which the 
 body lies. An elevated temperature and fluidity of the blood are 
 conditions which favor the formation of these spots. They are 
 more particularly observed in persons who have died of certain 
 affections, as severe fevers, gangrenous diseases, variola, scarlatina, 
 &c. &c. Under the same influences the epidermis can often be 
 detached from large surfaces by the slightest friction. It is impor- 
 tant, especially in examinations for legal purposes, not to mistake 
 post-mortem lividity for ecchymoses, which, as we have already 
 shown, are symptoms, and are caused by effused or infiltrated blood. 
 The color of the latter varies according to the time elapsed since 
 the contusion, and with the degree to which the reabsorption of the 
 blood has proceeded ; the livid spots formed after death are, on the 
 contrary, simply owing to a stagnation of the blood in the tissues. 
 Marks of putrefaction should also be observed ; this generally ex - 
 hibits itself first upon the abdomen and towards the iliac fossa3, in 
 greenish spots, and the body exhales a peculiarly fetid odor. 
 
 II. Having examined the exterior of the body with sufficient 
 attention, we proceed to inspect the internal organs.* 
 
 Most physicians commence the examination with the organ of 
 which there is supposed to be a lesion ; this method is not objec- 
 tionable if, after having found the suspected lesion, we proceed with 
 
 * The instruments necessary in the examination of bodies are nearly the same 
 with those employed in dissections, viz. scalpels, knives, blunt-pointed scissors of 
 different sizes, an enterotome, a rachitome, several probes, a saw, and a hammer ; 
 a glass tube is sometimes useful for inflating organs, in order to render certain le- 
 sions more apparent. 
 
360 NECROSCOPY. 
 
 the examination in order to ascertain whether any other exists ; 
 but as this latter is often neglected, it is better to make it a rule to 
 open those cavities, first, where no lesion is suspected. 
 
 Where there is no reason for preference, the abdomen should be 
 opened before the chest, and the latter before the head, because by 
 commencing with the abdomen, if it contain fluid, the quantity 
 and nature of the latter can be more readily ascertained, and if 
 there be any fluid in the thorax it is prevented from escaping, and 
 the depression of the diaphragm caused by it can be readily de- 
 tected. In commencing, however, with the thorax, unless care is 
 taken, there is danger of slitting down the diaphragm, and causing 
 a communication between the pleura and peritoneum ; besides, if a 
 liquid fills either of the cavities, a portion of it is liable to escape 
 into the other, and if it exists in both, mixture may ensue, and in 
 either case, error or great uncertainty results. When the abdomen 
 is opened, it is more convenient to extend the incision upwards 
 and open the thorax, than to pass to the examination of the head 
 and return to the chest, more particularly as after opening the 
 head, we are often obliged to return to the trunk to examine the 
 spinal marrow. 
 
 The three great cavities are opened in the following manner. 
 To lay bare the abdominal viscera, a semicircular incision should 
 be made, commencing at one of the hypochondria, descending 
 towards the pubis, skirting the anterior and superior spines of the 
 ilia, and terminating at the other hypochoridrium, making a large 
 flap including all the anterior wall of the abdomen. When this 
 flap is turned up upon the thorax, the incisions may be prolonged 
 to the articulation of the clavicles with the sternum, when the 
 chest is to be opened by dividing the cartilages of the ribs ; but 
 when the latter are to be sawed through, or, what is better, divided 
 by a costotome, the incision should be carried further outward. 
 When the ribs and clavicle are divided, or the cartilages cut 
 through and the sternum disarticulated, this bone should be re- 
 moved from the mediastinum by means of a scalpel, turning it 
 upwards towards the head, and, lastly, should be entirely detached 
 together with the flap. In some cases, in order to more fully 
 expose the diseased organs, it is necessary to dislocate, or to break 
 the ribs near their posterior extremity. 
 
 In opening the head, we commence by incising the integuments 
 circularly, carrying the incision a half inch above the eyebrows 
 and towards the superior occipital protuberance, or a little above 
 it.* This incision should be carried completely through the integ- 
 
 * A more simple, and certainly much less objectionable method of performing 
 this operation, and one which we have usually seen practised, is that in which an 
 incision is made, extending from one ear to the other, over the summit of the head, 
 the edge of the knife being turned upwards so as to cut from within outwards ; 
 the flaps are then dissected back far enough to permit a horizontal sweep of the 
 saw, in a direction nearly corresponding to that recommended, by the author, for 
 the first incision. We thus avoid the unsightly wound which must follow both 
 the methods proposed above. TRANS. 
 
NECROSCOPY. 361 
 
 uments, and the way for the saw carefully prepared. A crucial 
 incision may also be used, extending it from the root of the nose to 
 the occiput, and from one ear to the other, passing over the crown ; 
 the four flaps thus found, are then to be turned back. Having in- 
 cised the integuments, we should use the saw to divide the bone 
 when a lesion of either it or the pericranium is suspected ; in other 
 cases, a hatchet or hammer made for the purpose, with a sharp 
 edge, is more convenient. This instrument, it is true, jars the 
 head very much, but it does not tear the dura mater or cerebral 
 substance, as the saw is liable to do ; besides which, it occupies 
 Jess time than the latter. When the bone is cut through all 
 around, a hammer or chisel may be inserted into the anterior part 
 of the division so as to pry it open ; the fingers, well protected by 
 a towel, can then be introduced and the calvaria torn off, leaving 
 the dura mater exposed. 
 
 B. In the succeeding examination of the parts thus uncovered, 
 attention should first be given to the external condition of the 
 viscera, their color, form, size and consistence, their relations and 
 accidental adhesions, and to the fluids in the visceral cavities. 
 They may be then pushed aside to enable us to examine the parts 
 beneath, and turned over in order to expose their other surfaces, 
 and the membranes which enclose them cut through, &c. 
 
 Having observed with sufficient attention the exterior conforma- 
 tion of the viscera, we should proceed to examine any internal lesions 
 they may present. The method of examining the hollow organs, 
 differs from that employed in the examination of others. The 
 first, and particularly the organs of respiration and digestion, 
 ought to be carefully incised as soon as possible, and the fluids 
 they contain examined, and, if necessary, collected. The solid 
 organs, as the liver, spleen, brain and kidneys, should be incised 
 in different directions, and sometimes cut into thin slices, or shav- 
 ings, assulatim, as Morgagni expresses it; the ducts should be 
 slit open and their lining membrane examined, as well as the fluids 
 contained in them. A very delicate dissection is sometimes 
 necessary in order to appreciate lesions, and no pains should be 
 spared to examine them thoroughly, for one autopsy badly made, 
 does more harm than good. It is particularly in lesions of the 
 nerves, aneurismal tumors, considerable alterations of the structure 
 of certain viscera, and chronic inflammations of the serous mem- 
 branes with adhesions of the viscera, that a minute examination 
 is often indispensable. 
 
 It is often useful to inject the ducts and vessels of some organs 
 with a colored and coagulable fluid, whenever it is desirable to 
 know their new relations, their size, or the obliteration or develop- 
 ment of a collateral circulation. This process may also be resorted 
 to in cases of death from haemorrhage, in order to ascertain 
 whether the blood escaped from a small artery, ruptured or ulcer- 
 ated, or by simple exhalation ; as, for example, in the hemoptysis 
 of tubercular subjects. 
 
 31 
 
362 NECROSCOPY. 
 
 C. Such is the general method of procedure in the examina- 
 tion of the different viscera ; in making a further inspection of 
 them, the following method, which differs from that recommended 
 in their exposition, is to be preferred. 
 
 We should commence with the organs of circulation, examining 
 first the pericardium, the heart and the large vessels which leave 
 or empty into it. The heart is to be incised longitudinally, its 
 color, its consistence, the thickness of the walls, from the base 
 to the apex, should be noted. According to Bizot's researches, 
 the thickness of the walls and the entire volume of the heart 
 augment progressively from infancy to old age. This fact is an 
 indispensable element in our means of appreciating hypertrophy at 
 different stages of life.* The fore finger should be passed into the 
 different orifices of the heart to ascertain whether they are free. 
 If they are not, they should be exposed to view by an incision, in 
 order to discover, if possible, the degree and cause of the retraction. 
 Before however doing this, we should ascertain, by pouring water 
 into the venticle or artery, as the case may be, whether there is 
 inefficiency of the valves, that is, whether they be so affected as 
 to permit the blood-vessels to regurgitate through them. The larger 
 blood-vessels of the chest should always be opened, and sometimes 
 those in the neighborhood. They are generally found filled to 
 some extent with fluid and clotted blood, their walls presenting, 
 in such cases, the effect only of imbibition, a red color which 
 grows brighter upon exposure to the air. 
 
 We pass next to the organs of respiration. Before taking the 
 lungs from the chest, we should examine whether they present 
 marks of vesicular or interlobular emphysema ; squeeze them in 
 order to ascertain whether they are soft and elastic as in the 
 healthy state ; and incise them in different directions to ascertain 
 their structure.-)- 
 
 When tuberculous excavations or purulent cavities exist, we 
 
 * Bizot has furnished in his paper, exact dimensions of the walls and cavities 
 of the heart in the two sexes, and at different ages. 
 
 f The lungs present, upon examination after death, a phenomenon which was 
 long since observed, but not correctly explained. Their most dependent parts 
 are filled with fluid, making them darker and heavier than the others. It has 
 been supposed that this engorgement takes place immediately after death, and that 
 consequently we can tell in what position the body was placed at that moment. 
 Bayle, doubting the correctness of this opinion, made some experiments to ascer- 
 tain the fact. He recommended that persons dying upon their backs should be 
 immediately laid upon the belly, and so left until opening the body. He also noted 
 the position in which each patient lay during his last moments. The result of 
 these examinations was, that the engorgement of the lung always occurred in the 
 part dependent just before death ; that is, in the back in the greater number, at 
 the side in those who died upon the side, and at the base, in those who had retain- 
 ed the sitting posture during the last hours of their life. Placing the corpse upon 
 the belly, produced no engorgement in the anterior part of the lung. These ex- 
 periments are not only interesting in legal medicine, but are of the highest impor- 
 tance to the physiologist, for they concur m demonstrating the influence of phys- 
 ical laws upon man in disease ; an influence which becomes the more marked as 
 the vital powers diminish. 
 
NECROSCOPY. 363 
 
 should examine whether they communicate with the pleura or 
 with the bronchia ; whether they are in the pulmonary parenchyma, 
 or in that portion of the pleura which dips between the lobes of 
 the lungs (interlobular abscess). The communication of these 
 cavities with the bronchia, may be most readily ascertained by in- 
 flating the lungs through the trachea by means of a glass tube; if 
 the abscess have existed in the pleura, the cavity of the chest 
 should be filled with fluid, into which the bubbles of air will escape, 
 and thus demonstrate the communication. In some cases, how- 
 ever, they can be discovered by a simple inspection of the parts, 
 or by slitting open tne bronchia by means of a director and bistoury 
 or probe-pointed scissors. In examining the trachea and bronchia, 
 they should be slit open throughout their whole extent, in order to 
 judge of the modifications they may present as to their dimen- 
 sions (dilatation, contraction, obliteration), the color, consistence 
 and thickness of the parts which constitute them, and of the secre- 
 tions they contain. To see the larynx conveniently, the base of 
 the tongue must be separated from the inferior maxillary bone by a 
 semi-elliptical incision along the concave surface of this bone, and 
 prolonged at each end to the side of the neck. A second incision 
 should detach the volume of the palate and the posterior walls of the 
 pharynx ; then drawing out the tongue and larynx, the oesophagus 
 and trachea should be cut off low down in the neck. Having sepa- 
 rated the mass, the pharynx and superior part of the oesophagus are 
 first to be opened, next passing to the examination of the larynx, 
 particularly its superior entrance and the glottis, looking through 
 the latter to ascertain its size, and then slitting it open to inspect the 
 mucous membrane and cartilages. 
 
 Before opening the larynx, the state of the pharynx should be 
 ascertained, and if considered desirable the oesophagus may be slit 
 down throughout the whole extent, after examining the organs of 
 respiration and circulation. The stomach and alimentary canal can 
 then be opened with blunt-pointed scissors, or, what is better, 
 Cloquet's enterotome. This is important to ascertain the color of 
 the mucous membrane, whether it is injected, and if the injection 
 is uniform, or in patches, arborescences, or dots. The consistence 
 may be ascertained by detaching it in strips, which in health vary 
 in length according to the place whence they are torn. At the 
 greater cul de sac of the stomach they are three or four lines in 
 length; at the greater curvature, six or eight; an inch, inch and a 
 half, and sometimes two inches at the lesser curvature, and about 
 the pylorus and in the smaller intestine, from five to ten lines. 
 
 The thickness of the mucous membrane and the state of the 
 subjacent tissues should be attended to ; a careful examination 
 should also be made of Brumer's and Peyer's glands, which pre- 
 sent characteristic alterations in typhoid fever, and partake of the 
 tubercular degeneration in those who die of phthisis. In ascertain- 
 ing the state of the mesenteric glands, their relation with the in- 
 testine should be preserved, to enable us to determine if the lesions 
 respecting them correspond to those of the folds of the intestines. 
 
364 NECROSCOPY. 
 
 The liver, gall-bladder, biliary ducts, spleen, pancreas, blood- 
 vessels and lymphatics, where these exist, are to be taken up succes- 
 sively, afterwards the urinary organs, beginning with the kidneys 
 arid ureters, and ending with the bladder and urethra ; closing the 
 examination of the abdominal viscera, by that of the organs of gen- 
 eration. 
 
 The brain and its appendages require great attention. The 
 dura mater should never be incised before finishing the inspection 
 of the thoracic and abdominal cavities ; it supports the brain, and 
 prevents its tearing. It is even preferable not to open the cranial 
 cavity before finishing the examination of the chest and abdomen. 
 The dura mater should be divided with the scissors, or scalpel, 
 on each side of the falx, which should then be cut across near 
 its attachment to the crista galli and turned backwards, whilst the 
 dura mater thus freed may be pushed outwards from off the hem- 
 ispheres. Before going further, the cerebral convolutions must be 
 examined, to ascertain whether they are as prominent as they 
 should be, and equally so on both sides. When the flattening is 
 limited to one hemisphere we ought to find a severe lesion, as hae- 
 morrhage, or softening; when it exists in both, and the membranes 
 are not inflamed, it is owing either to an accumulation of serum in 
 the ventricles, or to a hypertrophy of the brain, as has often been 
 noticed in persons dying of cerebral affections produced by lead. 
 In opening the dura mater, notice should be taken of the quantity 
 of fluid contained in it, and in detaching the other membranes, their 
 strength as well as the degree of adhesion to the cerebral substance, 
 should be ascertained. It is generally better to examine the brain 
 in situ, a rule which is applicable to almost all the viscera. It 
 should be cut in thin slices, especially, when approaching the lat- 
 eral ventricles, which should be opened very carefully, when the 
 brain is sliced off level with the corpus cullosum, by plunging the 
 point of a scalpel vertically into the cerebral substance, three or 
 four lines from the median line, and a little nearer the anterior 
 than the posterior surface of the brain. Those cavities should be 
 opened throughout their whole extent; the fornix must be turned 
 back after dividing it in the middle so as to display the third ven- 
 tricle. The remainder of the brain is to be cut into slices as far 
 as the tuber annulare. The tentorium is then to be separated from 
 the edge of the temporal bone to which it adheres, and, carrying 
 the point of the scalpel far down into the spinal canal, the marrow 
 is to be divided, and the cerebellum removed. After taking this 
 organ from the skull, it is to be turned over, the fourth ventricle 
 may be examined, and then cut into slices to ascertain whether its 
 substance is healthy. The examination of the cranium is finished 
 by noting the vessels that ramify over the inferior wall of its cav- 
 ity, not forgetting to open the sinuses which are sometimes inflamed 
 or obliterated. 
 
 The length and difficulty of the preparations necessary for lay- 
 ing bare the spinal marrow without injuring its tissue, are the chief 
 reasons why its examination is so often neglected. It is desirable, 
 
NECROSCOPY. 365 
 
 in most cases, however, that it should 'be carefully made, and if 
 done with perseverance and discernment it would doubtless lead 
 to interesting results. 
 
 Many instruments have been devised for the double object of 
 saving trouble, and preventing injury to this organ and its mem- 
 branes. For the chisel and mallet, which were originally used, a 
 knife, first simple, then double, with a convex edge, was substi- 
 tuted. To this was next added lateral guards to prevent its pene- 
 trating too deep when driven by a hammer. A saw, single, or 
 double, with a convex edge, so as to cut the processes either on one 
 or on both sides simultaneously, was next proposed, and, lastly, 
 Magendie has of late employed large scissors, the cutting extremity 
 of which is very short and curved, so as to pass readily into the 
 canal whilst the other extremity being long, forms a powerful lever 
 with which the bony tissue can be easily severed. These various 
 instruments are called rachitomes. 
 
 There are certain diseases in which we ought to examine the 
 limbs, as in wounds, fractures, abscess, ulcers, caries, rheumatism, 
 contraction, dislocation, phlebitis, &c. This examination requires 
 no special rules. 
 
 Such is the most convenient method of making post-mortem ex- 
 aminations : * it can and ought to be modified by circumstances, a 
 detail of which would be here out of place. 
 
 ARTICLE SECOND. 
 The principal Lesions presented by the Organs after Death. 
 
 WE shall now proceed briefly to consider the chief lesions which 
 organs present after death. We shall class them in three princi- 
 pal series, viz.. 1st, lesions of solids; 2d, alterations in the fluids ; 
 3d, the presence of foreign bodies, either living or inanimate. 
 
 1st Series. Lesions of Solids. On account of the multitude 
 of subjects which these comprise, they will be divided into three 
 sections ; lesions of structure, lesions of comformation, and lesions 
 of relation. 
 
 1. Lesions of Structure. Among the lesions of structure, 
 
 * The reader may be surprised at our advising in one place to open the abdomen 
 first, and in another to examine the thoracic, before the abdominal viscera. We 
 have already stated why the abdomen should be first opened, and the following are 
 our reasons for first examining the thoracic organs. We cannot judge well of the 
 volume and distention of the heart, except when the large vessels that arise from, 
 and empty into it, are intact. If we commence by inspecting the abdomen, and 
 divide the liver, the vena porta, and the inferior cava, the heart will collapse be- 
 fore we examine it. For the same reason we should not pass to the lungs before 
 examining the heart. The oesophagus, which constitutes part of the digestive ap- 
 paratus, cannot be examined until after the heart and lungs, behind which it is 
 situated, be removed, which is another reason for following the rule we have laid 
 down. 
 
 31* 
 
366 NECROSCOPY. 
 
 we place inflammations, ulcers, fistulge, gangrene, tubercles, 
 cancer, melanosis, softening, induration, and organic transforma- 
 tions. 
 
 A. Inflammation does not uniformly present after death, the 
 same characteristics in the different tissues in which it is situated, 
 so that, in some cases, it is even more difficult to point out its effects 
 in the dead body, than to specify the symptoms which indicated 
 its existence in the living. In all cases, when, upon opening the 
 body, a part is found more voluminous, redder and more easily 
 torn, than in the healthy state, we have reason to believe that it 
 has been the seat of inflammation : the presence of pus, either col- 
 lected or disseminated through an organ ; albuminous, granulated 
 membranous or tubulated concretions, are sure signs of inflamma- 
 tion. It does not, however, always show itself in so marked a 
 manner, and the phenomena which characterize it must be studied 
 in each tissue. 
 
 In the mucous membranes, even the deepest redness is insuffi- 
 cient to characterize inflammation ; * in order to this, in addition 
 to the red color, there must be an alteration of consistence, a thick- 
 ening, ulcerations, or a creamy, purulent, or brownish exudation : 
 in fact, when death supervenes very speedily after the inception 
 of inflammation, the only traces of the latter, in many cases, 
 are an injection in fine points or in patches, and readily mistaken 
 for passive or post-mortem injections. The latter, however, take 
 place in dependent parts, being often noticed in the folds of the 
 intestines which dip down into the pelvis ; they are accompanied 
 by an injection of the veins, and the redness they produce often 
 disappear by washing or a short maceration, whilst the redness of 
 inflammation is persistent. The same test has been used to dis- 
 tinguish the effect of inflammation on the blood-vessels from the 
 redness of imbibition. 
 
 In the serous membranes, where inflammation neither produces 
 redness nor tumefaction, the presence of a purulent liquid, of false 
 membranes or adhesions, are characteristics which do not permit 
 us to doubt its existence, provided these signs are constant. But 
 these are not always necessary ; and especially in cerebral inflam- 
 mations, in which a slight alteration in the smoothness of the 
 serous surfaces, a pliability somewhat increased, a trifling infiltra- 
 tion of the cellular membrane which unites the arachnoid to the 
 cerebral substance, are considered by most physicians as signs 
 sufficient to indicate inflammation of this membrane. Lastly, in 
 some cases, the simple dryness of serous membranes in those who 
 die suddenly, would make an inflammation of short duration, the 
 elfect of which has been to suspend the normal secretion. This 
 
 * In persons who die of aneurism of the heart, the mucous membrane of the 
 digestive apparatus usually presents a blackish red color. We cannot however 
 allow that aneurism of the heart is always accompanied by inflammation of the 
 mucous membrane of the stomach. This livid redness is also found in the cheeks, 
 lips, hands, without there being any other indication of inflammation. 
 
NECROSCOPY. 367 
 
 opinion, first put forth by Marandel, has always appeared to ns haz- 
 ardous, and the facts observed in the epidemic Asiatic cholera* 
 which ravaged Europe, give increased weight to the doubts which 
 we have always expressed respecting the value of this anatomical 
 condition. 
 
 In the cellular or laminous tissue, inflammation shows itself 
 with very marked characteristics ; as redness, swelling, hardness, 
 and, at a certain period, the presence of pus infiltrated between the 
 layers of the tissue or collected in a cavity. It is nearly the same 
 with the lungs where it occurs under various forms, but with 
 characteristics generally very distinct and easily perceived. \ 
 
 This is not however the case with the brain, liver, spleen, kidneys 
 or uterus, particularly in women who die a few hours after con- 
 finement. In all these organs, if we except those cases where pus 
 exists in the parenchyma, the anatomical signs of inflammation 
 are rather obscure, so that what one would consider indicative of 
 it, another would regard as a disease of a totally different nature, 
 while a third would look upon it only as a variety of the normal 
 condition.]; 
 
 B. Post-mortem examinations often reveal, in the interior of 
 organs, ulcers, the existence of which may sometimes be recog- 
 nized or suspected during life, but whose anatomical disposition 
 can only be studied after death. These ulcers are sometimes pri- 
 mary or simple, that is, they are accompanied by no other altera- 
 tion of the part they occupy. But in most cases internal ulcers 
 are the consequence of the softening of tubercles, or cancer; or. of 
 the separation of an eschar, or of a specific inflammation, as 
 syphilis. An internal syphilitic ulcer presents characters analo- 
 gous to those of an internal one in the living subject ; ulcers from 
 gangrene or from tubercles, generally present in some portions of 
 
 * In a great number of those who die of cholera, the serous membranes pre- 
 sented a remarkable dryness. 
 
 f Inflammation of the lungs exhibits itself in five different stages. 1st. The 
 " engorgement " of Bayle or the "first degree " of Laennec, in which the lung is 
 heavier, more pliable than in the normal state, and of a red or violet color ; it still 
 crepitates, but less than in -health. If incised, it appears gorged with a frothy and 
 dirty bloody serum. 2d. Red hepatization or carnification, in which the lung 
 is easily torn, compact, granulated, red, heavier than water and contains no air. 
 3d. Gray hepatization, in which the lung is as heavy as in the last, does not 
 crepitate, but tears still more readily, and is permeated with a gray or reddish 
 purulent fluid. 4th. In some cases the lung presents all the characters of red 
 hepatization, except the hardness. In this state it is heavy, contains no air, and 
 soft like the spleen ; this issplenization. 5th. The pulmonary tissue is susceptible 
 of a gray induration without the exhalation of pus into its parenchyma ; in this 
 state, which seems to depend upon a chronic inflammation, it is not shining and 
 translucent as in cancer, and no puriform liquid escapes from it when torn, as in 
 hepatization. 
 
 J Softening of the cerebral pulp, cirrhosis, the granular disease of Bright, and 
 the engorgement of the spleen following intermittent fevers, are considered as 
 inflammations by some, and special alterations by others. In the numberless mod- 
 ifications in color and consistence of the liver, who can exactly make the bounds 
 between the normal and diseased state? 
 
368 
 
 NECROSCOPY. 
 
 their surface sloughs or tubercles, which indicate their nature ; in 
 cases of cancer, an incision of the part will at once disclose the 
 kind of lesion to which the ulcer belongs. 
 
 The existence, in the small intestines, of ulcers more or less nu- 
 merous, furnishes a very important anatomical character ; of all 
 acute dieases, typhoid fever is that alone in which this is an almost 
 constant lesion, and among chronic diseases, tubercular affections 
 are those in which it is almost exclusively noticed. In the severest 
 dysentery, whilst the large intestines are riddled with ulcerations, the 
 small intestines are generally exempt. On this account, whenever 
 numerous ulcerations are found in the small intestines, we should 
 look for the other lesions that ought to accompany them ; for tuber- 
 cle, if the patient have died of a chronic disease ; for typhoid alter- 
 ations, if he have died of an acute one. 
 
 C. We said something of fistula whilst speaking of the symp- 
 toms furnished by the internal appearances of the body; we will 
 only add here, that they can only be thoroughly studied by com- 
 parison of the functional disorders that they produce during life, 
 and the lesions which are presented after death. It is thus only 
 that we can accurately ascertain their direction, orifices, the pecu- 
 liarities of the structure of the canal, and, sometimes, even the 
 causes which have kept them open. 
 
 D. Gangrene, which consists in the death of some part of the 
 economy, is generally indicated by very marked signs which nev- 
 ertheless have still been confounded, in post-mortem examinations, 
 with black discoloration ; thus there is often some question as to 
 gangrene of the pleura, peritoneum and liver, diseases of very rare 
 occurrence. The black color may exist without gangrene, and the 
 latter may exist independently of the other. The eschars of the 
 mucous membrane are often of a grayish or whitish color ; those 
 produced by nitric acid are yellow ; Quesnay states that, in one 
 case, he saw the gangrened parts exhibit a remarkable transpar- 
 ence. The black color cannot therefore be considered as charac- 
 teristic of gangrene. Its principal characters are; 1st. complete 
 disorganization of the gangrened part, in which the element- 
 ary tissues can no longer be distinguished; 2d. softness and 
 flaccidity ; 3d. the fetid and characteristic odor which it exhales ; 
 and 4th. the sanies, ichor, and fetid gas which escape from it. 
 In that variety of gangrene termed dry, the part presents a black 
 color, a hardness sometimes like that of wood, and always a 
 complete disorganization of the tissue. Modern surgeons and par- 
 ticularly Richerand, consider necrosis as a gangrene of the bone. 
 
 E. Tubercles exist almost always in large numbers. They attack 
 principally the lymphatic glands, the viscera lined internally with 
 mucous membrane, and more especially the respiratory organs. 
 They are generally developed in the tissue of parts, which they, 
 finally, completely pervade. In some cases, they are enveloped in 
 
NECROSCOPY. 369 
 
 a membrane (encysted tubercles). Their size varies from that of a 
 millet seed to that of an orange or even of a man's fist. Their 
 aspect and anatomical characters differ according as they are in a 
 state of crudity, softening, ulceration, or cicatrization, so that unless 
 they have been traced through the intermediate stages, what are 
 but successive phases of the same affection might be taken for a 
 disease essentially different. Crude tubercle is formed of a whitish, 
 yellowish, or grayish opaque and solid substance, without cohesion, 
 resembling soft cheese, and in which no vessels or other appearance 
 of organization can be distinguished.* 
 
 In softened tubercle, the substance has lost its consistence ; it is 
 liquid, at least partly so, and resembling pus, or milk mixed with 
 white, opaque, cheese-like particles. It has been long supposed, 
 that this softening takes place from the centre towards the circum- 
 ference; but the ingenious researches of Mr. Lombard, of Geneva, 
 have led to a different conclusion. New observations are required 
 before we can decide upon this point. Subcutaneous tubercle 
 opens exteriorly by one or more openings often fistulous ; internal 
 tubercle when ulcerated, opens into the nearest mucous canal, and 
 soon exhibits sometimes a flattened ulcer, in which some particles 
 of unsoftened tuberculous matter, (tuberculous ulcer of the intes- 
 tines, larynx, fc.) and sometimes, as in the pulmonary parenchyma, 
 a cavity of greater or less size, often irregular and sinuous, in 
 which a purulent matter is alone discoverable. In some cases, 
 there only exists in the place of these excavations a sort of fibro- 
 cartilaginous mass, near which the surface of the lung is shrivelled, 
 and which presents in its centre traces of a cavity with which one 
 or more of the bronchi communicate. 
 
 The chalky concretions which are frequently met with at Ine 
 summit of the lungs, especially in old persons, are attributed to tu- 
 bercular disease, being considered as a transformation of the tuber- 
 cle, and one of the modes of a favorable termination of the affection. 
 This proposition, which has numerous partisans, and which is not 
 without plausibility, does not yet appear to us sufficiently demon- 
 strated. 
 
 F. Granulations are small globular bodies, transparent, smooth, 
 elastic, sometimes marked by lines or black points, and somewhat 
 analogous to cartilage in appearance. This lesion, which has 
 been particularly described by Bayle, has been considered by La- 
 ennec as the first degree or rudimentary state of tubercle, arid this 
 last opinion, adopted by most writers of the present day, is now 
 generally admitted to be correct. We do not, however, submit to 
 the general conviction. We acknowledge that where the lung is 
 pervaded by granulations it is not unusual to detect, in the centre 
 of some of them, a small point of opaque matter analogous to tuber- 
 
 * Chemical analysis gives 96 15 parts of animal matter, and some hundred! hs of 
 hydrochlorate of soda, of phosphate and carbonate of lime, with a slight trace of 
 oxide of iron. 
 
370 NECROSCOPY. 
 
 cle; we acknowledge also that, generally, tubercles and granula- 
 tions are found in the same subject ; but we do not think these 
 circumstances sufficient to demonstrate with certainty the connec- 
 tion between the two affections, any more than we should conclude, 
 from the tubercular matter in cancerous masses of the liver, that 
 cancer and tubercle are two alterations of the same nature.* 
 
 G. Cancer exhibits itself under the different forms of schirrus, 
 encephaloid disease, and cancerous ulceration. The characteristics 
 common to these lesions are indefinite increase, whatever be their 
 form (degeneration, or ulceration) ; an almost constant reproduc- 
 tion after excision or destruction ; a complete incurability when 
 abandoned to themselves, their general phenomena being progres- 
 sive wasting ; and alteration in the color of the skin, more particu- 
 larly of that of the face, which assumes a straw or sodden yellow. 
 
 Schirrus consists of a hard, grayish, or bluish white tissue, mak- 
 ing a peculiar noise when cut. This tissue is not completely ho- 
 mogeneous, but there may be distinguished in it a texture formed of 
 fibrous laminae, in which is contained a matter resembling, in color 
 and consistence, the skin of bacon. In other cases, these laminae are 
 arranged in radii, the cut surface of the cancer presenting an ap- 
 pearance analogous to that of a turnip ; it is this form that some 
 writers have termed napiform. By compressing the schirrus, we 
 can generally force out a transparent, albuminous fluid, which 
 some persons have designated under the name of cancerous fluid. 
 The injections made by Scarpa have led to the conclusion that 
 schirrus does not contain arteries or veins, or at least only a few 
 ramusculi. 
 
 Encephaloid or cerebriform cancer is an accidental production, or 
 organic degeneration of a milky white color, slightly tinted with 
 pink, exhibiting often the color and consistence of cerebral pulp, 
 and sometimes pervaded by effused blood collected in cavities of 
 greater or less size. M. Berard has demonstrated by injections and 
 dissections f that, on the one hand, the encephaloid tissue is pene- 
 trated by a great number of arterial vessels, the number and size 
 of which increase as the softening becomes more considerable ; and, 
 on the other, that there are no permeable veins in the centre of en- 
 cephaloid masses, whilst the periphery of these tumors consist of a 
 highly developed venous network. This development of the arte- 
 ries and atrophy of the veins satisfactorily explain the haemor- 
 rhages, to which parts affected with this kind of cancer are subject. 
 
 Encephaloid matter, like tubercle, attacks all organs ; the bones 
 themselves are very frequently affected. It sometimes exists in a 
 state of infiltration, but is most often found in layers or smaller 
 masses, and, sometimes, encysted. In some organs, as the lungs, 
 and more especially the liver, this matter is deposited in roundish 
 
 * See our article "Granulations" in the Dictionnaire de Medecine of 21 vols. 
 vol. x. 
 
 | Dictionnaire de Med. in 21 vols., Art. Cancer. 
 
NECROSCOPY. 37 L 
 
 masses, of the size of a filbert, walnut, or a hen's egg, which seem 
 to be developed in the interstices of the parenchyma, which they 
 separate and compress without affecting. They adhere but slightly 
 to the neighboring part and are easily enucleated. The soft vege- 
 tations which are developed upon some points of the mucous 
 membranes are generally encephaloid cancer. 
 
 Cancer shows itself upon the lips and the os tincse, particularly 
 under the form of a simple ulceration, without the existence of 
 schirhus or encephaloid matter beneath it, and which nevertheless 
 resembles cancer in the firmness which is felt in it when pressed 
 by the finger, and in the lancinating pain and general phenomena 
 which accompany it. This is a form of cancer which commences 
 where the others finish, and in which the ulceration seems to destroy 
 the cancerous tissue as soon as it is formed. 
 
 There is an affection characterized by the development of a whit- 
 ish transparent matter resembling jcalf s foot jelly, which has been 
 considered a species of cancer, and to which the term colloid or 
 gelatiniform has been applied. It is most often found in the ovaries. 
 This morbid production appears to us to be a development sui 
 generis, and to be too distinct from schirrhus, encephaloid or ul- 
 cerated cancer, to be confounded with them under the same name. 
 
 H. Melanosis * is an alteration of tissue which some authors 
 have considered as a variety of cancer, and to which they 
 have applied the term melanotic. It shows itself in rounded 
 or irregular masses, of firm consistence, of a black, purple or bluish 
 color, and size varying from that of a pea to that of the fist, and 
 presenting, in its consistence, form and color, some resemblance to a 
 truffle. Some physicians have thought that the melanotic tissue 
 is capable of being softened and ulcerating (Bayle and Laennec), 
 but there is no agreement upon this point. This is, in our opinion, 
 melanosis, properly so called, and that to which the name ought 
 alone to be given. It should not be confounded with the black color 
 often presented by the glands surrounding the roots of the lungs 
 and larger divisions of the bronchia, possibly produced solely by 
 age. Nor do we, with MM. Breschet and Casenave, consider the 
 blackish and pitchy matter which is met with, or the surface of 
 mucous membranes, thrown off in melena, and more rarely excret- 
 ed with the urine, as a variety of melanosis (liquid melanosis). 
 In our opinion, although chemical analysis may demonstrate the ex- 
 istence of similar elements f in melanotic masses and in the black 
 liquids which have been associated with melanosis, although there 
 may be between them as great an analogy as between cancer and 
 the sanies which flows from its ulcerated surface, we think that 
 a complete degeneration of tissues and a morbid secretion should 
 not be confounded under a common name, especially when obser- 
 vation exhibits, on the one hand, melanotic masses without any 
 
 * MtZag, black ; voaog, a disease." 
 
 | Many chemists, particularly MM. Thenard, Barruel and Lassaigne, have 
 detected in melanosis, as in the black matter thrown from the stomach, most of 
 the elements of the blood. 
 
372 NECROSCOPY. 
 
 traces of liquid melanosis, and on the other, the so called liquid 
 melanosis, without the existence of the former ; the secretion of 
 black matters, never in fact proceeds from a melanotic degeneration, 
 but is generally produced by cancerous ulceration. 
 
 The other alterations of structure, of which we are now about 
 to speak, have this in common ; that they all resemble some one 
 of the tissues of the animal economy in a healthy state. On this 
 account they are called, in general, transformations, each being 
 designated by a particular epithet. The principal of these are the 
 cutaneous, mucous, serous, fatty, fibrous, bony, cartilaginous and 
 horny. 
 
 I. The cutaneous transformation is often observed in mucous 
 membranes, where, in consequence of a prolapsus of the organs 
 which they invest, they become, as it were, external organs. This 
 takes place in prolapsus of the .vagina, of the uterus and rectum. 
 
 J. The like is observed in the mucous transformation which is 
 met with in fistulous tubes communicating with a cavity lined by 
 mucous membrane. The cellular tissue changes progressively its 
 nature, and takes the character, throughout the whole length of the 
 fistula of a mucous membrane, in which, however, there are no 
 villi or follicles. 
 
 K. Serous transformation is one of the most frequent. It oc- 
 curs in almost every instance where a foreign body remains for a 
 long time in any part of the animal economy, particularly in the 
 cellular tissue, the organization of which peculiarly resembles that 
 of the serous membranes. An accidental serous membrane, con- 
 stituting, like all serous membranes, a sac without an opening, may 
 be found around collections of pus ; apoplectic clots, heads of dis- 
 located bones and foreign bodies, such as missiles engaged in the 
 tissues; it is also an accidental serous tissue, to which the hydatids 
 attach themselves in the disease, known by the name of ovarian 
 dropsy. 
 
 L. Fatty transformation has been observed in various organs, 
 as the heart, muscles, mammae and pancreas. It is very frequent 
 in the liver, where it can be recognised by the whitish appearance, 
 unctuous feel and fatty streaks displayed by incising it, and still 
 more by the grease spot which it gives to paper when exposed to 
 the action of heat. Authors are not agreed as to the manner in 
 which the transformation is effected; some, among whom is Ari- 
 dral, think it is produced by a too profuse secretion of fat in the 
 tissue which ordinarily secretes it, whilst the neighboring parts are 
 compressed and atrophied without undergoing transformation, 
 properly so called. Others, on the contrary, suppose that the tis- 
 sue itself of the organs undergoes an alteration, and becomes 
 changed into fat ; fatty degeneration of the liver, which in health 
 contains no adipose cells, may be adduced in support of the latter 
 opinion. 
 
NECROSCOPY. 373 
 
 M. Fibrous degeneration generally occurs in certain cysts, in 
 various tumors, and more particularly in those of the ovaries. 
 
 N. Ossification is an alteration which frequently occurs in old 
 persons, but which has been also sometimes observed before adult 
 age. It is met with in the valves of the heart, in the arteries, 
 muscles, serous membranes, cysts, ligaments and cartilages. Pe- 
 trifactions have often been confounded with ossifications, properly 
 so called. Morgagni pointed out the laminated or fibrous tissue of 
 the bone, as the most proper means for distinguishing those lesions. 
 Chemical analysis furnishes a more ready and sure means of diag- 
 nosis; the osseous tissue consisting essentially of phosphate of 
 lime and gelatine, whilst petrifactions may present a totally differ- 
 ent composition. 
 
 O. Cartilaginous degeneration is generally but the first degree 
 of the osseous. 
 
 P. The corneous transformation has only been observed in the 
 skin. 
 
 $ II. We shall include in this section, all the modifications 
 presented by the external aspect of organs, as we have, in the first, 
 considered all those presented by their internal organization. 
 
 With these modifications, are connected those of form, volume 
 and color. We shall confine ourselves to their enumeration. 
 
 A. Among alterations of form, may be mentioned: 1. Solu- 
 tion of continuity in the hard or soft parts (from wounds, ruptures 
 from internal or external causes, fractures, separation of the carti- 
 lages and epiphyses). 2. Vices of conformation which some- 
 times can only be suspected during life, and which can almost 
 always be better appreciated after death. 3. Excrescences of all 
 kinds which are developed either upon the skin or the mucous 
 membranes, vesicular or hard polypi, bridles, &c. 4. Knots and 
 other inequalities which the surface of the viscera often presents, 
 as in cirrhosis or in cancer of the liver, nodes in syphilis. 5. Flat- 
 tening of the inequalities peculiar to certain organs, to the brain for 
 instance. 
 
 B. Under alterations of volume, may be mentioned: 1. Disten- 
 sion of the hollow viscera, and the approximation of their walls. 
 2. The enlargement or retraction of tubes in general, and of their 
 orifices in particular. 3. The augmentation or diminution of some 
 of the solid organs, as the brain and muscles. 
 
 C. Among alterations of co/or, we class the livid rubefaction of 
 all the tissues in the bodies of those who have died asphyxiated ; 
 the yellow color in jaundice, the red or blackish spots in scurvy 
 and certain cases of poisoning, the non-inflammatory redness of 
 
 32 
 
374 NECROSCOPY. 
 
 mucous membranes, that of the choroid membrane of the iris and 
 of the internal tunics of the vessels, the pale or deepened color of 
 the muscles, the black or pale yellow color of the liver, the mottled 
 appearance of the spleen, &c. &c. 
 
 2d Series. Alterations of the Fluids. Some of the alterations 
 which the fluids undergo are appreciable during life, and have al- 
 ready been considered in the chapter devoted to symptoms. We will 
 here only notice those alterations which are alone detected or made 
 more apparent by necroscopy. We shall first briefly examine the 
 alterations of the liquid, afterwards those of the gaseous fluids. 
 
 $ I. Alterations of the Liquids. We shall first consider the 
 liquids of the circulation, as the blood and lymph, and afterwards 
 the exhaled or secreted fluids. 
 
 A. We have above (pp. 182 to 189) detailed the principal al- 
 terations exhibited by the blood during life, escaping externally, 
 either in cases of haemorrhage or by an artificial orifice in the arte- 
 ries or veins. We have here but to discuss those which are revealed 
 by post-mortem examinations. 
 
 The blood drawn from a vein at the commencement of typhoid 
 fever generally presents no notable alteration, except a slight dimi- 
 nution in the consistence of the clot, a phenomenon by no means 
 constant. But if the patient die at a period when venesection 
 is no longer practicable, the blood is found sometimes fluid, but, 
 more often, united in black clots, which are soft and friable, and 
 consequently very different from the fibrinous and dense coagula 
 which are found in the vessels, and particularly in the heart, of 
 most of those who die of other acute diseases. 
 
 In some patients, who die with symptoms of purulent absorp- 
 tion, adherent or free clots filled with pus are found in the vessels 
 and heart. In other cases, pus has been found collected in a single 
 cavity in the centre of a clot, which becomes thus transformed, as 
 it were, into an abscess. 
 
 There is another alteration of the blood which necroscopy can 
 alone reveal. This is the presence of encephaloid matter in the 
 veins near a cancerous mass. Velpeau. who published one of the 
 first of several curious observations upon this subject,* supposes that 
 the blood coagulating in the vessels becomes converted into ence- 
 phaloid matter. It is the opinion of others, that in these cases 
 cancerous matter is absorbed by the veins, and that by it the fibrin e 
 of the blood becomes altered. It is possible that the encephaloid 
 matter developed either outside or within the walls of the veins, 
 might penetrate them, and produce those vegetations which have 
 been too readily attributed to a transformation of the blood. 
 
 B. The modifications to which lymph is subjected in the course 
 
 * Revue Medicale, 1825 and 1826. 
 
NECROSCOPY. 375 
 
 of disease cannot be detected during life, but may be sometimes 
 appreciated after death. 
 
 In women who die of puerperal fever, pus is frequently found 
 in the lymphatic vessels of the uterus. We have seen, in a case 
 of cancerous affection of the stomach and mesenteric glands, the 
 lymphatic vessels of the mesentery distended with pus so as to 
 make them much more distinct than could have been done by the 
 most perfect injection. Since Cruikshank,* bile has frequently 
 been found in the lymphatics of the liver. Sabatier,f Soemmering J 
 and many others have seen in the thoracic duct, a liquid resem- 
 bling the blood in color and consistence, and have admitted that this 
 fluid can pass directly into the lymphatic vessels. These observa- 
 tions, however, are far from conclusive, and it is, in our opinion, 
 with reason that of late, Miiller and Breschet$ have raised doubts 
 as to the nature of the red fluid found in the lymphatic system. 
 
 C. The mucous membranes, which open externally by one or 
 more orifices, sometimes permit a portion of the fluid which lubri- 
 cates them, to escape by the mouth, anus, urethra or vagina, espe- 
 cially when the secretion is increased in quantity. But even, in 
 these cases, it is not uninteresting to examine, after death, the mu- 
 cus contained in the air and digestive passages, bladder and uterus. 
 It is not unusual, also, to find, in some of the organs, collections 
 of mucus, which have not been voided during life. The fluid 
 should be examined after death, as during life, with regard to the 
 alterations in quantity, consistence, color, and admixture with other 
 substances caused by disease. 
 
 D. It is particularly for the study of the liquids enclosed in the 
 serous membranes, that post-mortem examinations are indispensa- 
 ble, the disposition of these membranes preventing, during life, an 
 examination of their contents. It is, in fact, only by the aid of 
 rational signs that we can ascertain the presence, increase or di- 
 minution of fluid within their cavities, or whether they are lined 
 with false membranes. It is true that sometimes by a special 
 operation we can see, and subject to close examination, the fluids 
 taken from the serous cavities. But such operations are rarely 
 practised, and the whole fluid is never withdrawn ; the denser por- 
 tions subside to the dependent part of the cavity, and the mem- 
 braniform concretions are generally adherent and cannot escape : 
 an examination of the body can then alone give a correct knowl- 
 edge of the morbid products contained in serous membranes. The 
 fluids found in them may be colorless or watery, transparent, 
 clouded or completely opaque, and may sometimes consist of pus 
 or blood, pure or mixed with serum. With these liquids we often 
 
 * Anat. des Vaisseaux Abs. p. 8, trad, de Petit Radel. 
 f Hist, de VAcnd. des Sciences, annee 1780. 
 j De Mortis vas absorp. p. 40. 
 Systeme Lymphat. p. 288. 
 
376 NECROSCOPY. 
 
 find various concretions in the form of flakes, bridles or false 
 membranes sometimes intimately blended with the sac, so as to 
 give the appearance of an increased thickness of the walls ; a close 
 examination, however, will show, as Prof. Fouqnier has demon- 
 strated, that these may be detached, and that the thickness of the 
 membranes is not increased. We may add that, in almost all cases, 
 they preserve their natural transparency, and that the red or black 
 color which they sometimes exhibit, belongs to the cellular tissue 
 adherent to their surface; this is readily shown by careful dissec- 
 tion. The false membranes above mentioned, may be either sim- 
 ple or multiplied, soft or firm, presenting the greatest variety 
 of color, from black to a grayish white. They assume, in a short 
 time, often in a few hours, the appearance of organization. Andral* 
 having injected some acetic acid into the pleura of a rabbit, found, 
 at the expiration of nineteen hours, soft false membranes penetrated 
 by numerous reddish lines, which anastomozed like blood-vessels. 
 Cloquet even remarked the same thing in persons who had died of 
 pleurisy, after a few days' sickness. Are these red lines vessels ? 
 This does not appear to us sufficiently demonstrated, and when 
 we remember the red lines seen in other secretions, as in bronchial 
 mucus and in the glairy matter thrown off by vomiting or stools, 
 doubts may be entertained respecting the existence of these acciden- 
 tal vessels, which should become more apparent in old false mem- 
 branes where they have never hitherto been clearly distinguished. 
 On the other hand, in these false membranes are found blood and 
 small tubercles, which would demonstrate a real organization, if it 
 could be proved that the blood or the tubercles were produced by 
 them, and not by the inflammation of the serous membrane ; this, 
 however, it is impossible to do. We may consider it as almost 
 certain, that, in serous membranes entirely lined by them, morbid 
 deposits, exhalation and absorption nevertheless continue ; but do 
 these deposits contain exhalents and absorbents, or do they merely 
 constitute a permeable layer into which the mouths of these ves- 
 sels open ? In the present state of the science, these questions do 
 not appear to us settled. 
 
 E. The liquids contained in the synovial membranes present 
 alterations analogous to those of the serous. In addition to these, 
 we sometimes find in them free or movable concretions, the pres- 
 ence of which during life has caused severe pains, these being more 
 or less constant, according to the part of the articulation occupied 
 by these foreign bodies. 
 
 F. The fluid contained in the cellular tissue is colorless or yel- 
 low, muddy or purulent, and, in some cases, mixed with blood. 
 Examination after death reveals the presence of serum in the sub- 
 cutaneous cellular tissue, in that between the muscles, in that in 
 the interior of the body, as in the cellular tissue of the peritoneum, 
 
 * Clin. Medical, vol. iv, p. 538, 4th ed. Par. 1840. 
 
NECROSCOPY. 377 
 
 and in the cellular appendages of the large intestines. Infiltration 
 sometimes exists in the cellular tissue of the pleura, and in 
 that which unites the pericardium to the exterior of the heart. 
 Serum has sometimes been detected in the cellular tissue which 
 unites the mucous membranes to the adjacent parts, both where it 
 is external, accessible to view, and where it exists in deeper seated 
 parts, as in the epiglotto-arytenoid folds, the glottis, and the valves 
 of the intestines. 
 
 G. The fluids secreted by the glands present some alterations, 
 but most of them are appreciable during life, except in the case of 
 retention of these liquids, of the bile and urine, for instance, in their 
 ducts and reservoirs. Post-mortem examination of the biliary and 
 urinary passages sometimes reveals, in these cases, very interesting 
 phenomena. 
 
 H. There is scarcely any cavity in which we may not find 
 after death some effusion, circumscribed or diffused, of liquid or 
 coagulated blood, of serous or thickened pus, with or without a 
 membraniform envelope. 
 
 I. Fluids enclosed in accidental sacs or cysts are also found 
 upon examination of bodies after death. These are sometimes 
 aqueous; at others, viscid, resembling honey, gelatine, pus, lard; or 
 they may be of a cretaceous character. In the first case, the cyst is 
 thin and resembles the serous membranes; in the others, it generally 
 has some thickness; it is often fibrous, and sometimes is even cartila- 
 ginous or bony. Some cysts present a different texture in different 
 parts. In such cases, their cavity is generally divided, by irregular 
 septa, into several sacs, each of which may contain a liquid of dif- 
 erent color and consistence ; these are termed multilocular cysts. 
 
 II. Alterations of the elastic Fluids or Gases. The gas 
 naturally exhaled in the alimentary canal, may, upon examination 
 of the body after death, exhibit important modifications as to its 
 quantity, distribution and chemical qualities. This latter point 
 has been as yet but little studied, and we cannot tell what advan- 
 tages may not be derived from a more careful investigation. The 
 diminution or increase in the quantity of gas in the intestines 
 and stomach may be ascertained as well during life as after 
 death. The most important fact to note, in reference to Pathologi- 
 cal Anatomy, is the accumulation of gas in one portion of the canal 
 whilst another contains none, or less than its usual quantity ; this 
 is a most sure sign of some contraction or stoppage, or other obsta- 
 cle to the passage of the gas. It often enlightens the physician 
 upon the subject of his investigations, pointing out to him, in some 
 cases, lesions which he did not suspect during life, and which even 
 after death, surrounded by others of more apparent importance, 
 such as peritonitis, might still elude his search, if he were not im- 
 pressed with the value of this phenomenon. 
 32* 
 
378 NECROSCOPY. 
 
 We sometimes meet with gas in parts which naturally do not 
 contain it, as in the pleura, peritoneum and subcutaneous cel- 
 lular tissue, very rarely in a cyst, of which we have above given 
 an example (p. 283). Some physicians suppose that these gases 
 may result from a simple morbid exhalation, but the more extended 
 our observations, the more convinced we become that the presence 
 of gas in the pleura, peritoneum and cellular tissue, is almost 
 always the result of a perforation of the intestines, lungs, or some 
 other portions of the air passages, as the trachea or nasal fossre. 
 We should therefore examine carefully for such lesions. The 
 presence of gas in a part that ought not to contain it, is sometimes 
 a phenomenon of putrefaction after death * and, possibly, in some 
 cases, arises from the decomposition of pus confined in a cyst, 
 particularly if it have been punctured. 
 
 3d. Series. The foreign bodies discovered in post-mortem ex- 
 aminations are of different kinds ; some inanimate, others pos- 
 sessed of life, or previously deprived of it. Among those which 
 are inanimate, some are found in the body, as biliary and urinary 
 calculi, intestinal concretions, and those which are found in the 
 articulations, salivary ducts, lungs, uterus, etc. Of those which 
 come from without, some are introduced by wounds, particularly 
 by gunshot wounds; others by the natural passages, as the mouth, 
 anus, urethra in both sexes, or the vagina in women. 
 
 The living foreign bodies which are found in man are the oxyu- 
 res or ascarides vermiculares, which are found particularly in the 
 rectum, the ascarides lumbricoides in the small intestines, the tri- 
 cocephales or trichurides in the ccecurn of those who die of typhoid 
 fever, and many varieties of taenise ; the tsenia lata is the most 
 frequent in France, and is generally met with in the small intes- 
 tine. Hydatids of various kinds are found in the interior of the 
 viscera, or in the splanchnic cavities. Those called by Laennec 
 acephalocysts are the most common, and are generally developed 
 in the liver. This viscus is moreover the exclusive seat of a spe- 
 cies of entozoa called thefasciola humana by Breza, being rarely 
 found in man. The kidney is also the exclusive seat of a species 
 of entozoa not less rare, to which the term strongylus has been ap- 
 plied. In Guinea, a long white slender worm called the Guinea 
 worm, or dracunculus, forms in the flesh, principally affecting the 
 negro race. 
 
 Such are the principal phenomena revealed by necroscopy. 
 
 The various disorders thus disclosed are not of equal impor- 
 
 * We assisted at the opening of a stout man who had died suddenly thirty-two 
 hours before. The emphysema which had come on since death was already so 
 considerable as that the volume of the trunk and limbs was nearly double their 
 natural size. The moment the scalpel penetrated the abdomen, which was as hard 
 as a board, the air escaped, producing an explosion as violent as that of a well 
 charged air gun. The alimentary canal had not been wounded, and remained 
 distended. The gas which produced the explosion was therefore collected in the 
 peritoneum itself. The emphysema was so general, that it escaped with the blood 
 in the form of a reddish froth upon incising the vessels. 
 
NECROSCOPY. 379 
 
 tance. 1. Some precede the symptoms of the disease, and appear 
 to have produced them, such as crude tubercles, which are often met 
 with in the lungs of persons whose respiration has not seemed af- 
 fected. 2. There are other alterations which only supervene in 
 the course of a disease, sometimes at a very advanced stage, and 
 which seem rather the effect than the cause ; such as the tume- 
 faction of the liver, and the anasarca in persons affected with 
 aneurism of the heart. 3. Other phenomena of pathological anat- 
 omy only occur in the last moments of life, as the engorgement of the 
 lungs above mentioned (p. 367), and also, doubtless, the gelatin- 
 ous and albuminous clots found in the heart and large vessels. 
 4. Many lesions only take place after death, and are called ca- 
 daveric phenomena, as the purple spots formed in the subcutaneous 
 cellular tissue, the transudation of bile which colors the neighbor- 
 ing parts of the intestines, the stomach and the inferior surface of 
 the liver ; the disengagement of air which may take place in a 
 very short time, less than twenty-four hours, for example ; the in- 
 filtration, which supervenes after death, and which is more fre- 
 quent under some atmospheric conditions, and possibly after par- 
 ticular diseases ; the slight effusion of serum found in the serous 
 membranes ; the putrefaction which is generally much more rapid 
 in some parts than in others, and which on this very account will 
 be liable to lead to error ; to these may be added certain changes 
 in the gastric mucous membrane, which, as Dr. CarswelPs experi- 
 ments have proved, may supervene after death by the corrosive 
 action of the gastric juice upon the walls of the stomach, and may 
 lead us to suspect the action of some caustic poison. Lastly, 
 there are lesions which are met with after death, but which 
 during life produced no apparent trouble in the functions, such as 
 adhesions of the lungs to the walls of the thorax, the white and 
 opaque spots that often exist upon the heart, certain encysted tu- 
 mors, various foreign bodies, and some incipient organic lesions. 
 
 It is of the highest importance to the physician nicely to appre- 
 ciate these different phenomena. It is with reason that Double in 
 his " Traite de Semeiotique,"* pointed out the errors to which post- 
 mortem examinations may give rise, especially at a time when we 
 are possibly disposed to give an undue importance to anatomical 
 lesions ; but we do not consider these errors as unavoidable, and 
 think that it is often possible, by carefully comparing and collat- 
 ing the phenomena observed during life, and the lesions found 
 after death, to distinguish, among these lesions, those which have 
 preceded, and those which have followed the development of the 
 symptoms and the death of the individual. O. 
 
 * S&m&iotique Ginirale, vol. i. p. 56, et seq. 
 
380 THERAPEUTICS. 
 
 CHAPTER XIX. 
 
 THERAPEUTICS. 
 
 IN man, as in other organized beings, there exists an internal 
 force, which presides over all the phenomena of life, in each of its 
 successive periods, contends unremittingly with physical and 
 chemical laws, receives the impression of deleterious agents, reacts 
 against them, and consequently developes the symptoms, deter- 
 mines the course and eifects the resolution of diseases, by an action 
 equally impenetrable in all. This force, which constitutes life, 
 commencing and ceasing with it, inherent in the organs, arid, 
 (were it not for its abandonment of them after a certain time,) in- 
 separable from them, wholly unknown as to its essential nature, 
 and manifested by its effects alone, while it has been termed by 
 certain authors vital force and internal power, has been more 
 generally known by the name nature,* from the times of Hippo- 
 crates downward. While physicians admit the existence of this 
 force, they are not agreed in regard to its attributes : some have 
 considered it an intelligent principle! all of whose acts are the 
 result of reasoning, and, as it were, voluntary ; others, going to 
 the opposite extreme, make nature to consist in the elasticity and 
 oscillation of the fibres, and in the progressive and circulatory 
 motion of the fluids ;J others, as Sydenham,^ have used the term 
 in the same sense which we attach to it at the present day. 
 
 Cure, or the transition from disease to health, is the result of a 
 profound change effected in our organs, itself necessarily subordi- 
 nate to the power presiding over all the vital phenomena : upon 
 this power, therefore, the cure depends. From the fact, however, 
 that many circumstances may embarrass or assist its action, art 
 concurs, more or less efficiently, in the cure of diseases, by prop- 
 erly directing and proportioning the efforts of nature, and removing 
 the obstacles likely to oppose them. Such is the office of thera- 
 peutics^ (therapeutice), the branch of pathology devoted to the 
 treatment of diseases. To treat a disease, is to remove everything 
 likely to exert upon it an untoward influence, and to combine all 
 those means suitable for the diminution of its duration and inten- 
 sity. 
 
 The majority of diseases are susceptible of cure without active 
 treatment, by the powers of nature alone; from this arises the 
 usurped reputation of an infinite number of inefficacious remedies 
 and of a crowd of ignorant charlatans. No disease can be cured 
 by art alone ; hence the impotency of medicine in a great num- 
 
 * tjF>?'(T(?, nature. 
 
 t VAN-HELMONT. 
 
 t RAYMOND, Maladie qu'il est dangereux de Guerir. p. 20. 
 
 \ Opera Omnia, t. i. p. 77, 78. 
 
 II OtQanivw, I take care of. 
 
THERAPEUTICS. 381 
 
 her of the diseases which afflict mankind. Cinchona and the 
 mercurial preparations, justly considered the most heroic remedies 
 we possess, are powerless when nature does not respond to their 
 action. Biood-letting alone will not dissipate inflammation, and 
 the adaptation of the edges of a wound is not sufficient to effect 
 reunion. In surgery, as in medicine, therapeutics, (in the great 
 majority of cases) merely favor the action of nature, which, unas- 
 sisted, would be able to restore an inflamed organ to the healthy 
 state, cicatrize a wound and unite the fragments of a broken bone. 
 
 Therapeutics, properly denned, is but the art of modifying the 
 secret action of our organs, for the purpose of curing or alleviating 
 disease. This assertion seems to us incontestable, even by the 
 most strenuous advocates of the power of artificial means. No 
 one will imagine that we intend to diminish the claims of remedial 
 measures in the cure of disease : on the contrary, we are con- 
 vinced, that by the omission of suitable treatment, and especially 
 by the influence of improper medication, very slight affections 
 even, may become incurable or fatal ; that the greater part of 
 severe diseases would terminate in death ; that many others, among 
 which should be classed certain forms of syphilis, would not admit 
 of cure, at any rate, in our climate : we only intend to say that 
 our therapeutical means have no direct action upon disease, that 
 they act only by determining modifications in the economy, by 
 means of which that favorable change which prepares and com- 
 pletes the cure, is effected : the extraction of foreign bodies and 
 the reduction of displaced parts are almost the only exceptions. 
 This doctrine, generally admitted at the present day, detracts 
 nothing from the importance of therapeutics, and gives to nature 
 the influence belonging to it: equally removed from the opinions 
 of those who ascribe the exclusive merit of a cure to art or to na- 
 ture, we believe that the concurrence of both is always useful and 
 often indispensable. 
 
 This mode of considering therapeutics exhibits also, its bases : 
 these are, first, the thorough knowledge of the course and tendency 
 of diseases towards various terminations, and, secondly, a like 
 knowledge of the proper means for opposing or assisting these 
 tendencies : observation and experience alone can direct us in this 
 difficult study. 
 
 Observation, in medicine as well as in all the other sciences, re- 
 quires, in those about to devote themselves to it, the perfection 
 of the senses, and a mind at once attentive, calm and unprejudiced. 
 Perfect senses are necessary, because by them are established those 
 relations between physician and patient which lead to the knowl- 
 edge of the disease. The entire attention is indispensable; he 
 who cannot command this, is incapable of proper observation, and 
 whatever tends to divert or enfeeble it, as fatigue of mind or preju- 
 dice, will disqualify even an individual who would otherwise be 
 an excellent observer. For this reason, meditation, previous to 
 visiting patients, is injurious to the physician, and it was not with- 
 out a sufficient motive that Hippocrates recommended them to be 
 
382 THERAPEUTICS. 
 
 seen in the morning rather than at evening, asserting that the 
 physician is more likely to observe well at that hour, as is the 
 patient to reply more distinctly to questions. The most complete 
 composure is equally necessary to the observer; any strong passion 
 absorbs, as it were, all the moral faculties and prevents the con- 
 centration of the mind upon other objects. A tender attachment 
 or too lively anxiety incapacitate one for thorough observation and 
 accurate appreciation of existing phenomena. It is a common 
 remark, that a physician nearly always errs in his opinions in re- 
 gard to the diseases by which his intimate friends are affected ; 
 still more decidedly is this the case in respect to affections of which 
 he himself is the subject : on this account it has become an estab- 
 lished principle that, in all such cases, no wise man should rely 
 upon himself. In order to correct observation, the mind should be 
 free from prejudice, which, as has been remarked, is a kind of 
 prism, concealing from our view one portion of objects and mag- 
 nifying arid distorting the other, thus presenting an image more 
 or less incorrect and always very imperfect. Systematic physi- 
 cians have ever been, and always will be, unskilful observers. He 
 who, in accosting patients, is not satisfied with the application of 
 his senses to the examination of phenomena, and with the recep- 
 tion of impressions transmitted by them, but searches for, and 
 wishes to find, in what he observes, the confirmation of previous 
 imaginations, is wholly unfit for an observer, and the results of 
 his observation are generally nothing more than the vagaries of a 
 deranged mind. 
 
 A quality more important than any previously enumerated, 
 should be added to the above requisites : viz. the spirit of observa- 
 tion. This quality, which implies the union of all the others, but 
 does not always accompany them, consists simultaneously in a sort 
 of natural inclination to examine objects attentively, and in the 
 faculty of promptly detecting and appreciating their relations and 
 discrepancies. It is an innate disposition, capable of development 
 by cultivation, but not of acquisition by those who do not natu- 
 rally possess it. Sound judgment is also indispensable to the phy- 
 sician, to enable him to rise gradually, and in the proper order, from 
 the isolated observation of particular facts to those general con- 
 clusions whose assemblage constitutes pathological physiology. 
 
 A physician long accustomed to accurate observation, can, from 
 the nature and form of diseases, their intensity, course, period, 
 etc., without other aid, accurately appreciate their tendencies to 
 various terminations, and, consequently, can decide upon the fit- 
 ting opportunity for active treatment, or prudent expectation, which 
 is never, properly speaking, a state of inaction, for it supposes, on 
 the part of the physician, a vigilant attention, necessary, not only 
 in opposing the accidents which may supervene, and in removing 
 everything likely to disturb the progress of a disease approaching 
 a favorable termination, but, moreover, in uniting all the hygienic 
 conditions most favorable to a prompt and complete cure. We 
 can understand how dangerous is that ignorant treatment that 
 
THERAPEUTICS. 383 
 
 torments with powerful remedies a disease, over which the natural 
 powers alone would prevail, or that unseasonable expectation 
 which delays action in presence of a disease sufficiently severe to 
 compromise life, and whose fatal termination might have been pre- 
 vented by active medication. Observation alone can preserve the 
 physician from these fatal errors, because it alone furnishes that 
 thorough knowledge of the course and connection of pathological 
 phenomena, constituting an unfailing rule in the treatment of dis- 
 ease. 
 
 If the study of the various tendencies of diseases be difficult, 
 the appreciation of the suitable means for favorably modifying 
 organic action is no less so ; it is based upon experience, whose 
 foundation is a combination of observation and experiment. " Ex- 
 periment (exp&rimentum) differs from simple observation in this, 
 that the knowledge we acquire from mere observation seems to be 
 freely presented, while that furnished by experiment is the result 
 of some trial, made with the intention of ascertaining the exist- 
 ence or non-existence of a thing. A physician who atten- 
 tively considers everything in the course of a disease, observes ; 
 and he who, in similar circumstances, administers a remedy and 
 endeavors to appreciate its effects, experiments. Thus the ob- 
 serving physician listens to nature, the experimentalist questions 
 her."* 
 
 Observation occupies the first rank in the delicate study of the- 
 rapeutical means. It necessarily preceded experiment in the natural 
 concatenation of human ideas and acquirements. Those who 
 were first led to attempt the relief of their species probably de- 
 rived their original notions from chance, and occasionally from the 
 instinct of the patients, and doubtless tried no experiment until a 
 subsequent period. We have previously enumerated the condi- 
 tions requisite for observation and will now attempt to sketch the 
 rules which should regulate experimentation. 
 
 Therapeutical experimentation seems the most simple and easy 
 thing possible, not only to persons unacquainted with medicine, 
 but also to the majority of practitioners. There is no physician 
 but has experimented more or less with remedies, and drawn more 
 or less positive conclusions from his experiments ; yet we all know 
 how few of such conclusions have received the sanction of time, 
 and, consequently, how few there are who appreciate the difficul- 
 ties of experimentation and the great circumspection and persever- 
 ance it demands in order to obtain accurate results. The number 
 of medicines declared by various experimentalists to be capable of 
 arresting the course of intermittent fever may be estimated at 
 several hundred, and yet, among them all, there is but one whose 
 action as a febrifuge is fully proved and universally admitted, f 
 
 * ZIMMERMAN, de V Experience, t. i. p. 22. 
 
 f Although the unfailing specific action of the sulphate of quinine has so firmly 
 and justly established it as the remedy par excellence in intermittent fevers, we are 
 inclined to consider the assertion that it is " the only one whose action as a febri- 
 fuge is fully proved and universally admitted" as somewhat too positive. We 
 
384 THERAPEUTICS. 
 
 The number of remedies vaunted as specifics in certain other dis- 
 eases, as epilepsy or gout, is hardly less considerable, and none of 
 them have stood the test of time and justified the confidence too has- 
 tily accorded to them by some experimentalists. The immediate 
 consequences of these facts are, that experimentation in medicine is 
 extremely difficult, and exact experimenters, unfortunately, very 
 rare. 
 
 Some experiments are undertaken with a view to determine 
 the action of certain therapeutical agents in a given disease ; 
 others, to ascertain the primitive effect of a medicine upon 
 the economy, as its purgative, diuretic or sudorific action. 
 The latter by no means present equal difficulties with the former, 
 
 have the best authority for the use of arsenical preparations in intermittents. 
 Among many writers who recommend them, may be mentioned Pereira, Copland, 
 Marshall Hall, and Watson ; every one is familiar with the extraordinary success 
 which attended the use of the arsenical solution in the hands of its originator. 
 (Med. Reports on the effects of arsenic in the cure of agues, remittent fevers and 
 periodic headache. T. Fowler, 1786.) This is mentioned by MM. Trousseau 
 and Pidoux ; (Traite de Thtrapeutique et de Mali ere Mfdtcale, % me edition, torn. 
 i. p. 302 ;) they also cite the strong testimony of Willan in its favor, who declared 
 " that he knew no remedy more sure, efficacious or convenient to take, than this 
 arsenical solution in the treatment of intermittents ." MM. Trousseau and Pi- 
 doux remark, that " no one can hesitate, at the present day, to consider arsenic as 
 nearly upon the same footing with quinine, as a febrifuge." (Op. cit. p. 303.) 
 A very elaborate and highly interesting paper upon the use and efficiency of ar- 
 senic in intermittent fevers, by M. F. Masselot, is published in the Archives Gen- 
 erales de Medecine ; (4 me Serie, torn. x. et xt.) several cases are given where the 
 sulphate of quinine had arrested the paroxysms of the disease, but recurrence 
 occurring, definitive cure was obtained by the employment of arsenious acid in 
 conjunction with emetics. Many important and positive inferences are deduced 
 by the author from his researches, apparently with the greatest reason. The ex- 
 perience of M. Boudin in the Military Hospital at Versailles, is conclusive in favor 
 of this remedy. From a table given by M. Masselot, (loc. supra cit.) we extract 
 the following : " Patients treated by sulphate of quinine, 111; return of the parox- 
 ysms in 14 cases, 12.5 in 100 : Patients treated by arsenious acid, 311 ; return 
 of the paroxysms in 10 cases, 3.2 in 100." Most authors, also, testify to the effi- 
 cacy of the alkaloid salicin in intermittents ; it possesses very analogous properties 
 with the sulphate of quinine, being, like that salt, an astringent tonic : some have 
 erroneously ascribed to it an equal and even a superior efficacy to quinine ; this 
 position it certainly does not hold, and probably never will, but in cases where the 
 latter medicine could not be obtained, salicin would be an invaluable substitute. 
 (Dr. Shapter, Intermittent Fever, Lib. Pract.Med. Tweedie. Am. ed. vol. i. p. 
 254. Pereira, Mat. Med. and Therap.) Although it requires to be exhibited in 
 larger doses than the sulphate of quinine, it is less likely to irritate the stomach, 
 (Pereira, Op. cit. vol. ii. p. 187, Amer. edit.) which is a decided advantage. 
 Miquel accords to it a distinguished place among febrifuge agents. (Gazette M&di- 
 cale de Paris, Janvier, 1830.) Magendie has seen intermittents cut short in one 
 day by three doses of six grains each. (Wood.) Trousseau and Pidoux, 
 as also Grisolle (Path. Int.) wholly deny its febrifuge action, but the weight of 
 evidence is certainly very decidedly in favor of it. While, therefore, the suprem- 
 acy of quinine as a febrifuge should be acknowledged, can it be said that no other 
 medicine possssses a c'early demonstrated and universally admitted febrifugal 
 action? Arsenic certainly fulfils both conditions, and the febrifuge qualities of 
 salicin are, as it seems to us, " fully proved," if not "universally admitted." 
 TRANS. 
 
THERAPEUTICS. 385 
 
 and yet, how many medicines have been entitled diuretics, dia- 
 phoretics and even purgatives, whose action does not at all justify 
 the appellations ! What physician has not experienced, in many 
 diseases, the impossibility of augmenting the urinary secretion or 
 of exciting abundant perspiration when the system refuses its con- 
 currence ? This kind of experimentation is not, then, free from 
 difficulties, but as these are far more numerous when the object of 
 experiment is the observation of remedial action upon the progress 
 of a disease, the rules we are about to propose for the latter, will 
 be applicable, a fortiori, to the former. 
 
 A physician who experiments, should, in the first place, know 
 thoroughly the nature of the medicine whose effects he would ap- 
 preciate, the individual upon whom it is to be tried, and the dis- 
 ease for which the remedy is employed. 
 
 The first duty of the physician, then, is to know thoroughly the 
 nature of the remedy about to be tried ; that is to say, no trials 
 should be made with medicines of whose composition he is igno- 
 rant. The Royal Academy of Medicine, authorized by govern- 
 ment to estimate the value of secret remedies, has adopted two 
 rules, first, to demand from the holders of such secrets, the exact 
 composition of thfc medicines, and secondly, to have them prepared 
 by an apothecary of their own selection. These wise precautions 
 should influence those physicians who are requested to experiment 
 with any therapeutical preparation. We once departed from this 
 rule, in favor of a respectable physician, who, without disclosing its 
 composition, requested us to make trial of a remedy in his posses- 
 sion, upon the success of which his future expectations and the sup- 
 port of a numerous family depended. Although the experiments 
 were favorable, and the remedy appeared more efficacious than any 
 that have been extolled in the same disease (tcenia), we have since 
 regretted having consented to its trial without knowing its com- 
 position, and from that time have uniformly refused all similar 
 requests. 
 
 A knowledge of the composition of the simple or compound 
 remedy submitted to him, should always be the first condition 
 upon which the physician should insist; he should know whether 
 it has been previously employed, and by whom, whether by one 
 physician only, or by several ; and if in a few cases, or very fre- 
 quently. If it have been often employed, and no accidents what- 
 ever have occurred, the only doubt being in regard to its remedial 
 efficacy, we may proceed with security, restricting ourselves to the 
 customary doses. But if no previous trials have been made, and 
 particularly, if the article be an extract from a vegetable substance, 
 in itself active, or belonging to a genus of plants containing poison- 
 ous varieties ; or if it be a mineral, some of whose preparations are 
 energetic in their action ; if experiments upon animals have re- 
 vealed in the remedy, or in combinations containing it, an action 
 sufficiently powerful to compromise life ; if it have a strong taste, 
 or if, when applied to the skin, it cause redness, vesication or gan- 
 grene, too much circumspection cannot be exercised in the first 
 33 
 
3S6 THERAPEUTICS. 
 
 trials to which it is subjected. The formidable accidents, whose 
 sudden manifestation we witnessed in a patient at the Hospital La 
 Charite, will always be vividly remembered. We were adminis- 
 tering a substance at that time lately extracted by MM. Pelletier 
 and Caventou from nux vornica, and called by them vauqueline, a 
 name since exchanged for strychnine, at the particular request of 
 the excellent Vauquelin. M. Pelletier having requested us to exper- 
 iment with this extract, which, in his opinion, acted more ener- 
 getically and equably than the other preparations of nux vomica, 
 a young man affected with paraplegia was selected for the experi- 
 ment, to whom the alcoholic extract of nux vomica had been ad- 
 ministered for many weeks, a dose of thirty-two grains, daily, 
 having been attained [26. 1-4 grs. Troy] without the slightest in- 
 fluence upon the muscles. We received, from M. Pelletier, six 
 pills, each containing one quarter of a grain of strychnine [.2058 
 gr. Troy] ; one was given to the patient the first day, two, at one 
 dose, the second, three, in one dose, the third day, without the 
 least effect; (1.1-2 Fr. grains = 1.23. grs. Troy.] A new supply 
 of the remedy was sent for, in half grain doses ; M. Pelletier fur- 
 nished us with two pills only, each containing one grain, being all 
 that he had prepared. Supposing that a dose off>ne grain, exhib- 
 ited to a patient who had taken three quarters of a grain on the 
 previous evening, without effect, and, some days before, thirty-two 
 grains of another preparation of the same remedy, would probably 
 obtain no result, and that, having afterwards but one similar dose 
 to administer, it would be impossible to give M. Pelletier the in- 
 formation he desired, we committed the error of passing at once 
 from three quarters of a grain to two grains of a substance whose 
 degree of energy was unknown. About a quarter of an hour after 
 the administration of the remedy, and even before the visit in the 
 ward St. Louis, in which the patient was, was completed, he was 
 seized with convulsive movements, confined, at first, to the limbs, 
 afterwards extending to the respiratory muscles, and fully as in- 
 tense as in the most severe cases of tetanus, causing, at very short 
 intervals, suffocation so imminent, that, for more than half an hour, 
 we momentarily feared the death of the patient from the violence 
 and duration of the convulsive action of the diaphragm. Our anx- 
 iety at this time, it would be impossible to express ; the necessity 
 of concealing it from the patient rendered it still more distressing. 
 We remained constantly at his bed-side, deeming it an imperative 
 duty to entrust to no one the care and responsibility of so fearful a 
 position. Judging, from its effects, that the medicine would be ab- 
 sorbed by the stomach, we refrained from exciting emesis, for 
 which (the above opinion being correct) there was no occasion, 
 and which, also, by the muscular contraction it causes, might have 
 increased the violence of the convulsions, thus adding considerably 
 to the threatened danger. A dose of wine of opium, equivalent to 
 about ten centigrammes (two grains) [1.64 grs. Troy] of solid 
 opium, was given immediately; the convulsions and suffocative 
 symptoms persisting and even increasing, the dose was repeated 
 
THERAPEUTICS. 387 
 
 five minutes after the first, and afterwards, every five minutes, and 
 even at shorter intervals, double the above quantity was adminis- 
 tered ; the narcotism that might be expected to supervene from so 
 large doses of opium, not being so dangerous, nor the peril so imme- 
 diate, as that resulting from the action of the strychnine. Finally, 
 after a half or three quarters of an hour's effort and anxiety, the 
 spasms were separated by longer intervals, and the suffocation was 
 less threatening; gradually, and in the space of a quarter of an 
 hour, all the symptoms produced by the strychnine had disappeared, 
 and no effect was observed from the enormous quantity of laudanum 
 taken by the patient, (about half an ounce) except slight somno- 
 lency, of a few hours duration, from which he was easily aroused. 
 We have often related the above case in our clinical lectures at La 
 Charite and the Hotel Dieu, for the same reason that induces us to 
 give it a place in the present work, viz. to show, by this example, 
 to those who listened to the lectures above mentioned, as well as 
 to those who may peruse this volume, with what circumspection 
 experimentation with a remedy of undetermined power should be 
 conducted. We would even add, that when such active remedies 
 have been prescribed for a long time to the same patient, it will be 
 prudent in the physician to resume the lowest dose whenever the 
 medicine is prepared by a different apothecary, or when the same 
 one, having exhausted his first supply, has procured another. 
 
 A knowledge of the patient about to become the subject of ex- 
 periment is the second and no less indispensable requisite ; and 
 we mean to imply a knowledge of his morality, judgment and 
 susceptibility. We have mentioned morality first, because when 
 a physician tries a remedy for any disease, and especially, when 
 his first experiments have acquired some publicity, it is not uncom- 
 mon, especially when he is connected with an hospital, that many 
 persons affected with the disease in question are placed under his 
 care; and, among them, there are, nearly always, some, who, 
 by mistake or fraud, are not actually affected. Individuals have 
 sometimes announced themselves the possessors of a specific reme- 
 dy for diseases considered incurable, as, for example, epilepsy ; and 
 other persons associated with them, have simulated the disease in 
 order to prove the efficacy of the medicine ; thus exposing the 
 public to double imposition. We have reason to believe that the 
 seemingly extraordinary effects of magnetism in the treatment of 
 disease, and in the production of certain unusual phenomena, have 
 really been, in many cases, a complete deception, in which one or 
 many actors have played a part by no means creditable. It be- 
 comes more important for the physician who experiments, to be on 
 his guard against frauds of this kind, from the fact that he is dis- 
 posed to hope for certain results in the researches in which he is 
 engaged, and eager to seize upon the favorable effects of a remedial 
 measure, to whose success he attaches the double value of utility 
 to suffering humanity and the advancement of his own reputation. 
 
 There is another class of patients who may unintentionally lead 
 the practitioner into error, either by exaggerating the relief or the 
 
388 THERAPEUTICS. 
 
 exasperation supervening in their sufferings, or by attaching to vari- 
 ous symptoms an importance they do not deserve, or, finally, by a 
 mental peculiarity which deceives them in regard to their actual 
 condition, some conceiving themselves to be improving, even till 
 the termination of the disease in death, others complaining more 
 and more, as amelioration is more distinctly perceptible and con- 
 valescence approaching or even established. These are evidently 
 improper persons for experiment. The same may be said of the 
 extremely susceptible, and of those in whom some idiosyncrasy 
 exists; the organization in both being too far removed from the 
 usual conditions to admit of drawing conclusions, applicable to the 
 generality of patients, from the experiments to which they might 
 be submitted. 
 
 To the most accurate knowledge possible of the means to be 
 tried and of the subject of experiment, that of the disease must 
 necessarily be added. It is an indispensable condition in every 
 experiment, that there be no doubt as to the diagnosis. We can 
 readily perceive how erroneous would be the results of experiment, 
 if, as is too often the case, from the imprudence or ignorance of 
 the experimenter, the trials were made upon one disease, while the 
 conclusions regarded another. 
 
 If the diseases experimented upon had a determinate duration 
 and uniform termination like rabies, the effect of experimental 
 measures would generally be easily appreciated. But nearly all 
 diseases are variable in their course, of uncertain duration, and 
 terminate in different ways. Thus, the experimental physician 
 should not only choose cases whose diagnosis is unequivocal, but, 
 moreover, his knowledge of diseases and of their different forms 
 should be sufficiently exact to enable him to foresee the modifica- 
 tions which they may spontaneously manifest, and their tendencies 
 to various terminations : these are indispensable qualifications for 
 determining those of the supervening phenomena that should be 
 attributed to the remedy under trial, and those depending upon the 
 natural course of the disease. We do not hesitate to assert, that to 
 ignorance or forgetfulness of this truth, most of the erroneous conclu- 
 sions of experimentalists are to be ascribed. Nearly all have referred 
 the favorable or unfavorable changes, supervening in diseases, to 
 the remedy employed. They have misinterpreted the incessant 
 action of the organism upon pathological phenomena, and have 
 attributed to agents, often inert, or even injurious, those favorable 
 modifications in whose production they had no part. 
 
 The remedy, patient and disease being understood, experimen- 
 tation requires, in addition, a peculiar concurrence of circumstan- 
 ces of more or less importance. 
 
 It is hardly necessary to premise that the therapeutical agent 
 employed experimentally, whether simple or compound, should be 
 uncombined with others. As has been remarked, it is very diffi- 
 cult to appreciate the action of a single remedy upon the course of 
 a disease ; the simultaneous employment of many medicines, pos- 
 sessing considerable energy, would render it almost impossible to 
 
THERAPEUTICS. 339 
 
 decide the value of each one in particular. We must, moreover, 
 assure ourselves that the medicine is used, and in precisely the 
 prescribed manner, nothing being added, removed or substituted. 
 
 Another important point is to remove, as far as possible, from 
 the patient, all those physical and moral influences capable of 
 modifying the course of the disease, as well as the action of the 
 experimental means. Change of abode and regimen often suffice 
 for the production of eifects too frequently attributed to remedies : 
 many febrifuge medicines have owed their anti-periodic action to 
 the circumstance of their prescription on the day after the patient's 
 entry at the hospital. What physician has not often observed, in 
 hospitals, in patients affected with cardiac disease, the disappear- 
 ance of anasarca, prematurely induced by fatigue or excess in 
 food or drinks, under the influence of a few days' rest and diet ; 
 and how many times, in such cases, has not this change, depend- 
 ing on an entirely different cause, been ascribed to remedies wholly 
 inefficacious ? 
 
 Atmospheric changes should not be disregarded by the experi- 
 mentalist. Their influence upon the course of certain affections, 
 particularly rheumatism and certain neuroses, is well known, and 
 should not be lost sight of. The changes supervening in tempera- 
 ture exercise an influence upon certain diseases, or upon some of 
 their symptoms, easily productive of erroneous conclusions in re- 
 gard to the action of the remedies employed. By a repetition of 
 the experiments made by various distinguished physicians upon 
 the action of certain medicines intended to diminish or suspend 
 the sweats of phthisis, we have been led to the following result, 
 that, giving priority in the production of this symptom to the alter- 
 ations effected in the pulmonary parenchyma, the secondary mod- 
 ifications, daily presented, are principally connected with changes 
 supervening, either in the temperature of the external air or of the 
 patient's chamber, the position of his bed, or, particularly, the con- 
 tinuance of his sleep ; for the state of sleep is a condition highly 
 favorable to the production of phthisical sweats. When the air 
 becomes cooler, or the patient's chamber is less heated, when he 
 lies upon a mattress, and the number and thickness of the bed- 
 clothes is diminished, and particularly, when he is awake, the 
 means suitable for subduing these sweats appear to have an in- 
 fluence ; in opposite circumstances, they most frequently produce 
 no effect. 
 
 It is equally necessary for the physician who experiments to be 
 informed in regard to the moral circumstances daily surrounding 
 the individual subjected to the experiment. When a disease de- 
 pends upon profound and concealed grief, the pharmaceutical agent 
 used to counteract it fails to attain its object; it is powerless when 
 the disease is exasperated and has no influence in its cessation, 
 still the physician is naturally inclined to attribute the superven- 
 ing changes to the action of the remedy he has prescribed. For 
 this reason, it is the more important to obtain the patient's entire 
 confidence ; an accurate knowledge of the disease, as well as of the 
 33* 
 
390 THERAPEUTICS. 
 
 appropriate remedies for its relief or cure, results from that confi- 
 dence. 
 
 The influence of the imagination upon the organism is so great, 
 that in a certain number of cases, and in some individuals, the 
 idea that a proposed remedy will cause a determinate effect has 
 proved sufficient for its production. The case of an individual 
 has been cited, who was salivated after taking inert pills, which 
 he supposed to contain mercury; another has been mentioned 
 where purging followed the administration of a medicine which 
 was imagined capable of producing such an effect. It has occa- 
 sionally been sufficient for the cure of insomnia, to give a pill of 
 crumb of bread or of thridace, assuring the patient that he would 
 sleep. How often has the progress of intermittent fever, even of 
 very obstinate character, been arrested by the use of amulets or 
 any other means, whose action cannot be other than imaginary. 
 When, therefore, we experiment with a medicine, it is generally 
 best that the patient be wholly ignorant of the effect which should 
 be produced by it, so that imagination may have no influence in 
 the phenomena subsequently supervening. 
 
 Finally, there is one condition among those capable of modify- 
 ing the progress of a disease, and consequently of leading to erro- 
 neous conclusions in regard to the action of experimental means, 
 which should not be forgotten, viz. the development of a new dis- 
 ease. When this new disease is of an acute character, there can 
 be no doubt as to the nature of this complication and the influence 
 it may exert upon the original disease. But if the secondary af- 
 fection be slight and slowly developed, or if the patient have any 
 motive for concealing it, it may thus become a source of error : we 
 mention this fact, that the physician may never neglect to inquire 
 daily into the condition of all the functions, and examine all the 
 organs, so that nothing likely to be of service in the difficult task 
 of experimentation, may escape his observation. 
 
 In order to show by how many causes of error experimentation 
 is surrounded, we will give an abstract of the trials undertaken 
 by us at the Hospital La Charite, for the purpose of examining 
 the action of the powdered holly (ilex aquifolium), in the treat- 
 ment of intermittent fevers. At our suggestion, twenty-two pa- 
 tients were selected by the central Office of admission, for entry 
 into the clinical wards, as affected with disease of intermittent 
 nature. Before commencing the use of the febrifuge, we were 
 obliged to wait several days for the complete establishment of 
 the diagnosis, and also that the remedy might be employed only 
 in those cases where the paroxysms could neither be suspended 
 nor even moderated by the new conditions in which the patients 
 were placed. The following was the result: of the twenty-two 
 patients sent to the hospital, as affected with intermittent fever, 
 seven presented no subsequent paroxysm; four had paroxysms 
 decreasing in intensity ; eight others manifested merely sympto- 
 matic paroxysms, connected with slight inflammations of the mu- 
 cous membranes, which yielded to simple anti-phlogistic measures, 
 
THERAPEUTICS. 391 
 
 as cooling drinks, diet, and blood-letting ; three only of the whole 
 number were found to present the proper conditions for experiment ; 
 viz. essential intermittent fever of full intensity, in the three or 
 four paroxysms succeeding admission to the hospital : the pow- 
 dered ilex was administered to these, at first, in the dose recom- 
 mended by the physician who had extolled the remedy, subse- 
 quently, in double, quadruple and octuple quantities, without any 
 appreciable effect upon the progress of the disease. Sulphate of 
 quinine was then given according to common practice and in the 
 usual doses, and the paroxysms were immediately arrested. If 
 the powdered ilex had been administered from the day of admis- 
 sion, to all these patients, or even to the fourteen who were affect- 
 ed with essential intermittent fever, we should have been led to 
 the conclusion that the medicine had acted as a febrifuge in nine- 
 teen cases out of twenty-two, or at least, in eleven out of fourteen, 
 and that the three cases in which it failed, were exceptional. 
 Greater circumspection obtained a very different result, viz. that 
 the medicine had not the least action in arresting the disease in 
 any of the cases where it was properly tried : it must be admitted 
 that the number of these was but small. 
 
 Experimentation in medicine, as in almost everything else, has 
 its advantages and inconveniencies. If experiment were wholly 
 forbidden, therapeutics would be nearly stationary. Whoever 
 devotes himself to any science, should regard it as a duty to do all 
 in his power to enlarge its domain ; and when the object of this 
 science is the cure of disease and the preservation of health, the 
 duty becomes even more imperious and sacred. The strictest ap- 
 preciation of the action of the means employed, and the use of 
 new means in the management of diseases, are the only two paths 
 capable of conducting to more positive and efficacious therapeu- 
 tics : and by experimentation, particularly, taken in the most 
 extended sense, this end is to be attained. 
 
 That experimentation, whose purpose is a more rigorous appre- 
 ciation than has hitherto been made, of the action of the thera- 
 peutical agents in general use, or a determination of the peculiar 
 conditions in which each of them is more specially indicated, and 
 the proportions in which it should be employed, seems to possess 
 almost unmixed advantages ; or if it have some inconveniences, 
 they are owing rather to the unskilful application of the means, 
 than to experimentation itself. This kind of experiment is allow- 
 able in all, and every physician who treats a disease by common 
 remedies, should study their effects, in order that each fact observed 
 by him may become, so to speak, an element suitable for the solu- 
 tion of the numerous problems presented by the indefinite perfect- 
 ing of therapeutics. It is otherwise in that kind of experimenta- 
 tion which consists in endeavoring to find, in new substances, 
 more efficacious remedies for the ills of humanity. Great respon- 
 sibility is attached to this species of experimentation, which is 
 generally set apart to certain individuals who are prepared for it 
 by a thorough study of all the trials of such nature, previously 
 
392 THERAPEUTICS. 
 
 made, and of the various success that has followed such experi- 
 ments. 
 
 There are, however, certain rare circumstances where experi- 
 ment becomes a duty for every one ; for example, when called to 
 a patient affected with communicated rabies, a disease hitherto con- 
 stantly fatal, should our efforts be limited to treating so terrible an 
 affection by the same means employed previously without success, 
 or should other remedies be tried, beside those whose inefficacy 
 has been proved ? We reply unhesitatingly that experimentation 
 is, in this case, not only allowable, but imperatively demanded ; 
 and that an uncertain remedy, suggested by the cause and symp- 
 toms of the disease, by theory or empiricism, should be preferred 
 to all those whose insufficiency has been decided. 
 
 There are other experiments not allowable in any one: we 
 mean those made with the intention of assisting the diagnosis of a 
 disease considered contagious, by inoculating persons apparently 
 disposed to contract it. In some cases, for example, where doubt 
 had existed in regard to the nature of certain varioliform erup- 
 tions, inoculation of the secretion of the pustules has been pro- 
 posed, and even tried upon persons who had never had variola 
 nor been vaccinated. A prudent and conscientious physician will 
 never allow himself to make such experiments, because it is not 
 for the benefit of the individual submitted to them, and the human 
 being should never be an object of experiment for the physician, 
 even when the interests of science and humanity are the object, 
 and the greatest advantages might be expected for both. 
 
 A single experiment, whatever be the result, cannot establish 
 the general efficacy of any therapeutical measure. Doubtless, it 
 would be a very remarkable event, if the symptoms of rabies were 
 suspended in a single case where a new remedy was tried ; a 
 unique fact, even, of this nature, would be a very important result, 
 particularly if from the circumstances antecedent to, and the ac- 
 companying phenomena of the disease, it were evident that the 
 affection was really rabies, and not one of those varieties of hydro- 
 phobia too often mistaken for it. But even in this case, new ex- 
 periments would be necessary, in order to form a correct opinion of 
 the effect of the experimental remedy ; still more necessary is it to 
 repeat the trials before a final conclusion, if the disease, instead of 
 inevitably terminating in death, when left to itself, like rabies, 
 be susceptible of various terminations. We cannot, therefore, de- 
 rive satisfactory results from experimentation, except when the 
 disease, influenced by the experimental remedy, terminates favor- 
 ably in a larger majority of cases, or in a shorter time, than under 
 any other treatment; from this arises the necessity of uniting the 
 greatest possible number of cases, taken from different sources, that 
 is, collected by different observers, in various times and places, 
 and of comparing arid counting them, in order to attain as positive 
 results in therapeutics as in etiology and semeiology. This con- 
 clusion leads us to declare our opinion of the numerical method, 
 applied to the study of diseases. 
 
THERAPEUTICS. 393 
 
 The enumeration of previously collected cases, the deduction of 
 accurate results from their comparison and number, either in re- 
 gard to the predisposing or determining causes of the disease, or its 
 characteristic phenomena, course and different terminations, or, 
 finally, as respects the influence of therapeutical means, constitutes 
 no innovation in medicine. Many historians of epidemic diseases 
 have adopted this course ; they have stated the population of the 
 place where the epidemic prevailed, the number of those attacked, 
 and also that of each sex, of children, adults and aged persons, and 
 the proportionate mortality in these various divisions. In Bayle's 
 work on Pulmonary Phthisis, in nearly all the French and foreign 
 yearly clinical recapitulations, etc., in our own thesis upon rheum- 
 atism, in 1813, and in various memoirs read by us either before 
 the Institute, upon the use of sulphate of quinine, or to the Acad- 
 emy of Medicine upon the powder of ilex aquifolium in intermit- 
 tents. this mode of presenting general results is employed as a 
 means of arriving at those more exact, without any one having 
 imagined it improper to draw numerical conclusions from a com- 
 parison of cases previously collected. It was at that period, only, 
 when Louis, the most accurate and conscientious observer of our 
 times, thought it right to apply this method, in its highest degree of 
 development, to the solution of many pathological questions, to 
 which the collision of opinions and the ardor of controversy had 
 given great importance, that this mode of deducing consequences 
 from facts was attacked, both individually and in its applications, 
 with a vivacity, inexplicable, except by calling to mind the 
 antecedent contest. In the heat of the discussion that arose in the 
 Royal Academy of Medicine, certain orators arrived at this 
 direct conclusion, that every enumeration of pathological facts was 
 essentially opposed to sound logic, and could not furnish other 
 than erroneous, and consequently, dangerous, results ; from thence 
 they argued an absolute proscription of this method, to which the 
 appellations numerical method or medical statistics have been ap- 
 plied. Without desiring to resume and retrace, in all its details, a 
 discussion, in regard to which there is still a difference of opinion, 
 we deem it proper to examine the main arguments employed 
 against the enumeration of facts : and to reply to whatever they 
 may contain that is plausible. 
 
 In order to examine this subject methodically, we remark first, 
 that in the enumeration of medical facts, there are two points, 
 wholly distinct, and both requiring particular study. While col- 
 lecting a large number of cases, comparing them together in all 
 their different aspects, making numerical tables of everything re- 
 lating to their causes, symptoms, progress, duration, various ter- 
 minations, and the influence of the different curative means em- 
 ployed, the physician is but an exact historian of actual facts, and 
 if narrations of this sort are uninteresting, they cannot be, and 
 never have proved, (we will not say dangerous) even incon- 
 venient. Let us suppose that two physicians, equally truthful, and 
 gifted with the same spirit of observation, both give an account of 
 
394 THERAPEUTICS. 
 
 an epidemic which they have observed together ; also, that the 
 first, in his description, states the precise number of inhabitants in 
 the city or village where the disease prevailed, the number of per- 
 sons affected, both those sufficiently so to require confinement to 
 bed, and those who, being less ill, are able to pursue some of their 
 occupations ; that he gives, in addition, the number of infants, 
 adults, and aged persons, and of males and females ; the proportion 
 of patients engaged in various occupations ; the duration, in days, 
 of the disease in these different circumstances ; the rate of mortality 
 in each ; and let this recapitulation be supported by observations 
 made upon each of these patients during the course of the epi- 
 demic. Let the other physician, on his part, relate the results of 
 his observation during the disease, as faithfully as his memory will 
 allow, but without any use of numbers, expressing himself thus, 
 for instance ; in a city rather densely populated, a considerable 
 proportion of the inhabitants were attacked by the epidemic, which 
 was more fatal among males than females ; its course was gener- 
 ally acute, its termination fatal in a large number of patients, etc. ; 
 we should not hesitate to pronounce the latter account very far 
 inferior to the former, and we should be justified in doubting its 
 correctness when compared with the other, even allowing for the 
 vagueness of the expressions employed. We are, in truth, so 
 easily prepossessed by the first cases that impress us, and so in- 
 clined to draw general conclusions from our first ideas, that we 
 need the uncompromising addition of numerous facts to confirm 
 or rectify our original opinion. It has often happened to M. Louis 
 and myself, when observing together the same patients, at the 
 Hospital La Charite, to arrive at a conclusion, whose inaccuracy 
 was subsequently proved by a numerical recapitulation of the 
 same cases. It is, then, useful to count the complete cases, and 
 the number of times their development has been preceded by a 
 certain cause, or that a certain symptom has appeared in the course 
 of the disease, also to enumerate the days of its duration, and the 
 number of favorable or unfavorable terminations ; and however 
 great may be the antipathy of certain physicians to numbers, we 
 cannot suppose that it can be carried so far as to reject the numer- 
 ical statement of complete cases ; this would be a rejection of ac- 
 curacy, and, consequently, of truth. 
 
 However true a proposition may be, it may always, for 
 want of good reasons, be attacked by specious arguments. Thus, 
 it has been objected that every numerical relation is not exempt 
 from errors, and that the apparent accuracy imparted by numbers, 
 renders it, for that very reason, more dangerous than ordinary 
 narration. We willingly admit that every problem in addition is 
 not necessarily exact, whether it be applied to pathological facts or 
 to anything else whatever ; that one may calculate erroneously in 
 medicine as in other matters ; it should be added that it is the duty 
 of those who accept a calculation, to verify it. But, it will be 
 said, if the calculation rest upon incomplete, inexact or prejudiced 
 observations, what a multitude of errors will be the result ! The 
 
THERAPEUTICS. 395 
 
 reply is easy ; the numerical method is not in fault, but the obser- 
 vations that have served as a foundation for the calculation. If, 
 therefore, it be attempted to conclude that a measure should be 
 renounced because improperly employed, observation itself must 
 be resigned, under the pretext that there are, in medicine, as in 
 nearly all sciences based upon observation, as many and more, 
 bad, than there are good, observers. 
 
 If the numerical method had had no other object than to ascer- 
 tain everything relating to complete cases, it would, doubtless, 
 never have aroused the violent discussions that have occurred. 
 But in medicine, as all are aware, the past is the instructor of the 
 present ; in the most thorough and accurate knowledge possible of 
 complete cases, all that the physician should know, may, and 
 ought to be discovered, as the causes of diseases, the signs that 
 characterize them or announce their tendency towards a favora- 
 ble or unfavorable termination, and the proper means for their 
 relief or cure. The numerical method, while it renders the study 
 of thoroughly observed cases more precise, as a natural conse- 
 quence, elucidates all the branches of pathology and particularly 
 therapeutics ; the controversy relates to these various questions, 
 and we shall examine it in connection with them. 
 
 Among the numberless objections that have been raised against 
 the numerical method as applied to pathology, some regard the 
 method itself, and others the improper use that has been or might 
 be made of it. The latter class of objections are nearly valueless ; 
 it can only be considered a kind of warning against the errors 
 liable to be induced by any method of studying cases and draw- 
 ing conclusions from them, in all the natural sciences as well as in 
 medicine. Observation itself is quite as obnoxious to these ob- 
 jections as is a method which may be termed the logic of the 
 sciences : with such axioms to commence with, we should be for- 
 bidden to observe, under the pretext, that bad observation is dan- 
 gerous; not only should figures be banished from reasoning pro- 
 cesses, but reasoning itself, however conducted, should share their 
 fate, because unskilful logic leads directly to error. Without 
 doubt there is both inconvenience and danger in numerical con- 
 clusions drawn from facts badly observed, not sufficiently numer- 
 ous, intentionally selected as more favorable to certain systematic 
 opinions, falsified or imaginary ; the evil, however, would be still 
 greater if this recapitulation 'of cases, without foundation upon 
 actual facts, were but a deceptive assertion uttered in defence of a 
 theory. But would the fault be ascribable to a method which re- 
 quires accuracy and truth, as fundamental conditions, both in the 
 facts themselves, and in the consequences resulting from their com- 
 parison and enumeration? These first objections, then, do not 
 deserve a serious reply, for they are not peculiar to the numerical 
 method, but apply equally to all the other modes of scientific 
 procedure and reasoning ; all, without exception, will lead us into 
 error if there be carelessness or deception in those who collect and 
 compare the cases, and unthinking credulity in those who receive 
 
396 THERAPEUTICS. 
 
 them. We may add, that if the distinction between truth and 
 error be frequently difficult, it is not, at least, beyond the power of 
 the human mind; and that in intellectual, as in moral affairs, it is 
 possible to attain, by effort, the knowledge of the truth. In the 
 case at present under consideration, it is doubtless quite difficult to 
 distinguish the observer worthy of confidence from him who is not 
 so; and also to determine, among the numerous observations daily 
 added to those of former days and ages, those that bear the im- 
 press of truth ; but the physician who associates a correct judg- 
 ment with the habit of observing nature, generally acquires the 
 power of ascertaining the degree of confidence merited by men and 
 things. Admitting, even, that inaccurate or even fictitious reca- 
 pitulations may have momentarily misled physicians upon any 
 one point in our science, new observations and conscientious re- 
 views will soon furnish opposite results : from this arises the 
 necessity, for all observers, of collecting facts bearing upon the 
 same question, and these should also be numerous, in order to at- 
 tain, by force of numbers, more positive conclusions ; upon this 
 depends the triumph of truth. Thus, if the faulty employment of 
 the numerical system have introduced errors into science, the same 
 method, and that alone, skilfully and conscientiously employed, 
 will definitively re-establish the truth. Passing over these objec- 
 tions, we hasten to consider those relating to the actual enumera- 
 tion of cases, and not to any want of conscientiousness or judg- 
 ment in those who employ it. 
 
 It should be remarked, in the first place, that those who do not 
 collect exact observations, nor note down facts which they observe, 
 and who, after a certain number of years of study and practice, 
 are, consequently, unable to state the sum of these facts, and still 
 less, to know, in each separate observation, the numerical expres- 
 sion of each condition presented by the disease, as regards causes, 
 signs and effect of remedies ; who have not thus added up the 
 whole, in order to have the exact sum total, adopt, nevertheless, 
 as the result of their observations and the rule of their practice, an 
 approximate total, which, if they possessed the necessary elements 
 for testing its accuracy, would, perhaps, be very far from true. 
 They wish to count approximatively, to add without figures, and to 
 draw conclusions from this exceedingly imperfect calculation, but 
 they will have no numbers ; yet who can deny the value of num- 
 bers, wherever applied ? Those who have grown old in our pro- 
 fession possess an authority mainly dependent upon the number of 
 facts they have observed ; for this reason their advice is sought 
 and followed by younger physicians, in serious and difficult cases; 
 from this, also, arises that public consideration and confidence 
 particularly attaching to physicians who, arrived at mature age, 
 and entrusted with hospital practice, have been favorably placed 
 for the observation of a larger number of cases and the acquisition 
 of greater experience : numbers may, then, be considered impor- 
 tant in medicine, and even those who do not employ the nu- 
 merical system would not fail to say, in a discussion with a 
 
THERAPEUTICS. 397 
 
 younger physician, c We have observed such a fact more frequently 
 than you have ; such an occurrence is more common than another ; 
 such a disease has appeared to us to be often, or nearly always, 
 favorably modified by a certain remedy,' etc. Doubtless this is 
 not enumeration, properly speaking, but it is a species of count- 
 ing; for, when affirming that a certain occurrence is more frequent 
 than another, there must be some recollection of the number of 
 times that each of the facts has been observed ; there must be an 
 approach to addition, subtraction and conclusion. He who would 
 disregard the number of facts observed by him, could not do it; he 
 would be led to keep account of them in spite of his efforts, as if 
 by unavoidable necessity. The power of facts depends especially 
 upon their repetition, and it is impossible for the mind to disregard 
 their number. Every physician, therefore, computes, consciously 
 or otherwise, properly or improperly, the facts he observes, and 
 experience in medicine implies the collection of a large number of 
 cases, accurately or approximative^ counted. 
 
 Every one is aware that the antagonists of the numerical system 
 are not opposed to approximative enumeration, but to the exact ad- 
 dition of facts and figures. When an observer, acknowledged by 
 them in other respects to be accurate and conscientious, commences 
 the addition of the cases he has collected and the deduction of the 
 numerical consequences resulting from their collation, they reg;ard 
 the procedure as a faulty method, both derogatory to the physician, 
 and communicating the worst and most dangerous direction to 
 scientific pursuit ! An absurd mode of reasoning indeed, is that 
 which allows, on identical subjects, an approximative and more 
 or less inaccurate calculation, while it forbids those characterized 
 by the strictest accuracy ! We shall, however, review the argu- 
 ments upon which these conclusions have been founded. 
 
 "The numerical method," it has been said, "leads to the substitu- 
 tion of calculation for reasoning, and of arithmetic for induction." 
 There is not the least foundation for such a reproach ; far from 
 excluding the reasoning process from medicine, the numerical re- 
 sults furnished by the collection and comparison of a large number 
 of cases give to reasoning a more secure foundation and a truer di- 
 rection, and preserve it from the errors too often arising when it is 
 based upon facts too few in number or imperfectly analyzed and 
 counted. In our opinion, the numerical method is the most suit- 
 able system possible for reinstating' reasoning in favor with those 
 physicians, who, considering only the mistakes into which sys- 
 tematic authors have too often been led by faulty logic, would wil- 
 lingly have proscribed the use of the reasoning powers in medi- 
 cine for the sake of preventing their abuse ! 
 
 One of the most plausible objections to the enumeration of 
 pathological facts, is, indisputably, the difficulty of uniting similar 
 facts in order to deduce from them general consequences. The 
 same disease presents such a variety of forms, that perhaps it 
 never occurs twice with a perfect similarity. But the infinite 
 variety of forms existing in animals of the same species, or in the 
 34 
 
398 THERAPEUTICS. 
 
 leaves of the same tree, does not prevent us from distinguishing, 
 notwithstanding the slight dissimilarity observed in these various 
 natural products, the species to which they belong, because the 
 fundamental characteristics possessed by them, in common, are far 
 more evident than the shades of difference they exhibit. The 
 same is true in pathology, as has been fully established by M. 
 Rayer, and diseases, when divided into genera, species and va- 
 rieties,* may be easily compared and enumerated, thus affording 
 exact conclusions. Let it be supposed, for example, that in all the 
 cases of mild tertian, of herpes zoster, variola discreta or confluens, 
 acute pneumonia, lenticular cataract, furunculus, and erysipelas of 
 the face, the disease is developed in individuals previously in good 
 health and of adult age ; we then have a collection of cases that 
 may be compared, and susceptible of furnishing, by this process, 
 numerical results presenting many points of interest. We would, 
 moreover, ask those physicians who derive their antipathy for 
 figures from the dissimilarity of diseases, if this want of resem- 
 blance be not quite as much an obstacle to general descriptions of 
 diseases as to the enumeration of isolated facts. If, therefore, 
 those physicians who have written upon general pathology, have 
 not been arrested in their labors by the infinite dissimilarities that 
 cannot have escaped their notice ; if their descriptions be con- 
 sidered not only useful, but indispensable, in the study of medi- 
 cine ; if many authors owe the high reputation heretofore and at 
 present accorded to them in the medical world, to researches of 
 this nature ; why should hindrances be thrown in the way of the 
 partisans of statistical medicine, when every one sees the necessity 
 of avoiding them, and which, without any compensation, would 
 reduce medicine to its condition in primitive times, that is, to a 
 mere collection of isolated observations inscribed successively upon 
 daily records, like those upon the columns "of the ancient temples? 
 The idea that no conclusions should be drawn from pathological 
 facts, except so far as they present a complete identity, (an iden- 
 tity not to be found in nature,) is a blind assumption which should 
 be condemned by good sense and the power of facts. 
 
 "Disease," it has been remarked, "being composed of various 
 elements, cannot be subjected to calculation like a single phenome- 
 non." " The advocates of statistics," it has been added, " while 
 they enumerate all the details of disease, separate its elements 
 from one another into so many different divisions that, subse- 
 quently, it is impossible to reconstruct the disease." 
 
 Thus, according to one class of objectors, the numerical method 
 is inapplicable to pathological studies, because it considers a thing 
 essentially complex as a unique phenomenon, and, according to 
 others, because it examines, singly, each constituent element of the 
 disease. Although these two objections antagonize one another, as 
 
 * See the chapters entitled, " The different Genera, Species and Varieties of 
 Diseases " ; and " Diagnosis." 
 
THERAPEUTICS. 399 
 
 it were, as it is possible that one of them may have some founda- 
 tion, we deem it proper to examine both. 
 
 We have previously declared disease to be complex in its na- 
 ture. Therefore, whenever the numerical method is applied to 
 the study of any disease, it is absolutely necessary, as we have al- 
 ready remarked, to divide the cases into as many groups as the 
 diversity of its assumed forms, or the various conditions in which 
 it is manifested, may require. The enumeration and comparison 
 of the cases comprised in these separate groups supply us with 
 conclusions which are always interesting, whether they are or 
 not, in accordance with generally admitted opinions. Not only 
 has care always been taken, in the application of the numerical 
 method to the study of disease, to subdivide the particular cases 
 according to their analogies, but, moreover, the elementary con- 
 ditions of these subdivisions have been separately examined, as, 
 for example, the causes, duration, termination and action of differ- 
 ent remedial means. There is, perhaps, no numerical collection 
 hitherto published that does not contain all these details. How 
 then can we imagine it possible that statistical medicine should be 
 reproached with considering a disease as a unique phenomenon? 
 The opposite objection is less surprising, viz., the subdivision of 
 diseases to an extent rendering it impossible to reunite their ele- 
 ments. This objection is, however, more specious than real, and 
 is quite as easily refuted as the other. The authors of nosographi- 
 cal works of any extent, after having described the disease gener- 
 ally, have nearly always considered the chief characteristic 
 symptoms separately, as, for instance, in pneumonia, the pain in 
 the side, dyspnoea and sputa, and have pointed out the different 
 degrees of intensity and the other varieties presented by these 
 symptoms. They have also devoted separate articles to the exam- 
 ination of some of the causes and of the modus operandi of certain 
 remedies. The same is done by means of the numerical system ; 
 the details, it is true, are not so interesting, because they are ex- 
 pressed in figures only; but, in reality, as we cannot examine 
 each element of a disease collectively, we are compelled, whatever 
 be the method employed, to examine them successively ; whether 
 it be into articles or columns, by means of words or figures, they 
 must be separated, or if the expression be preferred, scattered 
 (eparpiller) ; and we cannot see that the re-collection of the ele- 
 ments of the disease, if deemed necessary, is more difficult in one 
 case than the other. 
 
 It has, moreover, been asserted, " that statistics tend to establish 
 fixed modes of treatment." If medical statistics, resting upon nat- 
 ural bases, could lead to the result, that, in a given disease, a cer- 
 tain treatment would be constantly followed by more complete and 
 rapid success than /any other, we should be obliged to confess, that 
 science would derive therefrom very decided benefit. But from 
 the great accuracy it gives to the cases subjected to its application, 
 it is quite unlikely that it will ever attain such a result. It will, 
 more probably, lead to an exposition of the more or less numerous 
 
400 THERAPEUTICS. 
 
 exceptions to those general precepts which the mind is but too 
 readily disposed to establish and accept, when computation is not 
 employed : the evident mission of the numerical system is to de- 
 stroy these illusions. 
 
 It has, moreover, been advanced that " this method disregards 
 minorities and exceptions." If we admit that a certain fact is of 
 so general occurrence that there is but one exception in a hundred 
 cases, the enumerator will be obliged to record the proportion in 
 figures, thus, 1 and 99 ; while he who never computes, impressed 
 by the frequency of the fact in question, will readily conclude that 
 it is constant. He who never adds cases together may easily and 
 conscientiously forget minorities, while the physician who employs 
 the numerical method is obliged not only to consider the exceptions 
 but to give their number. 
 
 " The most useful therapeutical axioms have been discovered 
 without the aid of statistics." The object of statistics is not, and 
 cannot be, discovery, in the common acceptation of the word: its 
 purpose is to verify discoveries, appreciate the value of opinions, 
 and occasionally to reveal general truths previously unknown, but 
 not to imagine or invent. If, therefore, the assertion that nearly 
 all the valuable truths in therapeutics have been discovered with- 
 out the assistance of statistics, be correct, it should also be remem- 
 bered, that there is decidedly no process so prompt and sure for 
 confirming or disproving general therapeutical precepts, as the 
 numerical method. 
 
 " The physician must be guided at the bedside of the patient by 
 the knowledge of indications alone, and not by statistics." To 
 this objection we reply by the following questions : What is the 
 basis of the knowledge of indications ? How is it known that a 
 certain case requires blood-letting, and another, cinchona or fer- 
 ruginous compounds? Is it by theoretical opinion only, or because 
 experience has shown the utility of these several means in cases 
 similar to those under observation? What constitutes, moreover, 
 the basis of experience? Is it not* founded upon observations and 
 experiments sufficiently numerous to establish the therapeutical 
 action of various agents ; and are not statistics thus proved to be 
 the strength of that very science of indications which has been 
 cited as in entire opposition to them ? 
 
 One of the most serious objections raised against medical statis- 
 tics is that of M. Gavarret, whom we are far from considering an 
 opponent of the system. " However numerous," says he, "may 
 be the facts collected for the purpose of attentively examining any 
 point in medicine, we may still infer, that if the number had been 
 greater, the statistical results would not have been the same, and 
 that if the same observer had continued his researches for a longer 
 time before enumerating the cases, he would have arrived at differ- 
 ent conclusions." 
 
 It should be remembered that the numerical method is applicable 
 only to complete cases ; and that, assuming the principle stated by 
 M. Gavarretj the application of enumeration must be indefinitely 
 
THERAPEUTICS. 401 
 
 suspended, because the collection of a million of cases even, would 
 give results which might be modified, however slightly, by a com- 
 parison of double that number. Admitting such a principle, and 
 applying it in its full extent, all general description must be 
 abandoned : for the reunion of a larger number of facts would 
 modify that also. Doubtless it may be advantageous, and even 
 necessary, to include in numerical summaries the greatest possible 
 number of analogous cases; but this consideration should not re- 
 tard indefinitely the enumeration of those observed. As we have 
 previously seen, the progress of science would thus be impeded, 
 from an exaggerated apprehension lest it should wander from the 
 true path. 
 
 We remark, moreover, that the numerical system has not, and 
 cannot have, the pretension of fixing, from the present moment, 
 the laws of our science, or of establishing limits beyond which the 
 mind will find nothing to discover or rectify. The observer who 
 publishes a number of cases, compares them and deduces from 
 them numerical consequences, by no means pretends that a recom- 
 mencement of the same task is superfluous ; far from this, he en- 
 courages all, by example and precept, to follow the same course, 
 convinced that the truth can only gain thereby, either from the 
 entire confirmation of the results he has obtained, by new obser- 
 vations, or that from the collection and comparison of new facts, 
 conclusions more or less at variance with his own may be obtained. 
 
 It should, however, be remarked, that it is not always indis- 
 pensable that a considerable number of cases be collected, in order 
 to obtain interesting results and conclusions, which, in all proba- 
 bility, will be confirmed by time. When a physician who de- 
 votes himself to observation makes a numerical review, at the 
 years end, of those diseases whose history he has recorded, and by 
 comparing the results of the succeeding with those of preceding 
 years, ascertains, that upon certain points in etiology, diagnosis or 
 therapeutics, the numerical conclusions are uniformly the same, it 
 is very probable, to use no stronger expression, that the constant 
 occurrences of each of the past years will likewise characterize 
 those which are to come. Supposing, also, that an observer does 
 not commence computation until after a long time devoted to the 
 collection of cases, as, for example, ten years, and that, having, 
 in the first place, collected and computed all the facts relating to a 
 given disease in one general table, and analyzed their separate 
 elements, he next subdivide his observations into yearly tables, 
 still finding that the proportions in the single years correspond 
 with those of the general table, and consequently resemble each 
 other; such a constant reproduction of the same facts, for ten con- 
 secutive years, will certainly allow of drawing conclusions, which, 
 although not absolute, will be very valuable. 
 
 A final objection against the numerical method 'is, "that it leads 
 to the use of fictitious averages, which are useless in pathology and 
 therapeutics." In the first place, we will acknowledge that a de- 
 ceptive application of these averages may be made ; that if, for 
 34* 
 
402 THERAPEUTICS. 
 
 example, in collecting a considerable number of facts relating to 
 pneumonia, (a disease infinitely more serious from the second to the 
 fifth year, and after the sixtieth,) and endeavoring to establish the 
 mean age in fatal cases, the ages of children and old persons were 
 confounded in one enumeration, a mean age would result quite 
 evidently incorrect and in glaring contradiction with the very i'acts 
 upon which it was founded. Age has so great an influence upon 
 the result of the disease, that it is absolutely necessary to study 
 pneumonia in each of the vital periods and obtain the average 
 mortality peculiar to each. The same process is required when 
 the duration of any disease is considered, as of acute articular 
 rheumatism ; if many groups be not made, of which one shall in- 
 clude the greatest number of cases whose average duration is from 
 fifteen to eighteen days ; another, the exceptional cases, where the 
 duration is much less or far greater, there will result a mean con- 
 tinuance which will be insufficient and will not indicate the limits 
 within which the varieties of the disease are comprised. The same 
 is true when we would determine, not only by the numerical, but by 
 any other method, the doses in which it is proper to administer the 
 various remedies : several average doses should be established, one 
 of which will apply to the greatest number of individuals and the 
 others to the rarer cases, where the dose of the remedy should be 
 increased or diminished according to the age and susceptibility of 
 the patients, and the obstinacy and severity of the disease. This 
 supposes, indeed, numerous facts, collected with great care and 
 judiciously compared ; but, whatever method be adopted in the 
 practice of medicine, are not these conditions indispensable in order 
 to obtain accurate conclusions? 
 
 In concluding this discussion, doubtless too long continued, and 
 which we should not have undertaken if its actuality had not 
 made it imperative, will a deliberate answer be expected to the 
 singular charge, that the numerical method would detract from the 
 consideration in which physicians are held, either by rendering them 
 all equal, or by lowering their qualifications beneath those of the 
 most obscure artisan?* Does then the numerical method, by 
 furnishing a more solid foundation for the conclusions drawn from 
 particular cases observed in all ages and .places, by adding new 
 general facts to those already belonging to science, by offering an 
 additional means of distinguishing truth from error, diminish the 
 importance of the physician ? And will the science, which, of 
 all others, demands the greatest perseverance in its researches, em- 
 bracing so extensive a range of knowledge that the powers of the 
 human mind and an entire life are hardly sufficient for its acqui- 
 sition, requiring so much sagacity and circumspection in its appli- 
 cations, descend to the lowest rank in the scale, from the moment 
 
 * " If the numerical method were adopted, it whould place all physicians upon 
 an equality. If therapeutics were to be regulated by the computations of the 
 adherents of statistics, there would be more skill in the trade of a cobbler than in 
 the practice of medicine." (Seance de TAcaddmie Roy ale de Mtdecine, du%5 
 Ai-nl 1837 et suit-antes.) 
 
THERAPEUTICS. 403 
 
 when a surer method is interposed for the appreciation of the facts 
 upon which it is based? If the numerical method tends to 
 equalize all physicians, by reducing the most difficult of the arts 
 to certain rules so simple and clear that the most limited intelli- 
 gence suffices for their application, far from being proscribed, it 
 should be ranked above all that the human mind has ever con- 
 ceived that is useful and wonderful. Let those be encouraged, 
 however, who so much fear an equality, the very idea of which 
 offends them. Medicine, in its imperfect development, will always 
 present an unlimited field to the practitioner, where numberless 
 obstacles will be encountered, and in which talented minds will 
 show their power and superiority. 
 
 Having examined each of the principal objections to the appli- 
 cation of the numerical method to pathological facts, we think it 
 may be concluded that this system must lead to eminently useful 
 results, provided it be founded upon observations entirely correct 
 and sufficiently numerous, that no more be expected from it than 
 it can give, and that the necessary accuracy and discrimination be 
 employed in its application. 
 
 The length of the discussion into which we have been led, 
 obliges us to return to the point where it was commenced. Hav- 
 ing established the principle that therapeutics are based, on the 
 one hand, upon a profound knowledge of the natural tendencies of 
 diseases to various terminations, and on the other, upon the proper 
 means for opposing or encouraging these tendencies, we added, 
 that observation and experience were alone able to direct us in 
 this double study. We have pointed out the conditions necessary 
 for accurate observation and the principal rules for experimentation 
 in medicine, which led us to discuss the application of the numerical 
 method to pathology. We return to our starting-point, that is, ex- 
 perience, considered as a basis of therapeutical science. 
 
 Experience should not be confounded with experiments (experi- 
 ences) ; the latter are to the former as the materials to the edifice. 
 When the influence of a certain therapeutical agent upon the pro- 
 gress of a given disease has been ascertained by numerous experi- 
 ments, its effects are then sanctioned by experience. Thus, the 
 power of cinchona over intermittents, and the influence of diet in 
 acute diseases, is established by experience. This experience is 
 accurately transmitted from age to age, both by tradition and 
 books ; it belongs to no individual, but to the science itself. 
 
 There is another kind of experience which is differently trans- 
 mitted ; it is that acquired by the physician ; it belongs to him, 
 and dies, almost entirely, with him. Zimmermann* defines it to be 
 the art of preserving the human body from the diseases to which it 
 is exposed, and of treating it when actually laboring under disease ; 
 it results from the observations of each physician in particular. 
 In order to possess this experience, much, and particularly accu- 
 rate, observation is necessary. 
 
 * ZIMMERMANN, de VExperience, t. i. p. 22. 
 
404 THERAPEUTICS. 
 
 If the talent for observation were equal in all, experience might 
 be estimated by the number of years, according to the vulgar 
 standard, but it is so variously distributed, that age cannot be 
 considered an indication of the degree of experience. Every year 
 adds to the experience of some physicians, while the longest life is 
 insufficient to impart it to others. 
 
 The physician's private experience, it has been said, dies with 
 him, because there are certain things of which he judges instinct- 
 ively, and for which he cannot himself account, much less com- 
 municate them to others. We do not adopt this opinion. Admit- 
 ting that there are some impressions with difficulty accounted for 
 by the physician, and which are yet more difficult of expression 
 and transmission, we still think that, in these very cases, the 
 physician can and ought to discover, by attentive examination 
 and active analysis of the past circumstances and existing phe- 
 nomena of the disease, the reasons for his diagnosis and his con- 
 sequent determinations ; these reasons once ascertained, there can 
 be no real hindrance to their expression. We should not, then, 
 consider this power of forming instinctive opinions as the result of 
 long experience ; it is only the proof, either of the habit of incom- 
 plete observation of pathological phenomena, or of an indolent 
 mind that does not apply itself sufficiently to the scrutiny of their 
 value. In our opinion, an enlightened and conscientious phy- 
 sician should know how to avoid these vague conclusions andbe 
 able to communicate his own experience to those who observe his 
 daily practice. This direct transmission constitutes what is termed 
 traditionary medicine, which is the most useful form of instruction, 
 and renders evident that very remarkable and well known dif- 
 ference existing between physicians, who, during their term of 
 preparatory study, have seen much hospital practice, and those 
 who have gathered all their information in theoretical courses and 
 from books. Attendance on the medical visits of distinguished 
 physicians is the most suitable means for the rapid acquisition of 
 experience by the student. It has been justly remarked, "Medi- 
 cine cannot be learned except by association with physicians and 
 patients ; the physician cannot be self-formed ; an experienced 
 guide is necessary, without whom, the student loses his way 
 among the various systems, or becomes an empiric." * Tradition 
 is so highly important in the practice of medicine, that there is, 
 perhaps, no example of a skilful practitioner who has not enjoyed 
 the instructions of an experienced teacher. In medicine, as in all 
 practical arts, there are many hints of more or less value communi- 
 cated by the physician to those who observe his practice, and 
 which could not be otherwise transmitted. When an intelligent 
 and well instructed student has followed any practitioner for a 
 certain time, he can nearly always announce, after examining a 
 patient, riot only what treatment his instructor will adopt, but even 
 the remedial formulae he will prescribe. What work could give 
 
 * Essai historique sur la Medecine en France, by /. B. L. Chomel. Paris, 1762. 
 
THERAPEUTICS. 405 
 
 us such accurate knowledge, and who can flatter himself that he 
 could tell what Fernel or Boerhaave would have prescribed in a 
 given case ? 
 
 Observation and experience serve as guides in the treatment of 
 diseases only by the aid of the reasoning powers. This it is which 
 points out the analogy between various affections and leads the 
 physician to apply, in his own practice, the means that have 
 proved beneficial in that of others. Reasoning cannot, then, be 
 proscribed in medicine, as blind empiricism would advise ; * but 
 the only kind that should be employed, as Sydenham has ju- 
 diciously remarked, is simple and natural reasoning, derived from 
 good sense and apparently the immediate consequence of the facts 
 observed. Whenever a course of treatment is resolved upon after 
 a long series of arguments more or less ingeniously linked together, 
 errors are almost inevitably committed, equally injurious to the 
 physician and dangerous to the patient. 
 
 Some have endeavored to substitute other foundations for thera- 
 peutical science than observation and experience aided by natural 
 reasoning ; the physical and chemical theories have led t; eir parti- 
 sans to advocate the possibility of establishing the treatment of 
 diseases upon a new basis. Natural philosophy is useful in some 
 of its applications to a certain number of affections, particularly 
 mechanical lesions. An exact comparative analysis of the fluids 
 and solids, both in disease and health, with that of the remedies 
 employed, may likewise furnish, in certain cases, important indica- 
 tions. For example, when a chemical agent introduced into the 
 stomach causes toxicological symptoms, we may, while the poi- 
 sonous substance is still contained in the digestive canal, endeavor 
 to neutralize it by means of the reagents designated by chemistry. 
 When the urinary passages contain concretions of uric acid, the 
 use of alkaline remedies may dissolve them and consequently pro- 
 cure their expulsion. In diabetes mellitus, while the concurrence 
 of chemistry is requisite in tracing the changes that supervene in 
 the proportion of the saccharine principle, several useful indications 
 are also furnished by it for the treatment, in regard to the choice 
 of alimentary substances the least likely to furnish the elements of 
 sugar. But with the exception of a few diseases, chemistry is but 
 of slight service in therapeutics, and the error of those chemists 
 who compare the human body to an inert vase, wherein they sepa- 
 rate, precipitate or disengage the constituent principles of inorganic 
 bodies or of organized substances no longer subject to vital laws, 
 has been too long refuted to require any opposition on our part. 
 
 * "An empiric in medicine is one, who, totally disregarding the operations of 
 nature, the signs and causes of diseases, the indications, methods, and, particu- 
 larly, the discoveries of different ages, merely asks the name of the disease and 
 administers his drugs at hazard, or mechanically, following his routine and mis- 
 understanding the science. His experience is always deceptive, because he prac- 
 tices ignoramly and follows the prescriptions of others without inquiring into 
 their causes, essence or purpose." ZIMMERMANN, Traitt de rExptrience, t. i. 
 p. 19. 
 
406 THERAPEUTICS. 
 
 We have endeavored to give an accurate idea of therapeutical 
 science ; we have examined its foundations ; its applications will 
 be next considered. 
 
 Therapeutical science may be naturally divided into two 
 branches ; to the first belong the indications ; to the second, the 
 means for their fulfillment. 
 
 ARTICLE FIRST. 
 Indications. 
 
 WHEN the physician has discovered, by attentive examination of 
 the patient, the kind of disease with which he is affected, its pecu- 
 liar character, progress, tendency to favorable or unfavorable ter- 
 mination, its productive causes, influence upon the health, etc., 
 these united circumstances show the method of treatment to be 
 pursued, and apparently indicate it : this is termed indication. It 
 has been also defined to be the manifestation, furnished by the 
 disease itself, of the treatment likely to ameliorate the patient's 
 condition. 
 
 Indications should never be established upon theory or abstract 
 reasoning ; they should spring, as it were, from the phenomena of 
 the disease, and present themselves, unsought for, to him who has 
 become acquainted with all the concomitant circumstances. It is 
 rarely necessary, and often dangerous, to seek for indications when 
 they are not present : we are liable to imagine their existence, and 
 to misunderstand those which afterwards supervene in reality ; at 
 the bedside alone, and in proportion to the development of the dis- 
 ease, can they be distinguished and apprehended ; with this sig- 
 nification, the following axiom, taken from an art very different in 
 its results, but analogous in its principles, has been applied to med- 
 icine by a celebrated physician : * " We should take counsel in the 
 arena (consilium in arena, sumere)" 
 
 There is a certain number of circumstances in disease capable of 
 supplying indications. The principal are the kind of disease, its 
 peculiar form, its intensity, its type and its periods. The state of 
 the strength, the predominant symptoms, seat, complications, 
 causes and certain commemorative circumstances, the tendency of 
 the disease to various terminations, the influence it may exert upon 
 the patient's constitution, or upon pre-existing affections, the effect 
 of previously employed means, either in the case in question or in 
 others, and during epidemics, furnish indications which should not 
 be neglected; we shall give a brief explanation of these indi- 
 cations. 
 
 A. The genus of the disease is the most influential of all the 
 conditions from which indications are derived. The approxima- 
 tion of the edges of a wound, the coaptation of fractured bones, 
 
 * DuMOULIN. 
 
THERAPEUTICS. 407 
 
 restoration of displaced organs to their natural position, mainte- 
 nance of an inflamed part in complete rest, and of a position the least 
 likely to induce stagnation of the blood, the removal of everything 
 which might increase the pain ; blood-letting in pneumonia, the 
 administration of cinchona in intermittent fevers, and of mercury 
 in syphilis, are each, in these various diseases, the first, as well as 
 the most important, indication. Pathological anatomy concurs also 
 in furnishing very important indications, by revealing the seat of a 
 large number of diseases and the peculiar changes wrought by 
 them in the tissues of our organs. In many cases, however, other 
 indications occur,* which should not only be considered, but may 
 even exceed in importance those derived from the genus of the 
 disease. 
 
 B. The peculiar character of the disease is of great importance 
 in regard to treatment. There are many acute affections which 
 uniformly tend, of themselves, when regular in their progress 
 (maladies ligitimes), to a favorable termination, and consequently 
 need no active treatment ; while energetic means are required when 
 they are of inflammatory or adynamic character, etc. In such 
 cases the principal indications arise from the character of the dis- 
 ease, and those furnished by the genus are only of secondary value. 
 This is observed in erysipelas, bronchitis, and the morbillous erup- 
 tion, when manifested in one of the forms previously mentioned. 
 
 C. Very important indications are supplied by the type of the 
 disease. Experience having proved that all regularly periodical 
 diseases are susceptible of arrest by peculiar treatment, it is of the 
 greatest consequence that the intermittent type be distinguished 
 when present, and advantage taken of the valuable indication it 
 affords, especially in the malignant form of these diseases. The 
 patient's life is. here in the physician's hands ; if he neglect the 
 offered indication, death is nearly inevitable ; if he fulfil it prompt- 
 ly, health may almost always be restored. The different intermit- 
 tent types give rise also to some secondary indications ; the shorter 
 the interval between the paroxysms, the more energetic should be 
 the treatment; this becomes far more necessary when the paroxysms 
 approach still nearer and the type tends to the continued form. In 
 certain irregularly intermittent diseases, it has been stated that by 
 
 * We deem it proper to quote the very judicious reflections of Laennec upon this 
 subject : "I think that the study of pathological specimens is the only base of 
 positive knowledge in medicine, and that it should never be lost sight of, unless we 
 would pursue chimeras and create phantoms merely for the purpose of contending 
 with them . . . But I also consider it equally dangerous to give so excluive 
 an attention to the study of local affections, as thereby to lose sight of the 
 different causes on which they may depend, or, in other terms, their evident or 
 obscure nature. The necessary inconveniences arising from so restricted a mode 
 of study are an assumption of the effect for the cause and exposure to the still 
 more serious error of considering as identical, diseases in which the only visible 
 alterations are lesions anatomically resembling each other, and treating them all 
 similarly. 
 
408 THERAPEUTICS. 
 
 attentive observation of the reproductive causes of the attacks, their 
 return has been regulated, and the specific remedies subsequently 
 administered with advantage ; but it must be confessed, that the 
 action of cinchona in diseases artificially rendered periodical, is 
 not so well established as in natural intermittents. For this reason, 
 we cannot place entire confidence in the ingenious method em- 
 ployed by Professor Dumas of Montpellier, who, in a case of epi- 
 lepsy, first rendered the attacks regular, and then administered 
 cinchona. 
 
 D. The state of the vital forces is decidedly one of the most 
 important indications. Whatever be the genus of an affection, its 
 species or its type, it is of as much and even more consequence to 
 diminish excessive vital action and to sustain it when too far de- 
 pressed, as to treat the disease; on this account, it is indispensable 
 that the physician keep constantly in view, and attentively com- 
 pare, the probable length and the violence of the disease, with the 
 strength of the patient* He should be particularly on his guard 
 against debility, which might either cause the patient's death before 
 the usual period of termination of the affection, or embarrass the 
 series of phenomena or the necessary efforts for the re-establish- 
 ment of the functions. This indication becomes so urgent that it 
 should, when life seems nearly extinct, supersede all the rest, and 
 lead to the employment of the appropriate means for supporting 
 vitality, even in affections which seem to call for remedies of an 
 entirely opposite character, as in pneumonia, for example, or any 
 other phlegmasia : the ancients styled this the vital indication. 
 
 The estimation of the vital powers in disease constitutes, there- 
 fore, one of the most interesting points in practical medicine. 
 Nearly all therapeutical systems have been based upon the division 
 of diseases into sthenic and asthenic, active and passive ; and in a 
 considerable number of cases, the principal question is to know 
 whether the treatment should be tonic or debilitant. It is, then, of 
 the greatest importance to determine the signs by which the vital 
 force may be estimated, especially in acute diseases, where all delay 
 is dangerous and error causes very serious consequences. 
 
 It should be remembered that such an estimate of the powers of 
 life is, in a certain number of cases, very obscure and difficult; to 
 be convinced of this, we only need to glance at the divisions estab- 
 lished by Brown, and also at those substituted for them by authors, 
 who, like Broussais, were led to adopt an analogous division, 
 founded upon opposite principles. The same affections are enu- 
 merated, in one of these systems, among those characterized by 
 excess, which in the other are marked by diminution of vital 
 action. The same obscurity may perplex us at the bedside, and it 
 has sometimes happened that cinchona has been advised by one 
 physician for the same patient, in whose case another had pre- 
 
 * Galen compared the patient to a man carrying a burden, the disease to the 
 burden, and its duration to the distance to be traversed by the bearer. 
 
THERAPEUTICS. 409 
 
 scribed blood-letting. It is, however, but jnst to say, that such 
 difference of opinion is hardly ever manifested except among sys- 
 tematic physicians, and that there is scarcely an example among 
 skilful observers, accustomed to collect all the information that can 
 aid them, before resolving upon any mode of treatment. 
 
 There are many physicians who estimate the state of the vital 
 powers almost entirely by the pulse; if this be full and resistant, 
 they are, according to them, necessarily in excess. The most vio 
 lent partisans of the doctrine of irritation have gone still farther; 
 the frequency of the pulse, which in acute diseases increases with 
 the debility and is never greater than in the death-struggle, was 
 for them a sign of excessive vital action, or, what is the same thing, 
 an indication for the employment of the antiphlogistic treatment. 
 Others have adopted, as a criterion, the energy of the movements, 
 the color of the face, or the strength of the constitution ; certain 
 others, the pale or deep color of the urine ; many, the state of 
 the general heat ; others, finally, the power with which the heart 
 contracts. Many of these signs are certainly highly important in 
 the estimation of the vital forces, and none should be neglected ; 
 but doubtless, also, each of them when isolated from the rest is 
 insufficient. If examples were necessary to prove this, we might 
 cite the weakness of the pulse in certain inflammations accompa- 
 nied with severe pain ; its hardness, persisting even till death, in 
 certain cases of hypertrophy of the heart ; the sensation of general 
 coldness at the commencement of the most acute phlegmasiae ; and 
 the convulsive movements succeeding profuse haemorrhage. But 
 we need not insist upon a doctrinal point, upon which all experi- 
 enced practitioners are agreed, viz. : that in the estimation of the 
 vital forces, all the signs likely to express their degree should be 
 taken into consideration. 
 
 The vital powers may be modified in various ways in disease ; 
 they are augmented, diminished, suspended, perverted or oppressed. 
 They may also present no evident disturbance, as is occasionally 
 observed in diseases limited to one organ, and which do not, ap- 
 parently, disturb the others. 
 
 Increase of the vital forces is generally characterized by a lively 
 red color of the skin, redness and intumescence of the face, regular 
 and confident movements, full respiration, strong pulse, increased 
 heat, firmness of the muscles, marked diminution of the excretions, 
 particularly of the urine and fasces, and that amendment which su- 
 pervenes in the symptoms after spontaneous haemorrhage. The 
 blood is observed to be of firm consistence and a vermilion color, and 
 contains a greater proportion of fibrine arid corpuscles. These phe- 
 nomena are rarely observed united in the same individual ; in their 
 different combinations and intensity they present very various 
 gradations, either in different patients or in the course of the same 
 affection; they are, generally, far more strongly marked at the 
 outset of the disease and in the paroxysms, than during the remis- 
 sions or towards the decline. 
 
 Diminution of the vital forces is denoted by pallor of the cutane- 
 35 
 
410 THERAPEUTICS. 
 
 ous surface, shrinking of the features, languor in the attitude and 
 motions, fain tings, frequency and feebleness of respiration, weak 
 pulse, diminished heat, sensitiveness to cold, flabbiness of the mus- 
 cles, arid the abundance and tenuity of the excretions. If haemor- 
 rhage occur under these circumstances, the other signs become 
 thereby more manifest, and the effused blood is paler in color and less 
 consistent than in health. Diminished vital action may assume 
 various forms ; in some acute diseases, it may become quite decided 
 in a few days ; it is then evidenced by collapsed features, pale skin, 
 difficulty or impossibility of maintaining the erect or even the sit- 
 ting posture, diminution of heat, cold sweats, involuntary excre- 
 tions, deliquium animi and syncope.* These signs are usually 
 more distinct during the remission ; they are veiled, as it were, 
 by the transient excitement constituting the paroxysms ; conse- 
 quently, we here observe the contrary of that which happens 
 when the vital force is in excess, and where the sthenic character 
 of the disease becomes more marked in the exacerbations. There 
 are, however, some affections in which the debility becomes more 
 decided in the actual paroxysms ; this occurs in many varieties of 
 malignant fevers, as the syncopal form, [a variety of intermittent 
 in which there are one or more fainting fits in every paroxysm. 
 Dunglison. Med. Diet. A form of frequent occurrence, death 
 is almost inevitable after a second paroxysm. Grisolle. Path. Int. 
 vol. i. p. 149.] and febris algida : [algor, cold, a pernicious in- 
 termittent accompanied by icy coldness, often fatal in the second 
 or third paroxysm. Op. sup. cit. TR.] : diminution of the vital 
 forces, which is hardly noticed during the intermissions, is at its 
 extreme in the paroxysms. In chronic diseases, debility super- 
 venes but slowly ; its principal indicatory signs are emaciation of 
 the whole body, but particularly of the face, increasing difficulty of 
 motion, rapidly induced fatigue resulting from bodily or mental 
 exercise, feebleness of the pulse, sensitiveness to external cold, 
 sometimes oedema of the cellular tissue, and passive sanguineous 
 exhalation from different parts of the body ; it rarely attains such 
 a degree that it prevents patients from moving in bed, as happens 
 in many acute diseases. 
 
 Complete suspension of the vital phenomena, in syncope, con- 
 gelation and asphyxia, indicates a momentary abolition or suspen- 
 sion of the vital forces. 
 
 * The terms defaillance and syncope are considered synonymous by Dunglison 
 and some others, but Nysten (Med. Diet.) points out the shade of difference be- 
 tween them which is also implied in the text (See, also, p. 115.) Def alliance, 
 which we have rendered deliquium animi, is the first stage of syncope and might 
 be aptly designated fainting, consisting 'as it does in the sudden diminution of 
 the heart's action, progressively continuing, with greater or less rapidity, until the 
 syncopal state is fully attained, or else arrested by remedial means previously to 
 complete syncope. Lipothymia is characterized by the persistence of respiration 
 and circulation, sensation and motion being only diminished; syncope, by entire 
 suspension (usually momentary,) of sensation, motion, respiration and circulation 
 (syncope confirmee. Grisolle. Path. Int. vol. ii p. UU7, ^d edit.). The dis- 
 tinction seems highly appropriate. TRANS. 
 
THERAPEUTICS. 411 
 
 Perversion of the vital forces is denoted by a more or less mani- 
 fest change in the union or succession of those phenomena con- 
 sidered capable of indicating their measure: at one time it is 
 the simultaneous existence of symptoms not generally observed 
 united, at another, a rapid succession of phenomena opposed to one 
 another, and still more frequently, sympathetic disturbance of the 
 cerebral functions, particularly the intelligence, sensations, ex- 
 pression of countenance, gestures and movements. Perversion may 
 co-exist with augmentation and diminution of the vital forces, or 
 be manifested singly. From this arises the difficulty of perceiving 
 the indications in these embarrassing cases, and the disagreement 
 of authors and practitioners upon this important point in thera- 
 peutics. 
 
 Oppression of the vital forces * is that state in which there is 
 apparent diminution, but actual augmentation of the forces; it is 
 manifested, indeed, by phenomena nearly resembling those char- 
 acteristic of diminished vital force, as collapsed features, pallor or 
 lividity of the face, difficult motion, torpor of the senses and intel- 
 lectual faculties, feebleness and sometimes inequality of the pulse, 
 coldness of the extremities, etc. In such cases, we must refer to 
 antecedent circumstances in order to appreciate the actual state of 
 the forces. Real debility almost always arises from evident causes, 
 existing in individuals naturally feeble, or weakened by excessive 
 fatigue of body or mind, by prolonged grief, privation of food, or 
 the ingestion of that but slightly nutritive, excessive evacuations, 
 watching, and the abuse of physical pleasures. Oppression of the 
 forces, on the contrary, occurs particularly in strongly constituted 
 individuals of mature age, who are high livers or even epicures ; it 
 takes place suddenly, at the invasion, or at least in the first period 
 of diseases, while real debility is observed, generally, to be pro- 
 gressive and to occur in a later stage. In obscure cases, where 
 nothing that may elucidate should be neglected, the color and 
 consistence of the blood effused in haemorrhage or drawn by vene- 
 section, leeches or cupping glasses, the peculiar aspect of wounds 
 and blisters, and the qualities of the pus secreted and discharged 
 by them, deserve, also, the physician's attention. Another very 
 suitable means for ascertaining the state of the forces is observa- 
 tion of the changes supervening in the intensity of the disease, 
 either from the effect of the first remedies employed or from other 
 circumstances. If debilitants, and, particularly, blood-letting, 
 have procured relief; if spontaneous haemorrhage or alvine evacu- 
 ations seem to diminish the debility, oppression of the forces doubt- 
 less exists. If. on the other hand, spontaneous or artificial evacu- 
 ations have proved injurious, if wine and cordials have moderated 
 the intensity of the disease, the diminution of the forces is real, 
 
 * Oppression of the forces is that condition at the commencement of the phleg- 
 masiee, fevers, &c., in which the system is oppressed rather than debilitated : the 
 patient is embarrassed by excess of the vital forces (Nysten, Diet. Medecine) : 
 vascular action rises, as the obstruction to free circulation is relieved by bleeding, 
 purging, ^c. (Dunglison.) TRANS. 
 
412 THERAPEUTICS. 
 
 and the physician should act accordingly. Another sign, to which 
 the greatest importance was attached by Laennec, should be added 
 to the above ; this is the contractile power of the heart. Accord- 
 ing to this physician, " whenever the ventricular contractions, (as 
 appreciated by auscultation,) are energetic, we may abstract blood 
 fearlessly ; the pulse will rise ; but if the cardiac contractions be 
 feeble, even though the pulse retain a certain force, we should ab- 
 stain from depletion." In obscure cases, this suggestion should 
 not be neglected, although the phenomenon does not possess the 
 value attributed to it by Laennec ; the force with which the heart 
 contracts, depending quite as much upon the anatomical conditions 
 pertaining to the organ, as on the general state of the vital 
 forces. In persons affected with hypertrophy of the heart, its 
 contractions, as well as the arterial pulsations, continue with extra- 
 ordinary power, even to the moment of death ; in others, on the 
 contrary, the heart contracts feebly, although all the other indi- 
 cations are those of excessive vital action and demand depletion. * 
 Such are the principal circumstances by means of which the 
 state of the vital forces in disease may be estimated ; they cannot 
 solve all the questions arising upon so delicate and important a 
 point in practical medicine ; but they may assist the physician in 
 ordinary cases, a knowledge of which is the most important. It 
 should be added, before concluding this article, that the appreciation 
 of the forces is sometimes so difficult, that the most experienced 
 physician is obliged to withhold his opinion, and refrain, for a time, 
 from any active treatment, that he may not proceed at random. 
 
 E. The intensity of the disease is likewise a source of useful in- 
 dications. Not that the same affection may require opposite treat- 
 ment, according as it is severe or otherwise ; but there is so great a 
 difference between the indications in each case, in inflammation, 
 for example, according as it is very slight or exceedingly intense, 
 that this circumstance necessarily influences very powerfully the 
 physician's course of treatment. In one case, cooling drinks and 
 diet would alone be indicated ; in the other, copious and frequent 
 depletion and the most powerful revulsives should be employed. 
 
 F. The different periods likewise furnish various indications. 
 The treatment of typhoid fever is unlike in its first and third 
 
 * It may not be inappropriate to mention in this connection (although perhaps 
 more properly coming under the head, diminution of the forces, p. 409) the re- 
 searches of Dr. Stokes upon the indications for the administration of wine in 
 fever, which are derived from the phenomena of the heart's action. The very 
 valuable and interesting paper which contains the account of these researches and 
 the inferences deduced therefrom, may be found in the Dublin Medical Journal, 
 vol. xv. Dr. Stokes considers that softening of the heart exists in typhus 
 fever, as a local disease. The important conclusion derived from the asthenic 
 condition of the heart, &c. is as follows : " The diminution or cessation of im- 
 pulse, the proportionate diminution of both sounds, or the preponderance of the 
 second sound, are direct and nearly certain indications for the use of wine in fever." 
 TRANS. 
 
THERAPEUTICS. 413 
 
 periods, and the means which are proper at the commencement of 
 a grave inflammation cannot be employed to the same extent in 
 the second or third week of its duration. This rule is applicable 
 to nearly all acute diseases, whatever may be their genus, course, 
 or productive cause. If debilitants be indicated and evacuants 
 required, they should be employed particularly, if not exclusively, 
 at the outset and in the first period of the disease : they should 
 subsequently be resorted to more cautiously, in proportion as the 
 disease advances, without being entirely proscribed. In the last 
 period of acute and even chronic diseases, the supervening phe- 
 nomena should be attentively watched, and when the tendency of 
 nature has been ascertained, it should be assisted if it seem proper; 
 when sufficiently powerful in itself, we may limit our interference 
 to the removal of every hindrance from its path, or oppose it by 
 the most energetic means when necessary. 
 
 G. The symptoms, especially, supply us with indications not 
 to be neglected. They are, it is true, merely the effects of the 
 disease, and yield, most frequently, to the treatment it requires. 
 But in certain cases, some of them become sufficiently severe to 
 prove a serious addition to the danger of the primitive affection. 
 Thus, in typhoid fever, epistaxis may supervene, sufficiently co- 
 pious to endanger the patient's existence and demanding the phy- 
 sician's immediate and constant attention. The subjugation of the 
 predominant symptoms is, therefore, justly regarded as an impor- 
 tant part of the treatment, with the precaution, however, of not 
 magnifying the phenomena at the expense of the disease, and not 
 neglecting the main object for one of secondary consequence.* 
 
 The indications arising from the symptoms are sometimes even 
 more important, as in cases where the diagnosis is obscure : the 
 genus of the disease being unknown, the symptomatic treatment is 
 alone admissible. We do not intend by this term, f " that errone- 
 ous symptomatic treatment^ which, without rules or knowledge, 
 opposes symptoms indifferently, but that which, enlightened and 
 firm in its progress, at one time remedies alarming symptoms and 
 at another manages the disease according to the indications derived 
 from a union of all the symptoms, which render it similar to cer- 
 tain other affections, until it be more accurately defined." Thus, 
 in many cases, there will frequently supervene, in an individual of 
 good constitution and previously in excellent health, a chill, fol- 
 lowed by general heat, redness of the cutaneous surface, full 
 pulse, etc.. and still, nothing, thus far, may clearly reveal the 
 source of the very intense febrile action. Although the diagnosis 
 is here obscure, the physician may, and often should, fulfil the 
 indications presented by the symptoms, collectively considered, 
 prescribing depletion, once or repeatedly, without waiting for local 
 signs to inform him whether the commencing disease belongs to 
 
 * FRANK, Epitome, torn. i. 
 f Th6se dej& citee de BAYLE. 
 
414 
 
 THERAPEUTICS. 
 
 the thoracic inflammations or to some other of the nosological 
 genera. 
 
 H. The indications derived from the seat of diseases demand, 
 also, particular attention. Generally, the affected parts should be 
 maintained in a state of perfect rest, and their position should be 
 such that the circulation of the fluids, and especially that of the 
 blood, be as little obstructed as possible. The sitting posture is 
 peculiarly suitable in diseases of the head and chest ; the horizon- 
 tal, in abdominal affections and those of the lower limbs ; the 
 pain and swelling in paronychia and rheumatic inflammation of the 
 hand or wrist augment when the hand is pendent, but diminish 
 when it is elevated and rests upon a cushion; diseases of the 
 joints generally necessitate immobility of the affected parts ; those 
 of the digestive organs demand a restricted regimen ; those of the 
 chest often require silence, as do cerebral affections, mental repose. 
 
 I. Certain indications arise from the complications. Occasion- 
 ally, the physician disregards one of the diseases and devotes his 
 attention solely to the other, but subsequently returns to the con- 
 sideration and treatment of the former; at another time (and 
 this is most frequently the case) the treatment is regulated accord- 
 ing to the indications simultaneously furnished by the co-existing 
 diseases ; for example, in pneumonia complicated with peritonitis, 
 or chronic articular rheumatism with syphilis, the indications pre- 
 sented by each affection may be simultaneously fulfilled. 
 
 J. The productive or developing causes of diseases, are highly 
 important in regard to therapeutics, and the physician should 
 always endeavor to discover them. Determining causes supply 
 us with very reasonable indications. When a person is asphyx- 
 iated by an atmosphere filled with noxious vapor, the first indi- 
 cation is to remove him from its influence. When a foreign body 
 remains in a wound, its immediate extraction is indicated. If 
 poisonous substances have been swallowed, it will be necessary to 
 excite emesis, if any of the poison remain in the stomach, or else 
 it should be neutralized by the administration of appropriate anti- 
 dotes, or at least, its action should be enfeebled by large draughts 
 of liquids. If venomous secretions or virus be deposited upon any 
 part, both the morbific agent, and the part which has received its 
 action, should be destroyed by means of caustic. In all these 
 cases, by removing the cause, we may hope to jugulate the dis- 
 ease, sublata causa, tollitur ejfectus. In imaginary diseases, the 
 treatment should be moral. A young female in the pauper hos- 
 pital of Harlem, having had convulsions, many of the children at 
 the same time in the hospital, who had witnessed these attacks, 
 were similarly affected, the symptoms being repeated daily, by a 
 kind of imitation, in a large number. Many remedies were un- 
 successfully tried. Boerhaave, being consulted, directed that some 
 furnaces filled with live coals should be placed in the middle of 
 
THERAPEUTICS. 415 
 
 the Ward and iron hooks heated in order to transfix the arm of 
 the first child who should have convulsions. This method was 
 completely successful ; no more convulsions were observed. 
 
 General predisposing causes, as the season, the state of the 
 air, etc., furnish several indications, chiefly unimportant. It is 
 otherwise in regard to climate, which in certain catarrhal affec- 
 tions, and some of the neuroses, has so great an influence upon 
 the progress of the disease, that it becomes the most efficient agent 
 in the treatment ; the substitution of a warm for a cold climate 
 has frequently been followed by an amelioration not to be obtained 
 by any other means. 
 
 Temperament, constitution, age, sex, occupation, but especially 
 the habitual regimen of patients, are the sources of indications 
 more or less important. The sanguine temperament, for example, 
 indicates depletion in diseases, which, in themselves, and in per- 
 sons of different temperament, would not require it ; the necessity 
 for employing this means of treatment is still more urgent when 
 the nature of the disease requires it, while in the lymphatic and 
 nervous, blood-letting should be resorted to with great reserve, 
 and only when its omission would be seriously injurious. This 
 rule applies equally to individuals of naturally feeble or artificially 
 debilitated constitution. What has been said of sanguineous 
 depletion, naturally applies to the other active means of treatment, 
 as purgatives, opium, bitter tonics and cutaneous revulsives. 
 When about to employ these remedies, the temperament and con- 
 stitution of the patients should be particularly considered. 
 
 The indications derived from the different ages are not unim- 
 portant. The diseases of children, generally considered, require 
 more simple and fewer remedies than those of adults. The dis- 
 eases of the aged, which are apt suddenly to assume an adynamic 
 character, render greater reserve in the administration of debili- 
 tarits, and a more prompt resort to tonics, necessary. Sex also 
 has its indications, particularly in regard to pregnancy and the 
 menstrual period, which often render it necessary to modify the 
 use of energetic remedies, or to substitute others of less power. 
 The occupation and place of residence also suggest indications. 
 Certain diseases will continue so long as the affected individual 
 pursues his occupation or retains his habitation,* because these 
 are their productive and maintaining causes. 
 
 Ramazzini observed that country people, who labor hard, do 
 not bear artificial evacuations so well as the inhabitants of cities, 
 whose life is more tranquil, and whose food is also more nutri- 
 tive. f When considerable evacuations, excessive fatigue, pro- 
 longed watching, profound grief and great anxiety of mind, have 
 preceded a disease, the latter is usually accompanied by a debility 
 which necessitates a more prompt resort than usual to means suit- 
 able for sustaining the strength. 
 
 * See pp. 36, 43. 
 
 f RAMAZZINI, des Maladies des Artisans, traduction de FOURCROY, p. 451. 
 
416 THERAPEUTICS. 
 
 The physican often discovers important indications in the daily 
 habits of life. The various disorders of the digestive organs, and 
 many sympathetic phenomena arising from latent affections of the 
 stomach and intestines, such as cephalalgia, somnolency, vertigo, 
 dyspnoea and palpitations, very often depend either upon the 
 number and proximity of the meals, (which should be separated 
 by longer and longer intervals as man advances in years,) or 
 upon their methodical subdivision, or else upon insufficient exer- 
 cise, or finally, upon the habit of commencing study immediately 
 after the ingestion of food, particularly if the meal have been a 
 hearty one. These symptoms, which resist, for an indefinite 
 period, all remedial measures, yield, as if by enchantment, to 
 apparently very slight modifications of the daily habits, as the 
 restriction of the number of meals to two in adult age, the estab- 
 lishment of a longer interval between the .first and second ; 
 refraining from the use of meat and other articles of slow or diffi- 
 cult digestion at breakfast ; a change in the hours devoted to 
 exercise or study, so that walking exercise be taken after meals, 
 and intellectual employments deferred for one or more hours. 
 Nearly all students, or those obliged to devote the entire day to 
 intellectual pursuits, should restrict themselves to a single repast, 
 resigning almost entirely the morning meal, so that the whole day 
 may be devoted to their occupations, and indulging their appetite 
 at dinner, our social habits having reserved the evening for repose 
 and relaxation. 
 
 Secondary indications alone are derived from most of the occa- 
 sional causes : whether the invasion of pneumonia has been 
 preceded by a chill, a powerful emotion, or errors in diet, no impor- 
 tant modification of the treatment can result from these circum- 
 stances. If, however, suppression of an habitual evacuation have 
 immediately preceded the disease, we should recall or supply it, 
 as we should if it had been suspended long previously. If the 
 cicatrization of an ulcer, the dessication of an issue, or the sup- 
 pression of a rheumatic affection, seem to have excited the disease, 
 rubefacients or vesicants should be applied to the previously 
 affected surface, or an issue should be established. In like manner, 
 chronic affections of the skin, as erysipelas or any other exanthema, 
 should be re-established, if possible, in the part they originally 
 occupied, by the application of a sinapism or blister, or by excit- 
 ing an artificial eruption by means of croton oil or antimonial oint- 
 ment. If repercussion of urticaria preceded the development of 
 the disease, the most rational indication would be urtication of the 
 part whence the eruption had disappeared. Suppression of the 
 sweat most frequently furnishes no indication, except it occur 
 during the precursory period of the disease ; the latter being actu- 
 ally developed, diaphoresis would often be insufficient to arrest its 
 course and might sometimes increase its violence. 
 
 K. Among the commemorative circumstances there is one which 
 elucidates both therapeutics and diagnosis, and furnishes, in many 
 
THERAPEUTICS. 417 
 
 cases, particularly in chronic affections, indications of the great- 
 est importance ; we refer to the previous diseases, whose essence, 
 whatever it may have been, might have influenced the develop- 
 ment of the existing malady, without any revelation of its nature 
 being made by the apparent form of that malady. Observation, 
 indeed, daily shows us individuals, who, at different periods after 
 rheumatic attacks, or one of those chronic exanthemata commonly 
 known as herpetic, (yulgairement designes sous la denomination 
 commune de dartres,) * are affected with various disturbances of 
 the economy, often transient and inconstant, sometimes fixed as to 
 seat, but very variable in form and intensity, and most frequently 
 simulating certain chronic phlegmasiae or neuroses, either abdomi- 
 nal, thoracic or cerebral. These affections resist nearly all reme- 
 dial measures, until the appearance of an exanthematous eruption 
 or arthritic or muscular pain relieves the affected viscera from their 
 derangements arid reveals the productive and continuing cause. 
 It would be impossible to enumerate the number of cases where 
 this class of affections, however severe or chronic they may have 
 been, has yielded to remedies suitable for subduing or recalling to 
 their former position rheumatic and herpetic diseases. In dis- 
 guised syphilitic affections, we ascertain the origin of the existing 
 malady and determine its treatment by a consideration of the 
 anterior diseases. In most chronic diseases, especially those which 
 do not consist in those profound structural changes where thera- 
 peutics are powerless, thorough investigation of every previous 
 occurrence and attentive examination of all the physical, moral, 
 and intellectual conditions in which the patient is placed, will be 
 found to afford the truest indications and those explanatory of 
 the origin of the disease and the means of subduing it. 
 
 There are certain other commemorative circumstances, which, 
 without having any influence in the development of the disease, 
 are productive of particular indications ; among these are long- 
 continued habits. Those who, in health, are hearty eaters, and 
 who drink large quantities of wine and spirits daily, cannot, when 
 ill, support so severe a diet as the more temperate. A very robust 
 man, addicted to the use of fermented liquors and accustomed to 
 take a pint arid a half of wine daily, entered La Charite, on the 
 seventh day after an attack of pneumonia ; he was only once 
 bled, and from the succeeding day the disease declined. A man 
 thirty-four years of age accustomed to eat three pounds of bread 
 and the same quantity of meat, and to drink fifteen bottles of 
 wine and four of brandy daily, contracted syphilis. M. Cullerier, 
 when consulted by him, allowed him to take (during the inflamma- 
 tory period) a pound and a half of bread, the same amount of 
 meat, three bottles of wine and one of brandy.f Being convinced 
 of the injurious effects of a sudden interruption of even the worst 
 
 * The term dartre has been applied to nearly every disease of the skin. 
 (Dunglison.) TRANS. 
 f Theses de TEcole de Paris, ann. 1809, No. 17. 
 
418 THERAPEUTICS. 
 
 habits, we published, nearly twenty-five years ago, in the New 
 Journal of Medicine,* a paper upon the use of wine in the acute 
 diseases of the intemperate. Since then, we have allowed these 
 individuals, under such circumstances, a certain quantity of wine, 
 either pure or mingled with other fluids (tisanes), and have never 
 had occasion to regret it, having always observed death to occur 
 in those who had been entirely deprived of wine during the 
 disease. 
 
 There is still another commemorative circumstance that occa- 
 sionally furnishes useful indications ; if the patient have once, or 
 several times, previously, had illness similar to that under treat- 
 ment, we should inquire what means were then employed ; if the 
 same were resorted to in every attack and what their effect has 
 been. If the same remedy has been always successfully em- 
 ployed, it should be repeated, except in certain cases where the 
 physician's judgment forbids ; if many different remedies have 
 been tried, that most constantly productive of relief should be 
 selected; if, on the contrary, any means which had seemed to be 
 indicated by the kind of disease or any other circumstance have 
 proved injurious, they should be abandoned. 
 
 Before prescribing any medicine, the physician should ascertain 
 if the patient have taken it for any other affection, and also the 
 effects produced, and whether he is favorably or unfavorably im- 
 pressed by it. There are persons in whom opiates always act unfa- 
 vorably; this idiosyncrasy {particularity} should be known in order 
 that we may refrain from prescribing them. There are others who 
 have a decided aversion to these medicines or a great dread of their 
 effects ; if necessary to resort to them, they should be disguised. 
 
 L. When a disease has continued several days, and various 
 remedial means have already been tried, their influence upon the 
 intensity of the symptoms may supply important indications which 
 are of still more consequence where the genus of the disease is 
 unknown, or in cases when the disease being understood, the treat- 
 ment is doubtful. Tn many chronic diseases the physician relies 
 principally upon such indications, acting, as the saying is, a ju- 
 vantibus et Icedentibus. In certain acute diseases, where the appre- 
 ciation of the vital forces is difficult, the effect of the remedies first 
 administered is exceedingly important in enabling us to ascertain 
 their true condition and in supplying us with indications. The 
 efficacy or insufficiency of sulphur or mercury in certain diseases, 
 furnishes, after a certain time, new indications in regard to their 
 continuance or suspension, etc. It should not, however, be forgot- 
 ten, that the majority of acute diseases, particularly the phleg- 
 masise, exhibit a continued aggravation (period of increase) for 
 several days, notwithstanding the use of the most powerful medi- 
 cines, and that, in this case, the exasperation of the symptoms, while 
 
 * Nouveau Journal de M6decine, torn. vii. p. 181. 
 
THERAPEUTICS. 419 
 
 restricted within certain limits, by no means proves that the reme- 
 dies administered were not indicated. 
 
 M. When a disease prevails epidemically, certain indications 
 arise from other circumstances : as 1st, an exact comparison of 
 the causes and form of the existing epidemic with those observed 
 in the preceding, may furnish indications for treating those first 
 attacked ; 2dly, when a certain number of cases has been observed, 
 and the effect of remedies has been attentively watched, conclusions 
 may be formed in regard to subsequent treatment. When, how- 
 ever, the epidemic persists, the indications may vary during its 
 continuance, and the treatment originally successful may be in- 
 sufficient or injurious toward the termination.* 
 
 N. The tendency of a disease to different terminations requires 
 also the physician's attention. If the termination is likely to be 
 favorable, his care may be employed in the simple removal of all 
 aggravating circumstances, or in fulfilling the secondary indica- 
 tions already existing or subsequently supervening, and all active 
 medication may be abandoned, except the disease continue a long 
 time and there be no therapeutical means capable of suspending or 
 abridging its duration. If there be a tendency to a fatal termina- 
 tion, the most energetic means for its prevention should be tried ; 
 but when death is inevitable, the indications are restricted to treat- 
 ing the principal symptoms, with the intention of prolonging life 
 or rendering its last moments less painful. If the disease neither 
 increase nor diminish, as in paralysis, the perturbating treatment 
 is generally resorted to ; this consists in the employment of reme- 
 dies likely to produce a powerful diversive effect : this treatment, 
 however, would be dangerous, if the disease, which is really sta- 
 tionary, were of a nature liable to be exasperated by its employ- 
 ment : in certain cases of mammary cancer, for example, great 
 care should be taken not to employ active remedies when the 
 disease is stationary, because all change must necessarily be inju- 
 rious, p In certain acute diseases which may terminate in death or 
 the return to health, active treatment should be employed if the in- 
 dications be decided ; the opposite, if they be obscure : perturbating 
 treatment would not be proper, for example, in all the forms of 
 adynamic typhoid fever. These affections, notwithstanding the 
 apparent disorder frequently accompanying them, are not, more 
 than other diseases, a state of confusion, but rather a sort of 
 struggle between vitality and the causes which have disturbed its 
 harmonious action, a struggle whose issue is doubtful. In this 
 state of uncertainty, should we indiscriminately and in every case 
 endeavor to disturb the course of these diseases, or merely confine 
 ourselves to meeting the precise indications that maybe presented? 
 We unhesitatingly advocate the latter course. 
 
 * fUMAZzmi, Epidem. mutin., arm. 1691, in SYDEINHAMI Oper. torn ii. p. 38. 
 Genevee, 1736. 
 
420 THERAPEUTICS. 
 
 O. The influence which may be exerted by the disease upon 
 the patient's constitution and upon previous affections is also of 
 service to the physician. If the disease disturb the functions of 
 the organs remote from its apparent seat, and particularly of the 
 locomotive and digestive apparatus, or if it aggravate pre-existing 
 affections, its coarse should be arrested as speedily as possible. If, 
 on the contrary, the appetite and digestion improve after the 
 appearance of a cutaneous eruption or an attack of intermittent 
 fever; if the individual perceive an increase of strength, if certain 
 uncomfortable sensations, long experienced, cease completely, etc., 
 the progress of the disease should not be interrupted, all opposing 
 influences should be removed, and if anything suddenly arrest it, 
 it should, if possible, be reproduced. In proportion as its course is 
 favorable, the remedy will be unfavorable, morbi boni, remedia 
 mala.* There are, then, diseases which it is dangerous to cure, 
 as is proved by the collection of observations published upon this 
 important point in therapeutics:! their number, .however, is not 
 very large, and the dissertation of Werlhoff, De limitanda febris 
 laude, need not now be read in order to establish the truth of the 
 assertion. We must refer to the period when this work was writ- 
 ten, to avoid being astonished that any one should have seriously 
 endeavored to establish such a proposition. 
 
 Such are the principal circumstances from which indications for 
 treatment are derived. They are not all equally important ; but 
 none of them can be neglected without detriment. It is evident 
 from the above considerations, how erroneous is the opinion of 
 those who believe that there is a remedy for every disease, and 
 how different, a treatment founded upon experience, from empir- 
 icism ; the modifications of treatment are also manifest that are 
 founded upon the numerous indications which combine and form, 
 as it were, out of every disease, an affection dissimilar, in some 
 .respects, both as to treatment and symptoms, from all those that 
 most resemble it. It is not, as has been judiciously remarked, 
 dropsy or peripneumonia, simply, that is treated, but those diseases 
 as manifested in various individuals, of different ages, sex, tempera- 
 ment, habits, etc.J The great number of circumstances, which 
 should all be considered and their value appreciated in order to 
 perceive the indications, causes the difficulty experienced in the 
 detection of the latter. 
 
 There are but few cases in which a single indication only is 
 manifest; in nearly all diseases there are many. These simulta- 
 neous indications maybe analogous and concur in the same object, 
 as general bleeding, abstinence and topical emollients, all of which 
 should be combined in certain inflammations. But this is not 
 always the case, and sometimes, while certain circumstances indi- 
 
 * WERLHOFF, Dissert, de limitanda febris laude. Opera, torn. ii. 
 
 f Traite des Maladies quil est dangereux de guerir, par Dom. Raymond. 
 
 j Nee pneumoniam generatim, nee hydropem curamus, sed pneumoniam Sem- 
 pronii aut Tulliae, sexu, atate, victus genere, aut temperamento differentium. 
 JSpRENGEL, Pathol. general, p. 72. 
 
THERAPEUTICS. 421 
 
 cate one sort of treatment, others oppose its application. These 
 opposite indications are called counter indications. In typhoid 
 pneumonia there exists, on the one hand, an inflammation requiring 
 debilitating treatment, and on the other, a depression of the vital 
 powers demanding entirely different remedies. It cannot be dis- 
 guised that these cases are very embarrassing : if the inflammation 
 be combatted, the debility is increased ; if tonics be employed, the 
 inflammatory symptoms are likely to become exasperated. In such 
 an emergency matured tact is requisite for the accurate apprecia- 
 tion of the relative value of the opposing indications, meeting the 
 most urgent as completely as possible, taking care that the means 
 employed be favorable to one of the morbid conditions without 
 aggravating the other, or that the evils arising from the use of 
 certain remedies may be more than counterbalanced by their bene- 
 ficial action. 
 
 Embarrassment in regard to the treatment of a disease may 
 occur from other causes than the existence of counter indications. 
 It sometimes happens that an acute or chronic disease exhibits 
 more or less serious symptoms without furnishing any decided 
 indication. Should active means be tried in these cases, and a 
 species of instinct be obeyed which would lead us to suspect certain 
 indications of which we are doubtful ? Some practitioners pursue 
 such a course, but we should be unwilling either to adopt or advise 
 it: we act blindly when destitute of positive indications. The 
 judicious reserve of Sydenham and Morgagni may be fearlessly 
 imitated in such circumstances, while an opposite course would 
 often be regretted. " I need not blush to confess," says the former. 
 " that in the management of fevers. I have many times congratulat- 
 ed myself upon refraining from action when nothing manifestly fur- 
 nished indications of treatment : while thus attentively watching 
 the course of the disease, in order to seize the favorable moment 
 for attack, the fever either vanished spontaneously, or assumed a 
 form which indicated the remedies to be employed."* "In cer- 
 tain chronic diseases of doubtful nature," says Morgagni, " we 
 should not proceed rashly, but restrict ourselves to the employment 
 of remedies sanctioned by experience, which, while incapable of 
 inflicting injury, generally relieve to a certain extent."! Utility 
 is only the second rule of therapeutics ; the first is avoidance of 
 injury. 
 
 We do not, however, mean to imply, that in acute or chronic 
 diseases, the physician should constantly abstain from all active 
 treatment, because the indications are obscure ; but the greatest 
 circumspection is requisite in its employment. For this reason 
 
 * Neque pudetfateri, me non semel in curandis febribus, ubi nondiim constant 
 quid mihi agendum esset, nihil prorsus agenda et mihi et cegro consulvisse uptime; 
 dum enim morbo incigilarem, quo eum upportumus confudere voter em, febris vet 
 sponte sud sensim evanuit, vel ^n eum se typum redegit, ut jam mihi innotescerct 
 quibus armis esset dcbellenda (SYDENHAM, torn. viii. p. 158.) 
 
 f Temerl nihil audendum, sed its qua levaminis aliquid qfferre hactenw con- 
 suescunt, innoxiis remediis utendum. De Sedibus et Causis Morbor. Ixiv. 5. 
 
 36 
 
422 THERAPEUTICS. 
 
 cinchona is cautiously tried in certain affections resembling inter- 
 mittent fever, and mercury employed in those suspected to be of 
 syphilitic origin. These remedies become in such cases a sort of 
 touchstone. 
 
 There have existed physicians in all ages, who have been distin- 
 guished either by a dangerous predilection or an antipathy nearly 
 as blameable for certain indications. Some have seen, in every 
 disease, indications for depletion and emesis ; others always purged 
 their patients without exception, either during the course of the 
 disease or subsequently ; or else administered tonics indiscrimi- 
 nately. Others, adopting the opposite extreme, asserted that such 
 indications never existed, and that blood-letting, cinchona and 
 purgatives were always injurious. We shall not attempt to prove 
 how erroneous and dangerous are these opinions ; their mention 
 alone is sufficient for their reciprocal destruction. There is no 
 remedy of unfailing utility, nor any which is constantly injurious ; 
 this is so evident that we should not have noticed it, had not these 
 exclusive, we might say absurd, opinions received the sanction of 
 celebrated names. 
 
 The aim of medical treatment is not merely to combat the exist- 
 ing disease ; it should be also directed, either to the prevention of 
 those maladies that threaten the healthy, or to hastening the 
 re-establishment of the functions in the convalescent : there are 
 prophylactic* or preservative indications, and also those of conva- 
 lescence and the consecutive phenomena of diseases. 
 
 Preservative indications occur in various circumstances. 1. The 
 offspring of parents affected by hereditary disease, should be sub- 
 jected to treatment suitable for modifying this unfortunate predis- 
 position to its transmission. 2. When the precursory signs of a 
 given disease are observed in any person, they furnish a prophy- 
 lactic indication which it is sometimes very necessary to fulfil, as, 
 for example, in threatened apoplexy. 3. An individual who has 
 been once, or more frequently affected with a disease of frequent 
 recurrence, as rheumatism, gout, etc., should take the appropriate 
 measures to prevent its return. 4. If a disease prevail epidemi- 
 cally, various prophylactic indications arise, from its form, causes, 
 etc. : they are founded, in all these cases, upon ordinary therapeu- 
 tical bases. 5. When contagious disease appears in any place, 
 there is a peculiar indication for the preservation of those who 
 cannot escape the danger of its contraction by flight ; this is, for- 
 bidding all communication, direct or indirect, with the patients. 
 In this way the Orphan Asylum of Moscow was preserved f from 
 the plague which desolated that city, and the Hottentots thus shel- 
 tered themselves from variola brought to the Cape of Good Hope 
 by a European vessel ; thus, also, during many pestilential dis- 
 eases, certain cities, or particular quarters of them, or a number of 
 houses, have been kept from the contagion. The same may be 
 
 w, I anticipate : from (pvluaaw, I guard ; and TIQO, in advance. 
 MERTENS, torn. i. p. 203. MEAD, Opera, p. 306. 
 
THERAPEUTICS. 423 
 
 said, in like cases, of the peculiar individual indications for those 
 who, from their profession or duties, are obliged to visit or remain 
 with the sick. 6. When a disease prevails or reappears endemi- 
 cally in any place, it gives rise to indications of another kind. If 
 neighboring marshy grounds occasion intermittent fever every 
 autumn, it will be necessary to drain the marsh, or to surround it 
 with a perpendicular enclosure, or, what is preferable, to convert 
 the stagnant water into a continual stream. The fetid and corrupted 
 water of a river caused devastating disease throughout an entire 
 province ; Empedocles increased the rapidity of its current by con- 
 necting with it two other rivers; the diseases never reappeared. 
 
 In convalescence, the principal indications are gradually to re- 
 establish the strength by suitable regimen, considering the patient's 
 general debility, and that of the digestive organs particularly : by 
 regimen we mean, not only the choice and quantity of food, but 
 also everything connected with those general attentions by which 
 the convalescent should be surrounded. When there is a ten- 
 dency to reproduction of the disease, as is the case in intermittent 
 fevers, it is often necessary and always useful to prolong the use 
 of a successful medication during a portion of convalescence. 
 
 For a long period, purgation of all convalescents was considered 
 a therapeutical axiom. This practice, which was not unattended 
 with danger, has now become obsolete; but, as too frequently 
 happens, the opposite extreme was adopted, and the absolute pro- 
 scription of purgatives in convalescence is not without its objec- 
 tions. The prudent physician will adopt neither of these exclusive 
 rules ; he fulfils an evident indication for purging when it exists 
 in convalescence, but declines such procedure in opposite circum- 
 stances. * 
 
 The indications derived from consecutive phenomena vary ac- 
 cording to the previous diseases and the phenomena themselves. 
 In such cases, the physician must not lose sight of the state of de- 
 bility in which the previous disease has left the convalescent, nor 
 of the danger of relapse. Both these considerations should be 
 weighed, when the most appropriate treatment for the consecutive 
 phenomena is desired. 
 
 Having enumerated the principal sources from which indica- 
 tions arise, we shall glance at the means employed for their fulfil- 
 ment. 
 
 ARTICLE SECOND. 
 Therapeutical Means. 
 
 THE general term, therapeutical means, comprises all that may 
 be employed by the physician for the restoration of health. Air, 
 
 * " Nee reconvale$cc,ns omnis aut tiim sollicitb, aut film pared nutriendus, aut 
 alvo purgandus, aut demwn roborandus. sed sua cuivis morbo, subjecto, afati, etc., 
 recnnvalescentia est, qua. dicetam sibi propriam et medico menta interna, externa, aut 
 varia, aut nulla sibiexposcit." FRANK, Epitome, i. 35. 
 
424 THERAPEUTICS. 
 
 habitation, regimen, abstinence, exercise, amusements, etc., are 
 therapeutical means equally with remedies, properly so called. 
 
 From the above enumeration we readily perceive that they 
 are almost infinite. All natural bodies, every artificial combi- 
 nation, every vital act, even, become appropriate means for the 
 fulfilment of indications. We shall not consider them in detail, 
 but only in a general manner. With this intention we shall divide 
 them into two classes : in the first, we shall place therapeutical 
 means properly so called ; in the second, general or hygienic 
 means. 
 
 SECTION FIRST. 
 Therapeutical Means, properly so called. 
 
 Therapeutical means proper, differ from hygienic means, by 
 reason of the latter being equally applicable to the healthy and the 
 diseased individual, and tending alike to preserve health and op- 
 pose disease, while the former are particularly directed to the 
 treatment of the disease, and are applicable only to those affected 
 or threatened by it. They have been divided into external or 
 surgical, and into internal or medicinal. 
 
 $ I. Surgical or external means have been described in 
 various series : in the first, are enumerated those which act syn- 
 thetically, * that is, by the union of divided parts, or the restor- 
 ation of those which are displaced: such are uniting bandages 
 and agglutinative plaster for wounds, splints for fracture, taxis in 
 hernia, etc. in the second series (diceresis).^ are included all 
 those operations that consist in the division of entire parts by 
 means of the hand, the knife or caustics : all incisions, from 
 simple phlebotomy to gastrotomy, appertain to diaeresis. In the 
 third series (exceresis) { are united all the methods employed for the 
 extraction of foreign bodies or injurious substances : the extraction 
 of urinary calculi, and the destruction of poisoned or envenomed 
 parts by caustics, belong to this series. The fourth series (pro- 
 thesis) $ includes all the mechanical appliances intended to sup- 
 ply the place of missing or deformed parts. This division of the 
 surgical, is no more exempt from imperfections than that of the 
 medical, means. The same operation sometimes necessitates the 
 concurrence of means from each of these four series, and the most 
 simple operations frequently require the aid of several : || in the 
 operation for strangulated hernia, for example, there is division, 
 
 * 0tu>, T/dijut, I place; auv, with. 
 t JiuiQita, I divide. 
 t '-ES, from ; al'Qw, I draw, 
 ft Otw, Tlfypi, 1 substitute ; TTQO, instead of. 
 
 | Traitt des Maladies chirurgicales et des Operations qui leur conviennent, par 
 BOYER. Paris, 1814-1816. 
 
THERAPEUTICS. 425 
 
 reduction, application of a bandage in order to remedy the weak- 
 ness of the abdominal parietes. and occasionally removal of a por- 
 tion of gangrenous epiploon or intestine. 
 
 II. The means belonging to internal pathology are yet more 
 insusceptible of methodical classification. None of the divisions 
 hitherto proposed has met with universal acceptance. The old 
 division of remedies into evacuants and alterants is entirely aban- 
 doned at the present day, and those which have been substituted 
 are hardly more satisfactory. 
 
 Remedies should be classed wholly by their action upon the 
 economy : this action being nearly always complex, often variable, 
 and sometimes, in entire opposition to the intended effect, in certain 
 individuals and diseases, the difficulty of making a regular division 
 is apparent: on this account, we are obliged to class remedies rather 
 according to the intention with which they are employed than by 
 their effects. The principal intentions in the administration of rem- 
 edies are to increase or diminish the evacuations, to augment or 
 reduce the strength, to calm or stimulate, and to oppose diseases by 
 those specifics whose action tends to arrest their progress : we may 
 thus divide nearly all remedies into seven principal classes, viz., 
 evacuants and astringents, debilitants and tonics, sedatives and stim- 
 ulants, and, lastly, specifics. We are the first to perceive the defects 
 of this classification, but we think they exist in all others, which 
 have the additional inconvenience of far greater complication. 
 The evacuants, it is true, do not always produce evacuations, and 
 astringents sometimes increase them; substances of reputed debili- 
 tating influence may occasionally augment the strength ; we are 
 aware that sedatives, and particularly opium, have sometimes 
 caused actual stimulation, and that properly speaking, there are 
 no specifics ; but if, as has been very judiciously observed, the 
 positive is found only in the human imagination, and exists no- 
 where in the acts of nature, we cannot require its presence in the 
 object now under consideration, * and even numerous exceptions 
 should not prevent us from considering, in a general manner, the 
 potassio-tartrate of antimony as emetic, blood-letting as debilitating, 
 opium as sedative, ammonia as stimulating, cinchona and mercury 
 as specifics f in the treatment of intermittent fever and venereal 
 diseases. 
 
 * The majority of remedies display a complex action, and may, for this reason, 
 be divided into several classes. Purgatives are debilitating and evacuant ; 
 cinchona is tonic and febrifuge ; some of the diuretics are stimulant and even tonic, 
 etc. This inconvenience is inherent in the subject, and is found in all classifi- 
 cations. 
 
 f The number of specific remedies is very small ; mercury, cinchona and sul- 
 phur are the only ones deserving this appellation ; vaccinia may be added, whose 
 effect is only preservative. There can be no specific remedies, except for diseases 
 arising exclusively from specific causes : syphilis, scabies, variola and intermittent 
 fever are, thus far, the only affections for which specific remedies are known : it 
 may be considered certain, that if new specifics are hereafter discovered, they will 
 be applicable to affections produced by specific causes, such as rabies, scarlatina 
 
 36* 
 
426 THERAPEUTICS. 
 
 We have previously shown, (while explaining the rules which 
 should guide the physician in experimentation,) how delicate and 
 difficult is the appreciation of therapeutical means; we insisted 
 upon the necessity of not prescribing, in the majority of cases, but 
 one remedy at a time. Medication was entirely different in the 
 times preceding our own. Physicians thought it indispensable to 
 encumber their prescriptions with a crowd of ingredients, even 
 when the disease required no medicine ; a draught which did not 
 contain at least five ingredients would have been faulty in its 
 composition, and the prescriber would have been accused of ig- 
 norance, or at least of carelessness. Time has shown the absurdity 
 of such medication, and poly pharmacy * has but a few interested 
 or credulous proselytes, whose number diminishes daily. Medical 
 men are not alone in condemning this practice ; the public perceive 
 how useless and ridiculous are these monstrous combinations of all 
 kinds of drugs, which often endanger the patient's life, and essen- 
 tially impede the progress of our art. 
 
 This great reform in practical medicine, to which the genius of 
 Pinel so powerfully contributed, has already been productive of 
 excellent results, and promises infinite advantages to the profession. 
 In most cases, it is by the employment of only a single remedy at 
 
 and rubeola. Epilepsy, on the contrary, which depends upon various causes, can 
 never have a specific remedy. [Why may not iodine be considered a specific in 
 the treatment of bronchocele ? Although not holding the same rank with mercury 
 and cinchona in regard to specific action, there seems sufficient evidence of its 
 efficacy in'this disease to give it a claim to the above title. Pereira distinctly 
 applies the term ; mentioning the uses of iodine, and comparing its therapeutical 
 influence with that of mercury, he says, "Iodine evinces a specific influence over 
 the diseases of certain organs (e g. the thyroid body,) which mercury does not." 
 And he subsequently adds, "Of all the remedies yet proposed for bronchocele, 
 this has been by far the most successful. Indeed, judging only from the numerous 
 cases cured by it, and which have been published, we should almost infer that it 
 was a sovereign remedy." (Mat. Med. and Therap. vol. i. p. 2<!8, Amer. edit.) 
 Dr. Copland, (Med. Diet. cited by Pereira,) remarks that of several cases 
 treated by him, " there has not been one which has not either been cured or 
 remarkably relieved by it." Bayle (Bibliotheque de Therapeutique, torn. i. p. 
 394,) gives a summary from several authors ; out of 364 cases treated by iodine, 
 274 were cured. Trousseau and Pidoux, after noticing the extraordinary suc- 
 cess obtained by Coindet in bronchocele, by the use of iodine, (cure in two thirds 
 of the cases) proceed to explain the probable reasons why the remedy often 
 fail? ; they consider it to be chiefly owing to the modifications in the form of the 
 disease. The simple goitre, which is only an hypertrophy of the thyroid gland, 
 disappears readily under the influence of iodine, which will naturally have less 
 effect where there is degeneration of the tissue of the glands, such as the scirrhous, 
 encephaloid, tuberculous, osseous, tophaceous, cartilaginous and encysted for- 
 mations, sometimes noticed. These considerations are also suggested by Pereira, 
 ( Op. cit. p. 229,) Trousseau and Pidoux mention the curious fact of the cure of 
 goitre being accomplished by the simple removal from the region where it was 
 contracted to countries where it is not endemic (L'Eveille, Eymery, Fodere, 
 J/ard), without any remedy being administered. (Traiti de Therapeutique et de 
 Matiere Medtcale, torn. i. p. 267.) The failure of iodine in cases complicated by 
 the above degeneration of the glandular texture is no more surprising than that of 
 mercury under like circumstances in its own peculiar province. We cannot see 
 why the title specific may not be appropriately applied to iodine.] TRANS. 
 * Pulypharmacy ; nolvg, many; (paquaxuv, a remedy. 
 
THERAPEUTICS. 427 
 
 once that we can properly appreciate its effects upon the system, 
 and consequently dispel some of the darkness which still surrounds 
 the most important branch of medicine. While we condemn the 
 simultaneous employment of a large number of remedies, we mean 
 those only of an active character, for others may be combined 
 without risk of injury, in accordance with the taste and even the 
 caprices of the patient : the simultaneous or alternate adminis- 
 tration of an infusion of violet flowers or of mallows, of anchusa 
 officmalis, or of mullein leaves, is to employ several remedies, but 
 the treatment is not thereby changed, the action of all these means 
 being not sensibly different.* There are cases also where it is 
 necessary to combine several active remedies, as depletion and 
 emetics, cinchona, wine and blisters ; but when the severity and 
 pertinacity of the disease do not require it, one remedy at a time is 
 preferable. 
 
 The indications not being the same throughout the whole course 
 of a disease, it is generally necessary to change the medication. 
 Tonics may be indicated in the latter period while depletion was 
 required at the commencement; but these alterations should be 
 gradual, and it hardly ever happens that opposite remedies are 
 indicated upon alternate days. Thus, in grave fever supervening 
 in a young man, the inflammatory symptoms manifested at its 
 commencement require debilitants, particularly blood-letting; 
 later in the disease, weakness no longer admits of bleeding ; still 
 later, the employment of some slight tonic is indicated, which is 
 administered in small doses, and only during the remission ; the 
 dose may be increased daily and given at shorter internals ; finally, 
 when the adynamic symptoms are fully established, and particular- 
 ly, when there is diminution of heat and slow pulse, the most ener- 
 getic tonic remedies should be employed, as extract of cinchona, 
 camphor, generous wines, etc. In this case, the means employed 
 at the commencement and at the termination of the same disease 
 are in complete opposition; but the treatment cannot be ques- 
 tioned, because there is the same change in the phenomena of the 
 disease. Far different would be the case, if the physician, con- 
 stantly fluctuating in his opinion upon the nature of the affection, 
 and imagining opposite indications every little while, in the same 
 disease, should each day lay aside the prescriptions of the previous 
 evening, and resume those he had once before abandoned. How- 
 ever various may be the forms of disease, no excuse can be thence 
 derived for such vacillation, which always indicates, in the physi- 
 cian, unequivocal want of experience or indecision. 
 
 The number of remedies being infinite and that of the indica- 
 tions limited, it results that each of the latter may be fulfilled by 
 various remedies, from which the preferable one should be selected 
 
 * As Bayle has remarked, the treatment should not be confounded with the 
 remedy. Treatment is not the employment of a certain remedy in a given disease, 
 but the method of combatting that disease, by fulfilling, in the manner considered 
 most proper, a certain indication Remedies may vary according to situation, the 
 age in which we live, and even fashion , and yet the treatment be the same. 
 
428 THERAPEUTICS. 
 
 and administered in forms and doses varying according to a mul- 
 titude of circumstances, and consequently incapable of previous 
 determination. Therapeutics are less susceptible of mathematical 
 precision in this respect, than all the other branches of medicine. 
 When blood-letting is indicated, for instance, it is impossible that 
 all physicians should be able to declare the number of times that 
 it will be practised, and the precise quantity of blood that will be 
 drawn. In a disease where one would prescribe infusion of cin- 
 chona, another will prefer the decoction, powder, or extract ; one 
 will use serpentaria in a case where another will order angelica 
 or cascarilla ; all, however, will pursue the same treatment and 
 perceive the same indication ; the only difference will be in the 
 mode of its fulfilment. 
 
 The forms in which medicines are administered are extremely 
 various. Some are given in the solid state, others in the form of 
 gas, or of vapor, but the majority are liquid. They are some- 
 times applied externally ; most frequently, however, they are 
 introduced into the interior of the body, and particularly into the 
 digestive canal, whence they are absorbed into the system. 
 
 Certain medicaments are exhibited singly, others in a state of 
 combination with different substances, which at one time augment 
 or modify their action, at another merely serve as their vehicle. 
 The preparation and preservation of medicines are the peculiar 
 province of pharmacy.* 
 
 The dose of medicines must be regulated by the energy of the 
 active principles they contain, also by the proportion of those 
 principles, which sometimes varies, f the patient's age and suscep- 
 tibility, the kind of disease, and the effect desired ; it should also 
 vary relatively to the time during which the medicine has been 
 administered ; habit diminishes the power of medicines, as it does 
 that of morbific causes, and it is necessary, after a certain time, 
 to increase the doses, by a methodical progression, to change 
 their mode of preparation, or even to resort to other remedies, 
 when several will fulfil, equally well, the same indication. 
 
 SECTION SECOND. 
 General or Hygienic Means. 
 
 Hygiene J is that branch of medicine whose purpose is the pre- 
 servation of health and the prevention of disease. Whatever 
 conduces to this double result may be classed with hygienic 
 means. 
 
 If hygiene may be termed the medicine of the healthy, hygienic 
 
 * <J>u(>j/axov, a medicine. 
 
 f A mass of opium, or a portion of extract of nux vomica, may differ so 
 much in this respect, that the same dose, taken from the new specimen, shall 
 produce toxical symptoms. 
 
 \ 'Yyiiia, health. 
 
THERAPEUTICS. 429 
 
 means are as applicable and necessary to the diseased as to those 
 in health ; the latter may, sometimes, dispense with them with 
 impunity ; the former cannot. 
 
 Not only are hygienic means very useful in diseases, but even 
 more so than any medicines, properly so termed. The efficacy of 
 many remedies may be doubtful, that of hygienic means cannot 
 be contested. By their aid alone, without medication, the majority 
 of acute diseases may terminate favorably ; without their concur- 
 rence the most clearly indicated medicines will always be insuffi- 
 cient; this is not mere conjecture, but a truth confirmed by the 
 past and present observation of innumerable facts. In places 
 where there are no physicians, and where, consequently, there is 
 little, or, as too frequently happens, unsuitable medication, nature, 
 assisted by the hygienic means that good sense suggests, in the 
 majority of cases not only conquers the disease, but overcomes 
 also the aggravating influence of improper remedies. In entirely 
 different circumstances, where the patients have medicine and 
 skilful physicians to administer it, but are in bad hygienic condi- 
 tions, severe diseases terminate in death, almost without exception, 
 and those even originally far less dangerous, become fatal. The 
 crowding of patients in confined and ill- ventilated apartments, 
 bad air, entire want of cleanliness, destitution of linen and outer 
 garments, exposure to cold and rain, errors in diet, and depression 
 of spirits, have constantly produced the above fatal effect when- 
 ever their influence has been conjointly manifested; while in a 
 multitude of acute affections, as variola discreta and regular 
 typhus, a cure has been effected solely by the aid of general or 
 hygienic means, no active remedy having been employed. 
 
 We have previously pointed out the necessity of administering 
 active remedies singly, or at least, in small number at one time. 
 The contrary is the rule with hygienic means ; it is, we may say, 
 impossible to combine too many of them in the treatment of both 
 acute and chronic diseases. 
 
 These means, although not precisely similar in all diseases, are 
 analogous in the majority, both of the acute and chronic form, 
 which enables us to give a brief statement of them, as constituting 
 a very important point in general therapeutics. 
 
 $ I. General Means in Acute Diseases. 
 
 A. Circumfusa. In acute diseases, patients should occupy an 
 apartment of sufficient size to avoid deterioration of the air, and 
 having several openings, so that its renewal may be easily ef- 
 fected. The temperature of the room sjiould be mild; during 
 summer it may be lowered by excluding the solar light, or by 
 aqueous aspersion ; in cold weather it should be elevated by 
 means of fires. In winter, a westerly and southern exposure is 
 the best ; a northern and easterly one in summer. The tempera- 
 ture should vary also with the nature of the disease and the state 
 
430 
 
 THERAPEUTICS. 
 
 of the animal heat in the patient. A dim light is proper in dis- 
 eases characterized by augmented vital action ; where the latter is 
 diminished, a bright light is preferable. When the air of the 
 patient's room has become foul, when the exhalations or excre- 
 tions are fetid, and especially when the affection from which he 
 suffers is contagions, his own interest, as well as that of the 
 assistants, demands his removal, if possible, to a larger apartment, 
 frequent renewal of the air by opening the windows, the use of 
 ventilators, or aromatic fumigations, which, if they do not destroy 
 the contagious principles, at any rate communicate a stimulating 
 property to the air which the patient breathes. Great importance 
 has been attached, for several years, to fumigations with chlorine, 
 for the destruction of miasmata and virus; but since M. Bousquet, 
 by repeated trials, has proved that the addition of chloride of soda to 
 vaccine matter did not in the least change the contagious property 
 of the latter, chlorine has necessarily lost much of the reputation 
 for special action attributed to it by chemical theories.* 
 
 If the patient be in a small, damp chamber, or in one used in 
 common with him by several others, he should be removed, when 
 a more suitable place can be provided, notwithstanding the seem- 
 ing difficulties of transportation. Numerous examples prove, that 
 individuals very dangerously ill have been removed from hospitals 
 and carried a long distance, not only without aggravation of the 
 disease, but with an amendment daily more decided : the observa- 
 tions of Lindj in particular, support this assertion. 
 
 B. Applicata. The most scrupulous attention to cleanliness is 
 absolutely necessary for those laboring under acute disease ; the 
 linen, therefore, should be frequently changed. This principle, 
 generally admitted at the present day, was long misunderstood ; 
 and strange to say, in eruptive and contagious fevers, variola par- 
 ticularly, where the linen is constantly soiled with pus, and con- 
 sequently requires to be more frequently changed, the contrary 
 was most strenuously advised. There is no risk in changing the 
 linen, provided it be not too often repeated and fatigue be not 
 induced : it may even be done, with proper precautions, during 
 perspiration, f when chills are usually apprehended. 
 
 * Fumigations with chlorine are, however, spoken of in the most commenda- 
 tory terms by the best authorities ; the disinfecting property it possesses is of 
 so great service and such universal application, that it must necessarily always 
 be appreciated. Thomson styles it the most efficacious means of fumigation. 
 (Management of the Sick Room, p. 275, Amer. Edit.) Perejra says, " as a 
 fumigating agent, disinfectant, and antiseptic, chlorine, I believe, stands un- 
 rivalled." (Mat. Med. and Therap, vol. i. p. 219, Amer. Edit.) The appear- 
 ance of epidemic cholera or. yellow fever, notwithstanding its profuse employ- 
 ment, (as mentioned by Trousseau and Pidoux ; Therapeut., etc., art. Chlore,) 
 hardly prove, as these authors assert, its inutility in epidemics: can we declare 
 that the diseases would not have spread more widely or have caused greater 
 mortality, if it had not been used] These authors do not, of course, deny its 
 disinfecting qualities. TRANS. 
 
 f These precautions consist in passing very warm napkins beneath the moist- 
 
THERAPEUTICS. 431 
 
 Beds used by the sick require a certain degree of attention. The 
 wool mattress is most commonly employed ; one filled with hair 
 would be preferable in hot weather, for those affected with nephri- 
 tis, haemorrhage, or sanguineous congestion of the pelvic viscera : 
 patients should never be allowed to lie upon feather beds. It will 
 often be necessary to protect the bed, either with substances suita- 
 ble for the reception of the excretions, or by means of cloth imper- 
 meable by fluids; * cushions are sometimes needed, so arranged as 
 to relieve certain parts from injurious pressure. The arrangement 
 and position of the bed should conform to the circumstances of the 
 disease : if constant dorsal decubitus be requisite, the bed should 
 be on a horizontal plane ; in those affected or threatened with 
 cerebral congestion, it should be so inclined that the head may be 
 much higher than the rest of the body. Many kinds of mechani- 
 cal beds have been invented, for the purpose of elevating the body, 
 removing pressure from certain parts, or passing a bed-pan more 
 readily beneath the patient, etc.; these beds are particularly useful 
 in fractures of the lower limbs. 
 
 The application of hot napkins over the whole body or to par- 
 ticular regions, in cases of general or partial chill, and the use of 
 globes or tin vessels containing hot water, etc., should also be 
 classed among the general means. 
 
 C. Ingesta. The use of food and drinks is highly important 
 in acute diseases. There are two inconveniences, equally great, 
 that should both be carefully avoided, viz., too abundant and too 
 restricted nourishment. Ramazzini said very justly, that the 
 poor often died from repletion, when ill, and the rich from the 
 effects of the too severe diet to which they were restricted. 
 Hippocrates thought it less dangerous to slightly exceed the neces- 
 sary amount of nourishment, than to enjoin too strict abstinence. 
 The proper medium should be sought for, in acute disease, all solid 
 food being proscribed, but allowing, (when febrile action is not 
 very intense and the patient expresses a desire for them,) slightly 
 nutritious drinks, as veal, chicken or frog broth, and even certain 
 ripe fruits, a few grapes or some slices of orange, of which the 
 juice only should be swallowed ; but during the period of violence, 
 (chap. viii. p. 235,) the diet should be more restricted, and, most 
 
 ened body linen, in which the legs, thighs, abdomen, chest, and even the neck, 
 should be successively enveloped, so that when the moist linen is removed in 
 order that dry may be substituted, the patient may be completely covered by the 
 warm and dry clothes : the arms alone are momentarily exposed to the air; but 
 the rest of the body is protected. 
 
 * The great degree of perfection attained in the fabrication of caoutchouc, has 
 proved a source not only of convenience but of great comfort to the healthy as 
 well as the sick : the variety of uses to which it is now applied is almost in- 
 finite ; from beds, pillows, cushions, and portable baths, down to far more 
 minute and fanciful articles, it is seemingly well adapted to all. In surgery and 
 practical midwifery, for the sake of cleanliness alone, it is highly valuable ; 
 also in irrigation of different parts of the body, for the purpose of protecting the 
 bed-linen, etc. TRANS. 
 
432 THERAPEUTICS. 
 
 frequently, complete abstinence should be enjoined ; " the unseason- 
 able ingestion of food," remarks a celebrated physician, "nourishes 
 the disease and not the patient." During the period of decline, its 
 use should be gradually resumed. 
 
 D. Excreta. The immediate removal of excreted matters from 
 the sick room and from the patient's body, is of the greatest im- 
 portance during acute disease : the perspiration, when it cools upon 
 the body, is highly injurious ; the urine and faeces, already modi- 
 fied by the disease and liable to rapid putrefaction, communicate 
 noxious properties to the air ; matters which are vomited excite 
 retching both by their appearance and odor. When the urine and 
 faeces are excreted involuntarily, still worse results may follow 
 their contact with the patient's body : they may be absorbed by 
 the skin, or may rapidly determine either a pustular eruption or 
 excoriation of the sacral integuments, and excite the formation of 
 eschars, which are always dangerous and often fatal. 
 
 E. Acta. Rest and nearly constant confinement to bed is gen- 
 erally advised in acute diseases : patients are benefitted, however, 
 by daily removal from one bed to another, or by being seated in an 
 armchair, according to their strength, where they may remain until 
 fatigue or uncomfortable sensations oblige them to resume their 
 former position. Sydenham advised that patients should be re- 
 moved from bed daily; he considered this a preventive of, and a 
 remedy for, delirium. We have previously seen that passive exer- 
 cise, and even transportation for a long distance, was beneficial to 
 fever-patients: it is possible that this means, (whose beneficial 
 effects have been frequently proved by chance or necessity,) may 
 have been too generally neglected. 
 
 The position of patients too feeble to move without assistance, 
 should be frequently changed ; negligence in this respect almost 
 necessarily induces the formation of eschars upon parts exposed to 
 compression, and all their disastrous consequences. 
 
 Sleep is generally favorable in acute diseases: consequently, 
 everything likely to act powerfully upon the patient's mind or 
 senses, and thereby prevent it, should he avoided : for the same 
 reason, sleep should not be interrupted needlessly, either for the 
 administration of remedies or any other purpose, except it have 
 been very prolonged, or there be urgent necessity for taking medi- 
 cine. When sleep does not take place naturally, it may sometimes 
 be induced, by raising the patient for a few moments and arranging 
 his bed before replacing him ; when this is insufficient, if there be 
 no counter indication, a soporific may be prescribed. 
 
 Ft Percepta. The sensations, moral affections and intellectual 
 functions demand the special attention of the physician. We have 
 seen in what cases the presence of light is favorable or prejudicial : 
 noises, and particularly all sorts of conversation, are nearly always 
 injurious in the sick room : whispering often causes apprehension 
 
THERAPEUTICS. 433 
 
 in the patient ; loud talking fatigues him. Strong and penetrating 
 odors are generally dangerous in inflammatory diseases, but may 
 be serviceable in adynamic affections and certain neuroses. 
 
 The influence of the passions upon the progress of diseases is so 
 powerful, that nothing, which will give them a favorable direction, 
 should be neglected. For this reason the physician should put in 
 requisition all proper means for securing and retaining the patient's 
 entire confidence, and be on his guard continually that nothing in 
 his conversation or actions impair it. By listening to him very 
 attentively, and expressing a particular interest in his case, the 
 first object may be attained. Whatever may be his opinion as to 
 the result of the disease, a favorable prognosis should always be 
 given in presence of the patient ; he should be accosted confidently, 
 and calmness maintained while with him, even where there is 
 every reason to apprehend the greatest danger ; no inconsiderate 
 word, no unguarded gesture, no alteration of countenance should 
 lead the patient to suspect, in the least, the peril by which he is 
 threatened. Those who remain with him should be advised to 
 show no anxiety whatever ; and, for this reason, the extent of the 
 danger should not be disclosed to those who might not have the 
 resolution or intelligence requisite for concealing it. There are 
 patients who constantly urge their physician to tell them whether 
 they are in danger, protesting that they have no fear of death ; 
 but this very assertion, and particularly their eagerness to know 
 the probable termination of their disease, proves that they are far 
 from being resigned : the physician should be on his guard against 
 these importunities. Men who have been accustomed to brave 
 death under circumstances where they could perish gloriously, 
 have been observed to quail at the idea of the danger which threat- 
 ened them in sickness, and to lose all courage when their inevitable 
 death was announced. A truly philosophical, and still more, a 
 religious spirit, may impart to some, the firmness necessary for 
 receiving with calmness the announcement of their approaching 
 death ; but these few exceptions do not destroy the common rule : 
 the fear of death generally adds to the gravity of serious disease, 
 and the physician who permits a patient to suspect the danger of 
 his position, lessens the chances of cure. He who announces to a 
 patient that his disease is necessarily fatal, will be compelled to 
 reproach himself not only for shortening the life which he should 
 have endeavored to prolong, but also for bringing affliction and 
 despair to those whom he should console and encourage. 
 
 All mental excitement is injurious in acute affections : patients 
 should consequently be restrained, if necessary, from exposing 
 themselves to its effects; most frequently, however, they have 
 neither the wish nor the power to do so, and it will suffice for the 
 fulfilment of this indication, to recommend those in communication 
 with them to say nothing in their presence which might excite 
 serious reflection or profound meditation. 
 37 
 
434 THERAPEUTICS. 
 
 $ II. General Means in Chronic Diseases. 
 
 i 
 
 Hygienic means are quite as useful in chronic as in acute dis- 
 eases. Change of habitation and of climate, travel by land and sea, 
 frictions, cold and warm bathing, the form and texture of the gar- 
 ments, the number of meals and the intervals between them, the 
 choice and quantity of food and drinks, active and passive exercise, 
 walking, running, equitation and amusements of every description, 
 are the principal hygienic means recommended, with peculiar mod- 
 ifications, in the course of chronic diseases : in very many such 
 affections, their action is infinitely superior to that of medication in 
 the usual acceptation of the term. In nervous affections particu- 
 larly, especially those dependent upon moral causes, in those vari- 
 ous derangements of the digestive organs, so frequently occurring, 
 and so long and improperly confounded under the common denom- 
 ination of gastritis, what numberless resources are found by the 
 physician in the methodical employment of hygienic means, and 
 particularly in a more proper distribution of the time allotted to 
 mental and physical exercise, in a greater regularity of the meals, 
 and in that thorough change of all the habits effected by journeys 
 or residence in a different climate. The patient who passes the 
 winter in a warm climate, finds other circumstances favorable to 
 health, besides the mere amelioration of the atmosphere : his hy- 
 gienic condition becomes totally different. If, for example, he 
 leaves Paris for Pau, Hieres or Pisa, he not only enjoys a milder 
 climate, but the air differs in many other respects from that he 
 habitually respires ; his food and drinks will be of different quali- 
 ty ; his secretions will be modified ; his hours for taking food, for 
 sleep and waking will be changed ; his walks, his physical and 
 intellectual occupations, society and thoughts will be unlike those 
 to which he has been accustomed ; his clothing, even, will undergo 
 slight modifications ; in short, a thousand new influences will affect 
 him, and concur in modifying the organism in a way difficult to 
 describe, but sure in its results. 
 
 We commenced this chapter by glancing hastily at the founda- 
 tions of therapeutical science; examining afterwards the indica- 
 tions and the means for their fulfilment. It has been shown that 
 indications were not always evident ; but that, notwithstanding 
 this, inaction was inadmissible in cases where the disease made 
 daily progress. In these difficult circumstances, it is the physician's 
 duty, after having collected all the facts that can yield him 
 any information, and compared the case submitted to his care 
 with similar or analogous cases supplied by his own recollection or 
 the annals of the science, to treat his patient as he would wish to 
 be treated himself, if similarly affected. It was this favorite maxim 
 of Sydenham, which sustained him in the arduous as well as hon- 
 
NATURE OF DISEASE. 435 
 
 orable duties of his profession : " dEgrorum nemo a me alias trac- 
 tatus est, quam egomet tractari cuperem, si mihi ex iisdem morbis 
 cegrotare contingeret"* M. 
 
 CHAPTER XX. 
 
 NATURE OF DISEASE. 
 
 HAVING successively considered each of the principal subjects 
 within the domain of general pathology, confining ourselves as 
 far as possible to the positive part of this science, we feel con- 
 strained, if not to consider in its whole extent, at least to take a 
 brief survey of its hypothetical portion, that we may become con- 
 vinced of the total inefficacy of our own powers in guiding us 
 through this labyrinth, and thus bringing us to a knowledge of the 
 truth. 
 
 We shall first endeavor to show what is understood by the na- 
 ture, essence or proximate cause of diseases ; and afterwards, to 
 what extent, the means, which we have at our disposal, are avail- 
 able in aiding us in these investigations. 
 
 It is incorrect to suppose that disease consists, essentially and 
 entirely, of the symptoms it exhibits, and the anatomical lesions 
 revealed after death. In those cases of neuralgia in which no 
 appreciable lesion is discernible, there is necessarily some modifica- 
 tion in the affected nerve, from which the pain arises. In the de- 
 velopment of a phlegmasia or an organic degeneration, as tubercle 
 or cancer, some change is previously effected in the diseased parts, 
 and this change has induced the secondary alterations which, in one 
 case, characterize the inflammation, and, in the other, the cancer- 
 ous or tuberculous affection. The latter lesions are appreciable to 
 the senses, and are distinguished by their apparent characteristics ; 
 but the primary phenomenon which precedes and produces them 
 escapes us, both because it occurs in the most minute parts of the 
 organization, and because the structure, and, consequently, the 
 intimate action of these parts, not only in man, but in all living 
 beings, to whatever kingdom they belong, is beyond our means of 
 investigation. 
 
 We are aware that skilful anatomists, by works that deserve the 
 highest praise, are daily extending this branch of knowledge ; that, 
 by the most minute injections and the most delicate dissections 
 they are enabled to trace, in the tissue of organs, the course of the 
 vessels and nerves, further than any who have preceded them. 
 But, without referring to the legitimate doubts which may and 
 indeed must arise respecting the accuracy of these results in 
 
 * SYDENHAM, Opera, torn. i. p. 77. 
 
436 NATURE OF DISEASE. 
 
 microscopical anatomy, the continual subjects of dispute and 
 contradiction among those devoted to these labors, it should be 
 recollected that the difficulty is but farther removed, that it still 
 exists, and that if it be possible to show by injections the ultimate 
 arterial ramifications, with the secretory and excretory vessels of 
 the kidneys, pancreas and liver, we still remain ignorant of the 
 structure and action of these vessels, in the mysterious mechanism 
 of the formation of the urine, bile and pancreatic fluid. If it be 
 impossible, then, to distinguish the intimate texture of those parts 
 in their healthy condition, there is a still stronger reason for recog- 
 nizing the impossibility of appreciating, in disease, the intimate 
 modifications which occur in these delicate parts, whose regular 
 action is to us unintelligible, and whose organization, which death 
 enables us to examine with all our means of investigation, is no 
 less inexplicable. The history of medicine affords but too many 
 proofs in support of this opinion. 
 
 This absolute ignorance in regard to the peculiar modifications 
 of the organism in the production of disease, extends also to each 
 of its successive periods, as is evident if we but attempt to leave the 
 domain of secondary phenomena, for the purpose of investigating 
 primary facts. Thus, we are acquainted with the conditions 
 necessary to the production of intermittent fevers, but are unable 
 to discover the mechanism of their production and the return of 
 their paroxysms ; we see, in acute diseases, successive periods of in- 
 crease, acme and decline; we appreciate the successive changes pre- 
 sented by the symptoms in each of these periods, but the discovery 
 of the power which presides over these various changes escapes all 
 our efforts. Farther, when by the aid of means as energetic as 
 quinine, we are enabled to suspend, on any given day and hour, 
 the course of the disease, we must admit that we are completely 
 ignorant, both of its peculiar nature and the action of the success- 
 ful remedy. In short, health and disease, life and death, subjects 
 so productive, in their sensible phenomena, of meditation and study, 
 are, in regard to their primary causes or nature, incomprehensible 
 mysteries. 
 
 Physicians of every age have nevertheless attempted to discover 
 the intimate nature of diseases : some have followed, in these 
 difficult efforts to proceed from the known to the unknown, a course 
 apparently methodical. They supposed that, by carefully consid- 
 ering the causes which produce the disease, its apparent phenom- 
 ena, the circumstances which modify its course, and the accom- 
 panying organic alterations, they should be able to ascertain the 
 intermediate mode of action between the effects and causes, and 
 discover the peculiar change which precedes and induces the sec- 
 ondary modification. But among those who have undertaken 
 these obscure researches, many have followed a more adventurous 
 course. Instead of deducing their opinions from observations, 
 these did not hesitate to modify facts in order to preserve their hy- 
 potheses, and to overthrow therapeutics in rendering it conformable 
 to their theories : their proselytes were thus led into a double error ; 
 
NATURE OF DISEASE. 437 
 
 on the one hand, the path of observation was forsaken, and on the 
 other, an erroneous and dangerous method of treatment was incul- 
 cated. There have been at the same time, however, persons of 
 sound judgment and profound sagacity, who, in indulging in these 
 hazardous speculations, have, themselves, placed a proper estimate 
 upon their own conjectures ; their only object in proposing them 
 having been to pay the taste of their contemporaries a necessary 
 tribute, without which their works might not have been welcomed. 
 It was thus with Sydenham, who, by a reflection on himself, 
 acknowledged the insufficiency of his own theories, by adding that 
 in regard to practice, he had advanced nothing, the truth of which 
 had not been confirmed by his own experience. " I have directed 
 all my efforts," he farther adds, u to the elucidation of the treat- 
 ment of diseases, being persuaded that he who can point out a 
 method of cure for the most trivial affection, deserves higher praise 
 than he who becomes distinguished by his powers of reasoning, and 
 those pompous subtleties which are as unprofitable to the phy- 
 sician, in the cure of disease, as the knowledge of music to an 
 architect in the construction of a building."* 
 
 The results of researches undertaken for the purpose of acquir- 
 ing knowledge which is unattainable, have been and must be 
 widely different : we cannot then be surprised at the diversity in 
 the theories which have been proposed in regard to the nature of 
 disease ; it would be, on the contrary, a matter of astonishment 
 were this not the case. Among these hypotheses, some are based 
 upon alterations of the humors, others upon those of the solid parts 
 of the body, so that they may be referred to two great divisions, 
 humorism and solidism, each the subject of opinions as numerous 
 as the followers of these two theories. 
 
 The humorists, who made the essence of disease to consist in 
 the alterations of the fluids, applied, to most affections, terms in 
 accordance with their theories. Instead of saying that a disease 
 affected the liver, or the circulatory organs of the blood or lymph, 
 they placed its seat in the fluids themselves contained in these or- 
 gans. The morbific causes always affected the fluids; the aliments 
 elaborated by the stomach, and converted into chyle, modified the 
 qualities of the blood ; a similar effect was produced by the action 
 of poisons, virus, etc. In their exposition of symptoms, their lan- 
 guage was still in conformity with this theory; the color and con- 
 sistence of the blood, mucus, alvine matters, urine and pus, claimed 
 their particular attention ; other symptoms were hardly alluded to, 
 or were attached to their favorite nomenclature by means of col- 
 lective names. It was from the alterations of the humors that 
 they explained the connection and succession of symptoms. They 
 designated, by the terms, crudity, coction and evacuation, the three 
 principal periods of diseases, according to the condition of the mor- 
 bific matter. In the first period, this matter, endowed with all its 
 deleterious power, not having undergone any alteration, still 
 
 * SYDENHAM, Opera omnia, torn. i. p. 77. 
 37* 
 
438 NATURE OF DISEASE. 
 
 preserved its crudity ; in the second, in which coction was effected, 
 nature gradually gained the advantage ; and, finally, in the third, 
 the material principle, rendered movable, was evacuated with the 
 urine, sweat, fsecal matters, or by some other means, and the equilib- 
 rium was restored. When no evacuation took place, they sup- 
 posed that the morbific matter, after having undergone the necessary 
 elaboration, became assimilated with the natural humors, and from 
 that moment became harmless; coction was perfect or imperfect; 
 and the transformation of one disease into another was readily 
 explained by means of the transfer or emigration of the humoral 
 principle which presided over its development. It was particularly 
 from the inspection of evacuated fluids that they formed conclu- 
 sions with regard to the termination and duration of diseases ; the 
 urine, particularly, furnished signs to which they attached much 
 importance. They were confirmed in their opinion by necroscopy ; 
 the redness and swelling of inflamed parts, they regarded as the 
 effect of an accumulation of blood ; dropsy, as the dissolution of 
 this fluid ; tubercular degeneration they considered but a thick- 
 ening of lymph; and most other organic alterations but obstructions 
 produced by the consistence and coagulation of fluids. The thera- 
 peutical indications were in accordance with the other points of the 
 humoral doctrine. Bleeding was practised in order that the blood 
 might be renewed, to diminish its viscidity, or to remove a portion 
 of the morbific matter with which it was mixed ; purging, sweat- 
 ing, and diuresis were excited for similar purposes ; in short, all 
 the indications consisted in changing the quantity or quality of the 
 fluids, or determining their afflux towards certain organs. 
 
 The solidists regarded the same subjects in a totally different 
 point of view : according to this class of philosophers, the fluids 
 play but a passive part in the phenomena of life ; deprived of vi- 
 tality, sensibility and contractility, they are entirely subordinate to 
 the action of the sensible and contractile organs containing them. 
 Disease, consequently, resides essentially in the solids, which are 
 alone capable of receiving the impression of morbific causes, and of 
 furnishing important symptoms. Sympathy, whose seat is the 
 nervous system, satisfactorily explains the connection between the 
 symptoms and the general disturbance which accompanies any local 
 affection. Metastasis and crises are. in their opinion, more favorable 
 to their own theory, than to that of the humorists. " Indeed, the 
 discharge of a small quantity of blood, urine, fsecal matters or sweat, 
 is insufficient to explain the passage from disease to health, inas- 
 much as the presence of these in the economy is incapable of de- 
 ranging the regularity of the functions ; there is, according to them, 
 a transfer of action* or irritation^ and not of fluid; it is much 
 easier, seriously say they, for nature to transfer one than the other. 
 The organs, in disease, preserve or acquire certain relations, by 
 virtue of which they transmit to each other their impressions; the 
 
 * SPRENGEL, Pathol. general. 
 
 j- MA RAN DEL, These sur les Irritations. 
 
NATURE OF DISEASE. 439 
 
 irritation which affects any organ for many days, may thus be 
 transmitted to some other : the first resumes its functions, and if 
 the transmitted affection be slight, health is restored ; if it be grave, 
 it constitutes metastasis. The most convincing proof that there is 
 simply a transport of irritation, is, that metastases and crises are 
 sometimes observed, which consist solely in the transfer of pain or 
 some other nervous phenomenon, without the exhalation of any 
 fluid, as is noticed in the neuroses and rheumatic affections. Finally, 
 in cases where there is an afflux of fluid towards an organ, the quali- 
 ties of this fluid present the greatest variety ; the only constant cir- 
 cumstance is an irritation which precedes it, and which is character- 
 ized by pruritus, pain, heat, swelling, redness or some other analo- 
 gous change in the part, where the crisis or metastasis takes place. 
 In regard to the diagnostic or prognostic signs presented by the 
 fluids, they are always of secondary importance, and the results of 
 necroscopy, which so clearly show the alterations of the solid parts, 
 prove how slender is the basis upon which humoral pathology is 
 founded. Finally, the most accurate indications arise from changes 
 in the external appearance, movements and heat, and in the organs 
 of digestion, respiration and circulation ; all these symptoms are 
 evidently furnished by the solids, to which these functions be- 
 long." 
 
 Such are the principal points of the doctrines of humorism and 
 solidism : we have thought proper to present them together, with- 
 out adding any remark. The old doctrine of humorism was based 
 upon inaccurate data, furnished by the science of chemistry when 
 in its infancy ; upon a theory totally false, in which, with an entire 
 disregard of the vital influence, the alterations in the humors were 
 attributed to a fermentation or putrifaction analogous to what 
 takes place without the body. To show the absurdity of this sys- 
 tem, and to overthrow it, was by no means a difficult task. The 
 brilliant physiology of Bichat, the ardor with which Pinel attacked 
 the humoral doctrine, the zeal with which the study of pathologi- 
 cal anatomy was prosecuted, together with the prejudice in favor 
 of solidism^ which naturally arose, all these circumstances rapidly 
 effected a complete revolution in the science, and the entire medical 
 generation of this period and that immediately following, adopted 
 in reality, if not in principle, an exclusive solidism, from which 
 arose and became developed the system of irritation. All influence 
 of the fluids in the development of diseases was rejected, and all 
 the phenomena of life, in disease as well as health, were made to 
 depend immediately upon the solids. 
 
 We were among the first, in 1817, to contradict this opinion,* 
 and to endeavor to attach all the importance to the fluids, which 
 they deserve in the phenomena of life, whether in health or disease. 
 We attempted to show, 1st, by the normal composition of the hu- 
 man body, in which the fluids exist in an incomparably larger 
 proportion than the solids ; 2dly, by the alterations revealed by 
 
 * First edition of this work, 1817. 
 
440 NATURE OF DISEASE. 
 
 necroscopy which, in some cases, exclusively affect the fluids; 3dly, 
 by the nature of the various agents by which the health may 
 become deranged, some of which, as the aliments and drinks, 
 introduced into the economy by absorption, evidently modify the 
 composition of the fluids ; 4thly, by certain modifications which evi- 
 dently exist in the lining fluids, as those presented by the blood in 
 scurvy and icterus, by the urine in diabetes, by the bile in the 
 formation of hepatic concretions, etc., that the doctrine of solidism 
 is insufficient to account for the phenomena observed, and. sooner 
 or later, must yield to a less exclusive system. 
 
 Since that time, a great change has taken place in the opinions 
 of the medical world. To the facts to which we have just referred, 
 others have been added ; the diminution of albumen in the blood 
 and its presence in the urine, in those affected with Bright's dis- 
 ease ; the changes in the relative proportion of fibrine and red 
 globules in the blood in inflammatory fevers and chlorotic affec- 
 tions ; the presence in this fluid, either of pus in certain diseases, 
 or of venomous substances in cases of poisoning, and the various 
 modifications in the milk, urine and saliva,* have added such a 
 multitude of facts to those which we pointed out twenty years ago, 
 that an entire change of opinion has been effected. The chemical 
 and microscopical labors of many distinguished scientific men, 
 among whom may be mentioned MM. Thenard, Bright, Orfila, 
 Dumas, Andral, Donne, and Rayer, have contributed to restore to 
 the fluids their importance in the phenomena of health and disease. 
 It is possible that after so long discrediting the most manifest alter- 
 ations in the fluids, we may be at present rather inclined to suspect 
 their existence in all cases, and to admit them upon the slightest 
 indications, and without sufficient observation, and to exaggerate 
 their importance with the threefold reference to etiology, symptom- 
 atology and therapeutics : such is the proneness of the human 
 mind to extremes, and the difficulty, in all cases, to maintain a just 
 medium, the surest defence from exaggeration and error. 
 
 We shall not follow the humorists and solidists in the numerous 
 alterations which they have supposed, in order to explain the na- 
 ture of diseases ; we shall also abstain from exposing the various 
 systems,! which, from the earliest ages, have successively reigned 
 in the schools. They are now abandoned, and will live only in 
 
 * See pages, 185, 186, 208, 211, 225. 
 
 f We will, however, except the system of irritation, since its followers have, 
 till quite recently, been numerous, and even now it finds favor with a few. 
 
 " According to this theory, health and disease are but different effects of the 
 same principle, that of irritation. 
 
 " A disordered state of health is always owing either to an accumulation of 
 excitation or irritation in some part, through the influence of external stimuli 
 whose object is to maintain the functions, or to a deficiency of this principle in 
 the economy. 
 
 " The functions may be deranged in two ways ; they may be performed with 
 too great or too little energy. 
 
 " Irritation is then the primary cause or source of all morbid action ; the 
 phlegmasise, haemorrhages, neuroses, and degenerations of every kind, are but its 
 
NATURE OF DISEASE. 441 
 
 the history of the science ; they attest the feebleness of the human 
 mind whenever it attempts to attain a knowledge of the pri- 
 mary laws of the organization. In this, as in many other things, 
 we must remain ignorant of what it was not intended we should 
 know. All discussion upon insoluble questions is unprofitable and 
 dangerous ; unprofitable, because it can be followed by no satis- 
 factory results ; dangerous, because it almost always leads to error. 
 When once we enter upon the domain of hypotheses and theories, 
 it often becomes impossible for us to pause, and if, afterwards, we 
 attempt to retrace our steps and return to the investigation of posi- 
 tive subjects, they appear so cold and uninviting, in comparison 
 with the seducing speculations to which we have previously de- 
 voted ourselves, that they cannot fail to prove totally devoid of 
 interest. 
 
 Although it be shown that the intimate nature of things is above 
 our comprehension, and although this truth has been proclaimed 
 more widely in our own, than any previous age, there are neverthe- 
 less persons of true merit, who still think that they may yet be able to 
 explain the secrets of nature, and who have their proselytes. This 
 ceases to be a matter of surprise, if we but glance at the history of 
 medicine ; the human mind is always the same, and may be judged, 
 in the future, by the past. Systems have been the product of all 
 ages, and are still in process of formation : they have had, and 
 will continue to have, their admirers, and will be forgotten, as 
 have been those which preceded them. But, if it be objected that, 
 in order to the proper treatment of a disease, its intimate nature 
 
 effects, and cannot be considered as diseases, unless we consider suppuration also 
 an idiopathic affection." 
 
 Let us briefly examine this theory, which closely resembles those of Themison 
 and Brown, and see to what extent it has foundation. 
 
 It is generally supposed, and is, we believe, incontestable, that all diseases are 
 owing to some change in the action of our organs ; this intimate change precedes 
 and produces all the alterations of tissue ; so that, properly speaking, all that we 
 call disease is consecutive to this change. But as this peculiar modification 
 escapes, as we have stated in the preceding chapter, all our means of investiga- 
 tion, reason prompts us, this first truth being known, to direct our study and ob- 
 servation to the appreciable phenomena. It is thus that the progress of medicine 
 has been real ; it has been retrograde whenever it has been attempted to seek the 
 primary causes ; the principal defect in the theory of irritation. 
 
 Another and not less remarkable error is, to limit to two modes this change of 
 action, which is the source of all our diseases. According to M. Brnussais, the 
 stimulants have been either too powerful or too feeble, and the action of the organs 
 is increased or diminished : now, if we may be permitted to reason upon a subject, 
 the knowledge of which it was never intended we should attain, we might ask if 
 it is not probable that besides this increase and diminution of energy, there may 
 also be a perversion of action, itself susceptible of appearing under infinitely 
 various forms. If the effects of this primary change of action occur with number- 
 less modifications, as is evident from the numerous organic alterations which take 
 place in diseases, is it not natural to suppose that the causes which escape us vary 
 with their sensible effects? 
 
 These considerations appear to us more than sufficient to demonstrate the uncer- 
 tainty and instability of the foundation of the doctrine of irritation. If this were 
 the place to consider this system, the falsity of the consequences would furnish 
 additional proofs of the falsity of the principle. 
 
442 CLASSIFICATION OF DISEASES. 
 
 should be understood, to those we may reply, with Syd&iham* 
 that all the acts of nature are alike obscure, and that the Wisdom 
 which ordained the universe, has reserved to himself the knowl- 
 edge of the laws by which its harmony is maintained ; " but, be- 
 sides," as this celebrated practitioner remarks, " it is not upon a 
 knowledge of the first causes that therapeutics is based, but rather 
 upon observation and experience, which can and should alone 
 guide the physician in the practice of his profession." 
 
 We might have dispensed with the chapter upon the nature of 
 disease, which but reveals our own ignorance in regard to it, and 
 teaches us to abstain from directing our powerless efforts towards 
 its discovery ; but it is no less important, in the study of the sci- 
 ence, to point out the paths which lead to error, than those which 
 conduct to a knowledge of truth. O. 
 
 CHAPTER XXI. 
 
 CLASSIFICATION OF DISEASES. 
 
 THE classification of diseases, or nosology,^ is that branch of 
 medicine whose object is the methodical distribution of diseases 
 into a certain number of groups, to which the term classes has been 
 applied, and which are commonly subdivided into orders or fami- 
 lies, to these being referred all the genera and known species. 
 Felix Plater appears to have been the first to conceive and carry 
 into execution, the idea of a methodical distribution of diseases. 
 
 The division proposed by Plater was hardly known, when Sauv- 
 ages published, in the eighteenth century, his Nosologie Method- 
 ique, which was very favorably received, and considered as the 
 first work of its kind. Diseases were by him divided into ten 
 classes, which he designated by the terms, deformities, fevers, 
 phlegmasi(E, spasms, anhelations, debilities, pains, vesanice, Jinxes 
 and cachexies. Each of these classes was divided into several 
 orders, to which were referred a certain number of genera, which 
 presented all the characters of the class and order to which they 
 belonged, and also characteristics peculiar to themselves. 
 
 The classification of Linnceus closely resembled that of Sauv- 
 ages ; he added another class of diseases, which he designated by 
 the title suppressions, transferring some of those affections, consid- 
 ered by Sauvages under the class of fevers, into the class of critical 
 diseases, or those characterized by a brick colored sediment in the 
 urine. 
 
 * Opera Omnia, torn. i. p. 66. 
 t Nosog, disease ; Asyw, I collect. 
 
CLASSIFICATION OF DISEASES. 443 
 
 Vogel, Sagar and Vitel admitted nearly the same classes, under 
 different names. 
 
 Cullen reduced the classes of diseases to four, viz. : three classes 
 of general affections, pyrexiae, neuroses and cachexies, and one 
 class of local affections. 
 
 Macbride also admitted four classes, which he designated by the 
 terms general, local, sexual and puerile diseases. 
 
 All these classifications present so many defects and incongrui- 
 ties, that they have been generally abandoned. Those of Darwin, 
 Tourdes and Baumes are based upon theories too unstable to be 
 received. 
 
 The classification of Pinel is far less objectionable than any pre- 
 ceding it. This physician divided diseases into five classes, viz. : 
 fevers, phlegmasice, haemorrhages, neuroses and organic affections. 
 This classification approaches nearer than the others to that per- 
 fection of which the subject is capable. If, in his distribution of 
 diseases, Pinel has sometimes approximated affections which it 
 would seem should be separately considered, and separated others 
 which should more naturally have been connected, these imperfec- 
 tions do not prevent his nosological system from holding the first 
 rank. Besides, it is very doubtful if a nosological classification 
 can ever be as methodical, notwithstanding the idea of Gaubius* 
 as those of plants and animals, the characters of the latter being 
 more defined and more easily distinguishable. 
 
 These different classifications only comprise those within the 
 domain of medical pathology. Surgical diseases have also their 
 classifications, which are generally established according to the 
 seat rather than the peculiar forms of these diseases : some authors 
 have also objected that the divisions of external diseases, however 
 methodical they may be, should not be considered as classifications 
 properly so called. It matters little, however, whether diseases be 
 methodically distributed or classed, provided they be so presented 
 as to render their exposition the most easy. 
 
 Classifications are not indispensable to the study of pathology. 
 They have been for some time dispensed with, and it is not certain 
 that they have had any influence upon the progress of the science. 
 A good classification, however, aids and abridges the study, and 
 hence its utility cannot be questioned. Besides, by presenting 
 under a distinct head all the known diseases, it leads to a more 
 precise knowledge of their analogies and differences, and to a more 
 just appreciation of the value of general assertions and points of 
 doctrine, by enabling us to make a rapid application of them, to ail 
 the groups of diseases, arranged according to some order which 
 should be always present in the physician's mind. 
 
 * Non est cur disperent medici, fore aliquando, ut ingens morborum humano- 
 rum numerus, exemplo ab histories naturalis scriptoribus petito, in ordinem systeni- 
 aticum redigatur, qui ab omni hypothesi, sectarumque commenlis liber, sola mocus 
 fideli observations, classes, genera, species exhibeat, suis singula char act en smi s , 
 ccrtis manifestis, plenis interstincta. (Institut. Pathol.) 
 
444 TREATISES ON GENERAL PATHOLOGY. 
 
 Apart from these advantages, nosology presents serious incon- 
 veniences: the necessity of dividing all diseases, into a limited 
 number of classes, has led nosologists to bring together, in the same 
 series, diseases of a widely different nature, and often to omit those 
 which would not so naturally belong to the adopted group. 
 
 The different parts which collectively constitute the human body 
 are subject to numerous diseases, some of which are common to all 
 these parts, as inflammation, affections properly so called, atrophy 
 and hypertrophy, alterations of secretion and innervation, and, 
 also, the lesions produced by physical and chemical agents; others 
 are peculiar to each of the organs, affecting their structure alone, 
 and having no analogy, or at least a very remote one, to the dis- 
 eases of other parts. Among the latter affections, may be men- 
 tioned the various cutaneous exanthemata, apthae and the diptheri- 
 tic affections, rheumatism, emphysema, rachitis, invagination, 
 varix, aneurism, calculous affections, and certain primary altera- 
 tions of the fluids, as anemia and diabetes, all affections differing 
 from others in that they affect the structure or composition of the 
 solid parts or fluids. These affections cannot be properly included 
 in our classifications, the latter being particularly applicable to 
 those diseases which may affect all parts of the body. 
 
 We were led, from these considerations, upon devoting ourselves 
 more particularly to the instruction of pathology, to adopt a classi- 
 fication only of those diseases capable of such an arrangement, as 
 the phlegmasise, morbid secretions, the neuroses and common 
 organic lesions, without attempting the classification of those pe- 
 culiar to the various parts which collectively constitute the human 
 body. We are thus enabled to reap all the advantages and avoid 
 all the inconveniences necessarily connected with the classification 
 of diseases. O. 
 
 CHAPTER XXII. 
 
 PRINCIPAL TREATISES ON GENERAL PATHOLOGY. 
 
 THE first notions upon General Pathology are nearly as ancient 
 as medicine itself: they are found in the writings of Hippocrates. 
 His Treatise upon the Atmosphere, Water, and Localities, is par- 
 ticularly devoted to etiology, and prognosis is exhibited in many 
 of his books with admirable precision. Hippocrates, however, 
 has not considered diseases in an abstract manner. Galen seems 
 to be the first who conceived this idea. 
 
 In his essay de Differentiis Morborum, this accomplished physi- 
 cian first gives a general definition of disease, and this definition 
 is nearly the one we have adopted ; he afterwards treats of its 
 distinctions, and divides into three groups the various affections, 
 
TREATISES ON GENERAL PATHOLOGY. 445 
 
 according as they are peculiar to homogeneous and organic parts, 
 or common to both; he subdivides them all into simple and com- 
 plex diseases. 
 
 In other works * he treats generally of the causes and seat of 
 diseases, of symptoms and their differences, of periods, which he 
 ingeniously compares to the different ages of life ; of types, crises, 
 and decretory days. We find also in his works some general 
 remarks upon semeiol<^y and therapeutics. Thus Galen, without 
 having written a special treatise upon this subject, has displayed 
 the principal doctrinal points belonging to it, in as many separate 
 books : on this account we do not hesitate to consider him the 
 founder of general pathology. 
 
 The perusal of the works written upon this branch of medicine 
 is peculiarly fitted to confirm this opinion. Not to mention those 
 who, up to the epoch of the revival of literature, had confined 
 themselves to the translation or repetition of what had been said 
 before their time, we see the most noted physicians of the later 
 centuries, as Fernel, Sennert, Riviere, and Plempius, doing 
 nothing more than to complete, in a somewhat different manner, 
 the plan traced by Galen. Boerhaave himself has followed a 
 similar course, except in the distribution of symptoms. 
 
 The Treatise on Pathology by Fernel is included in his Uni- 
 versal Medicine ; f it is divided into two parts : the first treats of 
 disease in general, and of its causes ; the second of symptoms and 
 signs. In the portion devoted to disease and health, he remarks 
 that each has a certain latitude, and that between these opposite 
 conditions there exists an inter mediate stage, (constitutio neutra,} 
 which participates in the characteristics of each, but which differs 
 from both ; this condition may more nearly resemble health or dis- 
 ease, or maintain a medium position between them. Fernel, in his 
 Semeiology, treats particularly of critical signs, dividing them into 
 general and particular, and subdividing them very methodically 
 into the antecedent, accompanying and following signs of crisis. 
 
 In the work of Sennert% we also find numerous fundamental 
 ideas. When speaking of the symptoms furnished by various 
 functions, he examines successively their abolition, diminution, 
 depravation and exaltation ; it would be difficult to form a more 
 convenient division. He establishes, moreover, a distinction be- 
 tween diseases, according as they supervene under ordinary cir- 
 cumstances, or unusual conditions: to these two divisions he gives 
 the names morbi congnd et incongrui. 
 
 Lazare Riviere, in his Institutes of Medicine,^ treats of disease 
 
 * De causis liber unus. Liber de Locis affectis. De symptomatum differen- 
 tiis liber unus. De symptomatum causis lib ri ires. De morborum tempo nbvt 
 liber unus. Liber de totius Morbi temponbus. Liber de Typis. Liber </c 
 Crisibus. Liber de Diebus decretoriis. 
 
 f JOANNIS FERNELII, Universa Medicina. Venitiis. 1564, in-4. 
 
 | Institutionum Medicince, libri v. Auctore Daniele Sennerto. Wittebergte. 
 
 LA.ZARI RIVERII, Opera medico, universa, in. quibus contineiitur Institutionum 
 Mzdicarum, libri v. Lugduni, 1676. 
 
 38 
 
446 TREATISES ON GENERAL PATHOLOGY. 
 
 in general ; a chapter is devoted to the changes in disease, and 
 semeiology is divided into two branches, one relating to diagnosis, 
 the other to prognosis. The treatises of Plempius* and Charlton\ 
 contain nothing remarkable. 
 
 Boerhaave, in his Institutes of Medicine,:]: has devoted a few 
 pages only, to general pathology ; the concise remarks which he 
 has made upon this subject have been the theme of very exten- 
 sive commentaries. Among the authors w^ho have thus labored, 
 we find the names of Haller and of Dehaen;\\ the lectures of 
 the latter, collected by Wasserberg, contain all that is most inter- 
 esting; but a more or less detailed description of all diseases is 
 also found in them, and such a description, although it may with 
 propriety be treated of in the institutes of medicine, is out of place 
 in a work upon general pathology. 
 
 Among the published works upon this subject, the Institutes of 
 Pathology by Gaubius 11 is certainly one of the most remarkable ; 
 we discover, in many portions, ingenious thoughts, profound reflec- 
 tions, and luminous comparisons, which justify the favorable 
 reception accorded to the work, and its well deserved reputation 
 at the present day. He was the first to give the name General 
 Pathology to the branch of medicine of which we treat. 
 
 The Pathological Tables of Juncker** form a valuable collec- 
 tion, in which we find enumerated the various opinions of most 
 authors upon the principal doctrinal points. The form of this 
 work renders its perusal fatiguing, but it may be consulted with 
 advantage. 
 
 The short treatises of Ludwig\\ and Astruc JJ constitute abridg- 
 ments of pathological doctrines ; the latter is written with a 
 degree of elegance which has doubtless contributed to the success it 
 has obtained. 
 
 Since the commencement of this century, many works upon 
 general pathology have been published in Germany; a few 
 have also appeared in France. Many of these contain a 
 
 * Vopisci Fortunati PLEMPII, de Fundamentis Medicines, libri vi. Lovanii, 
 1638. 
 
 j- Exercitationes Pathologic^ in quibus morborum pent omnium natvra, gen- 
 eratio, et causa ex novis anatomicorum inventis sedulb inquiruntur, & Gualtero 
 Charltono. Londini, 1661. 
 
 J Institutiones Medicce in usus annuae. exercitationis domesticos digesta, ab 
 Hermanno Boerhaave. Editio ultima. Parisiis, 1747. 
 
 Hermann! BOERHAAVII, Preelections academics in proprias Institutiones rei 
 Medicce, edidit Albertus Haller. Gottingse, 1744. 
 
 || Pralectiones Antonii DEHAEN in Hermann! Boerhaavi, Institutiones Pa- 
 thologicas collegit, recensuit, additamentis aurit, edidit, F. de Wasserberg. Editio 
 nova. Coloniae-Allobrogum, 1784 ; 2 vol. in 4. 
 
 ^[ Institutiones Pathologic* medicinalis. Jluctore H. D. GAUBIO. Leidae Batavo- 
 rum, 1758. 
 
 ** Conspectus PathologifB ad dogmata slahliana pracipue adornatfB, et semeiolo- 
 gia Hippocratico- GalenicfB in forma tab alarum repr&sentatus. Jluctore D. J. 
 JUNCKERO. Hale-Magdeburgicae, 1736. 
 
 ff D. Christ. Gottlieb LUDWIG, Institutiones Pathologies. Lipsiae, 1767. 
 
 ^J Joannis ASTRUC, Tractatus Pathologicus, editio quarta. Parisiis, 1767. 
 
TREATISES ON GENERAL PATHOLOGY. 447 
 
 more or less complete account of generally admitted opinions; 
 some of them present different ideas from those commonly enter- 
 tained : we shall confine ourselves to a concise enumeration of the 
 latter. 
 
 The General Pathology of Sprengel* first published in Ger- 
 man, and afterwards in Latin, is, without any doubt, one of the 
 most finished works upon this subject; we have elsewhere re- 
 marked upon the planadopted by this author, and have said that 
 he occasionally added peculiar descriptions of diseases foreign to 
 his subject, and omitted certain doctrinal points which seem 
 naturally to belong to it;f but these slight defects in the arrange- 
 ment of the work are redeemed by the manner in which most of 
 the subjects are treated. Nearly the same may be said of the 
 Treatise of M. Caillot, J published two years after the first edition 
 of the present work, and also of that which appeared much more 
 recently, with the same title, by M. Dubois, of Amiens, one of the 
 distinguished physicians of our times. His opinions upon the 
 nature of disease, and the limits and extent of general pathology, 
 differ very much from our own : it is not, however, our province 
 to pronounce judgment upon them. 
 
 Reil, who has been called the Pinel of Germany, has published a 
 work upon this subject, in which he refers all the phenomena which 
 are manifested in the human body, in health or disease, to chemi- 
 cal conditions. If the composition of the animal matter be intact, 
 health is the consequence ; disease reveals a certain change in 
 this composition. 
 
 Dr. Puchelt, Professor of the Faculty of Heidelberg, in his 
 Treatise upon Hygiene, Pathology and general Therapeutics, 
 has presented some ingenious considerations upon the action of 
 morbific causes, which he divides into mechanical or physical, 
 which act upon the organs; chemical, which act upon the 
 humors ; and dynamic, which act upon the functions. He thinks 
 that the course of diseases is subject to planetary influences, and 
 particularly to the lunar phases. 
 
 Professor Schonlein, one of the most celebrated practitioners of 
 Germany, recently elected to fill the chair of general and special 
 pathology at Berlin, has delivered lectures upon this subject, which 
 have been collected and published by his pupils. He looks upon 
 disease as a contest between the principles of egoism and the 
 planetary principle, or, to speak in terms more in conformity with 
 our language, a contest between vital laws and those which rule 
 the universe. The particular form of diseases is subordinate to 
 the nature of their productive causes, to the organ which re- 
 ceives their impression, and to the individuality of the patient. 
 
 * CURTII SPRENGEL, Institutiones Medica, t iii., Pathologia generate. Am- 
 slelodami, 1813. 
 
 t Pa?e 4. 
 
 J Eternens de Pathologic generate et de Physiologic pathologique, par L. 
 Catllot, ancien medecin en chef de la Marine. Paris, 1819. 
 
418 TREATISES ON GENERAL PATHOLOGY. 
 
 Dr. C. H. Rosch endeavors, in an ingenious work, to give to 
 humoral pathology the importance it possessed among the ancients, 
 and to establish upon a basis of facts the existence of primary 
 affections of the blood and the other humors. Dr. HaurT, in a vol- 
 ume, entitled Solidarpathologie und Humor alp athologie, attempts 
 to disprove the theory of his compatriot, and to show that the 
 nervous system is the spiritns rector vita, the governing and con- 
 servative principle of all the functions. According to this system, 
 chlorosis itself is but the consequence of some disturbance of the 
 nervous system.* 
 
 A defect common to the greater number of the works we have 
 just enumerated, is the almost universal presentation of theories 
 associated with whatever facts appertain to general pathology, 
 which render its study dangerous when they are favorable, and 
 tedious when they are abandoned. Every work published pre- 
 viously to the close' of the last century is infected with the humoral 
 theory, manifested in various forms. In recent treatises, the 
 nervous fluid, irritation and the vital properties, are unceasingly 
 mingled with, or substituted for, the appreciable phenomena of 
 diseases. 
 
 There remains a certain number of works which, without com- 
 prising the whole of general pathology, belong, notwithstanding, 
 to the bibliographical history of that science, because they are 
 devoted to the elucidation of one or more points connected with it. 
 
 In advance of all others, we rank the Treatise on Experience, by 
 Zimmermann^ which is worthy alike of a skilful physician and a 
 distinguished philosopher. The work of Testa,\ upon Periods in 
 health and disease, although it does not exhibit so high an order 
 of thought, is no less important in a professional point of view. 
 The Pathogeny of Hufeland also deserves particular attention ; 
 but hypotheses are so often mingled with facts, that the perusal of 
 this ingenious essay is not without danger to those just com- 
 mencing their professional studies. It is quite otherwise in respect 
 to the considerations upon general pathology, with which the same 
 author commences his Manual of Practical Medicine, which are 
 the production of a rnind matured by experience. A large number 
 of theses read before the Faculty of Medicine at Paris, particularly 
 those of Bayle, Bally, Marandel, etc., contain an exposition of 
 many interesting points in general pathology. The Analytical Table 
 of Chaussier upon health and disease, the excellent Semeiology of 
 M. Landre-Beauvais, and the considerations upon general pathol- 
 
 * We are indebted to Dr. Otterburg, of Heidelberg, for information in regard 
 to several German works, that we could not ourselves have consulted, they not 
 having been translated. 
 
 | Trait't de V Experience en ginkral, et dans Vart de guerir en particulier, 
 traduit par Lefebvre de Villebrune. Avignon, 1800. 
 
 J TESTA, De vitalikus Periodis agrotantium et sanorum. Londini. 
 
 If/ees sur la Pathogcnie, ou Considerations sur Vinfiuence de la force vitale 
 sur I'origine et la forme des Maladies, par Christ. Will. HUFELAND, 1795. 
 (A long extract is contained in the Bibliotheque Germanique.) 
 
TREATISES OX GENERAL PATHOLOGY. 449 
 
 ogy which constitute the introduction to the Clinical Medicine of 
 Professor Rostan, are, morever, works whose perusal and study 
 we cannot too strongly recommend; the Semeiology of M. Double 
 may also be read with advantage. 
 
 The above are, to the best of our knowledge, the principal trea- 
 tises which have been published, both upon the entire science and 
 upon detached portions of pathology. Many of these we have 
 studied, others have been consulted, and certain selections made 
 from them for the present work. The course of instruction 
 in general pathology by Professor Andral, will doubtless commu- 
 nicate a new and powerful impulse to this important and too little 
 cultivated portion of medical science. Our design, we do not hesi- 
 tate to repeat, has been to define distinctly the limits of our subject, 
 endeavoring to attain without overstepping them, and to offer, in 
 an essentially abstract manner, a doctrine free from theories, and 
 founded solely upon facts and their immediate and rigorous conse- 
 quences. M. 
 
 [The only works that have been published upon General Pathology within our 
 knowledge, since the issue of the last edition of the present work, are the " Outlines 
 of Pathology, and Practice of Medicine," by William Pulteney Alison, M. D., of 
 Edinburgh ; and the Principles of Medicine, comprising General Pathology and 
 Therapeutics, and a brief general view of Etiology, Nosology, Semeiology, Diag- 
 nosis and Prognosis," by C. J. B. Williams, M. D., of London. TRANS.] 
 
 38* 
 
INDEX. 
 
 A. 
 
 Abdomen (symptomatology), 92: (diag- 
 nosis), 80S. 
 Abscess, by congestion, 202; metastatic, 
 
 Absorption (symptomatology), 220. 
 
 Access, 231. 
 
 Acquired diseases, 64. 
 
 Acute and chronic diseases, 233. 
 
 VEgophony, 149. 
 
 Affections, moral, 36. 
 
 Affective functions, symptoms furnished 
 by the, 110. 
 
 Age, its influence upon the seat of dis- 
 eases, 18 ; upon their production, 39; 
 upon their prognosis, 344. 
 
 Agents, chemical (etiology), 20. 
 
 Agrypnia, 114. 
 
 Air, atmospheric, 32; cold air, warm 
 air, 32; rnoist air, 32 ; unrenewed air, 
 32 ; its variations of temperature, 32 ; 
 of pressure, 33. 
 
 Alopecia, 90. 
 
 Alterations of organs, discovered after 
 death, 357 ; of the fluids, 374 ; of the 
 gases, 377. Some anterior to the 
 symptoms, others occur during the 
 disease, in the agony, or after death. 
 They may occur without there being 
 any symptom to indicate their exist- 
 ence, 379. 
 
 Alvitie excretion, 131 ; matters, 131 ; 
 their nature, 131; consistence, 132; 
 color, 132; form, 132; odor, 133; for- 
 eign bodies, 133. 
 
 Anaphrodisia, 226. 
 
 Anasarca, 77. 
 
 Animals, parasitic, 24. 
 
 Annual diseases, 64. 
 
 Anorexia, 117. 
 
 Apnoea, 136 
 
 Aphonia, 102; a prognostic sign, 349. 
 
 Appetite, 117 ; venereal, 226. 
 
 Applicata (etiology), 23, 45. 
 
 Aptitudes, 37, 57. 
 
 Apyrexia, 231. 
 
 Arteries, symptoms furnished by, 170; 
 auscultation of, 179. 
 
 Atmosphere, its influence in the produc- 
 tion of disease, 32. 
 
 Attack, 231. 
 
 Attitude, in health, 75; in disease, 75; 
 a cause of disease, 51 ; a prognostic 
 sign, 348. 
 
 Auscultation, 290 ; mediate and immedi- 
 ate, 290; rules to be observed in, 292; 
 of respiration, 138; of the voice, 148; 
 of the cough, 154 ; of the heart, 166; 
 of the arteries, 179 ; its other applica- 
 tions, 290; in cerebral disease, 290. 
 
 Authors upon General Pathology, 444. 
 
 B. 
 
 Balbuties, 103. 
 
 Barrenness, 226. 
 
 Baths (etiology), 48. 
 
 Beds (etiology), 48 ; as a hygienic 
 means, 431. 
 
 Bellows murmur of heart, 167; of arte- 
 ries, 179. 
 
 Bile, secretion, excretion and alterations 
 of, 208, 209. 
 
 Blood, experiments upon the, 182; al- 
 terations of, in respect to color, 184 ; 
 odor, 185; taste, 185; temperature, 
 185; separation of its elements, and 
 their modifications in different dis- 
 eases, 185; foreign substances, 186; 
 deleterious principles, 188; gases, 189. 
 
 Bodies, foreign, living and inanimate, 
 378; vulnerant (etiology), 23; their 
 action, 55. 
 
 Body, increase in the volume of the, 76 ; 
 its causes, 76; diminution in the vol- 
 ume of, 77. 
 
 Bones (symptomatology), 97. 
 
 Borborygmi, 128. 
 
 Boulirnia, 117. 
 
 Broncophony, 148. 
 
 Bubo, 191. 
 
 Buffy coat of the blood, 187. 
 
 C. 
 
 Calculi, 216. 
 Cancer, forms of, 370. 
 Capillary circulation, symptoms fur- 
 nished by, 180. 
 Caries, 97. 
 Carphologia, 99. 
 
452 
 
 INDEX. 
 
 Caruncula lachrymalis (symptomatolo- 
 gy), 87. 
 
 Carus, 115. 
 
 Catalepsy, 101. 
 
 Cataphora, 115. 
 
 Causes, definition of, 19; exist around 
 arid within us, 19; ancient division of, 
 20; three classes of, 21 ; their mode 
 of action, 55; their obscurity in some 
 cases, 63; their utility in diagnosis, 
 31 1 ; determining, 21 ; common de- 
 termining, 21 ; specific determining, 
 25; ordinary specific, 25; contagious 
 specific, 26 ; their mode of action, 27 ; 
 predisposing, 31 ; general predisposing, 
 32; individual predisposing, 36, 44; 
 aptitudes, 37, 57 ; their mode of action, 
 58; occasional, or exciting, 53; they 
 differ from specific and determining, 
 54 ; their mode of action, 55. 
 
 Cephalalgia, 107; often a sympathetic 
 phenomenon, 324. 
 
 Chattering of the teeth, 118. 
 
 Cheeks (symptomatology), 88. 
 
 Chemical means, employment of, in 
 diagnosis, 297. 
 
 Chemistry, its application to therapeu- 
 tics, 405. 
 
 Chest, 91 ; its inspection, 91 ; percus- 
 sion, 151; auscultation, 292; men- 
 suration, 284. 
 
 Chin (symptomatology), 89. 
 
 Chorea, 102. 
 
 Chronic diseases, 233. 
 
 Circulation (symptomatology), 162 ; of 
 blood, 163; in the heart, 163; arte- 
 ries, 170 ; capillary vessels, 180 ; 
 veins, 181; of lymph, 189. 
 
 Circumfusa (etiology), 22. 
 
 Classification of diseases, 442. 
 
 Climate, influence of, upon the progress 
 of diseases, 239; upon their prognosis, 
 346. 
 
 Climacteric years, 40. 
 
 Clonic spasms, 100. 
 
 Clothing, effect of, as a cause of disease, 
 45 ; wet, effects of, 36. 
 
 Coction, 437. 
 
 Color of the skin, 78. 
 
 Coma, its two varieties, 115; its diagnos- 
 tic value, 324. 
 
 Complications, 270; their distinction, 
 271 ; causes, 272 ; reciprocal influence 
 of complicated diseases, 272 ; are ob- 
 stacles to diagnosis, 337; their prog- 
 nostic value, 347. 
 
 Compression (etiology), 45. 
 
 Congenital diseases, 64. 
 
 Conjunctiva (symptomatology), 87. 
 
 Consecutive phenomena, 262. 
 
 Constipation (symptomatology), 129; a 
 prognostic sign, 353. 
 
 Constitution (etiology), 42. 
 
 Constitutions medical, 65. 
 
 Contagious principles, 26 ; their proper- 
 
 ties, 27; origin, 29; theory of Linnaeus, 
 31 ; their action, 56. 
 
 Contagion, 27 ; modes of, 28 ; circum- 
 stances which favor it, 28 ; to ascer- 
 tain if a disease be contagious, 66. 
 
 Continued type, 231. 
 
 Contractility, muscular, 98; lesions of, 
 98. 
 
 Contractura, 102. 
 
 Convalescence, 259; its phenomena, 
 259; its duration, 261 ; circumstances 
 which modify it, 261 ; a predisposing 
 cause of disease, 43; therapeutics of, 
 423. 
 
 Convulsions, 99; clonic, 100; tonic, 100 ; 
 their diagnostic value, 324 ; prognostic 
 value, 349. 
 
 Cornea, examination of the, 85. 
 
 Corns, 46. 
 
 Corsets, use of, 46. 
 
 Cough, 152 ; its varieties, 153; ausculta- 
 tion of, 154 ; sympathetic, 329. 
 
 Counter indications, 421. 
 
 Course of diseases, 230. 
 
 Crachotment, 155. 
 
 Cramp, 99. 
 
 Crepitation, 97. 
 
 Crisis, doctrine of, 246; division, 245; 
 theory of, according to the humorists, 
 438 ; solidists, 438. 
 
 Critical days, 256 ; phenomena, 247 ; 
 signs which precede and accompany, 
 248; favorable circumstances, 252; 
 their influence upon the changes that 
 take place, 253. 
 
 Crocidismus, 99. 
 
 Crudity, 437. 
 
 Crusts, 206. 
 
 Crystalline (symptomatology), 86. 
 
 Cure (termination of diseases), 242; 
 in general diseases, 243; in local 
 diseases, 243; in chronic diseases, 
 244. 
 
 D. 
 
 Days, critical, doctrine of, 256 ; indicat- 
 ing, 256; intercalary, non-decretory, 
 257; doctrine of Hippocrates, of Ga- 
 len, 257; medical, mode of reckoning, 
 240. 
 
 Death, termination by, 244. 
 
 Decline of diseases, 235. 
 
 Decretory days, 256. 
 
 Decubitus (symptomatology), 75 ; a prog- 
 nostic sign, 348; dorsal, 75; lateral, 
 76. 
 
 Defecation, 130. 
 
 Definition of disease according to its 
 intimate nature, 7 ; that of Sydenham, 
 7 ; of M. Littre, 9 ; of the author, 11 ; 
 of diseases in particular, 11. 
 
 Degeneration (pathol. anat.), 373. See 
 organic transformations. 
 
INDEX. 
 
 453 
 
 Deglutition (symptomatology), 123; ac- 
 celerated, 123; difficult, 124 ; impos- 
 sible, depraved, 124; prognostic value 
 of disordered, 353. 
 Degrees of diseases, 235. 
 Delirium, 111 ; its causes and forms, 
 112 ; often a sympathetic phenomenon, 
 323 ; its prognostic value, 351. 
 Deposits, urinary, 217. 
 Descent, a predisposing cause, 37. 
 Determining causes, 21; common, 21; 
 
 specific, 25. 
 
 Deuteropathic diseases, 69. 
 Diadexis, 245. 
 Diagnosis, 273; signs on which it is 
 based, 273 ; conditions necessary to 
 its establishment on the part of the 
 physician and patient, 275; its prin- 
 cipal elements, 311 ; circumstances 
 which render it difficult or uncertain, 
 321 ; 1st, the period at which the pa- 
 tient is examined, 321 ; 2d, predomi- 
 nance of sympathetic phenomena, 323 ; 
 3d, rareness of the disease, 336; com- 
 plications, 337; dishonesty of patients, 
 33d ; diagnosis the foundation of prog- 
 nosis, 343. 
 
 Diarrhoea, 129. 
 
 Diathesis, 59; principal kinds, 59. 
 
 Digestion (symptomatology), 117; stom- 
 achal, 125. 
 
 Disease, definitions of, 6 ; diseases com- 
 mon to all, or peculiar to certain tis- 
 sues, 17. 
 
 Diseases, circumscribed, disseminated, 
 17; innate, congenital, 64; acquired, 
 sporadic, 64 ; pandemic, annual, sta- 
 tionary, intercurrent, endemic, 64; 
 epidemic, 65 ; essential, primitive, 
 protopathic, 69 ; symptomatic, second- 
 ary, deuteropathic, 69 ; concealed, 
 feigned, 338 ; acute, chronic, 233. 
 
 Disgust, 118. 
 
 Distinction of diseases according to their 
 causes, 64. 
 
 Diurnal revolution, its influence on the 
 course of diseases, 236. 
 
 Drinks (etiology), 49. 
 
 Dumbness, 104. 
 
 Duration of diseases, 240; sometimes 
 uncertain, 240 ; sometimes fixed, 241 ; 
 circumstances which influence, 241; 
 its influence on prognosis, 347. 
 
 Dysorexia, 117. 
 
 Dyspermasia, 224. 
 
 Dysphagia, 124. 
 
 Dyspnoea, 135; sympathetic, 329. 
 
 Dysuria, 211. 
 
 E. 
 
 Ears (symptomatology), 90. 
 Electricity (etiology), 33. 
 Emaciation (symptomatology), 77, 223; 
 its prognostic value, 348. 
 
 Emanations, metallic, animal and vegeta- 
 ble, causes of disease, 25. 
 
 Emphysema, 77. 
 
 Ernprosthotonos, 100. 
 
 Encephaloid disease, 370. 
 Hndemic diseases, 64. 
 
 Eneorema, 217. 
 
 Ephemeral diseases, 241. 
 
 Ephialtes, 114. 
 
 Epidemic diseases, 65. 
 
 Epigenemata, 229. 
 
 Epiphenomena, 229. 
 
 Erections, 224. 
 
 Eruptions, 80. 
 
 Essential diseases, 69. 
 
 Etiology, 19. 
 
 Etymology, 15. 
 
 Evacuations, excessive or suppressed, 
 50, 51 ; involuntary, in prognosis, 354. 
 
 Exacerbation, 231. 
 
 Exciting causes, 53. 
 
 Excreation, 155. 
 
 Excrements, 131. 
 
 Excreta, 50. 
 
 Excretions (symptomatology), 219. 
 
 Excoriations (symptomatology), 81. 
 
 Exercise, its influence as a cause of dis- 
 ease, 51. 
 
 Exhalations, 196; natural, 196; morbid, 
 200 ; artificial, 206. 
 
 Exophthalmia, 85. 
 
 Expectoration, 154. 
 
 Experience, one of the bases of therapeu- 
 tics, 403; should not be confounded 
 with experiment, 403; the latter be- 
 longs to science, the former to the 
 physician, 403. 
 
 Experiment, 383. 
 
 Experimentation, in therapeutics, 383; 
 its object, 383 ; rules to be observed 
 in regard to, 383; its advantages and 
 inconveniences, 391 ; cases in which it 
 becomes a duty, 392; in which it 
 should never be attempted, 392. 
 
 Exspuition, 154. 
 
 Extent (to determine the extent of a 
 disease,) 315. 
 
 Exterior of the body, symptoms to be 
 derived from, 75; its value in diag- 
 nosis, 298 ; in prognosis, 348. 
 
 Eyebrows, 87. 
 
 Eyelashes, 87. 
 
 Eyelids, 86. 
 
 Eyes, 84; an important phenomenon, 
 'pointed out by Sanson, in the diag- 
 nosis of many diseases of the, 86. 
 
 F. 
 
 Face (symptomatology), 81 ; pinched, 
 82; hippocratic, 82; opinions of M. 
 Jadelot, 83; motions of, 83; volume, 
 83; color, 84; its eruptions, 84. 
 
 Facies vultuosa, 82. 
 
 Fainting, 116. 
 
554 
 
 INDEX. 
 
 Family diseases, 39. 
 
 Fatty transformation, 872. 
 
 Features, alterations of the, 82. 
 
 Febrile state or movement, its diagnostic 
 value, 332; its acute and chronic 
 form, 332; its continued, remittent, 
 intermittent type, 335. 
 
 Feet (symptomatology), 96. 
 
 Fissures, 81. 
 
 Fistula? (symptomatology), 81. 
 
 Flesh, firmness and flaccidity of, 78. 
 
 Fluctuation, 81. 
 
 Flux cceliac, 131. 
 
 Food, quality of, 36 ; diminution or ex- 
 cess in quantity of, 48. 
 
 Forces, vital, 356 ; their estimation, 408 ; 
 oppression, 411 ; therapeutical indica- 
 tion furnished by them, 408. 
 
 Fortune (etiology), 43. 
 
 Forehead (symptomatology), 88. 
 
 Friction sound of pleura, 147 ; pericar- 
 dium, 168; peritoneum, 290. 
 
 Functions, affective, 110; assimilative, 
 
 116; generative, 223; intellectual, 
 111; of relation, 75. 
 
 G. 
 
 Gangrene, 368. 
 
 Gases, irrespirable and deleterious, causes 
 of disease, 22; in the blood, 189; ex- 
 halation of, 200. 
 
 Genera in pathology, 266. 
 
 Generation, phenomena presented in 
 disease by the organs of, 94. 
 
 Generative functions, symptoms fur- 
 nished by the, 223. 
 
 Gesta, (etiology), 51. 
 
 Glands, lymphatic, 190. 
 
 Goitre, 33. 
 
 Granulations, 369. 
 
 Gravel, 216. 
 
 Grinding of the teeth, 118. 
 
 Gums, 119. 
 
 Gurgling in the stomach, 128; in the 
 intestines, 128; in the chest, 141; 
 circumscribed, 142; extending over 
 the whole of one side of the chest, 
 and everywhere uniform as to rhythm 
 and intensity, 142. 
 
 H. 
 
 Habit (etiology), 42; preservative dispo- 
 sition of, 62 ; often furnishes therapeu- 
 tical indications, 417. 
 
 Haemorrhages, 200; their divisions, 201 ; 
 diagnostic value, 326; prognostic value, 
 356. 
 
 Hallucinations, 108; differ from illusions, 
 108. 
 
 Hair, 90. 
 
 Head, symptoms furnished by, 81. 
 
 Health, definition of, 7 ; a predisposing 
 cause, 43. 
 
 Hearing, alterations in the sense of, 109. 
 
 Heart (symptomatology), 163; extent of 
 its pulsations, 164 ; its impulse, 165; 
 nature of the sounds, 166; rhythm, 
 169; sympathetic disturbances, 325. 
 
 Heat, morbid, 192; means of its appre- 
 ciation, 192; increase of, 193; diminu- 
 tion of, 194; its perversion, 195; its 
 prognostic value, 355 ; atmospheric, 
 
 Heavenly bodies, their influence on the 
 course of diseases, 238. 
 
 Hectic fever, diagnostic value of, 335. 
 
 Hemiplegia, 98. 
 
 Hereditary diseases, 37. 
 
 Hesitation of the voice, 103. 
 
 Hiccup (symptomatology), 152; a prog- 
 nostic sign, 354. 
 
 Horripilation, 194. 
 
 Humorists, doctrine of the, 437. 
 
 Hunger (symptomatology), 117; in- 
 creased, diminished, 117 ; depraved, 
 118; its prognostic value, 352. 
 
 Hydrophobia, 124. 
 
 Hydrops, its diagnostic value, 327. 
 
 Hygienic means, 428; in acute diseases, 
 429; in chronic diseases, 434. 
 
 Hygroma, 46. 
 
 Hypostasis, 217. 
 
 I. 
 
 Idiopathic, 153, (note). 
 
 Idiosyncrasies, morbific, 60; preserva- 
 tive, 61. 
 
 Ileus, 129. 
 
 Illusions, 108. 
 
 Imminence of diseases, 70. 
 
 Impotency, 224. 
 
 Impulse of the heart, 165. 
 
 Increase in stature during disease, 77. 
 
 Incubation, period of, 70. 
 
 Incubus, 114. 
 
 Indications, 406; their bases, 406; are 
 furnished by the kind of disease, 406 ; 
 by its character, its type, 407 ; the 
 state of the vital forces, 408; intensity 
 of the disease, the periods, 412; the 
 symptoms, 413; the seat, complica- 
 tions, and causes, 414; the tempera- 
 ment, constitution, age, sex, profes- 
 sion, regimen, 415; commemorative, 
 416; the means already employed, 
 418 ; epidemic constitutions, 419 ; ten- 
 dency of disease, 419; obscure, 421 ; 
 predilection and antipathy of physi- 
 cians in regard to certain indications, 
 422; prophylactic, 422; vary in the 
 course of a disease, 427 ; the same 
 may be answered in many ways, 427; 
 of convalescence, and those furnished 
 by consecutive phenomena, 423. 
 
 Infiltration, 76. 
 
 Inflammation, anatomical characteristics 
 of, in the principal tissues, 366. 
 
INDEX. 
 
 455 
 
 Ingesta (etiology), 23, 48. 
 
 Innate diseases, 64. 
 
 Inquietude, physical, 76. 
 
 Insomnia, 114. 
 
 Institutions, political, 36. 
 
 Instruments, necessary in necroscopy, 
 359. 
 
 Intellect, alterations of, 111. 
 
 Intellectual functions, symptoms fur- 
 nished by, 111. 
 
 Intemperance, as a prognostic sign, 345. 
 
 Intercurrent diseases, 64. 
 
 Intermission, period of, 231. 
 
 Intermittent type, 231 
 
 Interrogation of patients, 298. 
 
 Intestinal canal, symptoms furnished by, 
 ]28. 
 
 Invasion, 234; in prognosis, 346. 
 
 Irritation, theory of, 440. 
 
 Ischuria, 211. 
 
 J. 
 
 Jactatition, 76. 
 
 Labia majora, 95. 
 
 Lachrymal sac (symptomatology), 87. 
 
 Laughing, i52. 
 
 Leanness, 223. 
 
 Lesion, to determine the nature of a, 
 
 316 ; its degree, 318. 
 Lesions, of structure, 365 ; conformation, 
 
 volume and color, 373. 
 Lethargy, 115. 
 Leucophlegmasia, 77. 
 Lientery, 131. 
 Light, its influence upon the progress of 
 
 diseases, 237 ; absence of, a cause of 
 
 disease, 33. 
 
 Limbs, symptoms furnished by the, 95. 
 Lipopsychia, 115. 
 Lipothymia, ] 15. 
 Lips, 88. 
 
 Localities (etiology), 34. 
 Lochia, 225. 
 Locomotion, symptoms furnished by the 
 
 organs of, 97. 
 Lymph, circulation of, 189; alterations 
 
 of, 191. 
 
 M. 
 
 Magnifying glass, 297. 
 
 Malacia, 118. 
 
 Mammae, 91. 
 
 Marasmus, 77. 
 
 Mastication (symptomatology), 123. 
 
 Means, general or hygienic, 428; in 
 acute diseases, 429 ; chronic diseases, 
 434. 
 
 Medicine of tradition, 404 ; its import- 
 ance, 404. 
 
 Medicines, a cause of disease, 49; diffi- 
 
 culty of appreciating their influence, 
 and making a methodical classification 
 of them, 425; their forms and doses, 428. 
 
 Meibomius, fluid of the follicles of, 207. 
 
 Melanosis, 371. 
 
 Menstruation, 224 ; its increase, 224 ; 
 diminution and deviation of, 225. 
 
 Mensuration, 5i83 ; mode of practising, 
 and precautions to be observed in, 
 
 283 ; of the limbs, 284 ; of the chest, 
 
 284 ; its results, 284 ; in cases of pleu- 
 ritic effusion, 285 ; of the abdomen, 
 
 285 ; of the pelvic diameters, 286. 
 Mental labor (etiology), 52. 
 Metallic tinkling, 145 ; theories of, 145. 
 Metaschematismus, 245. 
 Metastasis, metaptosis, 245. 
 Meteorism (symptomatology), 93 ; in 
 
 prognosis, 353 
 
 Method, numerical, 392. 
 
 Merycismus, 126. 
 
 Miasmata (etiology), 25. 
 
 Microscope, applications of, to the altera- 
 tions of the blood, 297 ; of mucus, 
 of pus, 297 ; of milk, 297 ; of urinary 
 deposits, 218; its employment in diag- 
 nosis, generally, 297. 
 
 Milk, its secretion, excretion, deviation, 
 225. 
 
 Mode of examining and questioning pa- 
 tients, 298 ; of conducting post-mor- 
 tem examinations, 358. 
 
 Movements (etiology), 23, 51 ; (symp- 
 tom.), 98. 
 
 Mucus, its properties and alterations, 
 198. 
 
 Murmur, bellows, of heart, 167; of the 
 arteries, 179 ; respiratory, 138. 
 
 Muscles (symptomatology), 98. 
 
 Mussitation, 102. 
 
 Myopia, 85. 
 
 N. 
 
 Nails, 96. 
 
 Nature of disease, 435. 
 
 Nares (symptomatology), 88. 
 
 Nausea (symptomatology), 125 ; as a 
 
 prognostic sign, 353. 
 Nebula in the urine, 217. 
 Neck (symptomatology), 90. 
 Necroscopy, mode of procedure in, 358. 
 Night, its influence upon the course of 
 
 diseases, 237. 
 Nightmare, 114. 
 Nomenclature, pathological, 13. 
 Nose (symptomatology), 88. 
 Numerical method, 392. 
 Nutrition (symptomatology), 222. 
 
 O. 
 
 Observation, the basis of therapeutics, 
 383 ; conditions for a correct mode of, 
 in medicine, 381 ; the spirit of, 382. 
 
456 
 
 INLEX. 
 
 CEdcma, 77. 
 
 Opisthotonos, 100. 
 
 Organs of locomotion (symptom.), 97. 
 
 Orthopncea, 135. 
 
 Ossification, 373. 
 
 P. 
 
 Palpation. 278; mode of performing, 
 278. 
 
 Pain (symptomatology), 105 ; its causes, 
 105; its effects, 105 ; its modifications, 
 106 ; intensity, 106; type, 107 ; varie- 
 ties, and different names according to 
 its seat, 107 ; prognostic value, 350. 
 
 Pancreatic fluid, 210. 
 
 Pandemic diseases, 64. 
 
 Paralysis, 98; its diagnostic value, 325. 
 
 Paraplegia, 98. 
 
 Parasitic animals, 24. 
 
 Parotid regions (symptomatology), 89. 
 
 Parotis, 89. 
 
 Paroxysms, 231. 
 
 Passions (etiology), 24, 52 ; (symptom- 
 atology), 110. 
 
 Pathognomonic signs, 274. 
 
 Pathology, 1 ; its definition and import- 
 ance, 1 ; its extent, 2 ; divisions, 2 ; 
 general, 3: its advantages and dan- 
 gers, 4 ; principal treatises upon, 444. 
 
 Pectoriloquy, 150. 
 
 Pellicle, urinary, 217. 
 
 Penis (symptomatology), 94. 
 
 Percepta (etiology), 52. 
 
 Percussion, a method of exploration, 
 286; mediate, immediate, 287; rules 
 to be observed in its performance, 288 ; 
 in diseases of the pleura and lungs, 
 151 ; of the heart, 170 ; of the abdo- 
 men, 289. 
 
 Periodical diseases, 231, 
 
 Periodicity of diseases, 233 ; its causes, 
 233. 
 
 Periods of disease, 233. 
 
 Perspiration, 196. 
 
 Pharynx (symptomatology), 123. 
 
 Phenomena, 72 ; precursory, 70 ; value 
 of, in prognosis, 346 ; consecutive, 
 262; their progress, 264; duration, 
 264; diagnostic value, 319; sympa- 
 thetic, 227. 
 
 Phlyctaena?, 85. 
 
 Physiognomy in health, 82; in disease, 
 82; a means of prognosis, 349. 
 
 Pica, 118. 
 
 Pinched countenance, 82. 
 
 Pleurosthotonos, 101. 
 
 Plicatures (symptomatology), 80. 
 
 Poisons (etiology), 23; their divisions, 
 23. 
 
 Political institutions (etiology), 36. 
 
 Popular diseases, 64. 
 
 Precursory signs, 70 ; value of, in prog- 
 nosis, 346. 
 
 Predisposing causes, vide Causes. 
 
 Predispositions, not to be confounded 
 with predisposing causes, 59. 
 
 Pregnancy (etiology), 44 ; its influence 
 upon the progress of diseases, 240 ; on 
 their prognosis, 345. 
 
 Preludes of diseases, 70. 
 
 Presbyopia, 85. 
 
 Pressure (diagnosis), 276 ; differs from 
 palpation, 276 ; signs which it fur- 
 nishes, 277. 
 
 Primary diseases, 69. 
 
 Probes, examination with, 293. 
 
 Prodromes, 70. 
 
 Professions (etiology), 43. 
 
 Prognosis, 341 ; conditions necessary to 
 its establishment, 341. 
 
 Prognostic signs, 342 ; principal, 348. 
 
 Progress of diseases, 230 ; its importance 
 in prognosis, 347. 
 
 Protopathic disease, 69. 
 
 Ptosis, 99. 
 
 Ptyalism, 207. 
 
 Puerperal state, 345. 
 
 Pulse, 170 ; its frequency according to 
 age, 170; mode of examining, 172; 
 its varieties, 172 ; venous, 182 ; criti- 
 cal, 250; its prognostic value, 354. 
 
 Pupils (symptomatology), 85. 
 
 Purring tremor, 168. 
 
 Pus, physical and chemical properties of, 
 204. 
 
 Pyogenia, 201 ; formation of pus, 201 ; 
 its diplacement, 202; physical and 
 chemical qualities, 204. 
 
 R. 
 
 Reasoning in medicine, 405. 
 
 Recurrence, 265; its causes, 265 ; symp- 
 toms, 265. 
 
 Regurgitation, 125. 
 
 Relapse, 264 ; its causes, 264 ; symptoms, 
 265. 
 
 Remedies, precautionary, a cause of dis- 
 ease, 50 ; differ from treatment, 427 ; 
 their number infinite, 427. 
 
 Remittent type, 232. 
 
 Renvois, 125. 
 
 Repercussion, 242. 
 
 Residence, 34. 
 
 Resolution, 242. 
 
 Respiration (symptomatology), 134; fre- 
 quent, 134; quick, 135; full, 135; 
 small, 135; laborious, 135; painful, 
 135; suffocating, 135; unequal, 136; 
 irregular, 136; intermittent, 136; in- 
 terrupted, 136 ; sighing, 136 ; plain- 
 tive, 136 ; resembling the sound of a 
 flute, 136; stertorous, 137; rattling, 
 137. 
 
 Respiratory murmur, in its normal con- 
 dition, 138; is not of equal intensity 
 in all parts of the chest, 138 ; its modi- 
 fications in disease, 138. 
 
 Restlessness, 76. 
 
INDEX. 
 
 457 
 
 Retching, 125. 
 
 Return to health, 242 ; in general dis- 
 eases, 243 ; local diseases, 243 ; chronic 
 diseases, 244. 
 
 Revolution, diurnal, its influence on the 
 progress of diseases, 237. 
 
 Rhonchi, definition of, 140 ; crepitant, 
 140; subcrepitant, 141 ; mucous, 141 ; 
 cavernous, 14] ; sibilant, 144 ; sono- 
 rous, 144. 
 
 Rhythm of the cardiac pulsations, 169. 
 
 Rigidity, 99 ; a prognostic sign, 349. 
 
 Rigor (symptomatology), 194 ; as a prog- 
 nostic sign, 355. 
 
 Risus sardonicus, 89. 
 
 Rumination, 126. 
 
 Saliva, 207. 
 
 Satyriasis, 224. 
 
 Scabs, 206. 
 
 Schirrus, 370. 
 
 Scrotum, 95. 
 
 Seasons, a cause of diseases, 33 ; their 
 influence on the seat of diseases, 18 ; 
 on their progress, 238 ; on their prog- 
 nosis, 346. 
 
 Seat of diseases, 16; to determine the, 
 312; its prognostic value, 344 ; influ- 
 ence of age upon the, 18; influence 
 of the seasons, 18. 
 
 Secondary diseases, 69. 
 
 Secretions, 206. 
 
 Sediment, 217. 
 
 Semen, secretion and excretion of, 224. 
 
 Sensations, internal, 105; external, 108. 
 
 Sensibility, 104. 
 
 Sexes (etiology), 41. 
 
 Shoulders (symptomatology), 91. 
 
 Sighing respiration, 136. 
 
 Sight, alterations of, 108. 
 
 Signs, differ from symptoms, 72 ; pre- 
 cursory, 70 ; diagnostic, 273 ; their 
 division, 274 ; prognostic, 342. 
 
 Skin, its various colors, 78; spots, 79; 
 eruptions, 80 ; plicatures, 80 ; tumors, 
 excoriations, 81 ; fissures, fistulas, ul- 
 cers, &c., &c., 81. 
 
 Sleep and the waking state, as causes, 
 52; symptoms, 113; prognostic value 
 of, 351. 
 
 Sleeplessness, 114. 
 
 Smell, exaltation and diminution of, 109. 
 
 Sneezing, 152. 
 
 Solidists, doctrine of the, 438. 
 
 Somnolency, 115. 
 
 Sopor, 115. 
 
 Souffle, vide Respiratory murmur, and 
 Bellows murmur. 
 
 Sounds, respiratory, 138; of the heart, 
 166; bellows, 167; filing, 167; rasp- 
 ing, 167 ; musical, 167; sawing, 167; 
 auriculo-metallic, 168 ; friction, of 
 pleura, 147 ; pericardium, 168 ; peri- 
 39 
 
 toneum, 290; arterial, 179; examina- 
 tion with probes and, 293. 
 
 Species of disease, 266. 
 
 Specific causes, common, 25. 
 
 Speculum, 294 ; cavities explored by this 
 instrument, 294; mode of its intro- 
 duction into the vagina and rectum, 
 295. 
 
 Speech, anomalies of, 103. 
 
 Spitting, 155. 
 
 Sporadic diseases, 64. 
 
 Sputa (symptomatology), 155 ; their dif- 
 ferences, 156 ; they furnish important 
 prognostic signs, 354. 
 
 Sputation, 156. 
 
 Stages, 236. 
 
 Stationary diseases, 64. 
 
 Statistics, medical, 393; its application, 
 393; objections to it, with their refu- 
 tation, 395. 
 
 Sterility, 226. 
 
 Stammering, 103. 
 
 Strangury, 211. 
 
 Stature, rapid increase of, a prognostic 
 sign, 349. 
 
 Strength, 356; estimation of the, 408; 
 oppression of the, 411 ; therapeutical 
 indications furnished by the state of 
 the, 408. 
 
 Stupor, 82. 
 
 Subsultus tendinum (symptomatology), 
 99; as a prognostic sign, 349 ; epigas- 
 tric, 125. 
 
 Succussion, abdominal, 282; thoracic, 
 146. 
 
 Supervenientia, 229. 
 
 Suppuration, 204, 242. 
 
 Suspension in the urine, 217. 
 
 Sympathetic phenomena, 227; render 
 diagnosis obscure, 323. 
 
 Sympathies, morbid, 227. 
 
 Symptomatic phenomena, considered in 
 relation to diagnosis, 319. 
 
 Symptomatic diseases, 69. 
 
 Symptomatology, 72. 
 
 Symptoms, 72; differ from signs and 
 phenomena, 72 ; division of Boerhaave, 
 of Bayle, 73; order followed in their 
 exposition, 74 ; primary or local, 227; 
 secondary or general, 227 ; sympa- 
 thetic, 227; idiopathic, 153; principal, 
 228; accessory, 228 ; active, 229; pas- 
 sive, 229; of a symptom, 230; of a 
 cause, 230. 
 
 Syncope, 116. 
 
 Synonomy of diseases, 15. 
 
 T. 
 
 Taste (symptomatology), 109. 
 
 Tears, 207. 
 
 Teeth (symptomatology), 118. 
 
 Temperaments (etiology), 41. 
 
 Tempies, 88. 
 
 Tenesmus, 130 ; vesical, 211. 
 

 458 
 
 INDEX. 
 
 ^Termination of diseases, 242; by their 
 
 Mure, 242 ; by death, 244 ; by the su- 
 
 ; .' . pervention of another disease, 245. 
 
 Testicles (symptomatology), 95. 
 
 Therapeutics, 380 ; its bases, observa- 
 
 $$ tion, 381; and experience, 403; em- 
 
 ' ployment of reasoning, 405; applica- 
 tion of chemical knowledge, 405. 
 
 Thirst (symptomatology), 118 ; a prog- 
 
 I nostic sign, 352. 
 
 Time, between the application of the 
 
 cause and the development of the 
 disease, 69. 
 
 Tinkling, metallic, 145. 
 
 Tongue, in health, 119 ; in disease, 119 ; 
 its volume, 120; form, 120; motions, 
 120 ; color, 120 ; coats, 121 ; humidi- 
 ty, 122 ; eruptions, 122 ; temperature, 
 123 ; sensibility, 123 ; signs which it 
 furnishes to prognosis, 352. 
 
 Touch, sense of (symptomatology), 109 ; 
 exploration by the, 280 ; mode of its 
 performance, 280 ; by the vagina, 280 ; 
 the signs it furnishes, 281 ; by the 
 rectum, 281 ; in the pharynx, 282. 
 
 Transformations, morbid, 372 ; cartila- 
 ginous, 373 ; cutaneous, 372 ; fibrous, 
 
 ; 373 ; fatty, 372 ; horny, 373 ; mucous, 
 
 I 372 ; osseous, 373 ; serous, 372. 
 
 Trembling, 99. 
 
 Trismus, 101. 
 
 Tubercles, 368. 
 
 ^Tumors, 81. 
 
 i Tunica vaginalis, 95. 
 
 Tympanites, 93. 
 
 EType of diseases, 231 ; continued, 231 ; 
 
 > periodical, 231 ; varieties of intermit- 
 
 I tent, 231 ; remittent, 232 ; an element 
 
 ^ in their diagnosis, 320. 
 
 U. 
 
 Ulcers, 367. - 
 
 Univocal signs, 274. 
 
 Urine, the normal properties of, 210 ; the 
 changes in its physical and chemical 
 properties, and in its excretion, 211 ; 
 its deposits, 217. 
 
 V. 
 
 Vapors, metallic (etiology), 25. 
 
 Variations of the atmosphere, 32 ; their 
 influence upon the progress of dis- 
 eases, 238. 
 
 Varieties of disease, 270. 
 
 Veins (symptomatology), 181. 
 
 Venomous secretions, 26. 
 
 Vertigo, 116. 
 
 Vessels, lymphatic (symptomatology), 
 189. 
 
 Vibices, 80. 
 
 Virus, 26 ; mfo Contagious principles. 
 
 Vision, 108. 
 
 Voice, 102; auscultation of the, 148. 
 
 Volume of the body, 76. 
 
 Vomited matters, 126. 
 
 Vomiting, 126; sympathetic, 126. 
 
 W. 
 
 Winds, influence of the, 32. 
 
 Y. 
 
 Yawning, 152. 
 Years, climacteric, 40. 
 
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