145 155 ^IfikH UC-NRLF B 3 103 fl3b Ci*,irjy. ■:. ^,- ----- ■■.>-..-■.■.^.i-^ : . AiN ESSAY r O.X THE BLOOD IN DISEASE. BY G. ANDEAL. TRANSLATED FROM THE FRENCH BY J. F. MEIGS, M.D., AND ALFRED STILL6, IVI.D. BMMM THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA PRESENTED BY PROF. CHARLES A. KOFOID AND MRS. PRUDENCE W. KOFOID / ■. .;V >:* ^.l.\j.-.f^tC\ PATHOLOGICAL HJIMATOLOGY. AN ESSAY ON THE BLOOD IN DISEASE. BY G. ANDRAL, PBOFBSSOR OF GENERAL PATHOLOGY AND THERAPEUTICS IN THE DNIVERSITT OF FAHIS, ETC. ETC. TRANSLATED FROM THE FRENCH BT J. F. MEICS, M.D. AND ALFRED STILLE, M.D. ^Non ideo analyses sanguinis ulilitate svtH desiiluuntur, dum sapienier noverinius spel nos- tras recidere, neque plura docere quim a nature discimus. — Haller, Elem. Physiolt, lib. v. PHILADELPHIA: LEA AND BLANCHARD. 1844. TABLE OF CONTENTS. CHAPTER I. 4 Of the best method to puHsrE in the study of Pathological H.ema- t TOLOGT, .-.--...---15 CHAPTER n. Of the Blood ik Diseases, .--- 36 Article I. — Of the blood in Plethora, ---... 38 " II. — Of the blood in Anaemia, - - j - - - 43 " III.— Of the blood in Pyrexiae, 52 " . IV.— Of the blood in the Phlegmasiaei 6d • " V. — Of the blood in Hemorrhages, 92 « VI.— Of the blood in Dropsies, - - -. - - - 107 " VII. — Of the blood in certain diseases commonly called organic, 117 « AlII.— Of the blood in the Neuroses, 128 « ESSAY upon PATHOLOGICAL HiSMATOLOGY. HiEMATOLOGY is that branch of the natural sciences the subject of which is the study of the blood. This expression is not a new one in science : about a century since, an autlior now but little known, Thomas Schwenke, published, under the title of Hasmatology, a treatise as complete as it could then be, upon the blood considered in its state of health and of disease.* Before this author, and Since his period, many works, some theoretical, some experimental, -have been published on the blood; their simple enumeration would be a considerable un- dertaking, and one not without utility ; such however is not the end that I seek : but I come to add to all these works, of various importance, a new one, in which I design to make known the alterations that the blood has presented me in dif- ferent diseases, under the triple view of its physical proper- ties, and of its chemical and microscopic constitution. I shall endeavour to estimate the importance of these alterations in regard to semeiology and pathogeny, and I shall discuss finally the value of the methods that have been followed at different periods for the purpose of discovering the facts of pathological hasmatology. • Thomas Schwenk Hsematologia, sive sanguinis historia, experimentis passim superstructa, in 8° Hagcecomitum, 1748. 2 fvi354496 14 PATHOLOGICAL HEMATOLOGY. Already in two memoirs read at the Academy of Sciences in 1840 and 1842, I have exhibited the results that I ob- tained, in seeking to appreciate the variations of proportion, that some of the principles of the blood, to wit, the fibrme, the globules, the solid elements of the serum, and the water, may offer, whether in disease, or in different states of the physio- logical condition. To accomplish these researches I have fol- lowed the method indicated by M. Dumas, one which he him- self advised me to have recourse to, as answering the end that I sought to attain. May he permit me to express to him on this occasion my gratitude for all his kind advice. In the work that I now publish, I have sought to give a greater development to the facts and ideas contained in my preceding memoirs : there will be found in addition a certain number of results that I have obtained more recently, and which have not yet been made public. For many of the de- tails and ciphers I will refer the reader to the two other me- moirs ;* for I do not pretend to give to the world a finished and complete essay — even while continuing my researches, I desired to indicate the point to which they had attained, what results they had yielded, and what it may be possible to arrive at, if the pursuit does not become wearisome. * Recherches sur les modifications de proportion de quelques principes de sang (fibrine, globules, materiaux solides du serum, et eau) dans les maladies, par MM. Andral et Gavarret (^Annales de chimie et de physique, tome LXXV). Recherches sur la composition du sang de quelques ani- maux domestiques dans I'etat de sant^ et de maladie, par MM. Andral, Ga- varret et de la Fond (Annales de chimie et de physique, 3d serie torn. v.). The results detailed in these two memoirs, as well as those contained in this new work, are the fruit of researches common to myself and to M. Ga- varret, to whose learned and devoted collaboration I am greatly indebted. For the facts relating to animals, M. de la Fond, professor at the veterinary school of Alfort, kindly lent us the aid of his time and experience. The method that we have followed, and the results that it has given us, having been the subject of several criticisms, we have thought proper to an- swer these in a separate work, to which I shall also refer from time to time, and which has for title : Reponse aux principales objections dirigees contre les procedes suivis dans les analyses du sang, et contre Vexactitude de leurs resul- tats, brochure in 8°, 1842, chez For tin et Masson. THE BEST METHOD OF STUDY. 15 CHAPTER I. OP THE BEST METHOD TO PURSUE IN THE STUDY OP PATHO- LOGICAL HEMATOLOGY. It was one of the dogmas professed by the school of Cos, that in order to explain the phenomena of health and of dis- ease, we must take equally into consideration the solids which enter into the composition of the human body, the fluids with which it is so abundantly provided, and the forces which con- trol it. But few physicians however remained faithful to these principles, which Hippocrates has declared in several of his works, and particularly in his book on ancient medicine; and we find Galen reproaching his contemporaries with some bit- terness, for having broken this beautiful ensemble of the an- cient Grecian school, in order to interpose in their explanation of disease, some only the solids, others only the fluids, and others again only the forces which pervade and animate or- ganized matter. * And thus were determined from those ancient times, the three great points of view, which, now abandoned, and now again adopted, have produced the three systems of solidism, humorism, and vitalism. One of the characteristics, and I venture to say one of the glories of the present medical epoch, is to have understood to • Hippocrates, cum trifariam hominis elementa divisisset, in continentia, contenta, et ea quae impetum faciunt , baud scio quomodo successores ejus unam illam revera divinam JEsculapii medicinam ia tres partes sibi cobffirentes distribuerint atque divulserint. Alii enim liumidis, turn causam eorum quas secundum naturam babent constitutionem, tum causam eorum quae praiter naturam, solis attribuere, ut Praxagoras etHerophilus. Alii, soli- dis corporibus initia et elementa atiribuentes, ex his tum quae natura consis- tunt, tum morborum causas inde capiunt, et Erasistrates et Asclepiades, Athenaii vero et.Archig:enis imitatores, spiritu solo ea penetrante, tum natu- ralia consistere ac gubernari, tum morbos universes hoc prius offenso creari dixerunt. (Medicus.) 16 PATHOLOGICAL H^MATOLOGT. what incomplete and necessarily erroneous results these minute subdivisions of the science conduce; and, at the same time that it has given a due degree of importance to dynamism and solidism in pathogenic theories, it has returned to the study of the alterations of the blood; it has recognized their exist- ence, and has accorded them an influence in the production of disease. But, singular fact ! these alterations, of which the reality and importance are no longer denied by any, are nevertheless scarcely known, and but few facts could be cited in proof of the convictions arrived at on this subject; direct observation of the blood has thus far been much more rarely invoked than theory, and when recourse has been had to ob- servation, it has been made use of most frequently only to study in the sanguine fluid, the simple alterations of its physical pro- perties. But thus we remain ever in the infancy of the sci- ence ; to progress, we must analyze the blood : such is the idea which guided M. Magendie when, by modifying artifi- cially its composition, he proved that we can by these means create disease. Pathological hasmatology will begin to be enriched with facts of some value, only when the blood of a great number of patients shall have been submitted both to chemical investigation, and that by the microscope. Doubt- less, while studying by this double means of analysis the different elements of that fluid, and while thus following them one by one in all their possible variations of proportion and nature, we must not neglect the study of the changes it may undergo in its physical properties ; but we soon discover that this latter mode of examination is almost always insuflicient, and that when employed alone, without the control of analysis, it may often become a source of error. For we should be un- able to give an exact account of the different modifications that the blood is susceptible of in its physical properties, unless we have learned to connect these changes with others more inti- mate occurring in the composition of that fluid, and of which the first are but the effects. Thus it may happen that the blood shall present an identical appearance, and be equally buffed in diseases as different as are clilorosis on the one hand. THE BEST METHOD OP STUDY. 17 and pneumonia or acute articular rheumatism on the other. But is the blood alike in chlorosis and pneumonia ? Does the buff in these two diseases have the same signification ? This the simple consideration of the aspect of the fluid could not inform us; analysis alone can reveal it to us, as I shall show farther on. At other times it is the microscope which becomes our chief means of analysis ; it is this, for example, which will reveal to us alterations of quahty in the globules, or which will show us pus in the blood, etc. Finally, in these dif- ficult researches, where no source of light should be neglected, cheiTucal and microscopic investigation will find at times a useful aid in physiological experiments. By these last, in fact, we can modify in animals the composition of the blood, and as a consequence its physical properties, in such a way as to render this fluid more or less similar to what it is in certain diseases. Once these modifications produced, we observe what are the phenomena that result in different parts of the organism, and we can draw conclusions relative to the influ- ence that modifications of the same nature occurring sponta- neously in the blood of man, may exercise in the production of various morbid conditions. It is by acting in this way that M. Magendie has shown the influence that blood, less than usually charged with fibrine, may have in the production of sangume congestions and hemorrhages. By the direct analy- sis of the blood of the sick, I have arrived, in this respect, at results similar to his own. Such are the modes in which we must necessarily proceed, if we seek to give some impetus to pathological haematology. Of what use is it, indeed, to waste oiu: time, as has often been done, in mere speculations, on the part played by the blood in the economy, on the reciprocal influence of this fluid upon the sohds, or of the solids upon it ? Of what use is it again to deduce, by reasonmg, the existence of alterations of its com- position and their influence in disease, from a consideration of the causes and symptoms of these last ? Without doubt we may there find strong arguments to bring forward ; but they can conduct only to simple probabilities, or else we should in 18 PATHOLOGICAL HiEMATOLOGY. this way always remain with notions so incomplete as to be most frequently useless, and sometimes even dangerous. It is by this method that some have supposed the blood to be changed, and this change to be the point of departure of the disease, when this disease recognizes as cause the absorption of a miasm, of a virus, or of a poison. Yet that is only a presumption, and we might just as well admit that the blood, in cases of this kind, serves merely as a vehicle to the deleterious agent which has traversed without altering it, in order to pass on with greater or less rapidity to attack the solids alone. I might cite many other examples of the deplorable uncertainty in which we are forced to remain, while from the nature of the causes or of the symptoms we seek to adduce directly the nature of the alter- ation that the blood may have undergone ; would it have been possible, for exampje, by this method, to recognize the difference between the alteration of the blood in scm'vy and in chlorosis ? What has been said indeed of the state of the blood in these two diseases ? Nothing more than that it was deteriorated, and on this deterioration all the symptoms of scurvy and of chlorosis were made to depend. But why then are these symptoms so very different? It is because the nature of the deterioration is not the same in the two diseases ; in each of them there is a different element of the blood in fault, and thus analysis teaches us that scurvy and chlorosis are not diseases of the same nature, and by this means we can explain the great difference in their symptoms, notwithstanding the fact that a deteriorated blood exists in both. Thus, when anatomy fails to disclose to us any change, chemistry brings it to Hght, and I doubt not that it will become more and more one of the bases of pathogeny, notonly as is the case particularly at present by analyzing the fluids modified by disease, but also by tracing in the solids themselves the important >.study of the changes in proportion and nature of the elementary principles which compose these solids. Besides, it is not only in our day that the idea has arisen of seeking the origin of diseases in some alteration of the element- ary principles which enter into the composition of the bodies of THE BEST METHOD OP STUDY. 19 animals : this idea was brought to Hght in the earhest periods of science; but for a long time remained without rcsuhs, be- cause in place of seeking to establish experimentally the alter- ation of these principles, nothing more was done generally than to suppose it. The ancient humorism, during every epoch when it has prevailed, was but the exaggerated and hypotheti- cal expression of this idea. It is found entire in the dogmas of the Grecian philosophy, which attributed diseases to a certain number of modifications occurring in the elements, of which it supposed the human body to be primarily composed. This doctrine ruled in science without control from the time of Thales down to that of Galen, and from Galen to the chemists of the sixteenth century. These latter, in destroying the ancient doctrine of the four elements, overthrew likewise the medical theories that were attached to it ; but they preserved its original idea ; for they also determined that the origin of diseases ought to be referred to a vicious combination, or to some alteration of the simple principles which they thouglit to have discovered in nature at large, and in organized bodies in - particular. They troubled themselves but little, however, to make experiments for the purpose of proving their assertions ; what they saw take place in their crucibles, they boldly con- cluded must occur also in the living body ; they made the acids, alkalies and salts, which they had discovered in the organs, , react in their interior, without endeavouring by experiment to prove the reality of these reactions; and in this way they arrived in their pathogenic doctrines, at the strangest concep- tions : there remains to us for example, a nosology of this epoch, by Schenneman, a disciple of Paracelsus, in which that author makes ten classes of diseases, which he founds upon a certain number of modifications occurring in three principal constituents of the body, to wit : mercury, sulphur, and salt.* At this period, Sylvius Deleboti sought to found a complete medical system, by ascribing diseases to an alteration of the • See Sennerti operti, torn, i, do cheinicorum cum Aristotelicis etGalenicis consensu ac dissensu liber, cap. iii. 20 PATHOLOGICAL HiEMATOLOGT. principles which chemistry had just discovered. He assigned a prominent part in the production of diseases to the state of acidity or alkalinity of the humours. One of the most fre- quent causes of fever, according to him, was an dcre, possessed of different chemical properties, which irritated the heart. * He made inflammation to depend upon stagnation of the blood in the vessels, in consequence of which its more volatile and sub- tile parts which commonly dilute the acid or alkaline portions, evaporated ; then these latter became more acrid, produced a hot effervescence, because of the oleaginous molecules they contained, and the blood might in this way arrive at such a degree of inflammation as to be transformed into pus.t These doctrines and this language are scarcely intelligible to us; and yet, amid so many vain hypotheses, one is often surprised to find from time to time propositions which deserve a serious examination, and to which pathological physiology has of late returned. It is in this way that Sylvius explains a consider- able number of disorders of the digestive functions, sometimes by the unusual chemical reactions which take place in the stomach or in the intestines, sometimes by the formation in these parts, of an excess of acid, sometimes, on the contrary, by the diminution of the acid or alkalinematerials which ought naturally to be formed in the digestive tract. J Elsewhere, • * Quolibet acre, nunc acidum, nunc lixivo-salsum, nunc muriatico-salsum, par venas una cum sanguine ad cor propulsum, atque interne cordis paren- chyma mordicans. Francisci Sylvii Deleboe praxeos medicEe liber primus, caput xxvii. de Febribus in genere. •j- Arbitror autem incendi ac inflammationem parere sangulnem, quatenus ex ipso in vasis suis vald6 distentis, partibusve quibusdam aliis subsis- tente, hoc est stagnante, mox incipiunt evanescere partes spirituosse, ma- gisque volatiles ac subtiles turn acidas, turn salinas temperare solitce ; unde utrscque acriores factce acrius in se mutuo insurgunt, effervescentiamque ob partes sanguinis oleosas prsesentes calidam excitant; quin paulatim san- guinem ita corrumpunt, ut in pus vertatur. Sylvius Deleboe, loc. cit., lib. i. cap. xl. \ Idem, ibid, cap. i, de siti Isesa. — cap. vii, de alimentorura fermentatione in ventriculo laesa. — Cap. ix, de nausea, eructatione et vomitu. — Cap. x, de chyli a fcecibus alvinis secretione Isesa. — Cap. xi, de vitiosa bills, et succi pan- creatici una cum pituita continuo excitatain tenui intestino effervescentia. — Cap. xiv, de variis intestinorum doloribus. Might not several of the subjects announced in these titles of chapters be- THE BEST METHOD OF STUDY". 21 Sylvius seeks to account for the fluidity of the blood in malig- nant fevers and in the plague, by the presence in the mass of that fluid, of an excess of alkaline principles, formed in the economy, or introduced from the exterior ; and what occurs rarely in his works, he cites here seven experiments ; he says on the one hand, that the injection of acid substances into the veins of a living animal produces instantly coagulation of the blood, and on the other hand, that the blood becomes dissolved on the contrary, when the injection is made with alkaline substances.* These facts are amongst those which have been in a measure rediscovered by modern observers : and M. JNIagendie has proved that by efiecting in living animals a true dissolution of the blood, by means of an alkaline substance mingled with it, we produce in them several of the symptoms that belong to typhus fever.t Such was this Sylvius Deleboe, whose opinions long exercised so powerful an influence on the theory and practice of medicine; a truly distinguished man, whom the insufficient light of chemistry in its infancy, and of an imperfect method *of investigation, led to the most singular illusions, but who had the merit of discovering some truths, of foreseeing a great number, and of forming a body of doctrine, the founda- tions of which, some one may perhaps seek to reconstruct with more solid and more durable materials. It may be that I deceive myself, but it seems to me that while meditating on these hypotheses of the chemical physicians of the sixteenth century, though we may recognize most generally their futility, the mind is nevertheless arrested and returns to them, as though conscious that they place it upon a point of view, where im- portant truths are about to be disclosed to it. I do not pretend to pass in review the numerous authors come material for interesting works 1 this it is which attracts so strongly to the study of the works of Sylvius, and of many other of his contemporaries, though we feel that they do no more than propose problems without resolving them. ♦ Sylvius Deleboe, praxis medica, lib. i, cap. xxxiii, de febribus malignis. — De pesie, sectio iii. — Praxeos medicae appendix, tractatus ii. — De methodo medendi, lib. ii, cap. xxvi. \ Magendie, lejons sur les phenomenes physiques de la vie, passim. ^* 22 PATHOLOGICAL HiEMATOLOGT. who, before or after Sylvius, sought hke him to determine through chemistry the seat and nature of diseases. On this hst would appear the most illustrious names, such as those of Van-Helmont, of Willis, of Boerhaave and of his commentator Van-Swieten: so natural did it appear to these men, who followed in other respects such different doctrines, to bring into play, in their theories of disease, the consideration of the principles which the chemistry of their day showed to exist in the human body!* • To comprehend these authors, we must not deceive ourselves upon the meaning that they attached to the word so often repeated by them of ele- ments or principles ; here is the signification given to it by Willis, (de fer- mentatione, cap. 1): " Principiorum nomine intelligo baud entia simplicissim,a et omnino in- composita, sed tantum substantias, in quas veluti partes ultimo sensibiles, res physicge resolvuntur. Harum combinatione et motu intestino corpora gignuntur et accrescunt; harum mutuo ab invicem discessu et dissolutione alterantur et intereunt." But besides, the chimiatric doctrines of the three last centurie^ would be unintelligible for him who did not know, that in the language of those times, the expressions by which were designated the elements of the bodies then admitted, had a sense totally ditferent from that we give to them at present. For Sylvius, for Willis, as well as for Paracelsus, the words mercury, sulphur, and salt, were employed in a sense altogether metaphorical, as may be seen by the following passage from the chemistry of Sylvius, which I translate literally: Chemistry, says Sylvius, is nothing more than the separation of compound bodies into their principles: these latter are five in number, to wit: mercury, sulphur, salt, phlegm, and earth. Mercury is the name given by chemists to spirit, because, like mercury, it is volatile. This spirit or mercury is any subtle or penetrating liquor, as the spirit of rectified wine, or the spirit of salt of nitre. We call that also spirit which disengages itself from bodies in a state of fermentation, but we ought more particularly to confine this term to whatever is volatile in its material, no matter what may be its origin. In this way we find three spirits ; an in- sipid, a sulphurous, and a saline one. Sulphur is whatever is inflammable; it is sweet or bitter; the first exists in fat and in flesh, the second in absynlhium and in bile : there is one sul- phur which is volatile, and another which is fixed. Salt is whatever can be incinerated; it is acrid, sometimes fixed and some- times volatile ; a fixed salt is one, which may four times be exposed to heat without change ; a volatile salt is one which when exposed to a slight heat, THE BEST METHOD OF STUDY. 33 Nevertheless, even during their greatest development, these doctrines were not adopted without opposition ; they met with numerous and able opponents, amongst whom we find a learned natural philosopher, Robert Boyle,* and a celebrated observer, Thomas Sydenham. The first brought forward doubts on the reality of the existence of the chemical princi- ples admitted by his contemporaries ; he demanded that they should verify by experiment so many gratuitous assertions, and in this way made a wide breach in the applications that had been made of them in medicine. The second strongly opposed the physicians, who according more, said he, to specu- lation,' than to practical observation, long sought to explain diseases by the new inventions of the qhemists ; he accepted the aid of chemistry only to enlighten physicians in the pre- paration of remedies.! The absolute aversion, manifested by Sydenham for every application of chemistry to medical theo- ries, was certainly in him the very natural result of the im- pression that had been made upon his mind by the hypothe- ses of the iatrochemists, and particularly by the conclusions that they had deduced from them for the treatment of diseases, a treatment in flagrant opposition to that the power of which evaporates and is dissipated in the atmosphere, or which, when enclosed, at- taches itself to the sides of the alembic or recipient. Phlegm is any aqueous, insipid fluid, that is unsusceptible of being vola- tilized by a very strong fire. An earth is a gross, dry substance which has no other quality than that of remaining in this latter condition, no matter to what test we submit it. Of these five elements, ^the three first are called active, because upoa them depend all the movements of natural bodies ; the two last are called passive, because they do not act in themselves, and because they receive from the first the stations they must occupy; Paracelsus and others refuse them the title of elements." Sylvius de Leboe, de chymia in genere. • Robert Boyle, the sceptical chemist, 1661. f Et sicuti Hippocrates eos reprehendit, qui huic in humanis corporibus speculandis curiositati plus dant quim observationibus praticis, it4 pari jure prudens vir quispiam in hoc nostro seculo eos culpare possit, qui existimant artem medicans nulla re ulla magis promoveri posse quim novis chemicoruminventis at si intri pharmacopise limitescentineaturchimia, ars est satis quidem laudabilis. — {^Sydenham, tractalus de hydrope.) 24 PATHOLOGICAL HEMATOLOGY. was daily proved to him by a most admirable observation. Thus, this excellent genius was' led to disown and deny the truth of a principle, the abuse or improper application of which had too strongly prejudiced him. More recently Bor- deu reproduced these attacks of Sydenham against the utility of the application of chemistry to pathogeny.* In this way it happened, in consequence of the reaction which infal- libly occurs against the best principles when exaggerated, that medicine, which for two centuries had drawn most of its theo- ries from chemistry, came to reject in an absolute manner all aid from this science, excepting for pharmacology, as Syden- ham had desired; an instrument as yet imperfect was badly employed, it was broken. Nevertheless, more impartial than Sydenham or Bordeu, because he had studied more fully, Haller, while assigning limits to chemical investigation, pro- claimed it as necessary to the progress of medical doctrines; laying aside hypothesis, he noted with care, in his great phy- siology, the results of the few experiments that had been made before his time in order to determine the normal and abnormal composition of the blood ; he pointed out by this means the true method to be pursued, and wrote this phrase full of mean- ing : Non ideo analyses sanguinis utilitate sua distituun- tur, dum sapienter noverimus spes nostras redder e, neque plura docere quam a naturd discimusA Such were the fruits of the iatrochemical doctrines, and they existed in science but as wrecks, so to speak, when the genius of Lavoisier arose, to give to chemistry a new aspect, and im- part to it a certainty until then unknown. Medicine felt its influence, and began anew to search for the cause and seat of diseases in the various principles which a wonderful analysis had just revealed. But the first essays of this kind were most un- fortunate, for they had also for support merely pure hypotheses. While adopting the words of Lavoisier's chemistry, physicians took neither its spirit nor its method, and continued to advance • Bordeu, analyse medicinale du sang. f Haller, elementa physiologiae, lib. v. § xxsiv. THE BEST METHOD OF STUDY. 25 as in the time of Paracelsus. In this way was composed the strange nosography published by Baumes, in wliich, mider the titles of calorineses, oxigeneses, hydrogeneses, azoteneses and phosphoren^ses, the professor of Montpellier, divided diseases into five classes, giving to each one of them a name in relation with the principle or element, which he quite gratuitously sup- posed to produce them by its modifications of quantity or sit- uation.* Ancient chemistry has surely produced nothing more hypo- thetical or more extravagant than this singular classification of diseases : it is beside an imprudent, altogether conjectural application of chemical knowledge to the science of the sick man. If this method had been persevered in, the opinion of Sydenham, ' and Bordeu would certainly have triumphed ; happily however some wise spirits perceived all that was un- reasonable and dangerous in it. A few years after the disco- very of pneumatic chemistry, two chemists, Parmentier and Deyeux, associated themselves for the purpose of discovering by experiment, to what extent the normal principles of the blood are susceptible of change in disease ; but their work rested on too small a number of facts to permit us to draw any useful conclusion from it, and it therefore passed by mmoticed ; no one at that period pursued the excellent method: which they had just pointed out.t On the other hand, the spnit of the physical sciences which began to be introduced into medi- cine, caused all the uncertainty of the ancient humorism to be felt: they thought now only of combating and destroying it, and, in the eagerness of the reaction which followed, soon arrived at denying completely that the blood could, by its alterations, play a part m the production of disease. The ne- • Baumes, Fondements de la science methodiqae des maladies, 4 vol. in 8**. Idem, Traite sur la vice scrophukux, disc. prcUmin. Idem, Essai d'un systeme chimique de la science de I'homme, Nismes, 1788. f Memoir on the blood, in which the following question is answered: to determine by modem chemical discoveries, and by exact experiment, what is the nature of the alteration that the blood undergoes in iniiammatory diseases, in putrid febrile diseases, and in scurvy, by citizens Parmentier and Deyeux. This title stated the problem to be resolved in the clearest possible manner. 3 26 PATHOLOGICAL HiEMATOLOGY. cessary consequence of this doctrine, was the neglect of all ex- perimental research as to the alterations of the blood, to which they had ceased to attach the least importance. Vainly did Bichat at that period write thus in his general anatomy ; Hu- moral medicine has been exaggerated without doubt ; but it has solid foundations, and in a number of cases ive cannot deny that all should be referred to a vice of the humours* This protest from a man of genius was not listened to by his contemporaries, and if it had been they probably would not at that time, have followed the proper route for discovering and demonstrating this vice of the humours, as Bichat expressed himself in language borrowed from his predecessors : for at that epoch the most absolute contempt was generally expressed for the application of chemistry to the research of physiological and pathological facts. The same occurred as to the study of the blood by the mi- croscope, as had happened as to its study by chemistry. It was natural indeed that a short time after the discovery of Leeuwenhoeck,men should endeavour to discover what became of the globules of the blood in disease ; but instead of devoting themselves with this view to direct observation, they still pro- ceeded by hypotheses ; and, as they had explained diseases by alterations that they supposed to occur in the chemical ele- ments of the blood, in the same way, they explained them by certain alterations which they imagined quite as gratuitously to occur in the globules. It is thus that the celebrated theory of the error loci, invented by Boerhaave, by which he ex- plained a very great number of morbid phenomena, had its point of departure in the altogether hypothetical idea of the division of the globules into others much smaller, which could normally penetrate only into vessels whose diameter was proportioned to their own.t Another author, Huxham, sup- posed that, in fever, the globules became altered by too rapid a movement; he supposed beside that, in diseases called • Anatomie generale, tome 1, considerations preliminaires. f Van. Swieten commentar. in Harm. Boeerhaavii pphorismos, t. 1, p. ] 43, obstructio. THE BEST METHOD OP STUDr. 37 putrid, these bodies being softened, were torn and broken into small portions, which entering readily into the smallest vascnlar ramifications, arrived at the open orifices of exhalent vessels, and were thrown out externally; in this way Hux- ham explained the hemorrhages of putrid fever.* Had this author then seen the globules thus broken and reduced to fragments in the field of the microscope ? By no means : but he supposes by a pure intuition of his mind that it ought to be thus, and does not trouble himself to give the slightest experimental proof of so grave an assertion. If Huxham had examined with the microscope the blood of a patient la- bouring under putrid fever, he would soon have discovered how little foundation there was for his opinion ; for he would have found the globules neither torn nor broken, and would have been compelled to renounce his explanation of hemor- rhages. But just as we have seen the good sense of the pub- lic finally render justice to the hypotheses of iatrochemistry, so the time at length arrived when all the vanity of these sys- tems erected in consequence of the facts discovered by the microscope was to be recognized. Then it was that Bordeu attacked with bitter irony those authors who, said he, iveiit so far as to see or imagine the globules bursting and falling to pieces, like so mani/ globules of glass ; but sensible people, he adds, will care little for such puerilities. All these vain theories disappeared then, but with them unfortunately were dragged into oblivion the facts so full of interest and of pro- mise upon which they had rested for half a century. Physi- ology and pathology rejected as useless, or dreaded as a source of error, the employment of the microscope; and this instru- ment was completely abandoned, as chemistry had been before it. The glory of returning by the experimental method, to the microscopic, as it. has done to the chemical study of the blood, was reserved for our epoch. Thus, by turns abandoned and resumed, the idea of seek- ing the origin of disease in some change of proportion or of • Essai sur les fievres, par Jean Huxham, traduction Fran§aise, 1 vol. in 12, p. 3 et suiv., p. 68 et suiv. 28 PATHOLOGICAL HEMATOLOGY. nature that the elements of organized bodies may have under- gone, has advanced with various fortune from the origin of science down to our days; it has more or less swayed the mind first by the ancient doctrine of the elements, then by iatro- chemistry and by the microscopic researches of the three last centuries, and finally by the applications that have been made in medicine of the discoveries of pneumatic chemistry. And if, notwithstanding the many fallacies to which it has led, this idea has never been forgotten, if at periods the most diverse, and in spite of the falsity of the doctrines which have often been its fruit, it has continued to seduce and attract the most eminent men, this depends in my opinion, upon the fact that it contains an important truth, to wit, that one of the possible causes of disease, is some change of relation or proportion, which the elementary principles that compose organized bodies under their two forms of solid and liquid, are suscepti- ble of undergoing. Thanks to the progress of organic chemis- try, the moment seems to have arrived when more than ever we may hope to place this truth in its full light, by the rigorous employment of experimental methods; and it would afford proof of a culpable ignorance, or of a dangerous scepticism, to refuse to accept the results of the chemical science of our day, because those yielded by another, which had nothing in com- mon with it but the name, had been convicted of insufficiency or of error. But in order that chemical and microscopic analysis, applied to the study of the blood in disease, may yield results really useful, one condition is indispensable : which is, to acquire pre- viously V n accurate knowledge of all the varieties of the phy- siological condition of the blood. For want of sufficient ac- quaintance with all the diversities of aspect and composition that the blood may present, without health being interfered with, we might commit continual errors, as I am about to show by some examples. And first of ah we must not infer the composition of the blood of one species of animal by that of another. I have shown in the memoir published upon this subject in connec- THE BEST METHOD OF STUDY. 29 tion with MM. Gavarret and Delafond, the very remarkable diiFerences which exist in this respect in the various species of animals. We have proved in that work, that there are some classes whose blood contains more than double as much fibrine as that of others, and that these differences exist also for the globules. To what false results then should we not aiTive, were we to take as our point of departure in diseased animals, the physiological proportions of the globules and fibrine of man, in order to calculate the changes of composition that the blood may have undergone in these animals, as a consequence of disease. Neither is the healthy appearance of the blood the same in different classes of animals, and that appearance of this fluid which, in man, is the certain expression of a morbid condition, belongs to other beings in their physiological state : such is the case, for example, in regard to the buffed condition of the blood. In man, whenever a true buff, such as I shall describe farther on, occupies the upper portion of the clot, we may with certainty affirm the existence of a state of disease ;* and, what- ever may have been said about it, this buff never exists in man in a state of health. But mark ! it is not the same in other animals, for this assertion would not be tenable with respect to them. Thus, whenever we bleed a horse, and manage so that the blood flows in a continuous stream with a pretty strong jet, into a vessel neither too large nor too flat, we constantly observe the upper part of the clot occupied by a white mass, which resembles perfectly the buff of human blood. This was shown to me by the observations that I made at Alfort with MM. Gavarret and Delafond. This colourless mass constitutes a considerable portion of the clot ; in regarding it, one would take it for the perfect inflaimnatory • We must distinguish between the true buff of the blood, and those trans- parent pellicles, or irisations, which have not the same meaning, and which may be found on the upper surface of the clot in the most diverse conditions of health and of disease. I have shown elsewhere (Reponse aux objections dirig^es contre les analyses du sang, etc.) the causes which produce these discolorations of the clot. 3* '*• ®6 PATHOLOGICAL HEMATOLOGY. buif found in a man labouring under intense pneumonia, or acute articular rheumatism. Why then does the buff belong to the physiological condition of the blood of the horse ? I shall endeavour after a while to give the reason. In different individuals of the same species, supposed always to be in a healthy condition, the different elements of the blood may present variations in their quantity, which however al- ways remain within certain limits. There results from this, for each of these elements, a maximum and a minimum above and below which the physiological condition can no longer exist, while that condition is compatible with this maximum and minimum, as well as with all the intermediate propor- tions. The average of the fibrine, in human blood, is in the phy- siological condition, two- I have shown elsewhere that the value of this proportion could not be impaired by other num- bers that have been given by some experimentalists as repre- senting the normal quantity of the fibrine of the blood. (See answer to objections brought against the analysis of the blood, etc.) In healthy individuals, the fibrine may vibrate about this average, so as to fall to the proportion of 2.5, or to rise to the proportion 3.5, without the physiological state being there- by destroyed. There are some persons even, who, without being sick, may have in their blood nearly 4 in fibrine, or in whom this element may fall as low as 2. But these are, we must admit, maxima and minima very rarely compatible with the physiological condition ; they should be regarded as a kind of exceptional proportions which belong only to true idiosyn- crasies. In taking the proportion -iVVo ^s that which represents the average of the globules in human blood, we find, in the phy- siological condition, as the maximum of the globules the pro- portion 140, and as minimum the proportion 110. But this maximum 140 is linked with the plethoric condition, which, by development becomes a true morbid state. Force of con- stitution is the condition of the economy which most contributes to raise the globules towards their maximum, while congeni- THE BEST METHOD OP STUDY. 31 tal or acquired debility is that which lowers them towards the minimum. The solid materials of the serum, which are composed almost exclusively of albumen, present, above and below their mean 80,* a certain number of proportions which are equally com- patible Avith the preservation of health ; but there is likewise for these materials, and consequently for the albumen a certain degree of diminution which I have never met with, without their being at the same time disease. Independently of the individual constitutions which intro- duce into these proportions the variations that I have just sig- nalized, there are still, independent of disease, some circum- stances which may equally cause these proportions to rise or to fall, without our being able to accuse therefrom any disease. Thus I have shown in my first memoir that emissions of blood and the deprivation of aliment have for constant eifect to di- minish the amount of the globules, while the fibrine is much less rapidly and necessarily influenced in this way. I have begun some experiments Avith a view to determine to what point we may succeed in modifying the proportion of the va- rious elements of the blood, by giving to animals a more or less substantial nutriment. These experiments are not yet sufficiently advanced to enable me to make known positively the results : they will be published in a subsequent work, but I have thought proper to mention them here, as entering into the general plan of the researclies in which I am engaged. Happen what may, what I have just said suffices to show how important it is to have determined with some rigour, for the physiological condition, the possible variations of quantity that the different elements of the blood may present, before pursuing these analyses in the pathological condition. The same is true in regard to the microscopic examination • Pure albumen constitutes of this mean about 68 or 70. When, in the following portion of this work, I mention this principle, I refer to pure albu- men, separated from the organic and inorganic elements to which it is united in the serum ; in case this separation have not been made, I shall employ the expression of solid materials of the serum. 3-3 PATHOLOGICAL H^MATOLOGr. of the blood. This examination should be made with much time and care for healthy blood, before we think of studying by the microscope the changes which this fluid may have undergone. It is for want of having engaged in this preliminary exami- nation of the physiological condition, that so many erroneous assertions have been emitted upon the changes that the condi- tion of disease may produce- in the globules. I do not fear to affirm that up to the present time, no one has observed in a positive manner any alteration of form or texture in these little bodies, which can be regarded as the resuh of a diseased influ- ence, and that all their modifications of appearance which have been described, and others which have been less dwelt upon, result, some from the progressive destruction that they have undergone in proportion to the length of time that they have been removed from the influence of vitality, and others from some circumstances altogether peculiar, which act upon them, but which are not circumstances of disease. These circum- stances have not, in my opinion, been properly appreciated : some have considered, for example, as an indication of the destruction of the globules, that granular or raspberjy-like appearance which we so often find, sometimes in the blood of subjects, and sometimes even in the recent fluid, examined shortly after it has been extracted from a living vessel. The researches in which I have been engaged upon this subject, do not allow me to accept this opinion. The globules which assume the raspberry-like appearance have not been changed by disease, nor are they globules in one of the phases of their period of destruction. When we place in the field of the microscope, between two pieces of glass, a drop of blood immediately upon its escape from the vessel, we readily perceive near the globules properly so called, rounded, white corpuscles, j^^ of a millimetre in diameter, the existence of which has been proved by all observers. The red globules, which are at first perfectly regu- lar, with abruptly terminated outlines, soon become changed in their exterior shape. Some present upon their surfaces, one, /• » THE BEST METHOD OF STUDY. 33 two, or three little protuberances, and are called raspberry-like ; others, resembling iron cog-wheels, seem regularly festooned and cut upon their edges. So long as the desiccation of the drop of blood is not complete, the number of red globules thus deformed augments in proportion to the length of time from the commencement of the experiment. As to the white cor- puscles, tliey become more rare as the preceding alteration advances and becomes general. The rapidity of formation of the kind of nipples or protu- berances which stud the red globules, and the important fact that their exterior aspect and dimensions are absolutely the same as those of the white corpuscles, all led me to think that this deterioration of the globules was due to a simple attach- ment of the white corpuscles which surrounded them. By following attentively all the movements of displacement which occur in the field of the microscope, I have been enabled to witness the production of the phenomena, to see the white corpuscles approach the red globules, dispose themselves upon their surfaces, adhere to their edges, and in this way to form every possible variety of the raspberry-like and festooned globules. This mamelonated appearance, which some have regarded as the commencement of their destruction, and others as the result of a pathological influence, is but the result when strictly examined of the precipitation of the white corpuscles upon and aromid the red globules. But what is the nature of these white corpuscles? Here a general fact is about to appear. Whenever we examine blood as it escapes from the vessels, we establish first the presence of isolated white corpuscles, and afterwards the raspberry-like and festooned appearance of a certain number of red globules. When, on the contrary, we, in any way, deprive the blood of all its fibrine, before spontaneous coagulation, we no longer find white corpuscles in the field of the microscope, and the red globules present neither the raspberry-like, nor the festooned appearance. When left a long time to themselves, these glo- bules, thus separated from the fibrine, diminish gradually in size, become reduced to a kind of central nucleus, and finish 34 PATHOLOGICAL HEMATOLOGY.* by disappearing entirely, but in no case are either their sur- faces or their edges studded with prominences. The presence offibrine then is necessary in order that the drop of blood should contain white corpuscles, and without these the alteration of the globules is not produced. The fibrine may likewise be studied under the microscope before it has spontaneously concreted into thick and resisting membrane, in that semT-transparent and seemingly oleaginous layer, known under the name of liquid buff, which constantly and normally forms on the surface of blood drawn from the horse, and only in well-determined patl"tological conditions in man. This fluid buff", it is well known, is nothing more than serum holding in suspension an enormous quantity of fibrine, and this latter principle presents itself in the form of white corpuscles of the same exterior aspect and dimensions as those of blood not deprived of fibrine. In order to study the fibrine before its complete coagulation with yet greater ease, it is only necessary to mix .syme blood as it escapes from the vein with one-seventh its volume of a saturated solution of sulphate of soda. The mixture rapidly divides into two portions, one be- low consisting of perfectly unaltered globules; the other above, formed of an opaline fluid, where the whole of the fibrine is held in suspension, under the form of white corpuscles ^^o^b of a millimetre in diameter, as in the fluid buff. The solidifica- tion of the fibrine goes on very slowly, and one can readily trace the different phases througli which it passes, while chang- ing from the liquid to the solid state. If we take a drop of blood deprived of fibrine, the globules of which are in consequence perfectly pure, and can no longer undergo the change known under the name of the raspberry- like and festooned appearance, and add to it some fibrine in the condition of corpuscles prepared with the sulphate of soda, or taken directly from the fluid buff", we see reproduced all the phenomena of which I have spoken, in regard to blood not previously deprived of its spontaneously coagulable element. This granted, it is very easy to understand what happens when we place a drop of blood on a plate of glass, and blow THE BEST METHOD OF STUDY. 35 Strongly upon it, in such a way as to spread it out into an extremely thin layer. If the operation be well done and with rapidity, the globules remain perfectly unchanged, their sur- faces are smooth, their edges very cleanly cut, and left to themselves, they never become either rasp berry -like or fes- tooned. In these circumstances the evaporation of the serum is almost instantaneous, its solidification, so to speak, imme- diate, aiKl the fibrine has not time, as in the case where the blood is placed between two plates of glass, to oscillate about the red globules under the form of white corpuscles, and de- posit themselves on their surfaces and edges. Let no one object that the raspberry-like appearance assumed by the globules inclosed between two glasses depends on the fact of their being altered by the compression ; for, if we place a drop of blood entirely deprived of fibrine between two glasses, we never see the globules become surrounded by granulations. And if moreover I have dilated in this place upon such a sub- ject, it is in order to show, by this example chosen from many others, how important it is to investigate with minuteness all the influences that can take from the globules their normal aspect, before considering these changes as the product of a pathological influence. What beside more diversified than aU the variations of form that the globules may take from their simple contact, or than the figures they may assume by their agglomeration, without our being able to accuse disease of having given origin to such changes ? When we shall in this way have studied sufficiently all the influences which, foreign to disease, may produce in the blood changes in its physical properties, in its chemical composition, and in its microscopic constitution, it will become possible to investigate the alterations that it may undergo, in these differ- ent respects, by the fact even of disease. It is of this that I am about to treat in the following chapter. 36 PATHOLOGICAL Ha^MATOLOGT. # CHAPTER II. OP THE BLOOD IN DISEASES. I HAVE pointed out in the preceding chapter, the methods which it is most convenient to follow, and tlie preUminary researches to which it is indispensable to attend, in order to study with advantage the alterations that the blood is suscep- tible of undergoing in diseases. The alterations that chemical analysis and microscopic examination enable us to trace in the blood ought, it seems to me, to be divided into three great classes. In a first class, I range the alterations of the blood which result from the fact that the principles which enter normally into the composition of that fluid do not exist there in the pro- portion compatible with the physiological condition. The normal elements of the blood, in which the present state of our knowledge enables us to trace these changes of propor- tion, are the globules, the fibrine, the albumen of the serum, the different organic materials other than the albumen, which are found in the serum, (fatty matter and others,) then the inorganic principles contained in the blood, and in particular the free alkali which it contains, its different salts, and its water. But this is not all; and here the idea presents itself of in- quiring whether disease, in some of its manifestations, may not have the power of rendering more abundant, and conse- quently more appreciable by analysis, certain materials of the secretions which we may suppose to exist naturally in the blood, but in too small quantity to make it possible for us to discover them in its normal condition. Disease would furnish then the means of recognizing them, by increasing their pro- portion, as it sometimes makes more apparent also certain tissues, by causing them to emerge from their rudimentary state. OP THE BLOOD IN DISEASES. 37 Microscopic researches should not often be employed in the study of this first class of alterations ; it is not indeed by such means, as some persons have supposed, that we can even de- termine an augmentation or diminution of the number of glo- bules. Without being changed in quantity, the normal principles of the blood may become modified in relation to their size and their physical properties. The microscope may, for example, disclose diflerences in the volume or in the form of the globules, etc. Here we have a second class of alterations. Finally it may happen, that in the place of, or in connection with the normal elements of the blood, there may be formed new principles which have no analogues in the healthy condi- tion, and which may be compared in that fluid to what the accidental formations are in the solids. Here then is a third class of alterations of the blood, for the discovery of which should co-operate both chemical and microscopic researches. It is the microscope, for example, which will reveal to us the presence of pus in the blood, etc. I am as yet far from being able to trace a history even in- correct, of all these alterations ; but such is the circle which I have determined to pursue, by following out the modes of in- vestigation, whose value I have estimated in the preceding chapter. It was proper for me to commence with the study of the alterations comprised in the first class ; and in this class, the normal elements of the blood, whose changes of proportion in diseases I have sought to appreciate, are still only the globules, the fibrine, the solid matters* of the serum, and the water. I am about to exhibit, in the following articles, the results that I have obtained, and I shall strive to show how, in each disease, the changes of proportion that the blood may have undergone * In the memoirs which I have already published, I had estimated in mass the quantity of these sohd materials. More recently I have endeavoured to separate them one from the other, so that I might indicate with greater pre- cision for certain cases, the variations in proportion of the albumen properly so called, contained in the serum. 4 38 PATHOLOGICAL HiEMATOLOGT. in its physical properties are in relation to its changes of com- position, and are explicable by them. Besides, the analysis of the blood in the diseased condition reveals such great differences in the composition of this fluid, that it is difficult not to admit a priori that changes so re- markable in the relative or absolute proportion of its consti- tuent principles must exercise a strong influence upon the organism, and intervene as cause in the production of a more or less considerable number of diseases. When for example, we see in the morbid condition that the composition of the blood, varies to such an extent that instead of a thousand parts, there may be only seventy -five of solids, or even only seventy, we cannot understand that so enormous a difference in the quantity of the elements held in suspension or in solution in the water of the serum should not be taken into serious con- sideration in pathogenic theories. This it is which I shall endeavour to bring out in what is about to follow. I shall begin by showing what are the modifications pro- duced in the composition of the blood by two states of the organism, which, when to slight extent may still coincide with health ; which, when to a greater extent, cease to belong to the physiological condition, and which, in a great number of cases, complicate diseases and modify their symptoms. These two states are on the one hand plethora, and on the other auccmia. ARTICLE I. Of the Blood in Plethora. True plethora is more frequently constitutional than ac- quired : we cannot always create it at will by the use of a very substantial aliment. It is not sufficient, in order to pro- duce it, that an individual shall introduce daily into his di- gestive organs, a large quantity of reparative material, and that OF THE BLOOD IN DISEASES. 39 he shall expend very little. Plethora seems to depend often upon a primordial constitution of the blood, which it is im- possible for us to produce so readily as we can produce anae- mia, that is to say, in other words, that it is much more in our power to impoverish the blood than to increase its rich- ness. , In plethora, as in anaemia, the peculiar state of the blood is the appreciable cause of the general modification which the organism presents. This is for us at least the primitive fact beyond which we cannot go, and to which we have the right to refer all the others. Beyond a doubt some forces have been in action in the naturally plethoric or anaemic individual, from the commencement of the formation of the being, which have impresssed upon the blood a certain constitution that it is ordained to preserve ; but this constitution, once produced, does not the less remain the single demonstrable fact, the only one that observation can seize upon, in order to make of it the ex- perimental cause of the phenomena. But are the limits of the science established when it has been said in a general manner that the blood is abmidant and rich in plethora, that it is thin and impoverished in angemia ? — This question it is important to examine, and I proceed by turns to occupy myself in resolving it for both of these condi- tions. The most accredited opinion relative to the state of the blood in plethora, is, that it fills the vessels in very large quantity, that its different organic elements have become more abun- dant, and that it is in particular richer in fibrine. Let us examine one after another these different assertions. It is impossible to demonstrate the augmentation in quan- tity of the blood in plethora — how estimate in reality what is in weight or in volume the mass of fluid contained in the vessels ? But if we cannot arrive at this valuation, and if, in conse- quence, we are compelled to acknowledge our ignorance as to whether plethoric persons have in their circulatory apparatus 40 PATHOLOGICAL HEMATOLOGY. more or less blood than other individuals, we can seek to deter- . mine whether the blood of such persons has not a peculiar constitution. Now, with respect to this, here is what analy- sis has taught me : It has shown me in the first place that it is not true that, in plethora, the blood contains very much more fibrine than in any other condition ; I have found, in reality, 2,7 of fibrine,^ as the average of this principle, in thirty-one bleedings per- formed upon individuals in whom the plethora was fully cha- racterized. Some presented as yet no marked symptoms : in them the bleedings were simple measures of precaution ; in the others, were observed vertigo, tinnitus aurium, palpitations of the heart, excessive difficulty of respiration, an injection as though apoplectic of the conjunctivae of the eyes, and of the face, etc. Thus, in these individuals, the fibrine did not even quite equal the physiological mean. The symptoms of ple- thora do not depend then, as has often been repeated, upon an augmentation of fibrine in the blood. Consequently, in the point of view of the composition of the blood, plethoric indi- viduals should not be more disposed than others to contract inflammations, and I do not fear to affirm that, if clinical facts be interrogated as to this, they will lead to the same conclu- sion ; it is but a false analogy of symptoms which has caused it to be said that plethora disposed to the phlegmasias. The results yielded by the analysis of the blood are found here to be in perfect accordance with those to which clinical observa- tion conducts. The fibrine does not then sensibly augment in plethora ; it remains within the hmits of its physiological state, and does not even tend, in the greater number of cases, to mount, to- wards the higher limit of this state. The organic materials of the serum do not offer either, in plethora, any remarkable change of proportions. The globules alone remain, and it is effectively the great ele- vation of their proportion which establishes in the blood the character of plethora; in the 31 bleedings to which I have OP THE BLOOD IN DISEASES. 41 already referred, I found for the mean of the globules the cipher 141 ; for minimum, 131 ; and for maximum, 154. The blood of plethoric persons then differs from ordinary- blood in the greater quantity of globules and the much less quantity of water that it contains. The physical properties of this blood may be perfectly ex- plained by the nature of the changes that it has undergone in its composition. Thus, before coagulation, the blood of plethoric people is remarkable for its high coloration, which is in relation with the large proportion of globules it contains. When we examine it after coagulation, we observe gene- rally that the serum is more or less coloured, that the clot is large, voluminous, of moderate firmness, and that it retains a large quantity of serum ; we never find any bufi" upon its sur- face ; at most we may sometimes observe there a thin and transparent pellicle, or some scattered irisations, if the blood has flowed very rapidly from the vein. The considerable volume of the clot depends manifestly upon the large number of globules, and its softness, as well as the constant absence of the buff, depends upon the small pro- portion of the fibrine relatively to that of the globules. The excess of globules in the blood of plethoric people coin- cides in them with a certain modification of the physiological state, and also with a certain number of pathological facts which seem to be a consequence of it. Thus, all the functions are usually more active, and there is as it were an exuberance of life : digestion proceeds rapidly ; respiration is favoured by the great development of the thora- cic cavity ; the circulation is rapid, the heart beats with force ; but it is an error to admit, as has been done, that in such cases, its pulsations may be accompanied by a bellows-sound. I myself not long since put forth this opinion ; but a more at- tentive and a longer observation have convinced me that it is not so, and that consequently, in those cases where a bellows- sound had been heard in the heart or arteries of plethoric patients, it is because the diagnosis had been badly made 43 PATHOLOGICAL HEMATOLOGY. and because there had been some other disease with the plethora. While dwelling on all these modifications of functions which coincide with the plethoric condition, I do not wish to repeat here what is everywhere known ; it was only necessary for me to speak of them, in order to make evident their coinci- dence with the fundamental modification that the blood under- goes in that 'condition, to wit, an augmentation of its globules : however I will remark besides the peculiar disposition that the brain then presents to become excited, the facility and at the same time the mobiUty of the emotions, without our observ- ing at the same time those exaggerations or those aberrations of sensibility, and those nervous predominances, which we shall presently find to accompany almost necessarily an oppo- site state of the blood, to wit, the anormal diminution of its globules. The individuals whose blood contains an excess of globules are subject to some peculiar symptoms, of which no one has perhaps up to the present time given a very satisfactory ex- planation ; thus, the vertigo, the dizziness, the tinnitus aurium, the heat of head that they experience, have been accounted for by congestions of blood towards the brain ; but these con- gestions have never been, in like conditions, anatomically proved, and the mere passage of an excessive quantity of globules through the vessels of the brain appears to me a fact sufficient to account for them ; but, singular circumstance, if it happens on the contrary that too small a number of globules traverse these same vessels, analogous symptoms will still present themselves, so that a quantity of globules either too high or too low disturbs in the same way certain cerebral acts. An excess of globules in the blood coincides also with the more frequent and more ready appearance of certain hemor- rhages ; I shall endeavour further on to give an explanation of this. Finally, in these cases of excess of the globules, it is not un- common to see arise by intervals, a general increase of excita- OP THE BLOOD IN DISEASES. 43 bility of the organism, carried to such a point that a true fever may be the consequence. Vainly should we seek, in order to account for this, any alteration of the solids ; they do not pre- sent any, and the fever ought then to be considered as having its point of departme in some state of the blood. But, let us take another case : suppose that coincidently with some inflam- matory alteration of a solid, developed in an individual whose blood contains too many globules, there arises fever ; this will then present a physiognomy altogether peculiar ; it will be remarkable by the symptoms of high reaction which shall ac- company it ; it will present that type of fever called by Pinel angeiotenic; and this type will depend less upon the seat and nature of the local lesion, than on the condition of the blood itself. Venesection will certainly modify it, by acting on the blood, whose globules it will infalliby diminish ; but though evidently useful in this point of view, it Avill have a much less dhect influence on the inflammatory alteration which has produced the fever ; for this alteration is connected with another modification of the blood, upon which bleeding has much less direct and immediate influence, as we shall see further on. The phenomena of plethora, viewed in connection with the composition of the blood in this condition, may enlighten us on the part played by the globules of the blood in the organ- ism. ARTICLE II. Of the Blood in Jinxmia. I HAVE just pointed out what may result in the organism, in the state of health and of disease, from an excess of the globular element of the blood. But there are cases also in which this fluid comes to present a character precisely inverse, that is to say when its amount of globules falls much below the physiological mean, and diminishing more and more, 44 PATHOLOGICAL HiEMATOLOGY. reaches a proportion so low that we can scarcely comprehend how, with so few globules in the blood, life can still be main- tained. This diminution, in different degrees, of the globular ele- ment of the blood is the fundamental character of anaemia, a condition which, therefore, in regard to the composition of the sanguine fluid, as well as in relation to its symptoms, is the opposite of plethora. According to the degree of the diminu- tion of the globules, this condition is still compatible with a certain amount of health, or it becomes by itself a true morbid state, which may exist alone, or intervene as complication in all diseases. Thus then, independent of the solids, we find one of the principles of the blood, becoming distinct from all the others, exercising, sometimes by its augmentation, and sometimes by its spontaneous diminution, an influence such as to become the point of departure and the sole appreciable ma- terial element of a considerable number of diseases. I have found, as the average of the proportion of the glo- bules, in 16 cases of commencing anaemia, the cipher 109, and in 24 cases of confirmed anasmia, the cipher 65. I have con- structed these averages only from cases of spontaneous anae- mia occurring in the human race ; I should have found a lower average in the sheep kind, which are also exposed to become anaemic, and which, in this condition, may have a blood so deficient in globules, that I have seen one of them which had but 15 of those corpuscles (see Memoir, etc.), whilst in the human race, the lowest proportion of globules that I have ever met with in spontaneous anasmia is 28. It is true that man possesses normally in his blood more of the globules than does the sheep species ; whence it follows that, propor- tionally to the physiological condition, the minimum 28 of glo- bules, found in the spontaneous anaemia of man, is very nearly equal to the minimum 15 found in ansemic sheep. Besides, it is necessary to distinguish several kinds of anae- mia, according to the modifications of composition that they produce in the blood. In spontaneous anaemia, whether strongly marked or not, OP THE BLOOD IN DISEASES. 45 the globules alone are diminished : the fibrine and the solid matter of the serum have preserved their normal proportions ; thus in 16 cases of slight ansemia, I have found as the average of fibrine the cipher 3.0 ; and in 24 cases of confirmed anaemia the cipher 3.3.* In the anaemia which follows more or less abundant losses of blood, it may equally happen that we shall find the glo- bules alone diminished ; that is indeed the first eflect of every hemorrhage ; but if this augments or is renewed, there soon arrives a moment when the blood comes to lose equally its other principles, and we see the albumen and the fibrine of the serum diminish with the globules. It is in this way that in a woman who had suffered from very abundant attacks of metrorrhagia, the blood contained only 21 in globules, 1.8 in fibrine, and Gl of solid matter of the serum. The water had risen to the enormous proportion of 915. Anaemia may also be the result of certain appreciable modi- fications of the organism which exercise an influence on the blood. In this case, the composition of that fluid appears to be the same as in spontaneous anssmia, that is to say the globules alone are diminished, while the fibrine and albumen of the serum remain the same. This is what occurs in many preg- nant women whose blood loses its globules without losing its fibrine. The average of the globules is the same in them as we have found it in cases of slight anaemia. Why is it that woman is more exposed than man to this smgular alteration of the blood in virtue of which, without * The state of the blood of animals "shows perfectly to what point the fibrine and the globules may remain isolated in their increase or diminution; thus, the dog whose blood contains much less fibrine than that of man and of all other animals that I have examined, is precisely the animal whose blood is most rich in globules. On the contrary the horse, the sheep, the ox, whose blood contains more fibrine than that of man, and especially than that of the dog, have in their blood much less of globules than the two other beings. — (See the Memoire sur la composition du sang de quelques animaux domestiques, etc.) Besides, in the same species, those individuals who possess in their blood the most globules are not those whose proportion of fibrine necessarily rises highest, and vice versa. 46 PATHOLOGICAL HEMATOLOGY. any evident cause, the globules of this fluid . are thus dimin- ished in SO strong a proportion ? Why is she particularly ex- posed to it at a certain epoch of her life ? Yet men also are sometimes attacked with spontaneous anae- mia ; they present in such a case all the»symptoms which cha- racterize the chlorosis of the female, and I have proved that their blood then suffers the same alteration of composition ; it is with them equally the globules alone which diminish; the fibrine and the solid matter of the serum remain the same. I have met with examples of this spontaneous diminution of the globules both in men still young, and in others aged from forty to sixty years. When the influence of lead has acted for a long time upon the human constitution, there may result from it the produc- tion of a cachectic condition, very well described by Doctor Tanquerel ; I have found that, in this condition, the globules of the blood sufler as great a diminution as in spontaneous anaemia, and, as in this latter, the fibrine and other elements of the blood preserve their normal quantity. This effect of the saturnine intoxication repeated or prolonged is certainly very remarkable. It would be very curious to know whether the globules at the same time that they are diminished in quantity in anaemia, do not become altered also in their structure, and tend to undergo a true destruction. I announced in my course at the Faculte in 1840-41, the results that some microscopic research- es undertaken with this view have yielded me. It seemed to me, in two cases of chlorosis, that the globules were become smaller than we generally see them, and at the same time a certain number had no longer their accustomed form ; they appeared in the field of the microscope, as though broken, and disseminated, like kinds of fragments. A young girl who presented me this singular condition of the globules, on the 6th of December, 1840, was perfectly cured two months later ; her constitution had even undergone such a metamorphosis, that it had gradually arrived under our own observation at a plethoric condition; the 14th February 1841, 1 was obliged to OF THE BLOOD IN DISEASES. 47 bleed her, and her blood then presented me very beautiful globules, extremely different from those that I had observed in December. These facts seem to me of so much interest and import- ance as to make me feel the necessity of seeing them again, before accepting them definitely, and drawing deductions from them. The physical properties of the blood in anaemia are very well accounted for by the nature of the changes that it has undergone as to its composition. In the most ordinary condition, the one in which the only change undergone, consists in a diminution of its globules, the blood presents to the naked eye the following appearance : Supposing it to have flowed freely, we find in the vessel which has received it a small clot which swims in the midst of an abundant and perfectly colourless serosity. This clot, far from being soft, as we might have expected, is on the contrary remarkable for its density ; its molecules retain a strong power of cohesion, and it is not at all uncommon to find upon its surface a very characteristic buff ; one might take it for pleuritic blood, or for that of an acute articular rheuma- tism. This density of the clot, and the buff which covers it, are the more marked in proportion as the anaemia is more con- siderable. The existence of cupped blood in anaemia is not a new fact in science. Borsieri, amongst others, had noticed the presence of the buff in the blood of chlorotic patients, and he had with good reason, drawn from this an argument against those who pretended that this crust was always the necessary indication of a phlegmasia ; and it is curious to find that Tom- masini, who had also seen the coagulum of the blood of chlo- rotic patients become covered with a buffy c^at, would not for that abandon the principle sustained by him, that there is no buff in the blood without inflammation ; for, said he, chlo- rosis is nothing more than a chronic angioVtis. Such an asser- tion does not even require refutation.* • Tommasini suU' inflammazione, t. 11, p. 250 to 278. 48 PATHOLOGICAL HEMATOLOGY. I reffard as incontestable, the fact that the clot of the blood .g«.il^ ^^ Xi^V.WiX,,V.OlC..^lV., • of chlorotic patients is often buffed, and like Borsieri, I have from this long since drawn the inference that the presence of the buff is not always evidence of the existence of an inflam- matory disease, for chlorosis is certainly not of this character. But why is the blood, in this disease, often cupped ? It is because the blood of chlorotic patients has retained all its fibrine, and lost some of its globules ; it is in consequence of this that there is really in this blood, as in that of inflamma- tions, or as exists normally in the blood of some animals, excess of fibrine in proportion to the globules; now, whenever this excess takes place, whether it be absolute or relative, and whenever at the same time the coagulation of the fibrine is not very much too rapid, this principle will be seen to accu- mulate alone on the surface of the clot, and the cup will appear. This is the reason why the blood of anaemic individuals may be buffed, and why that of plethoric individuals is not ; it is the cause also why the coagulum of blood is firmer and more dense in the first than in the last. It is also one of the circum- stances which explains the constant existence of the buff in the blood of the horse. We must add to this, in the latter animal, the greater slowness of the coagulation of the fibrine. Thus, all those various functional disorders which accom- pany anaemia correspond to an alteration of the blood which is always the same, to wit, a diminution of the globules, and the intensity of these disorders is so much the greater in pro- portion as the globules have themselves undergone a more considerable diminution of their cipher. If this diminution be slight, it is compatible with the persistence of a certain phy- siological condition ; if it becomes rather greater, the disease commences. Whatever indeed be the cause that may have brought on diminution of the globules, the resulting symptoms differ only in relation to their degree of development ; but re- main the same as to their nature. Whenever we find the diminution of the globules to coincide with that of the albu- men, or with that of the albumen of the serum, we shall ob- serve peculiar symptoms appear, which I purpose mentioning OF THE BLOOD IN DISEASES. 49 further on ; so that what I am about to say at present will regard only the most common case of all, that in which the anaemia is tlie simple manifestation of a diminution of the globules alone. Tlie blood cannot be deprived of a certain quantity of its globules, without there resulting from it great prostration of the muscular system, very marked general feebleness, grave perturbations of the nervous system, which are betrayed by different disorders of the intelligence, of sensation and of mo- tion ; and various disorders of the functions of digestion, res- piration and circulation. Who is ignorant of the various neuroses to which anaemic patients are subject, their dyspepsia, their dyspncea, their palpitations of the heart ? Who has not observed the singular discoloration of their skin and exterior mucous membranes, which is so naturally explained by the small number of colouring globules which still flow in their vessels ? But what is less generally known is, that it is not uncommon to meet with individuals whose colour remains natural, whose cheeks even are habitually injected to a re- markable extent, and whose external aspect would easily make us regard them as of a plethoric habit, but who neverthe- less have in their blood, an insufficient quantity of globules ; this is because there exists in them a false appearance of ple- thora. Observe in effect such individuals a little more closely, and you will be struck with their feebleness ; they will have, as in the most advanced anaemia, vertigo, dyspnoea, and pal- pitations, upon the slightest effort ; they will bear with diffi- culty any kind of exertion, and still worse venesection, which far from diminishing, will increase their symptoms. All this shows that the diminution of the globules of the blood, before betraying itself by the discoloration of the cutaneous tissue, may declare its existence by the perturbation wliich it pro- duces in the different vital acts, and this perturbation is always marked by symptoms perfectly identical. There is a phenomenon revealed to us by auscultation, which constantly coincides with a certain diminution ol the globules ; this is the singular bellows-sound, heard in the iicart, 5 50 PATHOLOGICAL HJEMATOLOGT. and especially in the arteries, in all cases of anaemia however slight. For its manifestation, it is necessary that the impove- rishment of the blood should have fallen upon the globules ; it is not present when the fibrine alone has been diminished ; so that I have never met with it in scorbutic patients, unless they had reached that period at which the globules, at first unaf- fected, yield in their turn. Neither have I met with this bruit de souffle, in the cases which will be detailed farther on, where the impoverishment of the blood is owing particularly to a diminution of the albumen of the serum. Remark in addition, what the analysis of 88 cases in which this bruit existed in the carotid arteries, either continuously or intermittently, has taught me, in regard to the relation to establish between the diminu- tion of the globules of the blood, and the appearance of the bellows-sound in the arteries. Of these 88 cases, there were 56 in which the souffle was continuous, and 32 in which it was intermittent. Of the 5Q cases in which the bruit de souffle was continuous, and represented what M. Bouillaud has called the bruit de diable, I found 28 in which the cipher of the globules had not risen above 80, and had fallen even to 21; I found 13 in which the cipher varied between 80 and 100 ; 10 where it had risen from 100 to 115 ; and 5 again where from 1 15 it had in- creased even up to 125. Of the 32 cases in which the bruit de souffle was merely intermittent, there were only 3 below 80 in globules (76, 77, 77); 13, from 80 to 100 ; 8, from 100 to 115 ; 8 others from 115 to 126. We see then that the bruit de souffle of the arteries does not always show itself with the same degree of diminution of the cipher of the globules, in different individuals ; there are nevertheless some rules to be established in regard to this, such as the following : 1. When the globules are so much diminished as to be below the cipher .80, the bruit de souffle exists in the arteries as a constant condition. I have not found a single exception to this law. OF THE BLOOD IN DISEASES. 51 2. Wlien the globules remain above this cipher 80, the bruit de souffle may still show itself, but it is no longer constant : we continue to hear it not unfrequently, while the cipher of the globules oscillates between 80 and 100 ; it is still heard, but much less frequently, in proportion as the cipher of the globules passes 100, and finally is no longer observed, at least as dependent upon an alteration of the blood, when the cipher of the globules has risen above its physiological mean. Whatever be in other respects the nature of the disease in which the diminution of the globules exist, the bruit de souffle of the carotids does not the less show itself; I have verified it in the most opposite cases, in putrid fevers, in erup- tive fevers, pneumonia, acute articular rheumatism, and in a great number of chronic diseases. But in all these cases it occurred only in connection with the ciphers of the globules above indicated. The bruit de souffle shows itself sufficiently often in preg- nant women, which is in relation with the frequent diminution that the globules undergo in them. The intensity of the bellows-sound, is commonly subordinate to the degree of diminution of the cipher of the globules. Thus in 22 cases of chlorosis, I have found the intermittent souffle 8 times, the cipher of the globules oscillating between 117 and 77, and the continuous souffle 14 times, the cipher of the globules varying from 1 1 3 to 28. 1 have sought to find as to what extent the diminution of the globules exercised an influence upon the temperature of the living body, but have arrived in this respect at results merely negative. 1 have been not a little surprised to observe this temperature remain normal, even in cases where the globules had undergone the most considerable diminution of their cipher. It is thus that individuals who had in their blood no more than 50, 40, 30 and even 21 parts in globules for 1,000 parts of blood, preserved nevertheless in the axilla a tempera- ture which varied between 37 and 38° centigrade : is not this the temperature which belongs to the greater part of men in health ? And not only does the temperature not fall because 52 PATHOLOGICAL HiEMATOLOGY. the globules diminish, but we see it even rise, notwithstanding this diminution, as always happens, when anssmic persons are attacked with fever j for they are exposed to this like other individuals. We must not then forget that at the commencement of every disease, the blood may present two great modifications in its globules, one of which belongs to plethora, and the other to anaemia. It is upon a variation of increase or diminution in the cipher of the globules that depend the peculiar symptoms then observed, and which are superadded to those of the disease. ARTICLE III. Of the Blood in the Pyrexix. The pyrexiae form a large class of acute diseases which it has vainly been sought to dismiss from nosological systems, in order to throw them all into the order of simple inflamma- tions. Such pretensions however cannot be maintained : the pyrexiae exist as diseases apart ; the causes which often de- velope them, the symptoms which characterize them, the spe- cial nature of the alterations that they- produce in the solids, the epoch of development of these alterations often posterior to that of the febrile movement, here are already enough of grave reasons for not confounding the pyrexias and the phleg- masiae ; but the analysis of the blood comes still more to estab- lish a very remarkable difference between the one and the other class ; the results furnished by this analysis have something so marked, that they seem to me to fix in a definite manner the distinction, vainly combated, between the pyrexiae and the phlegmasiae ; this is what I am about to endeavour to prove. Whilst, in the phlegmasiae, there are always two constant alterations which march together, that of a solid, and that of the blood, it is no longer the same in the pyrexiae ; in these diseases in reality, the only phenomenon which never fails, is OP THE BLOOD IN DISEASES. 53 the fever itself; the various alterations of which the solids are the seat, may be entirely wanting, nor do the changes of com- position that analysis has discovered in the blood appear in all cases ; so that, in the present condition of our knowledge, the character of the pyrexiae still remains a negative one ; that is to say, that, luitil more fully inquired into, the fever, which accompanies the pyrexiae, recognizes neither in the solids, nor in the blood, any constant alteration that can account for it. Nevertheless, we can more or less frequently, find alterations in the blood and in the solids ; yet these are but the effects of a more hidden cause which governs the constitution, effects however which it is important to study thoroughly, since in their turn they themselves become causes of a certain number of symptoms, and because by their seat and by their nature, they serve to classify and denominate the pyrexiae. In my first memoir upon the alterations of the blood, I have proved that, the fibrine never augments in the pyrexiae, sup- posing them divested of all phlegmasial complication ; that it often remains in normal quantity, and that sometimes, it di- minishes to a point at which we do not find it in any other acute disease. I have shown that the pustules of variola, and the dothinenteric plaques of typhoid fever, do not have the power of increasing the cipher of the fibrijie ; and finally I have shown that with all the possible proportions of the glo- bules, whether they were very abundant, or whether they have become very rare, a pyrexia could equally arise with all its varieties of form and gravity. But is it indifferently, and as it were by chance, that the fibrine shows itself, in the pyrexiae, either in normal quantity, or in a proportion infinitely more feeble than in the physiolo- gical condition ? No, without doubt, and with regard to this, very clear general principles may be laid down. At every period of clmical observation, and upon whatever theoretical point of view, the observer was placed, it has been re- cognized that amongst the pyrexiae, there were some miattended by any grave symptoms, which marched naturally towards a favourable termination ; while there were others which, either 5* 54 PATHOLOGICAL HJEMATOLOGT. at their commencement, or during their course, were accom- panied by accidents of such a nature, that it seemed as though the forces which rule the organism were either vanquished, or profoundly disordered to such an extent that the extinction of life must be the consequence ; and at the same time it was found that in such cases the blood presented an altogether peculiar appearance ; it was observed that, become less con- sistent, it seemed to tend towards a sort of dissolution. Ad- mitted at all periods, but differently explained according to the prevailing theories, this condition which may develope itself in any pyrexia, and towards which several seem to tend natu- rally, has been called turn by turn putrid, adynamic and typhoid state : it has its greatest development in the typhus fevers properly so called ; it is in some sort inherent in them ; it is as it were their essence. The pyrexia now called typhoid fever, presents it in a slight degree from the invasion and the grave cases of this disease are its marked representation. It does not ordinarily exist in the eruptive fevers, but it often complicates them, and constitutes one of their dangers. Finally, in addition to the pyrexiae with well marked characters, and which have a fully determined place in nosological systems, there are others to which no name has been given, which may yet present in a high degree the different symptoms to which the ancients attached the idea of the putrid state. This is because there may exist in effect, in all the pyrexiae, a com- mon alteration of which the blood is the seat, and whose exist- ence constantly coincides with the appearance of those phe- nomena always the same, attributed by vitalism to adynamia, by solidism to relaxation of the fibre, and by humorism to putridity of the humours. This alteration of the blood consists of a diminution of its fibrine ; it is consequently an alteration the inverse of that which betrays in the blood the phlegmasial condition. This diminution of fibrine, every time that it takes place, produces remarkable modifications in the physical qualities of the blood. Whatever be the pyrexia in which it exists, blood drawn from a vein presents the following condition: tf'^^, OP THE BLOOD IN DISEASES. 55 The serum and the clot are imperfectly separated from each other, whence it follows that there seems to be but little serum in proportion to the clot. The clot is voluminous, it often fills the whole breadth of the vessel in which the blood has been received ; it is never elevated upon its borders, as is so commonly the case with the clot of the phlegmasia3. Its consistence is always slight, it is torn and broken with the greatest facility, and there are some cases even where, by the slightest pressure, it may be reduced to a true condition of diffluence ; it ceases then to form a single mass, and is divided into a number of grumous portions which mix with the serum, and colour it of a more or less deep red. This is the condition of dissolution of the blood so well de- scribed by the ancients, and which ought to be regarded as the necessary consequence of the diminution that the sponta- neously coagulable matter of this tiuid has undergone. Then, in effect, the net- work, which maintained the globules pressed one against the other, and which by its power of contraction squeezed out the serum, no longer exists but imperfectly ; thence also arises the great size of the clot, which is found to be in an inverse proportion to its density, and which is not a certain index of the quantity of solid material that it contains. Let us add however that the cause of the large size of the clot, is really also the large proportion of globules that it contains, especially in the early stages of the disease ; for these do not diminish in such cases, like the fibrine ; far from that, they may become remarkable by their abundance. Very fre- quently, hideed, I have been struck by the great elevation of the cipher of the globules in individuals with grave typhoid fever; and in my first memoir upon the alterations of the blood, I was even inclined to suppose that this superabundant quantity of globules was one of the characters of that fluid in the pyrexia3 ; but this was because 1 had not then sufllciently studied the condition of the blood in the plethoric ; since then I have convinced myself, that if, in typhoid fever, we often find this predominance of the globular element of the blood, it depends on the fact that typhoid fever most frequently attaclis 56 PATHOLOGICAL HEMATOLOGY. individuals, who by their age and constitution, are in a con- dition of plethora more or less marked ; but the superabund- ance of the globules depends so little upon the typhoid fever itself, that this disease, as I have myself seen, may occur m chlorotic girls, whose blood is so poor in globules. But whether these be abundant or not, the influence of the disease upon the fibrine remains always the same. There is another quite negative character of the blood in ^ , /, , , the pyrexias, which is of importance and which serves still „ff/i - more to distinguish the sanguine fluid of these diseases from that of the phlegmasiae. This character is the absence of the , , bufl". I may aflh'm here that I have never met with it, unless there was some phlegmasial complication, either in inflamma- tory fever, in slight or severe typhoid fever, in measles, in scar- latina, or in variola. Nevertheless, we may find the bufl" upon the surface of the clot, in this latter pyrexia, when the eruption is very confluent, and especiaUy when collections of pus exist beneath the skin, or in some organ; but this bufli" always appeared to me to have a pecifliar aspect ; far from being firm and consistent, like the ordinary crust of the phlegmasiae, it is very soft, and gelatinous as it were, and however thick it may at first appear, may be rapidly changed into quite a thin pellicle, by expel- ling by means of compression, the large quantity of serosity which infiltrates it. If, as I have already proved, the indispensable condition for the formation of the inflammatory crust, is a certain excess of fibrine in proportion to the globules, we can understand why this should not exist in the pyrexias, since, in these diseases, supposing them always without phlegmasial complication, two cases only can occur, one in which the fibrine has retained its normal proportion, and the other in which it has dimin- ished. Since the diminution of the fibrine does not exist necessarily in any pyrexia, it is perfectly clear that it is not in this altera- tion of the blood, that we should place the point of departure of this class of diseases. But what seems to me incontestable, OF THE BLOOD IN DISEASES. 57 is, that the specific cause which gives them birth, acts upon the blood in such a way, that it tends to destroy its spontane ously coagulable matter, while the cause which produces the phlegmasias, tends on the contrary to create in that fluid a fresh proportion of that matter. If this cause act with slight energy, or if the economy resist it, the destruction of the fibrine is not accomplished; if on the contrary the cause continue to act with all its intensity, and the forces of the organism be in fault, the destruction of the fibrine will commence either at the very beginning of the disease, which is very rare, or a cer- tain period after its commencement : all this applies itself equally well both to typhoid fever, and to the eruptive fevers. For me there is, in all these cases, a true intoxication ; if it be slight, its effect must to be sure always exist, but it is not ap- preciable ; if the intoxication be stronger, the effect which it has produced upon the blood becomes visible, and is marked in that fluid, by a diminution of the fibrine. Whilst then we establish, in certain forms of typhoid fever or scarlatina, that alteration of the blood which consists in a tendency to the destruction of its spontaneously coagulable matter, we no more attain by this means the true cause of the disease, than we do, by studying the alterations of which the tegumentary membranes are the seat. But, as these altera- tions of the mucous membrane or of the skin, once produced, bear their part in the production of the symptoms, just so does the peculiar alteration of the blood, which may then arise, bear its part. Amongst the phenomena which seem to me to have a direct connection with the diminution of the fibrine, I believe I ought to place in the first rank the hemorrhages that are so common in all the pyrexiai in which the adynamic or putrid type pre- dominates, that is to say those in which it has been proved by analysis that the blood had lost some of its fibrine. In variola, when the pustules are filled with blood, in scarlatina, when there are abunda«iit losses of blood from all parts, in individuals attacked with acute purpura hemorrhagica, as well as in ty- phoid fevers accompanied with epistaxis and buccal hemor- 58 PATHOLOGICAL IliEMATOLOGY. rhages which increase with the debiUty, I have shown that the blood was effectively very poor in fibrine, and 1 shall essay to prove further on that we cannot in such cases accuse the hemorrhage of having diminished the fibrine. It would seem that in this condition a certain diminution of the spontaneously coagulable matter of the blood has for effect to permit the glo- bules to abandon more readily the vessels which contain them. How again fail to remark the coincidence, so frequent in the pyrexias, of the diminution of the fibrine of the blood, and of the facility of production of those congestions or sanguine states which have so often been confounded with true inflam- mations ? wherefore this coincidence ? Deprived of the ordi- nary quantity of fibrine borne along with them in the torrent of the circulation, are the globules at the same time deprived of a means of regularization for their movements, and do they come in this way to accumulate and stagnate in the capillary rete ? I know not ; but it must be that there is some con- nection of cause and effect between the diminution of the fibrine of the blood and the production of these congestions, since these latter follow so constantly the former.* There is a peculiar congestion which rarely presents itself except when there exists a typhoid condition, whatever be in other respects the disease in the course of which this condition n ^ may have arisen. This congestion has its seat in the spleen, which becomes remarkable at the same time by its great size, and by the extreme diminution of consistence of the material which fills its cellules. The softening of the spleen, noted in these cases by all observers, does not depend on an alteration of its own tissue : for it is found quite untouched, when, by washing, it iias been emptied of all the material that it con- tains; it is evidently this latter which has lost its usual con- • I am happy to ^ay that all the facts, that I have just reviewed in this arti- • cle, are in perfect harmony with the principles emitted, since 1837, by M. Magendie on this subject. While employing different experimental methods, we have each arrived at similar results. OP THE BLOOD IN DISEASES. 59 sistence. But, what is this material ? it is nothing more than blood retained and coagulated, I know not by what influence, in the innumerable cellules or areolae of which the splenic tis- sue is composed ; but this blood ought to possess the same qualities as any other blood poor in fibrine, that is to say it ought to coagulate imperfectly; whence will result, in the spleen as elsewhere, a marked softness and at the same time a large amount of clot. It is always the same cause which pro- duces a similar kind of modification, whether in the blood that we extract from the veins during life, in that we collect from the heart and vessels after death, and in that again contained in the splenic cellules. Thus then, the augmentation in size of the spleen and 'its softening, which certainly accompany every well marked typhoid condition, may be regarded as the efl^ect of a diminution of the fibrine of the blood, and this change is one of its manifestations. Let no one say moreover that it is in consequence of the greater rapidity imparted to the circulation that the spleen conies to present the changes that I have just described : for, in the acute phlegmasise with fever, it presents nothing of the kind. I have already said that, however poor the blood might have become in globules, this did not prevent the temperature proper to the human body from persisting in its normal con- dition, and even elevating itself if there were occasion. The same is true in cases where the blood has lost a great portion of its fibrme : not only does not the temperature of the body fall in consequence, but it may even augment several degrees, just as in any other circumstance. Thus I have found it at 40° c. in cases of typhoid fever when the blood did not offer more than j-^-^-^ in fibrine. Yet this is likewise the most ordi- nary temperature that wc find in individuals who have fever symptomatic of an acute phlegmasia, even when the fibrine has doubled or tripled in quantity. Consequently the greater or less elevation of the temperature of the body in diseases, is not dependent upon the quantity of fibrine that the blood may contain. This temperature attains its maximum (42° c.) in intermittent levers in which, as I have assured myself, the 60 PATHOLOGICAL HEMATOLOGY. fibrineof the blood remains in normal quantity;* and the ave- rage even shows itself somewhat more elevated in typhoid fever or in scarlatina than in the acute phlegmasia;. ARTICLE IV. Of the Blood in the Phlegmasia. I HAVE now shown that there is a large class of febrile diseases in which the fibrine is never increased, but is often normal, and often diminished. There are others, again, in which there is constantly an increase of this principle, diseases which are symptomatic of that sort of alteration of the solids, which from time immemorial has been called inflammation. This is not the place to criticise the vagueness and insuffi- ciency of such an expression ; but it is my duty here to set forth prominently that remarkable coincidence, in certain dis- eases, between the increased quantity of the spontaneously coagulable matter of the blood, and the development of various lesions of the solids, which although differing in many respects, yet resemble one another so strongly in others, that in all ages they have been classed together by nosologists, as forming a single group of diseases. And yet it must be admitted that the organic changes are much more uniform in the blood, than in the sohds ; amidst the diverse lesions of the latter, the blood exhibits, by the identity of the alterations which it undergoes, a disease uniformly of the same nature. Not long since, Meckel defined inflammation to be, co?igest/on loith a ten- dency to new production. The study of the blood shows the justness of this definition. For what else than a new pro- duction is this excess of fibrine which suddenly appears in the blood of a person attacked with pneumonia or erysipelas, with an inflammation of the tonsils, of the tongue, of the bronchia, or of the peritoneum ? A new and redundant production of * See in our first memoir, the results which a certain number of analyses of the blood in intermittent fevers, have given to M. Gavarret and myself. OF THE BLOOD IN DISEASES. 61 fibrine in the blood is, then, the least variable sign of a certain number of diseases which present further analogies in the na- ture of the general symptoms accompanying them, and in the uniformity of the treatment they require. In my preceding essays, moreover, 1 have shown, that in these diseases, the other organic constituents of the blood, and particularly the globules, do not increase with the fibrine. In the phlegmasige, then, there is an excess of fibrine rela- tively to the globules, that is to say the reverse of what takes place in typhus. Hence may be explained the physical pro- perties of the blood drawn from a vein, in these diseases. While in the pyrexias, generally, the clot is bulky, flabby, and imperfectly separated from the serum, here, on the contrary it is smaller, more dense, and of superior consistence ; besides which, if the blood has been properly drawn, the clot will be covered with a bufty coat of variable thickness. I have already explained myself in regard to the value of the indications to be derived from the bufly coat. Except -% when it occurs in cases of anaemia, this production uniformly denotes a state of mflammation; I can cite in support of this assertion a summary of nearly eighteen hundred bleedings, hi which the blood, examined by myself, never presented a buffy coat except in one or the other of two series of cases, those of anaemic patients on the one hand, and those of persons attacked with various acute or subacute phlegmasicc, on the other. In the former, the buffy coat, which, indeed, is of moderate thick- ness, results from the great diminution of the globules, for the fibrine although in its usual quantity, is nevertheless in excess, relatively to the globules. But in the phlegmasiae the globules are neither increased nor diminished, while the fibrine having become redundant, the law which governs the formation of the buffy coat reaches its full development. jVIoreover, the fibrine of the new product entering into the composition of the buffy coat coagulates more slowly than the old, which is another cause favourable to the appearance of the buffy coat, since the gradual coagulation of the fibrine allows the globules to sink to tlie bottom of the vessel, leaving the fibrine above 6 ■»< qg PATHOLOGICAL HEMATOLOGY. them, still dissolved, or suspended, in the serum. Besides, if an analysis be made for the purpose of determining the quantity of librine in the buffy coat, or underneath it, some indeed will be found in the latter situation, but very little compared with what can be extracted from the buffy coat itself* There is a striking contrast between the usually great firm- ness of the buffy coat, and the extreme softness of that portion of the clot which retains its colour ; this softness is always great in proportion to the density of the buffy coat, and the brownish red mass which the latter surmounts, bears the great- est resemblance to imperfect and half liquid currant-jelly. On examining this mass through a microscope, an accumulation of globules is found in it, while none, or very few, can be • With reference to this subject I have studied the clot in three cases of pneumonia, and in two of acute articular rheumatism. In these five cases the fibrine of the clot was apportioned in the following manner: First case of pneumonia. Fibrine of buffy coat ----- 8.1 Fibrine of rest of clot 1.1 Total fibrine 9.2 Second case of pneumonia. Fibrine of buify coat 5.8 Fibrine of rest of clot 3.2 Total fibrine 9.0 Third case of pneumonia. Fibrine of buffy coat ----- 4.8 Fibrine of rest of clot - - - - - - 2.5 Total fibrine 7.3 First case of articular rheumatism. Fibrine of buffy coat ----- 7.0 Fibrine of rest of clot - - - - - -1.6 Total fibrine 8.6 Second case of articular rheumatism. Fibrine of buffy coat 7.5 Fibrine of rest of clot 1-7 Total fibrine 9.2 OF THE BLOOD IN DISEASES. 63 detected in that portion of the clot which forms the buffy coat. On examining the latter in the earliest periods of its separa- tion, and before the coagulation is visible to the naked eye, or just as it is commencing, certain phenomena may be witnessed; such I have verified with M. Gavarret, and which I will now describe.. We received in a glass vessel 80 grammes (about 21 ounces) of the blood of a person suffering from acute pneumonia ; the coagulation took place as usual, and a buflfy coat soon made its appearance upon the surface of the clot. Hardly had the yellowish and opaline liquid which constitutes its first rudi- ments appeared above the mass of globules, when we placed a drop of it under the microscope ; then, in addition to some red globules, the field of the instrument appeared to us filled with those grain-Uke corpuscles whose nature I have already endeavoured to determine. The opaline liquid became every moment more consistent ; when it assumed the appearance of a tremulous jelly denoting its approaching solidification, we again examined it under the microscope, and saw forming before our eyes numerous very fine fibres, resembling long and very delicate threads, crossing one another in various di- rections, so as to leave intervals between them of variable extent, and giving to the whole the appearance of a net-work. These fibres, at first, few in number, and scarcely visible, be- came more numerous and more distinct, until they occupied the whole field of vision; and, as they increased, formed superposed planes at certain points, where the net-work was succeeded by an appearance like felt. The fundamental form, however, continued to be reticular. As the solidification of the bufiy coat proceeded, this appearance of interwoven fibres disappeared, and there only remained visible a confused and amorphous mass. I have repeated this experiment several times, and always with the same result. I have also examined with a micro- scope the sero-fibrinous liquid which may be separated from the globules, as already stated, by subjecting the blood to the 64 PATHOLOGICAL H^MATOLOGT?. action of sulphate of soda, and then, upon examming the flakes which quickly appear in the Uquid, I have found these same reticulated fibres. I shall avail myself hereafter of this micro- scopical sign afforded by the fibrme of the blood, to prove the identity of this principle with other spontaneously coagulable matters, which, in certain cases, are found mixed with the serosity. Here, then, is the necessary, the indisputable modification offered by the blood in every inflammation acute enough to be accompanied with fever, the creation in that fluid of a new quantity of fibrine. Here we have an explanation of the phy- sical properties of the blood in the phlegmasiee, so different from what they are in the pyrexiae : here too the cause of the formation of the buffy coat, whose fibrinous nature is thus demonstrated as well by microscopical examination, as by chemical analysis. This spontaneous production of an excess of fibrine in the blood is, moreover, independent of the various conditions in which the system of the individual attacked with inflamma- tion may happen to be. For, remarkably enough, it does not fafl to take place even when a phlegmasia occurs during the course of typhoid fever, the influence of which is to create, at least, a tendency to lessen the quantity of fibrine in the blood. The real increase of the fibrine in such a case is not, however, very great, for I have never found its maximum to exceed 5i, which number corresponds to one of the lowest degrees of the inflammatory state, and in other cases the amount of fibrine was even less, its increment was only relative. Does it not, then, seem as if the fibrine were controlled by two forces, one of which, represented by the intercurrent phlegmasia, urges its increase, and the other represented by the typhoid fever, acts in the opposite direction, and reduces to its minimum the influence of the phlegmasia ? In this way we may under- stand how the fibrine, although exceeding its physiological quantity in cases of typhoid fever complicated by intercur- rent inflammation, is yet developed in a less degree than if its OP THE BLOOD IN DISEASES. 6^ increase were regulated only by the laws of the inflammatory state. Although the constitution may be exhausted by a chronic disease, or a more or less complete state of anajmia be estab- lished, the fibrine will nevertheless be augmented under the influence of whatever inflammation may supervene. Nor is there any thing surprising in this ; for, in the supposed circum- stances, the globules diminish, while the fibrine remains nor- mal, so that its increase, through the intervention of the inflam- matory state, is less singular than in the case of typhoid fever. In the above mentioned conditions of the economy I have seen it increase much more than in typhoid fever. In chlorotic patients, for instance, who had been attacked with acute arti- cular rheumatism, capillary bronchitis, pneumonia, or erysipe- las, I have found the blood to contain 6, 7, and even 8 parts of fibrine. While, tlierefore, clinical observation demonstrates the frequent coincidence of anaemia and inflammation, chemi- cal analysis discloses to us in the composition of the blood, circumstances which far from opposing this coincidence, should rather be held capable of favouring its development. For since in all cases of general debility the globules are dimi- nished, and the fibrine relatively increased, it follows that in the spontaneous anaemia occurring towards the close of many chronic diseases, the proportions of the several constituents of the blood to one another are such that the state of this fluid approximates more nearly to the change of composition eflect- ed by inflammation, than under any other circumstances, so that the blood may be said to have then a sort of predisposi- tion to the inflammatory state. I have not observed that, apart from the disease itself, the differences of constitution or temperament, of age or sex, modified in any notable degree the quantity of fibrine in the blood. Whether the individuals attacked with acute inflam- mation were strong or feeble, of a sanguine or lymphatic tem- perament, the increase of the fibrine was neither more nor less considerable, following only, amidst these various conditions of the organism, the variable intensity of the inflammation. 6* 66 PATHOLOGICAL HEMATOLOGY. I was much struck by a fact observed in some experiments which I undertook with M. Gavarret in order to settle the composition of the blood in animals deprived of food. This fact was a remarkable increase of fibrine ; but my surprise was at an end when, upon the dissection of these animals, 1 discovered in their stomachs lesions of the most clearly inflammatory nature, such as bright redness, softening, and numerous ulcer- ations of the mucous membrane. From that time, I have seen in those experiments only a confirmation of the principle I have just now laid down, to wit, the possibility of an inflam- mation developing itself in spite of the general debility of the system, and the simultaneous increase of the fibrine of the blood in spite of the general impoverishment of that liquid. The following are some details of those experiments. We bled three healthy and well kept dogs. Their blood contained fibrine represented by 2.3; 2.2; and 1.6 respect- ively. These variations are ordinary and physiological in canine blood, as I have elsewhere shown.* After having thus determined the composition of their blood, these three animals were made to fast, more or less rigorously, until they died. From the first both food and drink were withheld from De- cember 21st 1841 to January 11th 1842, when he died. Dur- ing this period he was twice bled, on December 28th and January 4th. The quantity of fibrine in his blood rose from 2.3 to 3.9 and 4.5. The second dog was not allowed to eat from December 21st to January 8th, the day of his death ; but all this time he was permitted to drink water. He was bled December 28th, Jan- uary 4th and 8th, and the fibrine of his blood had risen from 2.2 to 2.9 and 4.0. The third dog was not starved so absolutely : from Decem- ber 21st to January 16 th he received every morning a small ration of soup. He was first bled December 28th, and again January 4th, but there was no considerable increase of fibrine, although it was far from diminished, being represented by 1.8 * Mem. cit. OP THE BLOOD IN DISEASES. 67 instead of 1.6. Such was not the case, however, on January 12th, four days before the animal's death, and when the influ- ence of insufiicient food had been longer felt by the organism. In this third bleeding the increase of fibrine was very marked ; it had reached 3.3. The proportion was indeed less than in the other cases ; but it is worthy of remark that this third dog had not been entirely deprived of food, and was the only one whose stomach was not ulcerated ; the redness of his gastric mucous membrane was also less general and less vivid. Need I here recall the fact, that independently of the interest which belongs to these experiments in relation to the subject in hand, they entu'ely confirm the opinions which, ever since the time of Hunter, have prevailed in our science respecting the morbid and excessive excitement, and the inflammatory dis- organization, which may affect the stomach when, for a certain period, it has either received too little food, or none at all ? No matter, then, what may be the state of the system, the supervention of an acute phlegmasia involves necessarily, and in every case, the increase of the fibrine of the blood beyond its normal quantity. This law, too, prevails amongst animals, as well as amongst men, as I have become well assured by- analyzing the blood of dogs, horses, neat-cattle, and sheep, at- tacked with various inflammations which had been discovered during life, and after death. In man, when an acute inflammation is well established, the fibrine varies in quantity between 6 and 8 ; in a smaller num- ber of cases it rises as high as between 8 and 9 ; and, more rarely stiU, exceeds the latter number, and reaches by degrees lOi, which is the highest number I have yet found represent- ing the fibrine in phlegmasiae attacking the human race, though in a neat aflected with pneumonia I found it as high as 1 3. It must be remarked here, that since the physiological number representing the fibrine in animals is not the same as that for man, the increment in the former must not be judged of by the standards of the latter, but must be referred to the average obtained for each particular class of animals. Thus the phy- siological mean of the fibrine in dog's blood being only 2.1, 68 PATHOLOGICAL HEMATOLOGY. the numbers 3, 4, and 5 obtained when this animal was at- tacked with inflammation, would, in the case of man, indicate a development of fibrine to be represented by much higher numbers. On th^ other hand, the physiological mean of the fibrine in the blood of horses and neat-cattle being greater than that of man, the number 13 indicating the quantity of fibrine in the blood of one of these animals, would, in the case of man, represent a much inferior quantity. These corrections are indispensable, if we desire profitably to apply to human pathology the results obtained from studying the pathology of other species. In regard to the cases in which the fibrine falls below 5, they are either acute and slight inflammations, and which can hardly be said to have commenced, or whose activity and ex- tent are inconsiderable : in them it may happen that the fibrine falls from 5 to 4^, and sometimes even to 4; but this last number represents the lowest possible, and, as it were, excep- tional limit, of the quantity of fibrhie in the acute or subacute inflammatory state. To demonstrate the sudden change of composition which takes place in the blood of persons attacked with acute phleg- masiee, I might cite several cases in which the same person having been bled, some days before the outset of the phlegma- sia, and again during the course thereof, his blood, which con- tained the normal quantity of fibrine at the first depletion, was much more abundantly provided with it at the subsequent ones. The two diseases in which I have noticed the greatest de- velopment of fibrine, are pneumonia, and acute articular rheu- matism ; they are the only ones in which this augmentation reached the number 10. I will now pass in review all those diseases, different indeed, in seat, but not in nature, in which I have found, as an inva- riable characteristic, an increase in the spontaneously coagula- ble matter of the blood.* * For further details respecting the state of the blood in these various dis- eases, see the two memoirs already cited, and which are published in the OF THE BLOOD IN DISEASES. 69 And first, since inflammation of the cellular tissue is re- garded as the type of all inflammation, I will notice a case of phlegmon of the leg, of moderate extent, which terminated in abscess, and which was accompanied by a very slight febrile reaction. The first bleeding gave 4.7 of fibrine, the second 5. In another case of phlegmon of the breast which terminated in resolution, the blood furnished 4.5 of fibrine during the course of the afiection, and only 3.7 at its close. Out of 84 bleedings performed in the course of well marked cases of pneumonia, there were seven only in which the fibrine varied in quantity between 4 and 5 ; in the 77 others it ex- ceeded the latter number, was eleven times between 5 and 6, nineteen times between 6 and 7, fifteen times between 7 and 8, seventeen times between 8 and 9, nine times between 9 and 10, and six times at, or a little above, 10. In inflammations of the mucous membrane, the quantity of fibrine is found to remain normal, if the inflammations are slight, limited, and without fever ; but do they acquire ever so little of a certain degree of intensity, and manifest a febrile reaction, so surely does the fibrine of the blood augment. Thus I have seen it reach 6, 7, and 9 in cases of bronchitis of great extent and acuteness. I refer to my first memoir for the details of these cases, contrasted with others of chronic bronchitis in which there was no increase of the fibrine. In- flammations of the intestinal mucous membrane present the same phenomena. I may here be permitted to cite, somewhat less briefly, four cases of acute mercurial stomatitis which seem to me to possess some interest due, on the one hand, to the cause producing them, and, on the other, to the exact ratio which existed, in all these cases, between the intensity of the affection of the solid, and the quantity of fibrine in the blood. These four cases have, moreover, never been published. In the first a slight stomatitis occurred after a dose of twelve Annaks de chimie et de physique, vol. Ixxv of the 2d series, and vol. v of the 3d. I shall here only notice at any length the facts not published in these two memoirs. 70 PATHOLOGICAL HEMATOLOGY. decigrammes (18,5 grains) of calomel; there were a few pseudo-membranous films scattered over the lining membrane of the mouth ; the salivation was copious ; the pulse 80; the temperature of the skin 37.50.* The blood contained 4.5 of fibrine. In the second case a dose of only six decigrammes (9.5 grains) of calomel had given rise to a rather more acute in- flammation of the mouth ; and there was more fever. Pulse 100 ; temperature 39. The blood contained 5 parts of fibrine. In the third case, the affection followed the use of mercu- rial frictions simultaneously with calomel given internally ; it was more violent than the two preceding cases. Numerous and thick false membranes invested the gums, the lips, and the cheeks. The degree of fever was about the same as in the second case, (pulse 96, temperature 38.50,) we found 8.4 of fibrine in the blood. , In the fourth and last case, the stomatitis, produced as in the last case, was more considerable, for the whole mouth was enormously swollen, and encrusted with false membranes. The pulse was 120, the temperature 39. In this case the fibrine rose to 6.6, and its increase was clearly due to the in- flammation ; for the patient had, a few days before, been bled for a slight cerebral haemorrhage, and at that time his blood contained only 3.5 of fibrine. In the other three cases, there was no other affection before the mercurial sore-mouth, which could have produced any modification in the amount of fibrine in the blood. IVIercurial stomatitis, therefore, notwithstanding its specific nature, does not differ from ordinary inflammations in its influ- ence on the blood; and yet it has been asserted again and again, that one of the eflects of mercury introduced into the system is to bring about a state of dissolution of the blood, which is incompatible with an increase of fibrine. It is possi- ble that this may take place after a prolonged use of the medi- cine, but assuredly such is not the case soon after its first • Probably centigrade: but the author does not mention what thermometer was used by him. TV. OP THE BLOOD IN DISEASES. 71 exhibition. Consequently, when it is administered to combat certain acute phlegmasias, such as peritonitis, it is not right to assume that its antiplilogistic action consists in its producing in the blood a condition opposed to that which belongs to the inflammatory state. Nor do I find that this dissolving influ- ence upon the blood which is claimed for mercury, has ever been demonstrated, in any alleged case, by a rigorous exami- nation of that fluid. It appears to me that the opinion rests chiefly on a fancied analogy between the effects of mercury, and those of scurvy, upon the mouth. But this is a deceptive resemblance : in the aflection of the mouth following the administration of mercury, are to be ob- served all the marks of a true inflammation, which, if some- what intense, is accompanied with active fever. But the case is not the same in scurvy : the symptoms which then show themselves in the mucous membrane of the mouth are only amongst the phases of those haemorrhagic congestions which are ready to take place in nearly all the tissues. Proceeding with the exposition of our analyses of the blood in various cases of inflamed intestinal mucous membrane, I find it to be uniformly the fact, that a notable increase of the fibrine takes place whenever any portion of this membrane, from the fauces to the end of the colon, inclusive, is attacked with inflammation acute enough to excite fever : in these cases the quantity of fibrine has reached 5, 6, and 7, but never a higher degree. We have already shown that this increase does not occur, when the inflammation, seated in the follicles, exists only as one of the elements of a general disease, i. e. of a typhoid fever. The great distinctive traits separating cholera from proper inflammatory affections of the intestinal canal, might have found confirmation, if need were, in a recent examination I had occasion to make of the blood, in a perfectly sporadic case of this disease. The patient was a robust man, in middle life, who entered the hospital of La Charite with all the symptoms of a pretty severe attack of cholera : (copious vomiting and purging, colourless stools resembling rice water, cramps, apho- 72 PATHOLOGICAL HEMATOLOGY. nia, suppression of urine, cold skin, but a pulse of natural ful- ness, and moderate frequency.) The blood of this patient gave only 3.3 of fibrine, and contained only 118 parts of glo- bules, and 88 of the solid constituents of the serum. Finally, to close this review of the state of the blood in in- flammations of the mucous membranes, let me remark, that the increase of the fibrine has not failed to occur, either in various cases of acute cystitis, whether accompanied or not with nephritis, or in recent, painful, and intense inflammations of the utero-vaginal mucous membrane. In these different cases, which were all accompanied with fever, the fibrine oscillated between 4, 5, and 7.' I may mention that one of these cases was complicated with Bright's disease of an indo- lent and apyrectic form, to combat which I directed a bleeding which gave 3.6 of fibrine. Three or four days afterwards an acute pain attacked the right side of the lumbar region, and fever set in. The patient was again bled, and this time his blood, suddenly changed in its composition, contained 5 of fibrine. Inflammations of the skin, as well as of the mucous mem- branes, bring with them an increase of the fibrine of the blood. This I have ascertained in a person who had been severely burned ; while, on the other hand, there was no increase in another whose burn was slighter, and less extensive. It appears to me peculiarly interesting to determine, whether, in cases of burn, the blood becomes charged with fibrine, because in such cases, evidently, the disease begins in a solid, and the alteration of the blood can therefore only be regarded as consecutive. Further on I shall revert to this subject. The course of erysipelas, when acute and febrile, is like that of a burn, and shows an increase of fibrine represented by the numbers 6 and 7. The pustules of variola, and the exanthema of measles and scarlatina, like the follicular affection in dothi- nenteritis, exert less influence upon the blood, than simple erysipelas. I have likewise established this invariable law of augmen- OF THE BLOOD IN DISEASES. • 73 I have likewise established this invariable law, of augmen- tation in the fibrine of the blood, in regard to every acute in- flammation of the serous membranes. It was, for instance, very marked in a case of cerebro-spinal meningitis, in which, after death, I found the spinal marrow surrounded, in its whole extent, by a sort of purulent sheath, the pus having infiltrated the pia mater. In pleurisy, peritonitis, and pericarditis, I have also found in the blood this same excess of spontaneously coagulable matter. These various cases, 24 in number, are divisible into two series. The first comprises those in which the disease, whether acute or chronic, was accompanied with fever, and continually grew worse ; which suggests the probability that the primary cause of the disease was not exhausted, but maintained its action. In the cases belonging to this series, I Tuiiformly found an excess of fibrine in the blood, its minimum being 4, its maximum 8.4. ' In the second series, other facts present themselves. The inflammation seemed to be suspended ; the pulse lost its fre- quency ; and the only remains of the disease were a greater or less eff'usion into a serous cavity. The blood then ceased to contain an excess of fibrine. It may even happen, as I once saw, that this principle, although excessive at the commence- ment of the disease, may return to its normal proportion, while yet the fever persists, but only after the prolonged diura- tion of the malady has caused extreme emaciation. The case referred to is that of a woman attacked with peri- tonitis ; during the earlier stages I had her bled twice ; the blood gave 5.3 and 5.4 of fibrme. The peritonitis lost its in- tensity after this depletion, but was not cured, and gradually passed into a chronic state. The patient was already much emaciated, when I endeavoured, by another bleeding, to di- minish the fever, which had never for a moment ceased. This time the blood contained only 3.5 of fibrine. After this bleed- ing, there was no improvement, and the patient sunk speedily. The intestinal convolutions were united by organized false membranes, and the pelvis was filled with pus. The tempe- 7 74 • PATHOLOGICAL HEMATOLOGY. rature of the skin, even to the last day, remained at 40° cent., and the blood did not then contain more than 68 parts of glo- bules. In addition to these 24 cases of serous inflammations, I should cite another, in which the fibrine was so small in quan- tity as to contrast with all the other acute and recent cases. The form of the disease was, moreover, quite peculiar. It was seated in the pleura ; indeed commenced like a simple pleuro- dynia ; and then without any initial chill, or frequency of pulse, a considerable effusion took place rapidly on one side of the chest. In this singular case of pleuritic efl'usion without fever, the tibrine in the blood preserved its normal quantity, (3.5). It may be doubted whether there was, in this instance, a real inflammatory process. Was it not simply hydrotho- rax ?* There is a disease which, in. many respects, seems to differ ffom ordinary inflammations, but which, like them, obeys the law relative to the fibrine of the blood. I allude to articular rheumatism. If acute, the fibrine augments uniformly, as has been proved to me by an analysis of 43 bleedings, in which the fibrine was once represented by 4, six times by 5, fifteen times by 6, thirteen times by 7, three times by S, three times by 9, and twice by 10. But if the articular rheumatism be only subacute, there is less fibrine, although it generally exceeds the physiological quantity. In six cases of the sort it varied between 4 and 5. If, finally, the articular rheumatism be decidedly chronic, the fibrine returns to its normal standard. To bring this long catalogue to an end, I have yet to point out the modifications of the fibrine in certain inflammations of the parenchymatous tissues, regretting, at the same time, that I am unable to furnish more cases in point. But, thus far, I have not had the opportunity of collecting them. In two cases of acute inflammation of the lymphatic gan- glia of the neck, with fever, I have seen the fibrine reach 4.2 * The details of, this case may be found in my first memoir upon the alte- rations of the blood, p. 74. t OP THE BLOOD IX DISEASES. 75 and 5 ; one of these cases is the more conclusive, because the blood of the patient, who was bled for another reason, two days before the attack of ganglionitis, gave only 2 parts of fibrine. In a case, proved by the autopsy to be acute nephritis, this element reached the number 7. ♦ In conclusion, I give another illustration of the state of the fibrine in a case of softening of the brain. A woman was brought to the hospital labouring under a recent attack of apo- plexy. Her lirribs were paralyzed and rigidly flexed. I had her bled, and was struck with finding a larger quantity of fibrine in her blood (4.5) than is usually found in simple hemorrhages. She soon died, and the autopsy disclosed, in the right corpus striatum, and around a clot, a red softening of the cerebral sub- stance, of small extent, but very distinct. Inflammation had, then, existed around the apoplectic centre ; the contraction of the paralyzed extremities had indicated it during life, and the excess of fibrine in the blood had added to the value of that sign. It should also be remarked here, that if the excess of fibrine was small, the inflammatory complication was also very limited. Since the commencement of my inquiries, I have not met with a single case of acute hepatitis, a disease known to be rare in our chmate. I have several times analyzed the blood of persons aflected with jaundice, but found no increase of fibrine in any of them ; nor yet in a simple case of hepatic cirrhosis. The increase of fibrine in the blood takes place from the very commencement of the inflammatory state. I have fre- quently had the same individual bled twice ; the first time, on the day previous to the inflammatory attack, and the second time, a few hours after its distinctly marked invasion. The first time, the fibrme of the blood was normal, the second, in excess. I have, thus far, vainly striven to determine whether or not the composition of the blood was modified, before the change denoting inflammation appeared in the solids ; 1 have not succeeded, and my analyses have proved to me nothing more than the simultaneous origin of these two phenomena. This serious question does not yet, however, appear to me to 76 PATHOLOGICAL HEMATOLOGY. be set at rest ; a question, by the ultimate solution of which we must decide, whether in the great phenomena of inflam- mation, the source of disease is in the solids, or in the blood, or whether the alteration of the one is not so essential to that of the other, as that both must necessarily begin to exist at the same moment. Remark, too, what a variety of beghmings belong to the diseases ranked as inflammations : at one time there is no interval between a state of perfect health, and the invasion of the disease ; at another, there is a general uneasi- ness, and that slight disturbance of all the functions which we call the " prodrome" of diseases ; at another, a well marked fever sets in, from one to three days before the appearance of symptoms denoting a phlegmasia of some one of the solids. But even where the disease comes on without any " prodrome," it may do so in one of three ways : either there is pain, a purely local symptom, to open the attack, while the rest of the economy seems unaffected by the local disorder ; or before this latter is felt, there may be a violent chill as the only appre- ciable morbid phenomenon, and which may last for half an hour, for an hour, or even longer ; or else the local symptom and the chill may appear simultaneously. I ought to add that this last case is more common than the two others. We may well inquire whether, when its earliest symptoms are so dif- ferent, the starting point of inflammation is always the same. That which takes place in the case of a burn proves very clearlyt hat, under the circumstances, the blood is modified in its composition subseqviently to the alteration of the solid, and, inferentially, we may suppose that it must be so in all other inflammations. The analyses of the blood hitherto made would tend to confirm this view, for they have never revealed an excess of fibrine in the blood, before the occurrence of in- flammatory symptoms in the solids. On the other hand, there are certainly cases in which the sensible alterations of the lat- ter are so inconsiderable, so variable, and sometimes so ephe- meral, that it is difficult to understand how they can be the cause of such intimate and enduring changes as have then taken place in the blood. Is it not often so in articular rheu- OF THE BLOOD IN DISEASES. 77 malism, and is it not remarkable tliat this is one of the diseases remarkable for increase of fibrine ? In all this there are un- known quantities to determine : there is yet to be discovered that mysterious link, whose necessity is proved by its con- stancy, and which, in the phlegmasise, unites the alteration of the solids v/ith that of the blood. Yet, from the simultaneous character of these alterations, the deduction may still be made, that what we call inflammation is not a disease seated in the solids merely, that it does not influence the rest of the economy only by pretended s^pathetic radiations, and, that in all these things, the changes which are then taking place in the blood, play an important part. An inflammation, then, is not a purely local disease. Does the fever which accompanies every acute phlegmasia of some intensity depend upon the excess of fibrine contained in the blood ?* Observe that there is stiU an almost ♦ constant and reciprocal relation to be studied, between these two facts ; for, as the fever begins, the fibrine increases, and as the fever ceases, the fibrine returns to its normal condition, yet the local lesion may still persist with considerable acti- vity. How many times, for instance, have I not continued to find, by auscultation, the most perfectly distinct signs of pulmonary hepatization, when, for several days before, all fever, and every appearance of reaction between the lung and the system, had completely disappeared; so completely, that but for auscultation, one might have believed the disease at an end. And indeed it was so, in this sense, that the lesion of the lung was only the result, and almost an unimportant one, of a morbid action that had ceased ; thenceforth the fever also ceased, and the production of new fibrine, the index of this process in the blood, no longer took place. The disease had once more become entirely local, if indeed such a condition of the lung deserves the name of disease. It would be said, in the language of some of the schools, that the diathesis no longer • At any rate we should be able to explain only the symptomatic fever of acute phlegmasia;, in this way; for in the pyrexiae the fever is long, and in- tense, without there being an excess of fibrine in the blood. n* 78 PATHOLOGICAL HJEMATOLOGT. existed. But what is meant by this expression? To point out the existence of a general condition of the system of the same nature as the local lesion, and which causes the whole organism to share the suffering of one of its parts. There is not, says Tommasini, an inflammation, properly so called, without the production of a diathesis ; a local irritation caused by a thorn run into the finger, does not, according to this author, become an inflammation, unless, in consequence of this very circumscribed lesion, the sthenic diathesis should be established ; and it is established, he #dds, by the diffusion of the phlogosis of the vessels around the injured point, to those of the rest of the body. This theory is nothing more than the emphatic announcement of the important fact that the whole organism participates in the morbid operations which seem confined to a single one of its points. Who does not see, that in other words, and in another aspect, it is this same fact upon which is founded the law requiring the production of new fibrine in the blood, as soon as any solid becomes the seat of an inflammation intense enough to give rise to more than what Tommasini calls a simple irritation ? Is not the excess of fibrine then produced, the material representative, as it were, of what Tommasini terms the diffusion of phlogosis ? Thu(s it is that we reach the same conclusion, in spite of the sugges- tions of different theories, and of opposite methods of observa- tion. The formation, then, of an excess of fibrine in the blood is uniformly the accompaniment of inflammations of a grade high enough to give rise to fever; but this fact acquires a greater importance both as a diagnostic sign, and as an element of the doctrine which relates to the production of disease, if we reflect that it never takes place unless an inflammation exists somewhere. An excess of fibrine in the blood becomes, therefore, a pathognomonic sign of such inflammation. There is, however, a circumstance, occurring even during health both in man and the lower animals, which has the power of augmenting the proportion of fibrine contained in the blood ; I allude to gestation. But this augmentation, which is OF THE BLOOD IN DISEASES. 79 found only at certain epochs of pregnancy, is rather a high physiological maximum, than even the ordinary degree of pathological increase. Tiie following are the results obtained by M. Gavarret and myself from analyzing the blood of 34 pregnant woman. From the first to the end of the sixth month, the blood con- tained less than its average physiological proportion of fibrine ; the mean of the fibrine during the first six months being only 2.5; its minimum 1.9; and its maximum only 2.9. On the other hand, during the last three months of preg- nancy, the mean of the fibrine exceeded the physiological mean ; it reached 4, and the maximum rose to 4.8. And, further, it was found that the increase of the fibrine had become greatest in the last month of pregnancy ; at this period its mean was 4.3 ; its maximum was not reached until the access of labour, and it may be presumed that this maxi- mum was maintained, if not exceeded, for some time after delivery. It seems to me that this presumption is supported by the results which I obtained with MM. Gavarret and Delafond, by analyzing the blood of sheep and cows during their gestation, and again after they had brought forth; at which latter time these animals furnished more fibrine than before. (See the Memoir upon the composition of the blood ill certain domestic animals.) It is then demonstrated that in women, at particular periods of gestation, and in cows and sheep, after parturition, the blood contains a certain excess of fibrine. The blood, on these occasions, shows a remarkable tendency to assume the character of inflammatory blood ; and, assuredly there is mat- ter for reflection in the relation which may exist between the modification then effected in the blood, and the development of those peculiar attacks, generally of an inflammatory aspect, to which women in childbed are so liable. But ought the slight excess of fibrine in their blood, at that time, to be regarded as a predisposing cause of these attacks ? If so, this would be such a case as I recently sought, (and observation has not yet furnished me with any other) in which the proper inflamma- 80 PATHOLOGICAL HEMATOLOGY. lory alteration of the blood precedes the signs of inflammation in the solids. If in the later periods of pregnancy the blood contains rather more fibrine than in other states of health, we may understand how it happens, that when blood is drawn from a certain pro- . portion of pregnant women, its clot should be covered with a buffy coat ; and this should occur the more readily in them, because the amount of globules in their blood often falls more or less below the normal standard. Thus, of 34 pregnant women whose blood we examined, in one only who had reached the end of her second month, did the globules, (145) "exceed the physiological average; this woman was plethoric, and the quantity of her fibrine was only 2.8. In another case of pregnancy of from one to two months, the globules reached exactly the normal average, 127. But in the 32 others, they fell below this point, varying in six cases from 125 to 120, and in the 26 other cases from 120 to 95 ; whence it follows that there was a commencement of anaemia in all these women. This state of the blood, is also perfectly in keeping with the remarkable pallor, and the degree of puffiness of the face, which many women exhibit, as soon as they have conceived. Preg- nancy, then, which has often been looked upon as a cure for chlorosis, rather disposes some women to the affection while that state lasts.' But enough about this subject, upon which I have entered here only that I might render prominent the curious analogy that exists between the blood of pregnant women, and that of persons attacked with acute inflammations. Before concluding our notice of the state of the blood in in- flammation, I wish to direct the attention, for a few minutes, to the nature of those alterations which may occur in the solids. These products are either the natural secretion of the inflamed part, modified both in quality and quantity, or else pus, or some of the elements of the blood itself I shall, in this place, allude only to the third form. The two principal elements of the blood which are the most frequently separated from it, in inflammation, are albumen and w^ OF THE BLOOD IN DISEASES. 81 fibrine. But although the albumen of the serum may be given up by the blood in many conditions of disease which have no connection with inflammation, such is not the case with the fibrine, which does not leave the blood, in disease, except to be deposited in the tissue, or upon the surface, of organs whose texture has been altered by inflammation. The serum contained in an inflamed solid, moreover, as well as that which is separated from the blood under any other cir- cumstances, never exactly resembles the serum of the blood, in the proportion of albumen it contains. It may be laid down as a general principle that morbid secretions of serum, what- ever be their origin, are rarely as rich in albumen, as the serum of the blood ; but, other things being equal, those which most closely resemble the serum of the blood in the quantity of albumen they contain, sometimes even equalling the propor- tion contained in that fluid, are such as are exhaled from in- flamed surfaces. I shall demonstrate this in a subsequent article upon the state of the blood in dropsies. I have also endeavoured to discover how much albumen was contained in another variety of serum, that of a conges- tive abscess, and which had suspended in it a large quantity of pus-globules. To the naked eye this liquid appeared turbid, and of a milky hue ; but by filtering, we easily deprived it of the globules that diminished its transparency, and then we ob- tained a liquid so perfectly resembling pure serum in all its physical properties, as not to be distinguishable from it. This liquid, thus deprived of the matters suspended in it, we sub- jected to the ordinary processes, and found that it contained a proportion of albumen nearly equal to what exists in the healthy blood ; a result confirmatory of the principle just now laid down. Wc learn, besides, from this experiment, that a portion of the liquid furnished by an inflamed solid is nothing more than the serum of the blood, with which is mixed a greater or less number of those singular bodies called pus-globules. Thus, one efl'ect of the morbid process, called inflammation, is to deprive the blood of a certain portion of its serum ; the iras 82 PATHOLOGICAL HEMATOLOGY. latter, as may be conceived, is not then altered in its essential nature, but undergoes a change of aspect dependent upon the admixture with it of two new bodies; a principle (fibrine) which, like the serum itself, is an emanation of the blood, and of a matter (pus) which, as regards its physical properties, at least, has nothing like it in the blood. This process, then, whoise nature is wholly unknown, and which cannot be accomplished, without the blood is over- charged with fibrine, determines, whenever it takes place, the elimination of a certain quantity of fibrine. But this elimina- tion is not always distinct; it is especially observed, and in the most evident manner, either in the serum formed upon the skin by the action of cantharides, or in that which fills the cavities of inflamed serous membranes. It is not only at this day that the spontaneously coagulable matter found in these liquids has been considered fibrinous ; but there was no ground for its being so called, other than its property of becoming solid. To demonstrate that this sub- stance was really fibrine, I adopted another method of investi- gation : I examined, under the microscope, the flakes which the serum holds suspended, and also the yet soft false membranes lining the free surface of inflamed serous membranes, and found, in both instances, a net-work precisely similar to that presented by the fibrine of the blood, and which has already been described. Thenceforth I no longer doubted that the flake-like matter which swims in the liquid produced by blis- ters, and the false membranes .of serous tissues, were really composed of a substance perfectly analogous to the fibrine of the blood. I have not yet had an opportunity of determining whether or not this net-work, which is so characteristic of the presence of fibrine, is to be found in the pseudo-membranous layers which, in certain cases, cover the mucous membranes. To the naked eye, these concretions are far from resembling the serous false membranes, and it may be, that under the influ- ence of some pathological action, other principles, besides the fibrine, acquire the property of coagulability. Who knows OP THE BLOOD IN DISEASES. 83 how far the habitual acidity of the mucous membranes, and of the skin, may favour this coagulation of the albuminous principles which are thrown upon the free surface of these organs, either accidentally, or in consequence of disease ? But what is the nature of pus, and the mode of its forma- tion? It is very difficult to resolve these questions in the present state of science. I cannot admit, as has been main- tained by some, that the globules of pus are a transformation of those of the blood ; there is such a difference in their very nature, that if a little ammonia be added to a mixture of pus and blood placed in the field of a microscope, the globules of the blood are seen to disappear, while the globules of pus are in no wise changed. Nor is the pus formed at the expense of the serum, the albumen of which is foimd unchanged, the pus being merely suspended in, without being, the least in the world, confused with it. If a mass of pus be treated with nitric acid or alcohol, granite-like plates are seen, by the micro- scope, to form, just as in all serum treated in the same way, but the pus-globules undergo no change. May not, then, the pus-globules be nothing more than a modification of fibrine, which, instead of reaching the net-work form, has remained in the serum in that state of granular corpuscles, whose origin and nature I have already pointed out ? May not these cor- puscles, grouping themselves together with a certain regularity, produce the globules of pus ? Shall I say, in favour of this view, that on examining with the microscope the sero-fibri- nous liquid separated from the blood-globules by means of sul- phate of soda, I happened, more than once, to see the corpus- cles that were swimming in the liquid, arrange themselves in little masses which appeared to me to have the most perfect resemblance to pus-globules? It would have been quite im- possible to show any difference between them. And further, in the microscopic examinations of pus, not only are volumi- nous and regular globules observed, but alongside of them is seen a large number of little molecules precisely like those which swim in the scrum of the blood, and which evidently approach one another, unite together, and at last become ag- 84 PATHOLOGICAL HJEMATOLOGT. gregated in rounded masses. If finally, we examine atten- tively a well formed globule of pus, it appears to be made up of a collection of globules placed in juxtaposition, rather than blended. It is not, certainly, a body formed in a single piece, and constituting a perfectly homogeneous whole, like the glo- bules of the blood. Thus two substances are revealed by the microscope, the one globular, the other reticular, which characterize the pre- sence of the morbid process, termed inflammation, in the solids. The reticular substance is nothing more than fibrine identical with that of the blood ; the globular substance is per- haps this same fibrine, but altered in its nature, and arrested in its coagulation. These two matters have, moreover, very different destinies. One of them, the reticular, is capable of assuming organization; vessels may be seen to ramify in it; it may become a tissue ; this it is which forms adhesions, or which, under the name of coagulable lymph, places itself be- tween the lips of wounds and becomes the medium of their union ; far from causing injury by its presence, it is, then, in certain cases, the means of reparation to the tissues, and to that end it lives with their life, and ends by identifying itself wholly with them. But such is not the case with the globular mat- ter. Whether or not it have a common origin with that last mentioned, certain it is, that it constitutes a product which can- not remain within the solids without affecting, more or less, the whole economy ; it is incapable of organization, and reveals no trace of vitality. While the organism tends, in some sort, to assimilate to its own proper use the reticular substance, and employs it to repair the mischief it originally caused, it strives, on the contrary, to expel the globular matter, whose presence is pernicious ; so long as it is not eliminated the disease per- sists, and this elimination itself is not always effected without serious accidents. But can the globular matter, instead of being merely expelled, and after having been conducted more or less rapidly to those surfaces in direct communication with the exterior of the body, disappear from the place where it was formed, and enter directly into the circulatory torrent ? OP THE BLOOD IN DISEASES. 85 Ifis not easy to understand how such large globules as those of pus can penetrate in mass, by a sort of endosmosis, through the coats of the vessels ; at the most, they could traverse them only in fragments, and, as it were, in ruins. But once received into the blood could they again unite, and re-form new glo- bules ? I do not wish to exhaust this question ; and indeed I do not think it can be resolved by the facts we at present possess. Still, I will say that the presence of pus-globules in the circulating fluid, appears to me, after what I have seen, a fact that can in no wise be contested. I have found, more than once, in the midst of blood-globules taken from the vessels of dead bodies, globules of pus, well formed, and so distinctly characterized that they could not possibly be taken for any thing else. They were, certainly, neither altered glo- bules of blood either jagged or granulated, nor those white globules which are found mixed with the ordinary red ones, and which, besides, could not be confounded with globules of pus. The following cases are those in which I met with them. The first is that of a person who was brought, dying, into the hospital of La Charite, and in a very marked ataxo-ady- namic state. At the dissection I found very numerous ab- scesses in the brain, the lungs, the kidneys, and the spleen. The blood was everywhere either quite liquid, or grumous, and like thin currant-jelly. I collected a small quantity of blood from the crural vein for examination by the micro- scope ; in the midst of a great many disfigured and granu- lated globules of blood, (for such is their ordinary condition in the dead body,) a considerable number of pus-globules could be very distinctly made out. There was nowhere the least trace of phlebitis. This is one of the cases which the older writers would have designated under the name of purulent diathesis. Collections of pus in several of the solid organs, and pus in the blood, were in reality, the only lesions that could be detected. In another case I found pus in the blood under the following circumstances. A labourer had been wounded by a violent blow on the leg. He survived this accident but three days, 8 86 PATHOLOGICAL HEMATOLOGY. and died after an intense fever, with delirium, to which suc- ceeded great prostration, and coma. The veins in the neigh- bourhood of the wound offered nothing worthy of remark ; but the crural vein was filled with coagulated blood, without, however, its parietes presenting any notable alteration. Ex- amined by the microscope, this blood showed very small glo- bules, and yet, among them could be discerned, here and there, globules of pus as perfect as could have been found in an abscess. In the other portions of the vascular system, the blood offered no peculiarities, either to the naked eye, or to the microscope. The mguinal glands upon the injured side were swelled and suppurating. I will cite still another case, that of a woman who died at La Charite in consequence of a vast psoas abscess. Indepen- dently of this, I discovered the following lesions : numerous puriilent collections, like those called metastatic, were in both lungs : the coats of the right crural vein were uncommonly thick, carnified, as it were, and their internal surface rugose and uneven. The blood filling this vein resembled sanies, and the microscope revealed in it a large quantity of pus-glo- bules. But, in addition, these globules existed in the blood of the heart ; a great number of them was found in the fluid blood of the right ventricle, and they were again met with, but in much smaller number, in the blood of the left ventricle, which was also fluid. A very small fibrinous concretion was entangled in the columnse carnese of this ventricle ; in those of the right ventricle a membraniform web was interwoven, such as is found in the heart after all varieties of diseases, and deaths, and which is nothing more than a deposit of fibrine spread out like a membrane, as it is sometimes upon the surface of con- cretions. If I speak of it here, it is for the purpose of showing what degree of coagulability this pus-infected blood retained, and because I examined this sort of false membrane with the microscope, and found it constituted, like all fibrinous produc- tions, by a very beautiful net-work, in whose meshes were imprisoned globules of blood and of pus, as perfectly distinct from one another, there, as elsewhere. In this case, too, where OP THE BLOOD IN DISEASES. 87 blood and pus were mixed together at such different points of the circulatory system, I did not find the globules of blood dif- fering either in number or general aspect, in form or size, from what they usually are in dead bodies. These three cases prove clearly that pus, in the form of glo- bules, can circulate with the blood in the vessels, and even pass through the lungs from the right to the left side of the heart. It seems to me very evident that it was so in the last case : the greater part of the globules, urged from the venous system into the pulmonary artery, stopped in the ultimate ramifications of this artery ; whence the numerous abscesses that existed in the lungs ; but some of them were able to enter the pulmonary veins, and reach the left side of the heart where I detected them. In these various cases, the globules of pus appeared to me to remain as distinct from those of the blood, as they are when artificially mixed together in a vessel. I have often tried this experiment, and can give my assurance, that unless too little pus be mingled with the blood, the pus, on examination with the microscope, will be found to exist in it, under the form of well preserved globules : these even seem, in most cases, to unite together under the influence of a sort of attraction, so as to form little groups apart from the blood-globules, which do not appear to be in the least altered by the admixture. I have also determined by experiment, that on mingling directly pus with blood, the latter suffers no change appreciable by the naked eye, or by the microscope, nor any in the amount of its fibrine, so long as the pus is fresh. But such is not the case when pus, long separated from the body and partially decom- posed, is mingled with blood ; then the blood undergoes re- markable modifications, both in its appearance, and in its intimate structure, as the following experiment shows. I left to itself, from June 6th 1842, to the 12th of the same month, some grumous pus furnished by a cold abscess. It re- mained for six days, in the sun, exposed to a high temperature. At the end of this time it diffused a putrid odour, and had black- ened the diachylum which covered the vessel containing it. 88 PATHOLOGICAL HEMATOLOGY. 1 then had bled a patient suffering from acute articular rheu- matism, and divided tlie blood into three equal portions. I mixed with the first its tenth part of the pus which had been kept for six days, and the whole was beaten togetlier to extract the fibrine. Tlie second portion was left to itself, for twenty-four hours, without admixture of pus. At the end of this time it pre- sented a well formed coagulum covered with a thick buffy coat, and surrounded by colourless serum. From the first and second portions I extracted the same quantity of fibrine, viz. ToVo- The solid part was even a little greater in the_ first, on account of the pus which had been added to it. Finally the third portion of blood was, like the first, mixed with its tenth part of the same pus, and then left alone. ' An hour after this admixture I found a well formed coagulum, but without buffy coat, and surrounded with transparent serum. The pus, putrid as it was, seemed, then, to have had no pecu- liar action on the blood, (unless indeed it prevented the forma- tion of a buffy coat,) it had not diminished its consistence. But at the expiration of twenty-four hours, the condition of things had changed: the vessel was filled with a reddish liquid matter, like that obtained by adding ammonia to blood. There was no solid substance in this blood, except some fragments at the bottom of the vessel, and which together were hardly equal to a twentieth of the original clot. When subjected to the microscope, this liquid mass showed no traces of blood- globules ; but a large number of pus-globules was found in . it, so that putrefaction had not destroyed these latter. Jn the fragments forming the dthris of the clot, pus-globules were also discovered, together with some remnants of blood-globules irregular in form, and of diminutive size. In these remains of the clot, the fundamental character of the fibrine was not lost, for the microscope revealed in it a net-work of fibres. It is now proper that I should add, that having in other ex- periments, mingled with blood a tenth part of recent pus, taken from abscesses one or two hours before, and distinctly alkaline, in twenty-four hours I found the blood entirely coagulated, OP THE BLOOD IN DISEASES. 89 and in no apparent manner differing from another portion of the same blood simply left to itself during twenty-four hours. These two portions of blood furnished me the same quantity of fibrine. It is a clear deduction from these experiments, that the in- fluence of pus upon the blood is far from being the same when the pus is fresh, as when it has been long enough withdrawn from the living body, to have become putrid. Fresh pus has no appreciable action upon the blood; putrefied pus acts like ammonia upon the blood, destroying at the same time both globules and fibrine. But it is remarkable that this destruction does not take place immediately. The contact must have lasted several hours before the blood begins to present any traces of alteration. These results should incline us to believe, that in cases of disease where pus happens to circulate in the blood, the changes which the latter may experience in its constitution will vary according to the qualities of the pus which may chance to mix with it: if recent, the pus will leave the blood un- harmed ; if already old, and altered itself, it may become so potent a cause of disturbance to the blood, as to extinguish life suddenly and inevitably. But it is very remarkable that even in the second case, it is not the globules of pus which appear to affect the blood injuriously ; I am much more dis- posed to believe that what then destroys both the globules of the blood and the fibrine, is something which is no longer pus, but the ammoniacal product formed at the expense of the pus itself* And if, as can hardly be doubted, this ammoniacal product is that which remains upon a bistoury that has been thrust into a putrid subject, if it forms the basis of those dele- terious emanations which escape from animal bodies, either dead, or in dense crowds while alive, we may imderstand how, in these cases apparently so dissimilar, the blood must undergo alterations, identical in their nature, and variable only in degree ; and understand, also, how symptoms of the • The excellent thesis lately presented to the Faculty of Medicine by M. D'Arcet may be profitably consulted in regard to this subject. 8* 90 PATHOLOGICAL HEMATOLOGY. same order should result from causes which appear so dif- ferent. And thus it is that inflammation, the essence of which is to make the blood more consistent, by increasing its fibrine, may bring about, remotely, the liquefaction of the blood by the destruction of its fibrine. This is what happens, if the pus created by the inflammation becomes mingled with the blood, after undergoing a preliminary alteration and decomposition within, or without, the place where it was formed. But the disease has then changed its nature, and the inflammatory state is replaced, or at least, overpowered, by the typhoid state ; that is to say, instead of there being more, there is really less fibrine in the blood, than natural. The study of the altera- tions of the blood comes, then, to confirm one of the most im- portant principles of pathology, namely, that in proportion as a disease passes through its several phases, it is modified, not only in its symptoms, but in its essence. Clinical and thera- peutic facts, no less than those furnished by an analysis of the blood, do not permit our acceptance of the dogma maintained by Tommasini, that a disease, commenced with one diathesis, cannot change it during its course ; that if sthenic in the begin- ning, it will remain so to the end, and that consequently its treatment should continue to be uniform from beginning to end. I am unwilling to leave this subject, without saying a few words touching the influence of the ordinary antiphlogistic treatment upon the blood. Amongst the various forms of this treatment depletion holds the first rank. I have then naturally to inquire, how far bleed- ing, repeated more or less frequently, has the power of re- moving the excess of fibrine in the blood, rapidly or gradually. Now it is found that however repeated or abundant the bleed- ings, the fibrine increases none the less, if these bleedings are performed in the early stages of an inflammation of some in- tensity, or, in other words, at the period of the ordinary m- crease of the disease ; on the other hand the inflammation does not prevent there being found, after each bleeding, a progres- sive diminution of the globules. It seems, then, that when OP THE BLOOD IN DISEASES. 91 once the blood has set about producing an excess of iibrine, no matter what is done, a certain time must elapse before this disposition is exhausted. Besides, this resistance of the fibrine to the action of depletions, and the development it acquires in spite of them, are perfectly in keeping with what takes place in the inflamed solid itself, and in the rest of the organism. The most copious loss of blood does not effect the immediate removal of the lesions of the solid ; a certain space of time is always necessary for accomplishing this, and for the extinction of the fever. So that the iibrine, the quantity of which in the blood represents the degree of inflammation, obeys the same law wiiich makes the latter continue for a certain time, and pass through certain stages. Let it not, however, be thought that I deny the utility of blood-letting, when properly em- ployed, in this class of diseases. Experience has taught me, that without removing them suddenly, it often abridges their duration, and conspires to bring about a favourable issue. I even admit that if blood be drawn at the very outset of the inflammation, while yet there is nothing more than congestion in the solid, and the fibrine of the blood hardly above its nor- mal standard, depletion may stop the progress of the disease, and, in certain cases at least, render it really abortive. But if the disease be a little farther advanced, this will not be the case : it is not in the power of art to prevent a well formed pneumonia from lasting seven or eight days at least, although it may prevent its being prolonged for a fortnight. You cannot arrest a well marked case of acute articular rheumatism within eight, twelve, and oftener, fifteen or twenty days ; but by the use of blood-letting will more frequently see it arrested within the last named period, than if depletion had not been used. I will add a few words upon the modus operandi of the agents called revulsives. I do not deny that this term often expresses a real action, by virtue of which the movement they attract towards the skin, or the digestive mucous membrane, may put an end to that which disease has developed at another point : 1 even believe that one or more fluxionary movements may be established 92 PATHOLOGICAL HEMATOLOGY. towards these membranes, which will diminish the activity with which the fluids tend to the part originally irritated and congested. But another influence of these revulsive agents, and one that has been less noticed, is that which they may have upon the composition of the blood, which they must modify by means of the materials which they extract from it. Thus a large blister takes from the blood a certain quantity of its serum ; but, in addition, fibrine is deposited upon the raw surface produced b)'- the action of the cantharides. If the blood should contain a superabundance of fibrine, would that be a means of diminishing its excess ? Or, on the contrary, if the blister were large enough, if the resulting inflammation were very intense, if, above all, it increased the already exist- ing fever, would there not result a new cause for the forma- tion of an excess of fibrine in the blood, and would not this cutaneous inflammation, thus artificially created to diminish the intensity of another inflammation, and by the sort of influ- ence it would have on the blood, augment the morbid condi- tion which represents the inflammatory state in the blood, and is the measure of its intensity ? As to purgatives, which are also employed as revulsives, it may be asked what is the nature of their influence on the blood, according to whether they chiefly excite the flow of perspiration, of mucus, or of bile, and what changes of composition they may occasion in the blood. This is undoubtedly an interesting subject for investi- gation. ARTICLE V. Of the. Blood in Hemorrhages. I DO not intend, in this article, to treat of the influence which profuse losses of blood may have upon the composition of that fluid ; I have already spoken of this subject, and have stated that every hemorrhage certainly lessens the quantity of the globules, while, on the other hand, it must be very pro- OF THE BLOOD IN DISEASES. 93 longed or very copious, to diminish in any appreciable degree the amount of fibrine. I propose, at present, to inquire how- far all hemorrhages are due, originally, to some modification of the composition of the blood. From the examinations I have made of this subject, I be- lieve I may conclude that there is a certain number of hemor- rhages whose cause cannot be traced to any primitive lesion of the solids, and which are the results of a change in the composition of the blood, consisting in a relative or absolute diminution of its fibrine. And let us remember, at the outset, that the ancients ranked dissolution of the blood amongst the causes of hemorrhage. But what else is this dissolution, than a state of the blood in which it contains less fibrine than usual ? Let us also remember that hemorrhages are common in diseases where the blood contains but little fibrine, such as typhus fever and scurvy ; that, on the other hand, they are rare in diseases where there is an excess of fibrine, eitlier positively, as in the phlegmasias,* or relatively as in chlorosis. In the diminution of the fibrine relatively to the globules, we must recognize the grand condition of the blood favourable to the production of hemorrhages ; the relation of these two facts is so constant, that it seems to me impossible not to regard the one as the cause of the other. Let it not be said that the hemorrhage induces the diminution of the fibrine in the blood; for, as I have already stated, the loss of blood must be very copious to produce that effect, and I have seen the fibrine di- minish where the amount of the hemorrhage could certainly not explain that occurrence. Finally, I may add, as an argu- ment that appears to me unanswerable, that if the hemorrhage produced a change of the blood, in the cases under considera- tion, the globules should, unquestionably, be found diminished * It may be objected that the sputa of pneumonia are almost always tinged with blood ; but I reply that that is not an ordinary hemorrhage. The blood, which, in this disease, is mixed with the expectorated matter, is lite- rally the result of its forcible expression through the parietes of the ultimate bronchial ramifications. 94 PATHOLOGICAL HEMATOLOGY. in a larger proportion, even, than the fibrine ; but this is not the case, and so far from it, that the globules are most fre- quently in excess relatively to the fibrine. Two very different conditions of the blood, in which the law of the diminution of the fibrine relatively to the globules persists, may predispose to hemorrhage. The first of these is that in which the amount of globules has reached the highest limit of the physiological state, or has exceeded it, the fibrine meanwhile preserving its normal pro- portion, and standing at least as often below, as above, its average. This is what takes place in plethora, and common observation teaches us that plethoric persons are disposed to hemorrhage. Who is not familiar with their frequent epis- taxes, and with the relief afforded by them ? This is because these hemorrhages infallibly diminish the amount of globules of the blood, without affecting its fibrine ; the equilibrium be- tween these two elements is thus spontaneously re-established in these persons, and hemorrhages with symptoms of plethora are not renewed until an excess of globules is once more repro- duced along with the blood. But a second condition of the blood which is much more favourable than the preceding to the production of repeated and profuse hemorrhages, is that in which the quantity of fibrine is really under the standard, while that of the globules is natural. I have observed this in scurvy. This disease resembles chlorosis, in some respects, and both have symptoms in common. In both may be remarked the same feebleness, the same dizziness, the same aberrations of sensibility, the same dyspnoja, the same palpitations, the same dyspepsia. But that which distinguishes scurvy from chlo- rosis is the readiness with which hemorrhage occurs in the former affection, so as to constitute one of its characteristic symptoms. And why do hemorrhages so constantly take place in scurvy, so rarely in chlorosis? Because in the former there is an alteration of the blood quite difierent from that in the latter. In sciuwy the globules are not diminished as in chlorosis ; on the contrary the fibrine decreases as we have OF THE BLOOD IN DISEASES. 95 seen it do in typhoid fever of an adynamic or putrid type ; a disease, which not less from its symptoms, than from the alter- ations it caused in the blood, had been very correctly styled acute scurvy, by Borden. Well marked scorbutic cases are so rare in Paris, that for a long time I had to rest contented with mere conjecture con- cerning the state of the blood in scm*vy, and had admitted, as very probable, that it must contain less fibrine than natural. 1 have at length been able, by observing the following case, to satisfy myself that my supposition was correct. In the course of April, 1841, a labourer, forty-one years of age, entered my wards at the hospital of La Charite. For three years he had been wearing himself out by the daily toil of turning a crank in a dark and wet place, leaning against a wall from which the moisture was incessantly dripping. About once in every three weeks he indulged in wine to intoxication. He slept with seven comrades in a small, badly-lighted, and worse ventilated, chamber. At the commencement of March, 1841, he suffered from vertigo, and a contmual weariness that he could not account for ; he felt sore and broken down, and soon was attacked with bleeding at the nose, which recurred every morning. A little later, red spots (as he called them) began to appear all over his body ; these spots became more numerous, and larger, and, at the same time, his feebleness made such progress, that he was obliged to quit his work. When this patient came under my notice, his trunk, limbs, and face, were covered with numerous petechiae, and large ecchymoses, which might have been mistaken for bruises ; but so far from there being such, on the succeeding days we saw others like them forming before our eyes. The gums were soft, swollen, and bleeding ; the epistaxes continued, but spar- ingly. The patient complained of a general numbness, a heaviness of the head, and vertigo ; he begged to be bled to put an end to these symptoms. The powers of digestion were still unchanged ; there were some palpitations of the heart ; but no bruit de soxijp,t in the carotids. The pulse was 60, 99 PATHOLOGICAL HiEMATOLOGY. the respiration. 20, the temperature of the skin in the axilla 37.60. The great predominance of cerebral symptoms, and the idea that they might be caused by a sort of congestion, induced me to have the patient bled, and indeed he strongly desired it. I found in the blood, globules 119; solid con- stituents of the serum 86 ; and fibrine only 1.6. After five weeks of rest, and substantial food, and under all good hygienic influences, this man regained his strength, and the symptoms of which I have spoken had, at least, much im- proved ; yet a considerable number of petechise remained upon his skin, and his gums were still inclined to bleed. In this con- dition he went out on the 18th May. The 23d May, he was again attacked with violent vertigo ; his appetite was lost; he had a profuse epistaxis, and he returned to the hospital on the 2d of June. He was then ex- tremely feeble ; extensive ecchymoses covered his skin, and the conjunctivae were so infiltrated with blood, that they pro- truded beyond the cornea, and surrounded it like a pad: the case might have been taken for one of double chemosis. Blood exuded from the gums and mingled with the expectorated mucus. I again examined the blood ; it contained the same quantity of fibrine as at first; the globules had fallen to 111; the solid constituents of the serum remained at 86, of which 70 were albumen, and 9 of other organic matters. After some time the patient became much better, and went out.* • Nothing is more difficult than the complete and ultimate cure of those diseases in which the blood is gradually and spontaneously despoiled, either of its globules or its fibrine. It is well known how easily chlorotic girls relapse, and how long it is before their symptoms disappear entirely. In older per- sons, who become anaemic spontaneously, the reproduction of the blood-glo- bules is obtained with greater difficulty. As regards scurvy, that variety which arises under the influence of external causes, generally yields with as much ease, as soon as those causes cease to operate, as the other variety which arises spontaneously, often resists every means that may be brought against it. I have, it is true, seen some scorbutic patients recover, but I have seen a greater number whose disease, although at intervals appearing to improve, never totally ceased, and sooner or later became so aggravated as to induce a fatal termination. OF THE BLOOD IN DISEASES. 97 Here then is a disease, in some sort, of the same type with all those in which more or less frequent and spontaneous hemor- rhages arise in the same manner, and a remarkable alteration of the blood accompanies it, to wit, a diminution of fibrine. I have found the same kind of alteration of the blood in a case of scarlatina which terminated fatally on the second day of the eruption. In this case there were petechias all over the skin, a bloody exsudation within the mouth, and, at the autopsy, I found in the respiratory apparatus the anatomical signs of an extensive pulmonary apoplexy. The blood contained, fibrine 2, globules 133, solid constituents of the serum 81, of which 66 were albumen, and 6, other organic substances. I do not doubt that the fibrine of the blood would be found below its normal standard in all distinct cases of purpura hemorrha- gica : I can at least declare, that in a case of purpura whose symptoms resembled those of the severest typhus, I found the blood in that state of fluidity and dissolution which is the ex- pression of its loss of fibrine. But it is not only in these cases of repeated hemorrhage, or, if the term be preferred, of hemorrhagic diathesis, that I have seen the blood thus impoverished in fibrine. I have elsewhere cited cases of cerebral hemorrhage, where also the attack had been preceded by a diminution of the fibrine in the blood ;* Hence, whether the blood escape from several tissues at the same time, or whether it find exit through a single one of them, facts lead us to admit, in the second case as in the first, that some hemorrhages take place because the blood, deprived of its natural proportion of fibrine, has, on that account, lost a portion of its plasticity. And thus we are led to find, in an alteration of the blood, the starting point of certain morbid phenomena, the cause of which is usually referred to a lesion of the solids. The cases in which the fibrine is only dimi- nished relatively to the globules in excess, belong, by virtue of their symptoms, to the class of hemorrhages called active, and the cases in which the fibrine is really diminished belong to • First Memoir upon the alterations of the blood, &c. 9 98 PATHOLOGICAL HEMATOLOGY. that of hemorrhages called passive. A somewhat minute in- vestigation of the alterations of the blood lends a new support to this ancient classification, which though inadmissible into certain theories, is not the less essential, both in therapeutics, and in clinical instruction. In spite of every effort, it will never be possible to attribute identity of cause and nature, to the hemorrhage of a plethoric, and that of a scorbutic indi- vidual. I have abundantly demonstrated, that the most usual im- poverishment of the blood, that which results from the mere dimimition of the globules, is not a direct cause of hemor- rhage : yet it happens, from time to time, that hemorrhage is observed to come on, and to recur with disastrous obstinacy, in persons who have suffered from excessive loss of blood ; but this fluid is then so far exhausted, that after having lost a great part of its globules, it has also parted with much of its fibrine. When this latter condition exists, hemorrhages may take place ; so that their occurrence is connected with the last degree of impoverishment of the blood, not because the globules are then greatly diminished, but because the fibrine has, in its turn, given way. Besides, when blood enough is taken from an animal to destroy it, and this blood is divided into several portions for separate analysis, the fibrine is found less abun- dantly in the portions last drawn, than in the first. Profuse hemorrhages may, then, exhaust the blood of its fibrine, and this explains how it may happen, that towards the end of a very considerable hemorrhage, the blood may escape from other outlets than those from which it at first issued. I re- member, for instance, having seen a young man whose whole cutaneous surface was covered with petechige, during the con- tinuance of a copious epistaxis which could not be arrested ; although, until that time, he had never had such symptoms. These facts being known, we can conceive how a hemorrhage, which has exhausted the system by its copiousness, and by its frequent returns, may find a cause of persistence and relapse in the new condition of the blood which it has created. Hence, one of the dangers resulting from large depletion resorted to OF THE BLOOD IN DISEASES. 99 for the arrestation or prevention of hemorrhages ; it may, from its excess, have the effect of perpetuating them or of bringing . them back. Hemorrhagic blood, as regards its physical properties, does not differ from that of the pyrexiae. It never presents any buffy coat, without inflammatory complication. The clot is generally large, and never small, except in those cases of ex- treme poverty of the blood of which 1 spoke last. It is more commonly remarkable for considerable softness, and when the hemorrhage depends on a very great diminution of fibrine, the blood may be so little coagulable as hardly to form a veritable clot ; of it may happen that, instead of this latter, there is no- thing in the vessel containing the blood, except some discon- nected lumps suspended in reddish serum. This is that state of dissolutiou of the blood of which I have already spoken under the head of the pyrexiae, and which exists, more or less, in all the diseases characterized by a general disposition to hemorrhage. I have already had occasion, in several places in this work, to insist upon the relation which may be shown between the dissolved state of the blood, and certain morbid phenomena ; this is one of the most important facts in medicine, a fact very carefully studied by the observers of preceding ages, and from which the exclusive solidist doctrines of our day had entirely diverted the attention.* I have shown that this state of dis- solution of the blood uniformly coincided with a diminution of the quantity of fibrine. But is this the ultimate alteration we are permitted to arrive at ? Before the fibrine decreases, has there not been some other change of composition in the blood, • Let me here be allowed to remind my readers, that in a work published in 1823 {Clinique Medicale,t. I.) I had admitted and described this state of dissolution of the blood in certain cases of low fever, and that I had pointed it out as. capable of playing a part in the production of several of the symp- toms of these diseases, and especially of the hemorrhages which so often ac- company them. The investigations of M. Magendie have, more recently, thrown light on this important question of etiology. (See his Lemons sur les phenomenes physiques de la vie, 1837.) 100 PATHOLOGICAL HiEMATOLOGY. of which the depression of the fibrine below its normal ave- rage is itself only the consequence ? Upon this subject some facts may be cited. It may be remembered that on throwing into the veins of living animals, as M. Magendie has also re- cently done,"^ a concentrated solution of subcarbonate of soda, an almost fluid blood was found in the bodies of these ani- mals when dead, and that, during life, their symptoms were analogous to those observed in diseases, in which the older writers admitted a state of dissolution of the blood. It may ^Iso be remembered that some authors declare, that they have found an excess of alkaline matters in the imperfectly coagu- lated blood of persons who died of low fevers or scurvy. I may also state that in the investigations which I am now pursuing in regard to the variations in the proportions of the inorganic constituents of the blood, I have found, amongst other things, that the blood most highly charged with free alkali belonged to the scorbutic patient whose history I have, a little while ago, related. This is a result analogous to that announced by M. Fremy, several years ago. The different virulent and miasmatic substances which, on being introduced into the blood, diminish its coagulability, may, then, act upon the fibrine like the alkaline substances just alluded to. Thus, too, the venom of the viper may act, which, according to Fontana, produces a dissolution of the blood. It has been said that extreme agitation of the nervous sys- tem may deprive the blood of its power to coagulate. Accord- ing to several observers, a similar effect may be produced by a strong moral emotion, a concussion of the brain, the de- struction of a certain portion of the spinal marrow, or a violent blow upon the pit of the stomach affecting the nervous plex- uses of that region. If facts of this class were appropriately verified, they would, doubtless, be of the highest importance : for they would show that the nervous system exerts a power- ful influence on the constitution of the blood, and that, conse- • Magendie, t. II, p. 316. OF THE BLOOD IN DISEASES. 101 qiiently, a lesion of innervation may deteriorate the blood, just as an alteration of the blood may modify the nervous action. For the very reason that such facts may have extensive bear- ings, we are unwilling to receive them at present, and we wait until new facts have stamped them with their proper value. Professor Dupuy of Alfort announced that by dividing the pneumogastric nerves in horses, the blood of these animals lost its property of coagulating. But, as it seems to be the fate of our science that it shall appropriate no truth that has not been, as it were, purified, by the test of contrary facts, the value of these experiments has been lessened by others of Dr. Mayer, in which, this savant, having tied the pneumogas- tric nerves in living ailimg,ls, found that, uniformly, the blood had coagulated throughout the whole pulmonary circulation. These facts require |i new examination. Nor shall we receive, without additional proof, certain other allegations, already old, from which it would result that the blood is found in a state of dissolution in animals killed immediately after being violently driven. Whatever may be the truth regarding the number and the nature of the causes which render the blood less coagulable, it is not the less certain that there are some diseases in which the blood shows a strong tendency to dissolution, while there are others in which the blood becomes more coagulable. A learned Italian physician,* Bufalini, even regarded these two states of the blood of such importance, as to make use of them for dividing all diseases into two great classes : to one of these he assigns as cause what he terms the phlogistic process, and to the other an opposite state of the system which he desig- nates by the Xexm process of dissolution (processo dissolutivo). This division is equivalent to that which I have admitted, into diseases with an excess of fibrine in the blood, and those with less than the normal quantity of this principle ; for in the latter there is evidently a cause whose effect is, necessarily, to make the blood less coagulable. • Bufalini, Fondamenti di patologia analitka, Pesaro 1830, vol. ii, p. 327. 9* 102 PATHOLOGICAL HEMATOLOGY. I cannot here refrain from a short discussion of a historical question, long ago proposed by Grant.* This author, who practised medicine, and wrote towards the close of the last century, suggested the inquiry whether the peculiar hygienic condition of the people of Europe before the eighteenth cen- tury, must not have caused them to be frequently attacked with diseases, one of whose principal elements, if not their starting point, was a state of dissolution of the blood. It is certainly very remarkable that the observers of preceding ages, constantly speak of dissolved and incoagulable blood, in their histories of epidemics. I readily admit that the theories then prevalent may have contributed to make this state of the blood appear more common than it really. was. I know very well that there is more than one cause of error to be avoided in this case ; that, during life, blood may seem less disposed to coagu- late, merely because it has not run well from the vein, or been received in a proper vessel, I also know that blood which has coagulated, as usual, soon after the extinction of life, will subsequently become fluid, and that more or less speedily ac- cording to the temperature, after some degree of putrefaction has commenced in the body ; I admit that these circumstances, and several others, may have been overlooked more than once, and that blood has been regarded as dissolved by disease, when it was so only from some accidental cause. Neverthe- less, all the circumstances just enumerated were as well known by the ancients, as by ourselves ; and if they have sometimes taken no account of them, it appears to me difficult to suppose that they should always have overlooked them. Besides, in some histories of epidemics, they are very careful to say that the blood had not the same aspect in the different stages of the disease, and that, for example, it formed a distinct clot at the commencement, while, at a later period, it hardly coagulated at all. This record of the changes experienced by the blood, in proportion to the progress of the malady, gives a great value to these descriptions. At an epoch nearer to our own times, * Grant, Rtcherches sur ksfievres, Lefebure's translation, vol. I, p. 276. OF THE BLOOD IN DISEASES. 103 Sarcone,* in his history of the epidemic of Naples, has spoken of the difference between the blood drawn at the commence- ment, and tliat drawn towards the termination of the disease. " The blood," says this author, "was tenacious and buffy during the first week, and the first days of the second ; at the end of the second week, its aspect changed, and it appeared to be more distinctly altered ; the clot could be easily divided ; a slight pressure was sufficient to break it up. . . . ; lastly, these alterations still increased in the course of the third week, and especially that tendency to dissolution which appeared at the close of the second week. The blood, drawn from a vein, was converted into a thin, black coagulum, swimming in a dirty and bloody serosity."t The disease in which Sarcone observed this alteration of the blood, is one of the last remnants of those great epidemics, which continually prevailed in Europe during the middle ages, and whose incessant re-appearance seemed attributable to the bad ventilation and food peculiar to those times. In those epidemics, which, indeed, often become endemics, nothing was more common than to observe gangrene, hemorrhage from various parts, extensive ecchymoses, or thousands of petechiae covering the skin, while the general symptoms of our typhoid fever developed themselves with a high degree of intensity, and the greatest rapidity. J These pyrexiee, with their assem- blage of dangerous symptoms, and especially their hemorrha- * Sarcone, Systematic account of the diseases observed at Naples during^ the year 1764, translated [into French] by Bellay, vol. 1. f Huxham (treatise on fevers) has, in his narrative of the epidemic fever of Plymouth, described a much more complete dissolution of the blood than that mentioned by Sarcone. The blood of the patients, seen by Huxham, did not even present a distinct coagulum; the vessel appeared to contain nothing but a brown liquid, at the bottom of which was deposited a sort of reddish powder, formed by the separate particles of what should have been the clot. i This is not the place to enter into detail as to the nature of the hygienic influences, which even at a period not very far distant, gave birth to and maintained in Europe those general diseases in which the alteration of the blood seems to play so important a part. Even men unfamiliar with the 104 PATHOLOGICAL HjEMATOLOGT. gic form, rarely appear in these times, and, when observed, only as sporadic cases. Scurvy, as an endemic disease, has also disappeared, and now a few cases of it only are seen. This disease, the cases of which were formerly so numerous in Paris, can hardly be said to exist there at present, except by the traces it has left. But these different affections are, as it were, the external manifestation of the internal condition of the blood ; we must therefore admit, that in consequence of the change in the nature of the influences which necessarily act upon men, the blood, which receives before the solids, the im- pression of the greater part of these influences, must present changes in its constitution proportioned to those undergone by the agents which operate upon it. It would appear, then, that there must have been a time when a very peculiar consti- tution of the blood engendered maladies, which, in certain respects, may have differed from those now observed, and may not have required the same treatment. And thus it is, that at different periods of the existence of our race, and through the diversity of influences to which it may be sub- jected, diseases of very different types may arise, and undergo changes in their essential nature which are revealed to us by the specific character of their symptoms. This too, is one amongst many reasons, why, according to the times, some theories may be received with peculiar favour, and explains practice of medi(^e were, themselves, struck by it. Erasmus, the philoso- pher, who flourished towards the close of the sixteenth century, wrote that, in his day, the inhabitants of London were every year, from spring to harvest, attacked by a malignant fever, which committed the greatest ravages in that city, and especially amongst the poorer classes. I have been struck with the following details given by Erasmus of the causes to which he attributes this fever. " The supply of water," he says, " fails the inhabitants ; they have to seek it at a great distance from the city ; the river water is carried upon their backs, and is so dear that the poor cannot pro- cure enough of it to wash themselves, and keep their houses clean. These houses are of wood, and very cold in winter, which makes it necessary to fill the rooms with straw. But as this cannot be often renewed, it becomes spoiled, and very injurious." I find this passage in Grant, who quotes it, (vol. i, p. 288, op. cit.) OF THE BLOOD IN DISEASES. 105 how the development of these theories may be favoured by the very nature of the facts observed. The dissoUition of the blood has been regarded, at other epochs of our science, as connected witli another state, which was held to be very common during the empire of the old humoral doctrines, I mean piciric/iiy; and as, in our day, this term has been revived by some persons, it is well to ascertain its meaning. As long as the blood circulates in the living vessels, it is in- admissible to suppose that it can undergo a real putrefaction. Yet there is a certain number of diseases in which, after death, every part of the body, but especially the blood, much more speedily presents the signs of putrefaction, than in others, and these diseases are precisely those in which the blood has lost its coagulability during life. Independently of this common character, they have all a%)eculiar aspect ; their ordinary phe- nomena being rapid prostration, fostor of the excretions, and a tendency to hemorrhage, and gangrene. These the ancients considered as signs of the putrid state ; but they are nothing more than signs of the diseases in which the spontaneously coagulable matter of the blood is more or less diminished. The rapidity with which putrefaction after death is observed to take place, in these cases, simply depends, perhaps, on the tissues being more promptly impregnated with blood, on ac- count of its fluidity, which allows it to transude through the coats of the vessels very soon after the cessation of life. Let us also remark that, in the language of Boerhaave and Hux- ham, the phrases dissolved state and putrid state were sy- nonymous. So that, in their numerous treatises upon diseases which they called putrid, the older writers have done no more than transmit to us their observations and their hypo- theses touching that extensive class of maladies, in v/hich the blood docs not contain its normal quantity of fibrine,* and * Schwenck thus describes the qualities of the blood in putrid diseases: " In morbis putridis, dissolutio cruoris advertitur, et a vena emissus sanguis non coagulatur." (Schwenck, Haematologia, p. 129.) 106 , PATHOLOGICAL H^MATOLOGT. these, moreover, they set in opposition to inflammatory dis- eases, just as om' modern investigations authorize us still to do. Long before Schwenck, Fernel had also noticed the absence of coagula- tion in the blood as one of the fundamental characters of putrid diseases. Upon this subject he expresses himself thus : "Sanguis, qui per febres putridas detrahitur, seepe animadvertitur putri- dus, adeo ut nee sibi coheerere, nee concrescere queat, omnibus scilicet ejus fibris putredineconsumptis." (Fernel, De febribus, cap. v.) In a very remarkable work of Huxham, entitled "An essay on fevers, and on the different kinds of fevers which depend on the constitution of the blood" there is a chapter whose title is, " On the dissolved and putrid state of the blood," and there Huxham has recorded a very interesting case, which ap- pears to me eminently fitted to show the identity of nature of those diseases formerly called putrid, and those in which the blood has been proved, by analysis, to be spontaneously deprived of a certain quantity of its fibrine. The subject of this case was a surgeon, who in October 1741 was seized, without known cause, with alternate rigors md flushes of heat, a weak pulse, loss of strength and appetite ; and heavy respiration ; he continued at his business in spite of the fatigue he experienced. Four or five days after his seizure, Huxham met him at a patient's house, and observed that his breath was foetid. Two days after, he being at another patient's house, suddenly fainted. When he came to himself several livid and violet-coloured spots were observed on his hands and neck. On the way home, he fainted several times. The disorder increased every moment; he had extreme languor, and great oppression, with continual sighing; his breath was now insupportably foetid, blood leaked from his gums, and a great many livid, violet, and black spots appeared all over his body, on the trunk, as well as the limbs. Huxham continues the narrative as follows: "He was bled to about 3xii from his arm, but this gave him no manner of relief, the oppression, sighing, fainting, and anxiety continuing as bad as ever, nay rather increasing; — a violent hemorrhage also broke forth from his nose; which continuing from both nostrils, he was bled again to 3x about twelve hours after the fornaer bleeding: — neither did this give him any relief, but increased his weakness considerably, and he continued as anxious, rest- less, and oppressed as ever, without even the least sleep. The blood now not only issued from his gums and nose, but in a surprising manner likewise dropped, though slowly, from the caruncle of one of his eyes ; and several livid pustules on his tongue, and within side his lips, broke, and dis- charged a bloody, thin matter very copiously. "The hemorrhage being somewhat restrained, a bloody dysentery came on with severe gripes, and excessive faintness, and he was still exceeding rest- less and very feverish: his pulse now intermitted every sixth or eighth pul- OF THE BLOOD IN DISEASES. 107 ARTICLE VI. 0/ the Blood iji Dropsies. It is at present, generally acknowledged that, while some forms of dropsy depend upon certain alterations of the solids, there are others again whose point of departure must be sought for in an alteration of the blood. It has been asserted also in rather a vague way that serous effusions might be the conse- quence of an impoverishment of the blood, or of what has been called hydroa^mia. This opinion, I am now about to examine. And in the first place, we may understand by the expres- sion, impoverishment of the blood, very different conditions of that fluid. The blood may really have lost somewhat of its accustomed richness, from its containing either less fibrine, fewer globules, or less albumen than usual. In these three sation, and then fluttered on again vastly quick; he had likewise a constant tremor and subsultus. The hemorrhage all this while continued from one part or other, and when stopped at one place forthwith burst out at another; so that his urine now seemed tinged with blood. . . . Soon after he was bled the second time, I was sent for, and hastened to him. I found him in the manner described, under an inexpressible anxiety, )'-et quite free from a de- lirium, though he had no manner of sleep for several days and nights: his tongue was vastly black, and his breath and stools insufferably stinking. "I found that neither of the portions of the blood that had been drawn (not even the first) had separated into crassamentum and serum as usual, though the former had stood so many hours ; but continued as it were half coagu- lated, and of a bluish livid colour on the top: — it was most easily divided by the slightest touch, and seemed a purulent sanies rather than blood, with a kind of sooty powder at bottom. His hemorrhage still continued, especially from the tongue, lips, and gums, with a perpetual dripping of bloody ichor from the nose; with never ceasing tremblings, subsultus tendinum, and al- most continual faintings." — [An Essay on fevers, &c., by John Iluxham, M.D., 3d edition, London, 1757.] Huxham put this patient on the use of small and repeated doses of Peruvian bark, and various aromatic and astringent substances ; he endeavoured to nourish him moderately, and succeeded in gradually restoring him to health. 108 PATHOLOGICAL HEMATOLOGY. cases, it should be equally regarded as impoverished; do they all then give rise to dropsy ? Diminution of the fibrine, to whatever extent it may have gone, does not certainly produce, as one of its conse- quences, the formation of this disease. In those morbid con- ditions in which the blood has lost no other principles than its spontaneously coagulable matter, we do not see effusions into the areolae of the cellular tissue, any more than into the serous membranes, occur as an ordinary phenomenon. If these effusions are produced in that condition, it is the exception ; and it becomes necessary, consequently, to seek some other cause for them than the diminution of the cipher of the fibrine. Is the diminution of the globules, which, however slight, brings with it as a necessary result, the hydrosemic condition, a cause of the production of dropsy any more than the pre- ceding ? It is generally thought to be, and yet it seems to me that a somewhat rigorous observation does not permit us to adopt this opinion. Were it true that dropsy was the ordinary consequence of a diminution of the globules of the blood, it ought to follow from this that the greater number of chlorotic patients, especially those who have the disease in a marked manner, should sooner or later become dropsical. But, this certainly is not the case. I have never seen the serous cavities filled with fluid in cases of simple chlorosis, nor have I ever observed a true anasarca ; at most we may find in some chlorotic patients slight osdema around the malleoli, or slight puffiness of the eyelids, and that is all ! Neither have I observed dropsy to occur in men attacked with spontaneous anaemia, who, like chlorotic girls, had but a very feeble proportion of globules in their blood. I have said elsewhere that there is a kind of cachexia produced by the prolonged operation of saturnine emanations, a cachexia also characterized by a great diminution of the globules of the blood. I have treated many patients of this kind at La Cha- rite, and have never observed dropsy in any of them. OF THE BLOOD IN DISEASES. 109 '■ Phthisical persons, in whom there generally exists a rather low cipher of globules, do not become dropsical, unless the pulmonary tubercles coincide with some other affection, whose effect is to give rise to serous effusions, as for example, disease of the heart, liver, or kidneys. With the exception of chlorosis, I have rarely seen the glo- bules descend to so low a cipher, and the anaemia become so marked as in individuals exhausted by some chronic organic disease of the stomach. In such cases there existed, in conse- quence of this considerable diminution of the globules, a well marked hydroaemia, and yet they presented me no trace of dropsy. In women labouring under cancer of the uterus, the blood comes insensibly to contain but very few globules, in consequence of the hemorrhages which many of these persons suffer from almost constantly ; yet, we do not find dropsy super- vening in these cases, any more than in the preceding; there was, for example, no trace of it in one of these women, whose case I have elsewhere cited, and whose blood contained only 21 in globules.* Here then are many different cases in which, however im- poverished the blood may have become in consequence of the • I am not ignorant of the fact that, in some women who have cancer of the uterus, we find not unfrequently oedema of the lower extremities, or serous effusion into the abdomen; some have anasarca even. But, on the one hand, these various dropsies are not in such cases in proportion to the abun- dance or frequency of the uterine hemorrhages ; and on the other hand, whenever I have met with them, I have been able to account for their pre- sence by the existence of different alterations of the solids. Thus the oedema of the lower extremities was 'explained to me by tumours developed in the pelvic excavation, which compressed the crural veins, or by coagula formed •in those veins during life. Cancerous masses, deposited in front of the vertebral column, a disease of the liver, a chronic peritonitis, tumours ob- structing the circulation in the superior vena cava, or in the axillary veins, accounted to me for the occurrence whether of ascites, or of serous infiltration into one or both of the superior extremities. In the same way when cancer of the stomach is accompanied by ascites, we may affirm that the disease is not simple ; and, if cancerous tumours do not exist in the peritoneum, we may be almost certain that the liver has participated in the degeneration of the stomach. 10 110 PATHOLOGICAL HEMATOLOGY. diminution of its globules, dropsy does not result. But, in all these cases, the blood has been slowly and gradually de- prived of its globules. I have now to examine another con- dition, that in which the diminution of the globules has oc- curred rapidly and almost instantaneously: thus it happens in persons who lose suddenly a very large quantity of blood. Do we see dropsy estabhsh itself more readily in such a case? I do not fear to affirm that, even in this case, serous effusions occur only as an exceptional condition ; they are observed much less frequently than has been asserted after even very abundant bleedings ; let us remark however that this cause produces them somewhat less rarely in children than in adults Neither do excessive spontaneous hemorrhages necessarily give rise to dropsies : I will cite as proof of this the case of a young woman who, a few days before her entrance into La Charite, and in good health up to that time, had had, in conse- quence of an abortion, a metrorrhagia so profuse that she resembled when I saw her, a chlorotic person in the most advanced stage ; a very strong bruit de souffle could be heard in the heart and two carotids. This woman was so feeble and exhausted that it seemed as though she would expire in some of the continual syncopes which she fell into. During the following days, her strength improved somewhat; she retained however the paleness of death, and could not as yet make a movement without being threatened with fainting. It was necessary for two months to elapse before she could begin to leave her bed, and yet at the end of this time she still re- tained a bruit de souffle in the heart and carotids. During these two months, and afterwards, I sought with care for the slightest traces of dropsy in her case, but discerned none ; the pressure of the finger produced not the slightest mark upon the malleoli. She had merely, as some chlorotic patients have, a slight swelling of the face, which is not oedema, for the skin in such conditions does not retain the impression of the finger. I have seen so many cases like the preceding that I do not hesitate to assert that dropsy does not generally result, when the impoverishment of the blood depends simply upon the OF THE BLOOD IN DISEASES. Ill diminution of its globules. Consequently, when it does occur, we should reasonably infer that the blood must, at the same time that it has lost some of its globules, have become im- poverished in some other mode ; and as it is not the diminu- tion of its fibrine which can bring on this result, we may ask ourselves whether it be not owing to a diminution that shall have taken place in the albumen of the serum. Let us see what facts will reveal to us on this point. There is a disease which, at the same time that it adds to the ordinary prhiciples of the urine a certain amount of albu- men, lessens more decidedly than any other the cipher of the albumen of the blood. Now, in this disease, which has the kidney for its seat, one constant phenomenon appears sooner or later ; this is dropsy, which, at first partial and slight, ends by becoming general and very considerable. This dropsy augments in proportion as there escapes from the kidneys a larger quantity of albumen, and as we find less of it in the blood. Hence there are three facts which co-exist, disease of the renal parenchyma, diminution of albumen in the blood and dropsy. Is it the disease of the kidneys which produces the dropsy directly, as does an affection of the heart or liver ? This cannot be admitted, for it is manifest that the kidneys exercise an influence upon the formation of the dropsy but indirectly, and in so much only as the change that has occurred in its texture allows it carry off from the blood its albumen. It is then the diminution of this latter, in the serum of the blood, which must be regarded as the true cause of the dropsy. Whatever then be the cause which makes this albumen di- minish, dropsy will result. And moreover, it is not necessary, in order that this effect be produced, for the globules to di- minish at the same time with the albumen. In Eright's dis- ease, there is at first diminution of the cipher of the albumen alone, and the globules do not begin to decrease until later, when dropsy already exists. Diminution of the albumen of the blood has, up to the pre sent period, been met with in man only in cases where this fluid has first lost a portion of its albumen through the kidneys 112 PATHOLOGICAL HEMATOLOGY. I have shown in another work,* that, in animals of the sheep kind, the diminution of albumen may occur, independently of the preliminary discharge of this principle by the urine ; serous infiltrations also result from it occasionally in these animals, which helps to prove that their production is not in imme- diate dependence upon the disease of the renal parenchyma ; but sheep in this case always have entozoa in the biliary duct. Is this then, a cause of the loss of albumen from the blood of those animals ? We do not then as yet possess any well established case proving that the albumen, like the glo- bules and fibrine, may spontaneously diminish in the blood, to an extent sufficient to produce disease. Nevertheless we have a right to affirm that there is but one kind of change of com- position of the blood which results necessarily in the produc- tion of dropsy, and this alteration is the diminution of the albumen ; consequently, whenever we see dropsy arise from what we suppose to be some modification experienced by the blood, W3 ought naturally to seek whether this fluid has not lost a portion of its albumen. Besides, it is not only from an excess of watery particles in the blood, that serous effusions are formed •, for, if this were true, as I have before said, every chlorotic person should become dropsical, whereas, we see dropsy on the contrary, depending on another kind of altera- tion of composition of the blood, one in which it does not con- tain a great superabundance of water. The dropsy which occurs towards the end of certain cases of scarlatina, seems to me equally to recognize as exciting cause a diminution of the albumen of the blood; for in this species of dropsy I have always found that the urine had be- come albuminous. We sometimes see individuals Avho, having been exposed to some sudden cause of cold, are attacked a few hours after with anasarca. This accident, somewhat rare in our climates, is common on the contrary in equatorial regions. Upon what * Memoire sur la composition du sang chez quelques animaux domes- tiques. OF THE BLOOD IN DISEASES. 113 depends this kind of dropsy ? I long accounted for it by sup- posing tliat the sudden suppression of the cutaneous function of transpiration rapidly produced a superabundant exhalation of serum into the areolae of the cellular tissue and the serous cavities. But a fact that I have recently observed permits me to explain otherwise the formation of this kind of dropsy. This fact is the following : A young man, previously in good health and strongly con- stituted, enters the hospital of La Charite with considerable anasarca and commencing ascites. He relates to me that, a few days before, being abed and asleep, some of his comrades poured upon him a pot of cold urine, while he was in a state of perspiration. He got up naked in order to pursue them, and was very much chilled ; he remained, said he, as though frozen. From the day following this occurrence, he began to perceive a slight degree of swelling, which rapidly augmented. I examined the urine of this patient, and found it albuminous. I concluded from this that the blood had been deprived by the kidneys of a certain amount of its albumen, and in this way accounted to myself for the formation of the dropsy. It is then upon the kidneys that the action of the cold had fallen. This dropsy was not, moreover, of long duration ; at the end of a fortnight, the cure was complete. Cases of dropsy following insufficient alimentation have been cited, and Dr. Gaspard has even reported a true epidemic of this kind, that prevailed in 1816, through several departments of the interior of France, as the result of a great scarcity which had afflicted those districts.* The inhabitants had been re- duced to seek their food among the roots and herbs of the fields, which they cooked, etc. A large number of them be- came dropsical. History informs us that the same thing has occurred at other epochs under the influence of the same cir- cumstances. It is probable that, in these singular epidemics, the insufficiency of alimentation must have modified the com- position of the blood ; that there was the point of departure of • Journal de Physiologie experimentale, par 31. Magendie, tome ii. 10* 114 PATHOLOGICAL HEMATOLOGY, the dropsy, and, after what I have said m the preceding pages, it is allowable to conjecture that the blood, under the empire of this influence, experiences a diminution of its albumen. What may still add some weight to this conjecture, is what takes place in sheep, when they have fed, for some time, in humid places, in pasturage of quality insufficient to furnish a good reparative material for their blood ; in them also, the blood loses a portion of its albumen, and they become drop- sical. I shall not seek to discuss the question why blood, which has become poor in albumen, brings on readily the formation of serous effusions, and wherefore diminution of globules in the same blood does not produce a similar result. Is it the change effected in the physical qualities of the serum, by the loss of albumen which assists the passage of the former through the vascular parietes ? Is this then a case of exosmosis favoured by the diminution in density of the fluid, or is it that the water of the blood flows with more difficulty in the capillary rete, be- cause, being less charged with fibrine, it has become less unc- tuous, and shdes perhaps less readily over the internal surface of the vessels? If it be so, the diminution of albumen in the serum of the blood would, as one of its effects, render more diffi- cult the passage of this ffuid through the small vessels, and con- sequently as to the immediate cause, there would not be so great a difference between dropsy following an organic disease of the heart or liver, and that which follows the diminished pro- portion of albumen in the blood. Let no one believe however that, in cases of dropsy, there occurs only a separation of serum such as it existed in the blood ; it is not so in any case of simple dropsy, for the con- stant rule is, that the serosity which has been effused, even while remaining composed of the same materials as the serum of the blood, contains proportionally more water than this, and much less of the organic principles, particularly albumen. Thus, in sixteen analyses that I have made of the fluids of diff"erent dropsies, I found for the maximum of albumen the cipher 48, and for minimum the cipher 4. In no case, there- OP THE BLOOD IN DISEASES. 115 fore, was the quantity of albumen even equal to that which the serum of the blood contains. We may see moreover, by these extremes, how much the proportion of albumen con- tained in tlie fluid of dropsies may differ. In the sixteen ana- lyses, I found the proportion of albumen in one thousand parts, represented by the ciphers, 48, 47, 41, 40, 30, 28, 19, 15, 14, 12, 12, 11, 10, 8, 6, 4. In six other analyses of serosity taken by puncture from the tunica vaginalis of the testis (cases of hydrocele), I found the albumen generally more abundant than in other effusions of serosity : thus, in these six cases, there was in albumen 59, 55, in two 51, 49, 35. The highest cipher in these six cases is far from equalling the mean of albumen in the serum of the blood. I have not observed in these dif- ferent cases that the seat of the dropsy, any more than its cause, exercised an influence upon the greater or less elevation of the cipher of albumen ; but it was different as to the more or less complete state of integrity of the constitution: in pro- portion as this remained stronger and more entire, so in gene- ral did the serosity elf used contain more albumen. Here is very probably the reason why the fluid which came from the tunica vaginalis was usually richer in albumen than that of any other dropsy ; because, in all these cases of hydrocele, the individuals operated upon were stiff full of health and vigour. In cases, on the contrary, where I have had occasion to exa- mine the serosity taken from the abdomen of the same indi- viduals by several successive tappings, I have constantly ob- served, that the more frequently the operation was repeated, the less abundant was the quantity of albumen contained in the serosity, which fact appeared to me to depend upon the progressively increasing debUity of the constitution. As to the water, I found it in all these specimens of serosity ' much more abundant than in the serum of the blood ; its high- est cipher was 986, and its lowest 930: consequently the ef- fused serosity which had the minimum of water, still contained more than the serum of blood most highly charged with this principle : in this serum, in fact, we have found the maximum of the water for man 915; the minimum 725, and the mean 116 PATHOLOGICAL H-EMATOLOGY. 790. Besides it is in the serosity taken from cases of hydro- cele that we have met with the least amount of water ; it was in one of these cases that our minimum 930 existed, whilst the maximum of water for these same cases, was 947. On the contrary, in the sixteen other cases relative to serous effu- sions whether of the cellular tissue, of the pericardium, of the pleura, or of the peritoneum, this maximum 947 becomes almost the minimum ; in all these cases, save two, we find more than 950 in water, 4 times from 950 to 960, and 10 times from 960 to 986. Moreover, all these samples of serosity presented us, like the serum of the blood, fatty and extractive organic matters, an alkali, and alkaline and calcareous salts. The quantity of the saline matter appeared to us nearly similar to that of the same matter in the serum of the blood. With the exception of our six analyses of the fluid of hydro- cele, all the others are relative to cases where the dropsy was the result of some obstacle to the free return of the venous blood towards the heart ; I much regret that none had any connection with Bright's disease. In these cases then, as in those of hydrocele, there is separated from the blood propor- tionally more of water than of albumen. I have already said that the proportion of albumen separated from the blood, becomes more considerable when it is an in- flammatory process which has provoked the effusion of sero- sity. This may be proved by an analysis of the fluid of vesi- catories. Cases, on the other hand, may present themselves where a fluid, similar to serum in its aspect, and like it alkaline, fails to show by re-agents any trace of albumen. This I have ob- served in the liquid, clear and limpid as rock-water, which is contained in hydatids of the liver. This fluid, slightly alka- line, was not sensibly clouded either by heat, by alcohol, or by nitric acid. It contained some alkaline chlorides, some sulphates, and much fatty matter.* Did the albumen which * The fatty matter, which -we find in serosity has at times a nature dif- OF THE BLOOD IN DISEASES. 117 was absent from this fluid exist in the parietes of the Uving sac which contained it? It is worthy of remark that, in a case where, in the same individual, there exists simuUaneously several serous efl'usions in different parts, the fluids which constitute them may differ considerably from each other, as to the quantity of albumen which they contain. Thus, in a female attacked with an or- ganic disease of the heart, there were 30 parts of albumen in the serosity of the pericardium, while there were but 4 in the serosity of the cellular tissue of the inferior extremities. ARTICLE Vir. Of the Blood in certain diseases commonly called Organic. I HAVE studied the composition of the blood in five cases of hypertrophy of the heart ; in all of them the amount of glo- bules was natural, as was, also, the albumen of the serum. Once only the fibrine showed a slight elevation, represented by 4. In the four other cases it preserved its physiological quantity, being represented by the numbers 2.6; 2.7; 3.0; and 3.7, respectively. These differences in the proportion of fibrine, bore a strict relation to those observed in the symp- toms themselves. For, in the cases which gave 2.6, 2.7, and 3.0 of fibrine, the affection of the heart was chronic, and the pulse not accelerated. In the case which gave 4 of fibrine, the disease, on the contrary, presented a totally different aspect. The symptoms of the heart disease were only of two ferent from that of the same matter ordinarily existing in the serum of the blood. It is thus that while examining with the microscope the fluid of a hydrocele obtained by tapping, I found in it crystals of cholesterine assuming the form of the purest parallelogram. To the naked eye the liuid psesented us, at the moment of its escape from the tunica vaginalis, a clouded appear- ance due to an infinity of little micaceous spangles which it held in sus- pension, and a great part of which were precipitated upon the bottom of the vessel by repose. 118 PATHOLOGICAL HiEMATOLOGY. months' standing. They came on acutely during the course of an attack of articular rheumatism, and survived it. In ad- : dition to the signs of hypertrophy, a very distinet bruit de souffle might be heard at every contraction of the ventricles. In the case where 3.7 of fibrine was found in the blood, that is to say, one of the highest maxima of the physiological state, the bleeding was performed under peculiar circum- stances. There was no articular rheumatism, but a sudden exacerbation of the disease of the heart; the movements of this organ were excessively agitated, a very strong bruit de frottement was heard during both systole and diastole ; the dyspnoea was extreme; the pulse beat 108 in a minute. The depletion was followed by great improvement, and, after a few days, the rubbing sounds had become much feebler. These facts teach us that the alteration of nutrition, which produces hypertrophy of the heart, does not affect the fibrine of the blood, when free from all complication; and that the increase of the fibrine takes place only under peculiar circum- stances, and accompanied with symptoms which recall those of the inflammatory affections. The mere deposit, within the tissues, of the morbid sub- stances known as tuberculous, scirrhous, and encephaloid, and the development of hydatids, do not augment the fibrine. It may however, happen that at certain periods of the existence of these several productions, an excess of fibrine may be found in the blood, but that is because some other morbid condition has supervened. The following rules may be laid down in regard to this matter. So long as tubercle and cancer preserve the character of hard masses, without any inflammation around them, an analysis of the blood uniformly gives the normal quantity of fibrine. But, as the softening of these hard masses advances, and a process of elimination, analogous to that of inflamma- tion, is set up around them, the blood becomes more and more charged with fibrine ; so that the excessive formation of this principle is not due to the development of the accidental pro- duction, but wholly to the inflammation excited by the latter OF THE BLOOD IN DISEASES. 119 at certain stages of its existence. This is a new proof to be added to the many others which show that the process engen- dering the diflerent accidental productions, such as tubercle, cancer, melanosis, hydatid, &c., is not of an inflammatory nature. In order to justify the principles I have just laid down, I will first cite a very remarkable case, in which tubercles de- veloped in the pia-mater simulated acute meningitis ; but the qualities of the blood, even before the autopsy, excited doubts regarding the existence of the latter disease. A sempstress, 24 years of age, entered the hospital of La Charite, May 27th 1841, complaining of having had a cough, and shortness of breath, for some time ; she stated that she suflered from continual head-ache; on May 18th she met with a serious disappointment, and, a few days afterwards, her headache increased ; from that epoch slie experienced creeping chills. From May 23d she grew more seriously ill; on that day her headache was unusually severe, and, at the same time, she had humming noises in her ears, intolerance of light, and bilious vomiting. From the 27th to the 30th of May, the symptoms of an acute cerebral affection grew more and more distinct. From May 30th to the day of her death, which hap- pened June 5th, she uttered piercing cries like those called hydrocephalic ; there were delirium, strabismus, rigid flexure of the limbs; distressing moans and convulsive movements whenever the skin of the trunk or limbs, which seemed to have its sensibility greatly exalted, was at all rudely touched ; and; towards the close, tetanic rigidity of the neck. At the autopsy, the pia-mater was found thickly studded with tuberculous granulations, which were collected most nu- merously about the fissures of Sylvius. In no other part, either of the brain or its membranes, was any appreciable alteration detected. Tuberculous granulations similar to those which filled the pia-mater, were also found in the pleurae of both sides, and in the peritoneum, both of which mem- branes were covered with them; both lungs were filled with miliary .tubercles. 120 PATHOLOGICAL HJEMATOLOGr. In this case, then, the only lesion revealed by dissection was the equal development in all the great serous membranes, and in the lungs, of small and hard tubercles, with no signs of inflammation around them. The anatomical characters of meningitis were completely wanting. Let us look now at the analysis of the blood in this case. At the first bleeding we found 3.0 of fibrine, and at the second 3.4 ; so that the quantity of this principle did not exceed its physiological limits. While the patients lived, we were as- tonished at this result; it seemed strange that in a disease which appeared to us to be acute meningitis, the amount of fibrine should not be increased; the autopsy explained this anomaly, or rather showed us that the anomaly was only apparent. What evidence could be stronger than this, that whatever may be the extent or the rapidity of the formation of tubercles, it does not, in the beginning, augment the fibrine in the blood ? An examination of the blood, in cases of pul- monary consumption, had already led me to lay down this proposition, in the first memoir I published with M. Gavarret. Since the publication of that memoir, we have collected ad- ditional, and confirmatory cases, of which the following is an abstract. We weighed the fibrine obtained from the blood of thirty tuberculous patients, drawn at thirty-three different bleedings. In seven of these patients the tubercles were still crude ; in nine others they were softening, and in the remaining fourteen, there were cavities in the lungs. The six patients of the first series were bled, altogether, nine times. Seven times the fibrine was found to be normal, vary- ing between 2.7 and 3.5. Twice, however, the fibrine ex- ceeded its physiological quantity, and gave the numbers 4.8 and 5,1. But, in each of these two cases, there was an in- flammatory complication; in one a sub-acute entero-colitis, and, in the other, a bronchitis of much greater intensity than is usual in the first stage of phthisis. In ten bleedings performed on the nine patients of the second series, we already come to different results. Nine times out OF THE BLOOD IN DISEASES. 121 of ten the fibrine was in excess, sometimes very slightly, hardly reaching 4, and sometimes varying between 4 and 5. In the tenth case, there were only 3 parts of fibrine. In fourteen bleedings performed on the fourteen patients of the third series, the fibrine was in excess twelve times, but much more so than in the second series. The minimum found was 4.0, and that once only. In three other cases, the fibrine varied between 4.4 ^nd 4.6 ; in all the others it was between 5.0 and 5.9. The only two cases of the third series which did not follow the rule of the increase of fibrine, must be regarded as excep- tional ; the subjects of them were far gone in marasmus, when we attempted, by a snmll bleeding, to diminish the state of half asphyxia which they presented ; and, indeed, they were momentarily relieved by it. In one of them the fibrine was at its physiological mean, in the other it had fallen to 2.0. In the third stage of phthisis, therefore, although the fibrine is generally in excess, there are yet some cases, in which the exhaustion, consequent on the softening of the tubercles, is indicated by an opposite modification in the amount of fibrine ; it augments during the process of elimination, and then di- minishes, so as to fall even below the lowest limit of its phy- siological state. Let us now examine how far the quantity of globules in the blood is affected by pulmonary consumption. This investi- gation will lead us to results worthy of some attention. From the very commencement of pulmonary tubercaliza- tion, and when even auscultation can hardly detect its exist- ence, the globules are already diminished. I have never seen them reach even their physiological average, 127, in any case of the kind. Their highest representative was 122, their low- est 99,* and they usually varied between 120 and 100, ap- proaching the latter number oftener than the former. The blood of persons, then, whose lungs are beginning to be tuber- • This minimum was found in the patient spoken of a little while ago, and whose serous membranes and lungs were thickly studded with tubercles. 11 M 122 PATHOLOGICAL HEMATOLOGY. culous, offers that particular modification which belongs to feeble constitutions ; they are, truly, in a state of commencing ansemia, and their blood is like that of patients who have been bled several times. This condition of the blood which accom- panies the first stage of phthisis, and which, to all appearance, precedes it, is the same general condition found in every case, where, from any cause, the powers of life have lost their energy. What need is there of saying' that these results of analysis agree perfectly with clinical observation? Who is not familiar with that shrunken, pale, and feeble look, which belongs to most consumptives, even in the first stages of their malady ? There are yomig girls, who, when consumption is imminent, become so frail and pallJH, and yet have so few invocal symptoms, that it sometimes happens that the nature of their disease is misunderstood, and that they are supposed to be chlorotic. On the other hand, there are cases of chlorosis which, owing to the complication of a bronchitis, or of a merely nervous cough, have thrown the most accomplished observers into doubt, and made them apprehend a develop- ment of tubercles. In all commencing phthisis, there is, then, a certain degree of anzemia ; but is that equivalent to saying that the impover- ishment of the blood is the sole efficient cause of tubercles? Certainly not ; for, in such case, a greater number of persons affected with phthisis would be found among chlorotic females than are so found, and I do not believe that girls with chloro- sis become tuberculous oftener than others. The decrease of globules, from the outset of consumption, is not, then, a cause of the formation of tubercles, but we must regard it as a certain sign that this disease arises during a marked impairment of the constitution, and, by adding it to those signs furnished by the clinical observation of all ages, it helps to enlighten us in the choice and application of modes of treatment. As the tubercles of the lungs advance, however, the diminu- tion of the globules grows more and more considerable, and, at last, reaches its minimum when the lungs are filled with cavities. Yet, this minimum is not always what theory might OF THE BLOOD IN DISEASES. 123 lead US to suppose it. It would seem, indeed, that in a disease in which the essential organ of haimatosis is so seriously in- volved, and has become so unfit to fulfil its functions, the glo- bules ought to diminish nearly as much as in chlorosis. But this is far from behig the fact. In the second and third stages of phthisis, I have not yet seen more than a single case, in which the globules had fallen below SO; in it they were at 72, and the fibrine at 5.5. In all other instances they varied from 80 to 100. Is it not strange that in chlorosis, without any appreciable alteration of the lungs, or other solid, the globules should fall even lower than 30, while their minimum is at 72 in a disease in which it should seem that the state of the lung could hardly permit the formation of the blood, at all ? And yet not only do the globules not diminish as much as might be expected, but, when even a large part of the lung is de- stroyed, the fibrine increases, and the temperature of the body may rise, just as in typhoid fever, or acute pneumonia. I have seen the temperature rise to 39° and 40° in the hectic fever which usually accompanies the last stage of phthisis. I heard a bruit de souffle in the carotids of one only of the phthisical patients whose blood I analyzed, the same in whose blood the globules were at 72. This patient was a man about thirty years of age. The occurrence of the carotid souffle in him was well explained by the extreme poverty of his blood in globules ; and its existence, in this single case, goes to cor- roborate the principles we have already laid down in regard to the connection of this sound with a certain decrease in the globules of the blood. The appearance of the blood in the several stages of phthi- sis is well explained by the changes occurring in its composi- tion. In the earlier periods of the disease the blood offers no pecu- liarity, except that its clot is generally rather small and dense, which may be explained by the moderate quantity of its glo- bules, and its preservation of a normal proportion of fibrine. But with the progress of the disease, the softening of the tubercles, and the formation of cavities, the clot becoming 124 PATHOLOGICAL H^MATOLOGr. smaller and smaller, is covered with a bufFy coat, the more perfectly formed in proportion to the degree of disorganization of the lung. Two circumstances evidently contribute to pro- duce this buffy coat ; the increase of fibrine which takes place so frequently in the last stage of phthisis, and at the same time, the progressive decrease of the globules; so that, the^re are two causes of an excess of fibrine relatively to the globules, and, if the blood flow in a proper manner, a huffy coat must necessarily be formed. This, indeed, is what happens, and a buffy coat upon the surface of the clot, is nearly as constant in the advanced stages of phthisis, as in pneumonia, or acute articular rheumatism. Considered in relation to the causes which govern its formation, it holds a middle place between the chlorotic, and the inflammatory, buffy coat. Let us now examine the characters of the blood in cases of cancer. It may be inferred from the cases I have collected, upon this subject, that in cancer, as in tubercle, the fibrine of the blood does not increase until the scirrhous or encephaloid matter is advancing to, or has already reached, its stage of softening and destruction. Yet, if the cancer, owing to its situation, interfere with the functions of an organ, which is subservient to the reparation of the blood, this fluid may show a diminished quantity of fibrine. But that is a peculiar case. In four cases of cancer of the stomach, we found the normal quantity of fibrine three times, in the fourth case it was less than this, being only 1.9. In two cases of cancer of the liver, we found, on the other hand, a certain excess of fibrine in the blood ; in one case 3.7, and in the other 5.0. In the first case, the tumour of the right hypochondrium seemed to be in a state of transition between immaturity and softening: although usually indolent, it sometimes grew pain- ful, and then a temporary fever was excited. The symptoms of the other case were totally different ; a patient had, in the region of the liver, a large, very painful and indistinctly fluctuating tumour, which had become rapidly developed, and was accompanied whh continual fever. The OF THE BLOOD IN DISEASES. 125 liver, in its whole extent, and beyond the place occupied by the tumour, was very much enlarged. The patient presented all the signs of an inflammatory affection so distinctly, that we conjectured the existence of a hepatic abscess. He sank rapidly, without our having, a few hours before his unlooked for death, seen any thing to indicate so sudden a termination. It was explained by our finding, on dissection, an immense eflusion of blood in the peritoneal cavity. The source of this blood •was a spongy cancerous projection, completely softened and ulcerated, and which occupied the free edge of the liver. Nu- merous encfephaloid masses, reduced to a sort of detritus, filled the parenchyma of the liver, as well as several branches of the vena-porta. In a case of cancer, ascertained by dissection to be ovarian, and which was accompanied with fever, and acute pains, the fibrine rose to 4.5. The cancerous mass was partially softened, and innumerable vessels traversed it in every direction. There were some traces of a slight peritonitis around it. Finally, in two cases of cancer of the womb, we found that very different numbers expressed the quantities of fibrine ; viz. 5.6 and 1.8. But the progress of the first case indicated a state of pretty intense phlogosis; the whole hypogastrium was tense and painful, and there was constant fever. In the second case there was complete apyrexia; the patient was thoroughly exhausted by repeated hemorrhage from the uterus. This was the remarkable instance of which I have already had occasion to speak, in which the blood contained only 2 1 parts of globules. I have not, yet, had an opportunity of analyzing the blood of persons affected with hydatids, but, in sheep, I have often made this examination, and have always fomid the quantity of fibrine normal, where no other aflection complicated the hydatids; but augmented, whenever an inflammatory process had been established around them.* » Researches into the composition of the blood of certain domestic ani- mals, &c. 11* W' 126 PATHOLOGICAL HJSMATOLOGT. In the several cases of cancerous disease I have just re- viewed, the globules of the blood offered nothing remarkable,' except the progressive diminution tliey undergo, whenever the organism is subjected to any cause whatever of exhaustion. The profuse hemorrhages which accompany some forms of cancer, the defective nutrition which must result from the greater number of cancers of the stomach, explain why, in many diseases of this nature, the blood is found sparingly sup- plied with globules. But this deficiency does not appear to' take place in cancer, as in tubercles, at the commencement of the disease ; it comes on late, and quite accidentally, from the causes just enumerated. The predisposition of the organism to form cancer, is not, then, like its tendency to form tubercles, expressed from the outset, by an impoverishment of the blood. It should be remarked, too, that, while from the very origin of his disease, and even before it is susceptible of demonstra- tion, the tuberculous patient is always remarkable for his de- bility and paleness, such is not the case with one who has cancer. The latter may, before the commencement of his disease, and during its first stages, present every variety of constitution and temperament. What is more common than to see a cancerous affection in persons of a sanguine tempera- ment, and who have the appearance of plethora ? And what more rare, on the other hand, than the development of tuber- cles in such conditions of the system? Doubtless, there are not a few cases of young persons becoming tuberculous, amongst those who are fleshy, and have a ruddy complexion, with a certain appearance of strength : but the plethora of these individuals is deceitful, they have, in reality a lymphatic tem- perament, and if their blood be analyzed, its globules are found at, or even a little below, the lowest physiological limit. There is ground for the question, whether, when once the cancerous cachexia is well established, there may not be an absorption of the cancerous detritus, and whether some traces of it may not be detected in the blood. To ascertain this, M. Gavarret and I have, several times, examined with a mi- croscope, blood taken from the bodies of persons who had OP THE BLOOD IN DISEASES. 127 died of various cancerous affections, and, in some instances, we found well formed globules of pus in the blood. These globules were not, indeed, portions of cancerous matter ; they were merely a product of the inflammatory process, which, at a certain stage of the disease, is developed in the tissue where the cancer originates. Nevertheless, this is a fact in the his- tory of cancer, important to be known, since it proves the pos- sibility of a purulent infection of the blood, in this disease. In a case of osteo-sarcoma, with consecutive production of a large cancerous mass in the anterior mediastinum, we met with a large quantity of pus-globules mixed with the blood in the right ventricle of the heart. But along with these globules we found other bodies of an altogether peculiar aspect, and which we have, in this case only, detected in the blood. They were elliptical lamellx, with a granite-like surface, much larger than globules of pus, and of a much more regular form than simple albuminous flakes. But these lamellas were not found only in the right ventricle mixed with pus-globules. We found a great many of them in a little of the ichorous fluid taken from the centre of the cancerous tumour of the medias- tinum. Are they, then, to be considered as denoting the pre- sence of softened cancerous matter, or of the ichor \ which it furnishes ? We can only say, that we have found the same latnellx in other cancerous masses. The subject merits further investigation. Before concluding this subject, I may add, that in a patient who died of ulcerated cancer of the liver, I detected the pre- sence of some pus-globules in the thoracic duct; the contents of this vessel were reddish, and, along with the pus-globules, the microscope showed globules of blood, the most of them serrated at their circumference, and very distinct from globules of pus. If, then, either before or during the development of these various accidental productions, one of the elements of their formation consists in some change effected in the composition of the blood, that change is, apparently, to be found neither in the fibrine, nor in the globules, nor in the albumen, but rather 128 PATHOLOGICAL HEMATOLOGY. in those numerous organic substances, mostly of an undeter- mined character, and which are compreiiended in the term extractive matter. But are new substances generated ? Are those which naturally exist modified in quantity or quality ? What happens to the blood when tuberculous matter, instead of increasing, disappears, leaving a calcareous deposit in its stead? When accidental productions are formed of wholly inorganic substances, as by an accumulation of the salts of lime, what takes the place of these salts in the blood ? What happens to the blood in those cases where the whole vascular system is filled with ossific concretions ? Or what, when the bones are softened, and, being deprived of a large portion of their phosphate of lime, seem reduced almost to a cartilaginous state ? Is it in some change in the composition of the blood, appreciable by analysis, that we are to look for the cause of those excessive secretions of uric acid that take place in gout and gravel? Medicine must wait for something of its advance- ment, till these, and many analogous questions, are resolved. ARTICLE VIII. Of the Blood in the Neuroses. The title of this article may, at first, seem singular. For what could be found in the blood in diseases whose seat is the nervous system, whose symptoms are the various disturbances of the functions of that system, and which it- is not customary to refer, either to an alteration of the solids, or of the fluids? I admit these notions, and yet I shall endeavour to prove, that even in the neuroses, the study of the state of the blood may be important. Clinical observation has long since demonstrated, that one of the most powerful causes of many nervous disorders, is a certain degree of feebleness of the constitution ; whence, the incontestable advantage of a tonic treatment, in many of these diseases, which by reviving the strength, restores the equili- OP THE BLOOD IN DISEASES. 129 brium of the nervous system, and removes the disorder of its functions. The results of an examination of the blood are confirmatory of those furnished by clinical experience. Thus, it is found, that in many cases of neurosis, the glo- bules of the blood are very scanty. Now it is well known that the increase or decrease of the globules of the blood, in- dicates the vigour or feebleness of the constitution. If the globules be diminished, either by depletion, or by insufficient nourishment, the nervous disorder will certainly be aggra- vated; but if the opposite course be pursued, in all proba- bility the nervous affection will be mitigated. In this way may be explained the happy influence which the ferruginous preparations, and substantial and nutritious food, exert upon the termination of certain neuroses : and it is because the globules are inevitably diminished by depletion and diet, that we so often see such disturbance of the nervous functions follow great loss of blood, and a too prolonged abstinence from food. But are we to be understood as declaring that such is the origin of every neurosis ? Certainly not ; there are diseases of this sort, and many of them, in which the quantity of glo- bules in the blood is normal, and in which, even the aspect of the patient gives no indication of constitutional feebleness. In these cases, the blood lias nothing to do with the production, nor with the maintenance, of the disease, whose etiology must be sought elsewhere, as well as the treatment most appropriate to it. These various facts are not inconsistent with one another ; they only throw new light on one of the most im- portant of medical truths, namely, that two diseases may have identical symptoms, without being of the same nature, and that however close their resemblance, they may, still, require different modes of treatment, because very different conditions of the economy may give rise to, or maintain, them. THE END. CYCLOPAEDIA OF PRACTICAL MEDICINE. LEA AND BLANCHARD, PHILADELPHIA, WILLPUBLISH THE CTCLOPiEDIA OF PRACTICAL MEDICINE; COMPRISINa ^' TREATISES ON THE NATURE AND TREATMENT OF DISEASES, MATERIA MEDICA AND THERAPEUTICS, MEDICAL JURISPRUDENCE, &c. &c. EDITED BY JOHN FORBES, M.D.,F.R.S. Physician in Ordinary to her Majesty's Household, &o. ALEXANDER TWEEDIE, M.D.,F.R.S. Physician to the London Fever Hospital, and to the Foundling Hospital, &g. JOHN CONOLLY, M.D. Late Professor of Medicine in the London University, and Physician to the Hanwell Lunatic Asylum, &c. ^ THOROUGHLY REVISED, WITH ADDITIONS, BY ROBLEY DUNGLISON, M.D. Professor of the Institutes of Medicine, &c. in the Jefferson Medical College, Philadelphia ^ Lecturer on Clinical Medicine, and Attending Physician at the Philadelpliia Hospital ; Secretary of the American Philosophical Society, &c. TERMS OF PUBLICATION. THE WOnK VILL BE PRINTED WMH A NEW AND CLEAR TYPE, AND BE COMPRISED IN TWENTY-FOUR PARTS, AT FIFTY CENTS EACH, FORMING, WHEN C O JI 1' L E T E , FOUR LAUGE SUPKIMiOYAL OCTAVO VOLUMES. EMnUAClNG OVER THREZ: THOUSAND U N X7 S XJ A L L IT ZiARGE PAGES, IN DOUBLE C O L U .M N S . Any person forwarding Twcnfi/ Dollars, free of postage, in Current Funds, will be entitled to two copies. The whole work will be conipleled during the year 1844. PUBLISHERS' NOTICE TO THE CYCLOPAEDIA OF PRACTICAL MEDICINE. 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PROGNOSIS ACUPUNCTURE > CONVALESCENCE THE CHEST AND PULSE AGE COUNTER-IRRITATION ABDOMEN SOFTENING CHANGE OE AIR CONGESTION AND DE- GALVANISM MEDICAL STATISTICS ANTIPHLOGISTIC TERMINATION OE HEREDITARY TRANS- STETHOSCOPE REGIMEN BLOOD MISSION OP DISEASE^ SUDDEN DEAl'H ASPHYXIA DERIVATION INDURATION ^SYMPTOMATOLOGY AUSCULTATION PjIETETICS IRRITATION TEMPERAMENT BATHING DISINFECTION INFECTION TOXICOLOGY BLOOD-LETTING PHYSICAL EDUCATION LATENT DISEASES TRANSFORMATION MORBID STATES ELECTRICITY 1 MALARIA AND MIASMA TRANSFUSION OF THE BLOOD ENDEMIC DISEASES j PERFORATION TUBERCLE CLIMATE EPIDEMICS PSEUDO - MORBID AP-^ VENTILATION COLD j EXPECTORATION i PEARANCES ^MINERAL WATERS and those of various general articles on the pathology of organs. It will be found, too, that admirable articles from the best sources have been inserted on the important subjects of DISEASES OF WOMEN AND CHILDREN, AND OF MEDICAL JURISPRUDENCE. 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Such a work, it is believed, will be most acceptable to the members of the profession throughout the Union, as -there exists, at this time, no publication on Practical Medicine, on the extended plan of the one now presented. To adapt it to the Practice of this country, and to thoroughly revise the various articles, the atten- tion of PROFESSOR DUNGLISON will be dJrocted ; whose character and established reputation are a sure guarantee that his portion of the work will be carefully executed. CONTENTS OF, AND CONTRIBUTORS TO, THE CYCLOP/EDIA OF PRACTICAL MEDICINE. Abdomen, Exploration of, Dr. Abortion Dr. Abscess Dr. Abstinence Dr. Achor Dr. Acne Dr. Acupuncture .... Dr. Age Dr. Air, Cliange of, . . . Dr. Alopecia Dr. Alteratives Dr. Amaurosis Dr. AmenorrhcEa .... Dr. Anaemia Dr. Anasarca Dr. Angina Pectoris . . . Dr. Anodynes Dr. Anthelmintics .... Dr. Antiphlogistic Regimen Dr. Antispasmodics . . . Dr. Aorta, Aneurism of, . Dr. Aphonia Dr. Aphthae Dr. Apoplexy, Cerebral, • Dr. Apoplexy, Pulmonary, . Dr. Arteritis Dr. Artisans, Diseases of, . Dr. Ascites Dr. Asphyxia Dr. Asthma Dr. Astringents Dr. Atrophy Dr. Auscultation .... Dr. Rarbiers Dr. l>athing Dr. Beriberi Dr. Blood, Morbid States of, Dr. Bloodletting .... Dr. Brain, Inflammation of, Bronchitis Dr. pr. Bronchocele . . . . Bulla? Calculus Calculous Diseases . . Catalepsy Catarrh Cathartics Chest, Exploration of, . Chicken Pox . . . . Chlorosis Cholera Chorea Climate Cold Colic Colica Pictonum . . . Coma Combustion, Spontane- ous Human, . . Congestion of Blood Constipation . . . Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. CDr. ^Dr. Dr. Dr. I- Dr. CDr. ^Dr. Contao;ion Dr. Convalescence . . . Dr. Convulsions .... Dr. Convulsions, Infantile . Dr. Convulsions, Puerperal Dr. Coryza Dr. Forbes. Lee. TWEEDIE. M. Hall. Todd. Todd. Elliotson. ROGET. Clark. Todd. CONOLLY. Jacob. LococK. M. Hall. Darwall. Forbes. Whiting. A. T. Thomson. Barlow. A. T. Thomson. Hope. Robertso.v. Robertson. Cluttereuck. Townsend. Hope. Darwall. Darwall. Roget. Forbes. A. T. Thomson. Townsend. Forbes. Scott. Forbes. Scott. M. Hall. M. Hall. QtTAIN. Adair Crawford. Williams. And. Crawford. Todd. Thos. Thomson. Cumin. Joy. Williams. A. T. Thomson. Forbes. Gregory. M. Hall. Brown. And. Crawford. Clark. Whiting. Whiting. Tweedie. Whiting. Adair Crawford. r. Apjoun. Barlow. Hastings. Streeten. Brow.n. Tweed IE. Adair Crawford. LococK. LococK. Williams. Counter Irritation . . Dr. Croup Dr. Cyanosis Dr. Cystitis Dr. Delirium Dr. Delirium Tremens . . Dr. Dentition, Disorders of . Dr. Derivation Dr. Determination of Blood Dr. Diabetes Dr. Diaphoretics .... Dr. Diarrhoea . . . . s t^ ' Dietetics Dr. Dilatation of the Heart . Dr. Disease Dr. Disinfection .... Dr. Diuretics Dr. Dropsy Dr. Dysentery Dr. Dysmenorrhcea . . . Dr. Dysphagia Dr. Dyspnoea Dr. Dysuria Dr. Ecthyma Dr. Eczema Dr. Education, Physical, . Dr. Electricity Dr. Elephantiasis Arabum . Dr. Elephantiasis Graecorum Dr. Emetics Dr. Emmenagogues . . . Dr. Emphysema .... Dr. Emphysemaof the Lungs Dr. Empyema Dr. Endemic Diseases . . Dr. Enteritis Dr. Ephelis Dr. Epidemics Dr. Epilepsy Dr. Epistaxis . . • . •. • Df- Erethismus Mercurialis Dr. Erysipelas Dr. Erythema Dr. Expectorants .... Dr. Expectoration .... Dr. Favus Dr. rDr. Feigned Diseases . . •? Dr. (.Dr. Fever.General Doctrine of. Dr. " Continued, and its 5 £) J Modifications, (_ " Typhus ... Dr. " Epidemic Gastric Dr. ** Intermittent . . Dr. " Remittent ... Dr. " Infantile Remittent Dr. Hectic .... Dr. " Puerperal . . . Dr. " Yellow ... Dr. Fungus Hocmatodes . . Dr. Galvanism Dr. Gastritis Dr. Gastrodynia .... Dr. Gastro- Enteritis . . . Dr. Glossitis Dr. Glossis, Spasm of the, . Dr. Gout Dr. Haemorrhoids .... Dr. Williams. Cheyne. Crampton. Cumin. Pritchard. Carter. Joy. Stokes. Barlow. Bardsley. A. T. Thomson. Crampton. Forbes. Paris. Hope. CoNOLLY. Brown. A. T. Thomson. Daewall. Brown. LococK. Stokes. Williams. Cumin. Todd. Joy. Barlow. Apjohn. Scott. Joy. A. T. Thomson. A. T. Thomson. Townsend. Townsend. Townsend. Hancock. Stokes. Todd. Hancock. Cheyne. Kerr. BURDER. TWEEDIE. Joy. A. T. Thomson, Wilson. A. T. Thomson. Scott. Forbes. Marshall. Tweed IE. Tweedie. Tweedie. Cheyne. Brown. Brown. Joy. Brown. Lee. GiLLKREST. Kerr. Apjohn. Stokes. Barlow. Stokes. Kerr. Joy. Barlow. Burns. CONTENTS, &c., OP THE CYCLOPEDIA OF PRACTICAL MEDICINE. Headach Dr. Burder. Heart, Diseases of the, Dr. Hope. Displacement of the, Dr. Townsend. Hetnatemesis Hemoptysis Hemorrhage Hereditary Transmis sion of Disease Herpes ; . . Hiccup . . . Hooping-Cough Hydatids . . Hydrocephalus Ilydropericardium Hydropho'.)ia Hydrothorax Hypertrophy Hypertrophy of the Hypochondriasis Hysteria . . . Icthyosia . . Identity . . . Impetigo . . Impotence . . Incontinence of U Incubus . . Indigestion . Induration . Infanticide . Infection Inflammation Influenza . . Insanity . . . Irritation . . Ischuria Renalis Jaundice . . Kidneys, Diseases Lactation , . Laryngitis . . Latent Diseases Lepra . . . Leucorrhoea nne D of, Dr. GoLDiE. Dr. Law. Dr. Watson. Dr. Bkown. Thomson. Dr. A. T Dr. Ash. Dr. Johnson. Dr. Kerr. Dr. Joy. Dr. Darwai.l. Dr. Baudsley. Dr. Darwall. Dr. Townsend. Heart Dr. Hope. Dr. Pritchard, Dr. CONOLLY. Dr. A. T. Thomson. Dr. Montgomery. Dr. A. T. Thomson. Dr. Beatty. Dr. Cumin. Dr. Wii.LiAMS. Dr. Todd. Dr. Cakswell. Dr. Af.rowsmith. Dr. Brown. A. Crawford, Dr. Tweedie, Dr. Hancock. Dr. Pritchard. Dr. Williams. Dr. Carter, Dr. BUKDER. Dr. Carter. Dr. LococK. Dr. CnEYNE. Dr. Chkistison. Dr. Houghton. Dr. LococK. Dr. Houghton. Dr. Stokes. Dr. Venables. Dr. Brown. Lichen . . . Liver, Inflammation of, " Diseases of, . Malaria and Miasma Malformations of the Heart Dr. Williams. Medicine, Principles and Cr, n Pracliceof, . . jDr. Conolly. Melaena Dr. Goldie. Melanosis Dr. Carswell. Menorrhagia . . . . Dr. Locock. Menstruation, Pathology of Dr. Locock. Miliaria, Dr. Tweedie. Mortification .... Dr. Ca^jswell. Narcotics Dr. A. T. Thomson. Nephralgia and Neplmtis Dr. Carter. Neuralgia . . . . . Dr. Elliotson. Noh me tangere, or Lupus Dr. Houghton. Nyctalopia Dr. Grant. Obesity Dr. Wili.ia.ms. Oedema Dr. Darwall. Ophthalmia .... Dr. Jacob. Otalgia and Otitis . . Dr. Burne. Ovaria, Diseases of the Dr. Lee. Palpitation Dr. Hope. Pancreas, Diseases of the, Dr. Carter. Paralysis Dr. R. B. '1'odd. Parotitis Dr. Pellagra Dr. Pemphigus Dr. Perforaiion of the Hol-fj^ low Viscera . . "^ Pericarditis and Carditis Dr. Hope. Peritonitis .... Dr. M'Adam, Dr. Stokes. Persons found Dead . Dr. Beatty. Phlegmasia Dolens . . Dr. Lee, Kerr. Kerr. CoRRIGAN. Carswell. Pityriasis ..... Dr. Plague Dr. Plethora Dr. Pleurisy, Plearitis, . . Dr. Plica Polonica .... Dr. Pneumonia Dr. Pneumothorax . . . Dr. Porrigo Dr. Pregnancy, &c., Signs of. Dr. Prognosis Dr. Pseudo-morbid Appear- C p ances ....(_ Psoriasis Dr. Puerperal Diseases . . Dr. Pulse Dr. Purigo Dr. Purpura Dr. Pyrosis Dr. Rape Dr. Refrigerants .... Dr. Rheumatism .... Dr. Rickets Dr. Roseola Dr. Rubeola Dr. Rupia Dr. Rupture of the Heart . Dr. Scabies Dr. Scarlatina Dr. Scirrhus Dr. Scorbutus Dr. Scrofula Dr. Sedatives Dr. Se.x, Doubtful, ... Dr. Small-Pox Dr. Softening of Organs . Dr. Somnambulism and Ani- 9 r\- mal Magnetism . C Soundness, &,c., of Mind Dr. Spinal Marrow, Dis- eases of, ... Spleen, Diseases of, Statistics, Medical, . . Stethoscope .... Stimulants Stomach, Organic Dis- eases of, ... Succession of Inherit- ance— Legitima'fcy, Suppuration . . Survivorship . . Sycosis .... Symtomatology . Syncope .... Tabes Mesenterica Temperament . . Tetanus .... Throat, Diseases of Tonics .... Toxicology . . . Transformations . Transfusion . . Tubercle . . . Tubercular Phthisis Tympanites . . Urine, Morbid States Urine, Bloody, Urticaria . . Uterus, &c. Patholog Vaccination . . Varicella . . . Veins, Diseases of, Ventilation . . . Wakefulness . . Waters, Mineral, Worms .... Wounds, Death from, Yaws Cumin. Brown. Barlow Law. CoRRIGAW. Williams. Houghton. A. T. Thomson. Montgomery. Ash. r. R. B. Todd. Cumin. Hall. Bostock. A. T. Thomson. Goldie. Kerr. Beatty. A. T. Thomson. Barlow. Cumin. Tweedie. Montgomery. Corrigan. Townshend. Houghton. Tweedie. Carswell. Kerr. Cumin. A. T. Thomson.. Beatty. Gregory. Carswell. Pritchard. Pritchard. R. B. Todd. BfGSBT. Dr. the, of, of, Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Hawkins. Williams. A. T. TiioM«ow Houghton. montgomev ■- R. B. ToDp.. Beatty. Cu.MIN. M. Hall. Ash. Joy. Pritchari , Symonds. Tweedie. A. T. Tuo, - , Apjohn. duesbury Kay. Carswelv. Clark. Keur. BuSTOCK. Goldie. IIoUGHTa Lee. (jREGORY Gregory. Lee. Brown. Cheyne. T. Thom» 5. Joy. Beattt. Kerr. LEA & BLANCHARD'S PUBLICATIONS. SIR ASTLEY COOPER ON HERNIA, WITH ONE HUNDRED AND THIRTY FIGURES IN LITHOGKAI'HV. THE ANATOMY AND SURGICAL TREATMENT OF ABDOMINAL HERNIA, BY SIR ASTLEY COOPER, BART. Edited by C. Aston Kev, Sur- geon to Guy'ri Hov«pital, &.e. Ttiis important work of Sir Astley is printed from tlio aiitlmriscd sccoiwi edition, published in London, in laice super-royal folio, and edilid liy his nephew, Prole.-sor Key. It contains all the Plates and all tlie Letlerpri'ss — there are no onjissious, interpolations, or inodiliralions — it is the eoiiiph te Work in ONE I,AKGK I.MI'EKIAL OCI'AVO VOl.UMli, U'll H (AKl! l:,() I'KJL'UErf ON J WKN'JXSIX PLATES, .AND t)Vl;K 4IKI LARGE PAGES OF LE r'PEK-PR ESS. 'J'I.e eorrec tne.ss of the platcB is guaranteed by a revision and riose exaniin.ition under the eye of a distnifrcjisNed Surfieon. The value of this work of Sir .\sth-y Cm pi-r's is so universally ac know hiified hy all medical men, that in presentine this edition to the Anieriean profession, the piililishers nave only to state that they have used their utmost endeavours to remhr the merhanical e.vrutioii of the work worthy its c xalted reputa- tion, and to put it in siich a form and at such a price as to place it « ithiu tliu reacli of tlRise wlio liave been prevented from obtaining it by the size and rarity of former editions. WATSON'S TRACTICE OF rilYSIC. NOW COMPLETE. LECTURES OX THE PRINCIPLES AND PRACTICE OF PHYSIC, DE- LIVEliED AT KING'S COLLEGE, LONDON, BY THOMAS WATSON, M. D., Fellow of the Royal Collrpe of Physician!-', Physician to the Middlesex Hospital, &c. &.C., embracing Ninety Lectures — cotnplete in one octavo volume of over nine hundred lar^e and condensed pnges; well bound in leather. In presenting the following, from numerous commendations of this work, the publishers would state thHt it is amonc the cheapest volumes ever otlered to the profession. " By the publication of this work, the medical literature of this country has been enriched by a work of standard excellence, which we can proudly hold up to our brethren of foreifiu cMiuiitries, as a repre- seulative of the natural state of Brilsji medicine, as professed antl practiced hy our most enliiilitened physicians. — We hesitate not to declare our belief that for sound, trustworthy principles, and substantial. <;ood practice, it cannot be paralleled by any similar [iroductioii in any othi-r country. — We would advise no one to set himself down in practice, unprovided with a cttpy."— British ^- Foreign Med. Review. " We know of no other work better calculated for being placed in the hands of the student, and for a text-book, and as such we are sure it will be very extensively adopted." — Jim. Med. Journal. " Open this Imce and welltinislied volume u lierever we may, the eye immediately rests on something that carries value on its front. \Ve are impressed at once with the strength and depth of the lecturer's views, and he gains on our admiration in pmporticn to the extent of our ac(piaintance with his profound researches. Whoever owns this Ixiok will have an acknowledgid treasure, if tlie combined wisdom of the highest authorities bo appreciated." — Boston Med. and Hur/r. Journal. CONDIE ON CHILDREN. A NEW WORK. NOW READY. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN, BY D. FRANCIS CONDIE, M.D., Fellow of the College of Physicians, Member of the American Philosophical Society, &c. &c. In one volume, 8vo. " Dr. Condie has studiously endeavoured to be understood by students, who need to liave the elements of Therapeutics presented to I hem iu a comprehensiblr form. The volume is methodically arranged iu two parts. In Part I. are considered the hygienic inanage- ineut of ( hililren ; the peculiarities of organization and fuiiclions in infancy and childhood ; p.iiliology of infancy and childhood ; and the s<;iiiei(dogy of the iliseases of infancy and childhood. In Part II. are embraced disea.-es of the digestive organs; the monlh, throat, a'sopbai'us, stomach, iutesliues, resjiira- tory orL'ans, nervous system, the skin, eruptive fi-vers, e laneous eriipliims, nutrilive functions, and uri- nary I'r^ans ; and lastly, congenital .iltictnuis, .ind acciilenis occurrini; somi alter birth, lint this is only an outline of the subjccis brought under sp:'cial notice."— Ba.<(on J\IrU. and Sur^. Juurnal. " ReL'ardiiig this treatise as a whole, it is more complete and accurate in its descriptions, wliile it is more copious and judicious in its theraiieutical directions than any of its predecessors, and we feel per- suaded that the .■Vmirican uK-dical profession will very soon rigard it, not only as a very good, but as the verij licst ' Practical Treatise ou the Diseases of C'hiidren.' "—jitn. Med. Journal. " .An excellent Prnrtical Treatise on the Diseases of Children, and a very safe guide to the juvenile practitioner and student." — Med. Kzamincr. HARRISON ON THE NERVES. AN ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM, BY .lOIlN HARRISON, M.D., Profes.=or of Physiology and Pathology in the Medical College of Louisiana. In one volume 8vo, LEA AND BLANCHARD'S PUBLICATIONS. A NEW WORK ON PRACTICAL SURGERY, With over Two Hundred and Fifty Illustrations. A SYSTEM OF PRACTICAL SURGERY, BY PROFESSOR WILLIAM FERGUSSON, OF king's college, LONDON. ILLUSTRATED BY OVER TWO HUNDRED AND FIFTY SPLENDID CUTS, EXECUTED BY GILBERT, FROM DESIGNS BY BRAGG ; WITFl NOTES AND ADDITIONS, BY GEORGE W. N O R R I S, M.D. One of the Surgeons to the Pennsylvania Hospital. In One Volume, Svo. Tlie object and nature of this volume are thus described by tlie author: — " Tlie present work has not been produced to compete with any already before the Profession; the arrani;ement, the manner in which the subjects have been treated, and the ilhistrations, are all different from any of the kind in the English language. It is not intended to he placed in comparison with the elementary syi^tenis of Cooper, Burns, Liston, Pymes, Lizar, aiid that e.\cellent epitome by Mr. Drnilt. It may with more propriety bo likened to the Operative Siirg-enj of Sir C. Bell, and tliitt of Mr. Averill, both excel- lent in their day ; or the more modern ))roduclioii of Mr. Hargrave, am! the Practical Surgery fif Mr. Liston. There arc subjects treated of in this volume, however, which none of these gentlemen have noticed; and the author is sutficiently sanguine to entertain the idea that this work may in some degree assume that relative position in British Surgery which tlie classical volumes of Valpeau and Malgaigiie occupy on the Continent." The publishers commend this work to the attention of the Profession as.one combining cheapness And elegance, wilh a clear, sound, gnd practical treatment of every subject in surgical science. No pains or expense have been spared to present it in a style equal, if not superior, to the London edition, and to match the edition of "Wilson's Anatomy," lately published, and "Churchill's System of Mid- wifery," and " Carpenter's Physiology." CHURCHILL'S MIDWIFERY, "WITH ONE HUNDRED AND SIXTEEN ILLUSTRATIONS. THEORY AND PRACTICE OF MIDWIFERY, BY FLEETWOOD CHURCHILL, M.D., M.R.LA., Licentiate of the College of Physicians in Ireland ; Physician to ths Western Lying in Hospital, Lecturer on Midwifery, &c. in the Richmond Hospital School of Medicine, Author of " A Treatise on the Diseases of Females," &c. &c. WITH NOTES AND ADDITIONS, BY ROBERT M. HUSTON, M.D. Professor in the Jefferson Medical School of Philadelphia ; WITH 116 ILLUSTRATIONS FRO.M DRAWINGS BY BAGG AND OTHERS, ENGRAVED BY GILBERT, " Tliis is inconlcstably one of the very best books, on the important subject on whicli it treats. The author has had great experience, and is, withal, an a!)le nnil accomplislied writer; well read in his profession, and gifted ^^ith a vigorous and condensing mind; while the ."Vmcrican editor is known as a skilful practitioner of obstetrics, and well acquaint.-d witli every thing that has been said or done in that departni;-nt. 'I'he notes which he has ailded bear ample testimony to his possessing those qualifications. The work does not consist simply of the ipse dizit of the author. It embraces a brief statement, well expressed, of the views of the best autlnnities, and is illustrated, as the title sets forth, with nnmcrons woodcuts, which, by the way, are beautifully executed. ThJ-book is altogether well 'got up,' and we can conscientiously recommend it most stroricly as an excellent accompaniment to the tyro in his stmlies, and to the practitioner when beset vvith doubts or diffi- culties. It forms a fit accompaniment to Wilson's Anatomy, and Fergusson's Surgery." PROUT ON THE STOMACH. ON THE NATURE AND TREATMENT OF STOMACH AND RENAL DISEASES; Being an Inquiry into the Conne.xion of Diabetes, Calculus, and the other Affections of the Kidney and Bladder, with Indigesiion; BY WILLIAM PPvOUT, M.D., F.R.S. FELLOW OF THE ROYAL COLLEGE OF rHYSICIAN.S, &C. From the Fourth revised London Edition; with Coloured Plates. "This trenlise was received wiih so much favour by the medical profes^i.^n in Knclnnd. that wilhin hree yrars from the pulilicnliori of the third edili.in nl it, a fnutlh w.is m.-,de nei-e^saiy by the itideiisins deinaiid. Ti.o much can h.inl y bo paid iniis praise, as a practical cstory of no li-ss than three h;indr.-d and sixly-one cases, thus embodying the records of a life of practice of the .Author and his various editors. Thire are also additional Ob.servations from notes furnished by John C. Warren, M. I)., the Professor of Anatomy and Surgery in Harvard University. WILLIAMS' PATHOLOGY.-BY CLYMER. PRINCIPLES OF MEDICINE, COMPRISING GENERAL PATHOLOGY AND THERAPEUTICS, and a brief general View ofEiiology, Nosologv, Semeiology, Diagnosis, and Prognosis.' By CHARLES J. B. WILLIAMS, M.D., F.R.S., Felbw of the Royal College of Physicians, &c. With Addiiions and Notes, by MEREDITH CLYMER, M.D., Lecturer on the Insiitute of Medi^'ine, &c. One VoI.'8vo. "With many excellent and elaborate treatises on the details of Medicine, we have scarcely any which treat of those general principles in the nature and tre'.'ilmeiit of disease, which are really funda- mental in the practice of medicine. V\'e therefore tliink that the " Priiiriji/m" of Dr Williams iseMti- tled to assume a station along with the works of Chnniel and Dubois, in the French, and Neumann, ill the German. It is without a competitor in our language, and fills most successfully a decided gap in our medical literature. The actual state of our science is very fairly ri-prosented, and besides a free appropriation from the writings of liis contemporaries, the .Author has drawn largely from his own experience; ' a conliunal observalion of disease for the last twenty years in Hospital and private practice,' atfording him abundant opportunity for its accumulation." BRODIE ON THE JOINTS. PATHOLOGICAL AND SURGICAL OBSERVATIONS ON THE DISEASES OF THE JOINTS. By Sir Benjamin C. Brodie, Bart., F. R. S., Sergeant Surgeon to the King, &,c. &c. From the Fourth London Edition, with the author's alterations and addiiions. In one volume 8vo., cloth. To both the practical physician ;ind the stiidrnt, then, this little volume will be one of much service, inasmuch as we have here a condensed view of these coniplicat-d subjects thoroughly investigated by the aid of the light atTorded by modern Pathological Surgery. — JV. i'. Journal of Medicine. WALSIIE ON THE LUNGS. THE PHYSIC.\L DIAGNOSIS OF THE DISEASES OF THE LUNGS. By Walter Hayle Walshe, M. D., Professor of Pathological Anatomy in University College, London, (fcc. &.c. In one volume 12mo., e.xtra cloih. The Rrilisli and Foreign Medical Review, edited by Dr. John Forbes, the translator and annotator of Ijaennec's immortal work, says, " we do not hesitate to say that there exists in no language any work on the physical diagnosis of diseases of the lungs, suited for stndenis, so cbar ami precise, and at the same time so comprtdnnsive and practical as this. It is one which no b'ariier in auscultation can fail to possess, without losing advantages eLsewhere iinallainable ; and it is one which very few even among the most exp rienced auscultators will consult without adding something to their previ- ous stock of knowledge. " LEA AND BLANCHARD'S PUBLICATIONS. SIXTH EDITION OF SPECIAL ANATOMY AND HISTOLOGY, BY WM. E. HORNER, M.D. PROFESSOR OF ANATOMY IN THE UNIVERSITY OF FE.NNSYLVANIA, MEMBER OF THE IMVERIAL MEDICO-CHIRURGKAL ACADEMY OF ST. PETEKSBVRG, OF THE AM. PHIL. SOCIETY, &,C. In Two Volumes, 8vo. This edition has undergone a complete revision hy Prof. Unrner, and perfected from recent sources of information. The prirtiou on HisTot.ocY iiml Histooeny is iwo-lliirils new, and a new chapter on Glandular Structure lias been added. The author has ileenied ii adwsaljle Id h.ive an Atlas ok .'\n.\- TOiMiCAi, Plates prepared, to illustrate his lectures. This has been undertaken under his supervision, by Dr. H. H. Smith, and forms an additional volume. A TREATISE ON THE DENTAL ART, FOUNDED ON ACTUAL EXPERIENCE. ILLUSTRATED BY TWO HUNDRED AND FORTY-ONE FIGURES IN LITHOGRAPHY, AND FIFTY-FOUR WOOD CUTS | By B. F. MAURY, DENTIST OF THE ROYAL POLYTECHNIC SCHOOL. Translated from tlie French, with Notes and Additions, BY J. B. SAVIER, DOCTOROFDENTAL SURGERY. One Volume, 8vo. This work is used as a Textbook in the Baltimore ('ollege of Dental Snrjrery, and commends itself to the Profession from the great reputation of the a'lthor, and as eniliracin^;; the latest information on the subject. Its steady demand is the best testimony of the general favour with which the professioti has received it. It is in fact a Cyclopaedia of the science. CARPENTER'S PHYSIOLOGY, "SFTITH OVER OriE HU1\TDRED SPLEUriD ■WCCD CUTS. PRINCIPLES OF HUMAN PHYSIOLOGY, With their chief applications to Pathology, Hygiene, and Forensic Medicine. Especially designed for the use of Students ; with over One Hundred Illustrations. BY WILLIAM B. CARPENTER, M.D., LECTURER ON PHYSIOLOGY IN THE BRISTOL MF.DICAL SCHOOL, &C. FIRST AMER. EDITIO.N. WITH ADDITIONS BY THE AUTHOR, AND NOTES AND ADDITIONS BY MEREDITH CLYMER, M.D. Lecturer on the Institutes of Medicine, Physician to the Philadelphia Hospital, Fellow of the College of Physicians, &.c. One Volume, Octavo. 8i!rThis edition of Carpenter's Physiology has been most carefully prepared by Dr. Clymer, at the request of Professor Jackson, for his lectures at llie Universiiyof Penn- sylvania. "Though the resources of the author's comprehensive mind are ajiparetitly devoted to the advance ment of new beginners in study, there is a splendid exhibition of the powers of analysj.s, an uncommon dejjroe of success in niakini; abstruse objects clear, and iu forcibly impr-ssin; upon otiiers the laws of life, which he so well understands himsidf, whicli will -.'ive eclat lo br. (.'arpenter's repu. tation, when he will be insensible to praise. All who can allord lo have a good system of Physioloiry, should possess this ; and those who are able to keep pace with the pro'.'ress of science should not be without it. There are (iKS pa,!;i!s, larse si/.e octavo, on good pap^T, u ith a type ;is distinctly made as it can be executed. Probably this edition does not cost more than oiir-ililrd llio price asked for it in England, and yet it is superior in very many respects."— £o»7uji Medical and Surgical Journal. WILSON'S DISSECTOR, ■WITH NU3VIEROUS CUTS. THE DISSECTOR, OR PRACTICAL AND SURGICAL ANATOMY. By Erasmus ^VI^soN, author of a System of Human Analoinv, &c., edited and rearraiitfed by Paul liitk Goddard, Ml)., Demonstrator of Anatomy, &c., in the Universiiyof Pennsylvania; in one large IJnio, volur.ii!, with numerous llluslratioiis. FIG. 4. FIG. 5. &H -< H • W M ^ -5-1 tH -!l ^ :? ^ cu CJ o - ^ l-H o liP^H w H-1 '^ w b o o ^ E^ ^ ^ -< F I G . 7. ISWISj iy t^.^'^/ llW 111'' lit |:l::.l . FIG. 4. A Longitudinal skction of a Femuu, SHOWING THE CeLLULAR STRUCTURE AT ITS EXTREMITY. FIG. 5. A Longitudinal section of a Tieia, SHOWING 1. The Compact Structure. 2. Tlic Cellular Structure. 3. A Transverse section of the Femur, showing its Compact Suljstancc, its Internal Cellular Structure, and the Medullary Canal. FIG. 6. The Texture of a Bone as shown in a humkrus, after maceration in dilute acid. 1.1. The Compact Matter as usually seen. 2. 2. The same split, so as to show the Lonone seen under its Articular Curtilage. FIG. 7. A VIEW or THE Concentric Lamellae of THE Compact Matter of a Bone. LEA & BLANCIIARD'S PUBLICATIONS. A MEDICAL LIBRARY FOR THE PRACTITIONER AND STUDENT. A SYSTEM OF PRACTICAI, MEDICINE, Comprised in a Series of Oricriiial Dissertations, arranged and edited by ALEXANDER TVVEEDIE, M.D., F.R.S., &.C., &c. Tlie whole revised, witli Notes and Additions, by W. W. GERHARD, M.D., Lecturer on Clinical Medicine to the University of Pennsylvania. The second American Edition, now complete in Three large Volumes. The d'jsiffn of this work is to supply the want, generally admitted to exist in the Medical Literature of Great Britain, of a comprehensive System of Medicine, einhodying a condensed, yet ample view of the Piesent State of the Science. The desideratum is more especially felt by tlie Medical Sl\ident, and by many Members of the Profession, who, from llieir avocations and olher circumstances, have not the opportunity of keeping pace witli the more recent improvements in the most interesting and nseful branch of liuman knowledge. To snpply tliisdeficiency is the object of the LIBRARY OF MEDICINE; and the Eililor expresses the hope, tiiat with the assistance with wliich he has been favoured by contri- butors, (many of great eminence, and all favourably known to the Public), he has been able lo produce a work, which will form a Library of General Reference on Theoretical and Practical Medicine, as well as a Series of Text-Books for the Medical Student. Advertisement of the Americaji Publishers to their New Edition in Three Volumes. The matter embraced in the Three Volumes now presented, was published in London in Five separate volumes, and at intervals republished in this country. The rapid sale of these volumes, embracing as they do, a History of Practical Medicine, is the best evidence of the favour with which it lias been re- ceived by the Physicians of the United States. Embodying as it does the most recent information on nearly every Disease, and written bv men who have specially devoted themselves to the study of the Disorders which form Ihe subject of their Articles, the work is the most valuable for Reference within the reach of a Practitioner. The arrangement of the Libuary into Classes of Diseases, gnniiied accord- ing to tlie cavities of the body, is much more agreeable to the reader than the alphabetical order, and nearly as convenient for reference. DISEASES OF CHILDREN. A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILDREN, BY WILLIAM P. DEWEES, M.D., late Professor of Midwifery in the University of Pennsylvania, &c. &c. The Eighth Edition, brought up to 1843, in 1 vol. 8vo. This edition embodies the notes and additions prepared by Dr. Dewees before his death, and w ill be found much improved. The objects of this work are, 1st, to teach those who have the charge of children, either as parent or guardian, the most approved methods of securing and improving their physical powers. This is attempted by pointing out the duties which the parent or the uiiardian owes for this purpose, to this interesting but heli)li!js class of beings, and the manner by which their duties shall he fullilled. And 2d, to render av;iil- ablo a huig experience to those objects of our affection when they become diseased. In attempting this, Ihe author has avoided as much as possible, " technicality ;" and has given, if he does not flatter liims(df too much, to each disease of which he treats, its appropriate and desisnating characters, with a fidelity that will prevent any two being coni"ounded together, with the best mode of treating them, that either his own experience or that of others has suggested. Physicians cannot too strongly recommuiid the use of this book in all families. A NEW WORK,— DUNGLTSON'S THERAPEUTICS AND MATERIA MEDICA. GENERAL THERAPEUTICS AND MATERIA MEDICA, ADAPTED FOR A MEDICAL TEXT-BOOK, BY ROBLEY DUNGLISON, M.D., Professor of Institutes of Medicine, &.C., in 2 vols. 8vo. — Just ready. A second edition of the work on General Therapeutics, being called for by the publishers, the author lias deemed it advisable to incorporate with it an account of the dilferent articles of the Materia Medica. To Ibis he has been led by the circumstance, that the departments of General Therapeutics and Materia Medica are always associated in the Medical Schools. The author's great object has been to prejiare a work which may aid the Medical Siurlent in acquiring the main results of modern observation and rellec- tion ; and, at the same time, be to the Medical Practitioner a trustworthy book of reference. Tliroiighont, he has adopted the Nomenclature of the last edition of the Pharniacopn^ia of Ihe United States, a work which ouglit to be in the hands of every practitioner as a guide in the preparation of medicines; and he has endeavoured to arranirc the articles in each division, as nearly as he could, in the order of th<;ir efficacy as Therapeutical agents. DEWEES' MIDWIFERY. A COMPENDIOUS SYSTEM OF MIDWIFERY, chiefly designed to facilitate the inquiries of those who may be pursuing ihi.^ branch of study. Illustrated by occa- sional cases, with many plates. The tenth edition, with additions and improvements, by W. P. DEWEES, M.D., late Professor of Midwifery in the University of Penn- sylvania, in one volume 8vo. LEA «fe BLANCEIARD'S PUBLICATIONS. A NEW WORK ON ANATOMY, WITH ONE HUNDRED AND SEVENTY ILLUSTRATIONS. A SYSTE.M OF HUMAN AN.\TOMY, GENERAL AND SPECIAL, BY ERASMUS WILSON, M.D., Lecturer on Anatomy, London. The American edi- tion, edited by Paul B. Goddard, A,J\]., M.D., Demonstrator of Anatomy in the Uni- versity of Pfnnsylvnniti, &,c. ; vvitli one liundred and seventy illut^trations on wood, by Gill)ert, from desii^n.5 prepared expressly for this work, by Bagg, printed from the second London edition, in 1 vol. 8vo. — Jusl ready. " Ar\ Ricffant edition of one of t!in most useful and accurate Systems of Anatnmical Science, wliicli has been isrJueil from tlie press. The ilhistralinns are really heautifiil, ami tin ir execution reflects the liisliest credit on the aide American artist who copied tliem for tliis edition of the work. In its style the work is extremely concise and iutelliiiilile. Dr Goddaril has addi'd a nuinlier of valuahle note's, and has made some juX/*j \j'\.'N/N/^ THE URINARY ORGANS, &c. LECTURES ON THE DISEASES OF THE URINARY ORGANS, BY SIR B. C. BRODIE, BART. F.R.S. PVoi/i the Third London Edition, with alterations and additions, a small Bvo. volume. — Now ready. The work has throiiiihout been entirely revised, some of the author's views have been modified, and a cour^iderable proiiortion of new matter lias been added, among which is a Lecture on tile Operation of Lithotomy. RICORD ON VENEREAL. A PRACTICAL TRF.ATISE ON VENERE.^L DISEASES; OR, CRITICAL AND E.XPKRIMENTAL RESEARCHES ON INOCULATION, APPLIED TO THE STUDY OF THF-SK AFFECPIONS; WITH A THP.RAPEUTiCAL SUMMARY AND SPECIAL FORMULARY, BY PH. RICORD, M.D.. Surgeon of the Vtjncroal Ho.'^pital of Paris, Clinical Professor of Special Pathology. &c. Translated from the French, by Henry Pilkington Dfuinmond, M.D., in one volume. — Now ready. LAWRENCE ON RUPTURES. A TREATISE ON RUPTURES, BY W. LAWRENCE, F.R.S., Author of a Treatise on the Diseases of the Eye, &c. i^'c, from the Fifth London Edition, consi- derably enlarged. In 1 vol. Bvo — Now ready The peculiar advantage of the treatise of Mr. Lawrence is, that he explains his views on the anatomy of hiTiiia, and the (lilicrcnt varieties of the disease, in a manner wliirli renders his book iH'Ciiliaily useful to the sludi'iit. It must be siipcrtluoMs to cxpri'ss our opinion of its value to the siir^'iral practitioner. As a treatise on hernia, prcsentiii;.' a coniplele view uf the literature of the subjeri. — in the niciliral ilirti'marii's niCL'ssiMt' In lln-ni. •' It may. iiidi'od, lu; cirrrclly nlhrnii-il, tliat wo liavi- ini iliclinnary ormcilical s'llrjccts ami torinj wliich can 111! Iimki'il II poll as ailnptrd to tin- Flati- of lliu sciriicc. In proof" of this I lie atitlior iioi-d Imt to remark, llial Ik; lias found oica.^ion |o add .several tliousaml iMedical 'IVrins, wliicli are not to be liift Willi ill the only iiiediial li'.sicon at Ihi.s lime in circulation in this country. "The present c-ditioii will he found to rnntaiu many tiumsand Terms more tlian the first, and to have trxperieiiced numerous Additions and .ModifieatioMs. " The author s id)jeet has not heeii to make the work a mere lexicon or dictionary of terms, hut to alTlird, under each, a coiiilen.'^ed view of its various medical relations, ami thus to render the work an epiloiiie of the e.xislinii cmnlition of Medical Stiiuice." This \ew Editi'Ui includes, in the ho.ly of the work, the Index or Vocahu'ary of pynonymes th;it was in lh<' former Kililions pi inted at the em! of ihi' Volume', and embrace.s many Corrections, with the addi- lion of over Two 't'liouband New Words and Terms. PEREIRA'S MATERIA MEDICA, EniTED nV DK. CARSON, WITH NEAU THRICE HUNDRED ENGRAVINGS ON WOOD. EEE.MENTS OF MATERL\ MEDICA AND THERAPEUTICS; COMPRE- HENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, COMPOSITION, EFFECTS, AND USES OF MEDICINES, BY JONATHAN PEREIRA, M.D., F.R.S., Assi.-tant Phy.-ician to the London Hospital, &c. Pan I, contain." tlie General Action and Classilicatiim of Medicine,", and the Mineral Materia Medica. Tart II, the Ve^'euiljle and Animal Kiii;;doins, and iueludins iliairrams iwplanatory of the Processes of th" l'liarniaco|xi'ias, a Tahular view of the History of the Alateria Medira, from the earliest times to the presiMit d;iv, .aud a very cnpious index. From the Sicmid London Edition, which has been thonuighly revisi'd, with the Introduction of the Processes of the New Rdinburj;li Pharmacopcnia, .Tiid containing adililioiial articles on Mcuilal Remedies. I.ijilit. Ileal, Cidd, Klcrtricity, .Ma^'uelism, Flxercise, Dietetics, and t'limale, and many additional Wool Cuts, illushative of Pharinaceutical Opcralions, Crystallogra- phy, Shape and (Organization of the Feiulas of Ciunmerce, and the Natiir;il History of the Materia Mi'dica. 'I'iie object of the author has been to sup|i!y the Meilical Slndent with a Class liook on Materia Medica. conlainiu!.' a fiithtul outline of this Departmeiil of .Medicine, which shoulil cinhrace a concise account of the most imporlant modern discoveries in .Catural History, Chemistry, I'hysiology, and Therapeutic.'' in so far as tliey pertain to Pharmacology, and treat the subjects in the order of tlieir natural historical relation?. ( This great Library or Cyclopedia of Miieria Mrdica hna been fully revised, the errors corrected, anil numerous additions made, by DR. JOSEPH C.VRSUN, Professor of Materia Medica and Pharmacy in | the"C(dlege of Pharmacy," and forms Two Vidumes, octavo, of near lliOO lar^e and closely-printed' pages; and it in,iy be fully relied upon as a permancat and standard work for the country,— embodying, as^it does, full references to Ihc U. S. Pharinacopea and au account of the Medicinal Plania indif^e- nous to the United Stales. PRINCirLES AND PRACTICE OF SURGERY, WITH CUTS. THE PRINCIPLES AND PRACTICE OF MODERN SURGERY, BY RO- BERT DRUITT. From the Second London Edition, illustrated with fifty wood en- piavings, with notes and comments by Joshua B. Flint, M.D., in one volume 8vo., at a low price. EXTRACT FROM THE ALTItOR's PRKFACE. '• The arrangement of a work of Ibis kind ought not, as I conceive, to lie regarded as a matter ofmere iiwiitfi reec.-, or at most of convenience, but it onjjhl lo embody in it something of a principle; ami I I., lieve that the arrangement of this work may be us.ful to the student, by sho\Mng hini Ml what order he mav best prosecute bis researches into Hie principles of his profession. . ., " Of the live tarts into v. bich it is divided, the first two are more especially ilevoted to the principle!", and the three art considers the various tissues, organs, and regions of Hie body in order, and describes the various acciileuils they are liable lo, kr. ...,.,, . . " The fifth part ile«cribe« such of the operations as were not included in the former parts. &c. •• To the whole is appended a collection of formula-, the niimb.r of which is very much increased in thi.s edition." ^ LEA & BLANCHARD'S PUBLICATIONS. FEVERS OF THE UNITED STATES. THE HISTORY, DIAGNOSIS AND TREATMENT OF TYPHOID AND TYPHUS FEVER, WITH AN ESSAY ON THE DIAGNOSIS OF BILIOUS REMITTENT AND OF YELLOW FEVER, BY ELISHA BARTLETT, M.D., Professor of tlie Theory and Practice of Medicine in the Transylvania University, In one volume 8vo; a new work. Notice lias alreaiiy been given of the appearance of this work : we have become satisfied of its sterling value, and, lliiTefore, without hesitalioii, foel justified in again recommending it to the immediate no- lice of practitioners. — Boston Medical and Surgical Jourval. MULLER'S PHYSIOLOGY. ELEMENTS OF PHYSIOLOGY ; BY J. MULLER, M.D., Professor of Ana- tomy and Physiology in the University of Berlin, &.c. Translated from the German by William Baly, M.D., Graduate in Medicine of the University of Berlin. Ar- ranged from the Second London Edition by .John Bell, M.D., Lecturer on Materia Medica and Therapeutics, &c., &c. In One Volume, 8vo. — Jusl ready. In arranginc the Vfdunie now offered to American readers, from the materials furnished in Mullf.r's Elements of Physioi.og?, the Er raiiciCiil tlioory, imr ol'iiili; liypnUifsis, Imt dl' c'lii.>(', pirscvoriiif; Clinical (Jlisii vatioii, aiT-m as to be easy of ri^ference, and a Irustv, orUi) t'uide in practice, yi contains not only l.he Virus of the Ai.lhor, on all tlnse poinis, derived from extensive opportunities for observation, but those of Ihe r!istin'.';iishiil obser\ers of the