.UC SOUTHERN REGIONAL LIBRARY 
 
 G 000 005 791 9
 
 GIFT OF 
 
 ■R-* n1 ->
 
 \ 
 
 fl 
 
 I
 
 OPINIONS OF THE PRESS 
 
 ON 
 
 WATSON'S PEACTICE OF PHYSIC. 
 
 The Publishers have great pleasure in submitting the following letter from 
 Professor Cliapman, as well as a few of the notices of the medical press, with 
 which this work has been honoured. 
 
 Philadelphia, September 27th, 1844. 
 Watson's Practice of Physic, in my opinion, is among the most comprehen- 
 sive works on the subject extant, replete with curious and important matter, and 
 written with great perspicuity and felicity of manner. As calculated to do much 
 good, I cordially recommend it to that portion of the profession in this country 
 who may be influenced by my judgment. 
 
 N. CHAPMAN, M.D. 
 
 Professor of the Practice and Theory of 3Icdicine 
 In the University of Pennsylvania, 
 
 " We know of no 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. On every import- 
 ant point the author seems to have posted up his knowledge to the day." — America?i Medical 
 Journal. 
 
 " In the Lectures of Dr. Watson, now republished here in a large and closely printed volume, 
 we have a body of doctrine and practice of medicine well calculated, by its intrinsic soundness 
 and correctness of style, to instruct the student and younger practitioner, and improve members 
 of the profession of every age." — Bulletin of Medical Science. 
 
 " We regard these lectures as the best exposition of their subjects of any we remernber to 
 have read. The author is assuredly master of his art. His has been a life of observation and 
 study, and in this work he has given us the matured results of these mental efforts." — New Or- 
 leans Medical Journal. 
 
 "We know not, indeed, of any work of the same size that contains a greater amount of inte- 
 resting and useful matter. The author is evidently well acquainted with everything appertaining 
 to the principles and practice of medicine, and has incorporated the stores of his well-stocked 
 mind, in the work before us, so ably and agreeably, that it is impossible for the interest of the 
 reader to flag for a moment. That they are well adapted foi such a purpose, all must admit; 
 but their sphere of usefulness may extend much beyond this. We are satisfied, indeed, that no 
 
 fihysician, well read and observant as he may be, can rise from their perusal without having added 
 argely to his stock of valuable information." — Medical Examiner. 
 
 "In this volume of the ' Principles and Practice of Medicine,' we have before us a mass of 
 information which is rarely to be found within the boards of a single volume. This is the age ol 
 condensation. Here is bi-ought together mature views of the present state of the science, by a 
 lecturer, acknowledged by all to be of the first order, and that which was spread over 1700 pages 
 of the London edition, we have in about 1100, (of course large pages,) and so cheap that no me- 
 dical reader will hesitate a moment to transfer it from the bookseller's counter to his own table 
 where it should lie constantly before him." — U. S. Gazette. 
 
 " We know of no systematic work on the Practice of Medicine equal to this. To extensive 
 erudition and natural cleverness, the discrimination and tact of a practical man, personally fami- 
 liar with all he treats of, is added. Besides showing himself a sound pathologist in these pages, 
 he proves that he is an admirable therapeutist. A vein of practical good sense distinguishes 
 every page. The time and patience of the reader are not consumed by idle disquisitions on 
 mooted points of no real utility. The style is agreeable, and we may even say fascinating. To 
 the medical student we consider the work as invaluable, and there are few practitioners, old or 
 voung, who, on reading it, will not be willing to acknowledge their obligations to it." — Saturday 
 'Post. 
 
 " 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 other countries as a representative of the natu 
 ral state of British medicine, as professed and practised by our most enlightened physicians. 
 And, for our own parts, we are not only willing that our characters as scientific physicians and 
 ■kiiful practitioners may be deduced from the doctrines contained in this book, but we hesitate
 
 2 NOTICES OF Watson's practice. 
 
 not to declare our belief, that for sound, trustworthy principles, and substantial good practice, it 
 cannot be paralleled by any similar production in any other country. * * * * \ye would 
 advise no one to set himself down in practice, unprovided with a copy." — British and Foreign 
 Medical Ixeview. 
 
 " We cannot refrain from calling the attention of our younger brethren, as soon as possible, to 
 Dr. Watson's Lectures, if they want a safe and comprehensive guide to the study of practical 
 medicine. 
 
 "In fact, to any of our more advanced brethren, who wish to possess a commodious book of 
 reference on any of the topics usually treated of in a course of lectures on the practice of physic, 
 or who wish to have a simple enunciation of any facts or doctrines, which, from their novelty or 
 their difficulty, the busy practitioner may not have made himself master of amidst the all-absorb- 
 ing toils of his professional career, we can recommend these lectures most cordially. Here we 
 meet with none of those brilliant theories which are so seductive to young men, because they 
 are made to explain every phenomenon, and save all the trouble of observation and reflection ; 
 here are no exclusive doctrines ; none of those 
 
 'Bubbles that glitter as they rise and break, 
 On vain Philosophy's all babbling spring.' 
 
 But we have the sterling production of a liberal, well-stored, and truly honest mind, possessed 
 of all that is currently known and established of professional knowledge, and capable of pro- 
 nouncing a trustworthy and impartial judgment on those numerous points in which Truth is yet 
 obscured with false facts, or false hypotheses." — Provincial Medical Journal. 
 
 " We find that, from the great length we have gone in our analysis of this work, we must 
 close our notice of it here for the present, not, however, without expressing our unqualified 
 . approbation of the manner in which the author has performed his task. But it is as a book of ele- 
 mentary instruction that we admire Dr. Watson's work." — Medico- Chirurgical Review. 
 
 " One of the most practically useful books that ever was presented to the student — indeed a 
 more admirable summary of general and special pathology, and of the application of therapeutics 
 to diseases, we are free to say, has not appeared for very many years. The lecturer proceeds 
 through the whole classification of human ills, a capite ad calcem, showing at every step an ex- 
 tensive knowledge of his subject, with the ability of communicating his precise ideas, in a style 
 remarkable for its clearness and simplicity." — N. Y. Journal of Medicine, cj-c. 
 
 " The style is correct and pleasing, and the matter worth the attention of all practitioners, 
 young and old." — Western Lancet. 
 
 " Wc are free to state that a careful examination of this volume has satisfied us that it merits 
 all the commendation bestowed on it in this country and at home. It is a work adapted to the 
 wants of young practitioners, combining, as it does, sound principles and substantial practice. 
 It is not too much to say, that it is a representative of the actual state of medicine as taught and 
 practised by the most eminent physicians of the present day, and as such we would advise every 
 one about embarking in the practice of physic to provide himself with a copy of it." — Western 
 Journal of Medicine and Surgery. 
 
 " It is an admirable digest of general pathology and therapeutics. As a text book for medical 
 Bchools, it cannot be surpassed, and in no other treatise can practitioners find so concise, and at 
 the same time so complete a summary of the present state of the science of medicine." — Balti- 
 more Patriot. 
 
 "It is the production of a physician of undoubted talent and great learning, and whose indus- 
 try in performing the most laborious duties of this profession has been well known for a long 
 series of years. * * * Let us not forget to add that the style and general character of the 
 work are peculiarly practical ; and the cases which Dr. Watson has from time to time introduced 
 to illustrate his views, are highly appropriate and interesting, and add much to the value of the 
 work ; and this certainly must be admitted to be one of the great advantages of casting this 
 work in the shape of lectures, in which these cases assuredly appear more fitly, and in which 
 they are introduced more easily and naturally than they could have been had the form of the 
 work been ditferent. 
 
 " Lastly, we are well pleased to observe that a strong vein of common sense, as well as good 
 tuste, runs through the whole treatise, and sustains both the interest and the confidence of the 
 reader throughout." — Edinburgh Medical and Surgical Journal. 
 
 " In calling the attention of the profession to the elegant volume recently published by Lea & 
 Blanchard — the lectures delivered at King's College, London, by Dr. Watson — we do not suppose 
 any one at all conversant with the medical literature of the day to be unacquainted with its gene- 
 ral character. Dr. W. delivered these now celebrated lectures during the medical session ot 
 lt<3(J-7. I'hey have been revised by the author, and those who now study these erudite pro- 
 ductions will have them divested of any objectionable matter that might have formerly crept in 
 through inadvertence. There are ninety lectures, fully written, embracing the whole domam of 
 human maladies, with their treatment, besides an appendix particularly remarkable for its rich- 
 ness in important practical information. We could not give even a tolerable synopsis of the sub- 
 jects discussed in this great undertaking without materially entrenching on the limits assigned to 
 other matter. * * * Open this huge well-finished volume wherever we may, the eye imme- 
 diately rests on something that carries value on its front. We are impressedT at once with the 
 strength and depth of the lecturer's views ; he gains on our admiration in proportion to the extent 
 of our acquaintance with his profound researches. Whoever owns this book will have an acknow- 
 ledged treasure if the combined wisdom of the highest authorities is appreciated." — Boston 
 Medical and Surgical Jourfial.
 
 LECTURES 
 
 PRINCIPLES AND PRACTICE 
 
 OF 
 
 PHYSIC; 
 
 DELIVERED AT KING'S COLLEGE, LONDON, 
 
 BY 
 
 THOMAS WATSON, M.D., 
 
 fELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; LATE PHYSICIAN TO THE MIDDLESEX HOSPITAtJ 
 AWD FORMERLY FELLOW OF ST. JOHn's COLLEGE, CAMBRIDGE. 
 
 THIRD AMERICAN, FROM THE LAST LONDON EDITION. 
 
 REVISED. WITH ADDITIONS 
 
 BY 
 
 D. FKANCIS CONDIE, M.D., 
 
 8ECKETARY OF THE COLLEGE OF PHYSICIANS ; AUTHOR OF A TREATISE ON DISEASES 
 OF CHILDREN, ETC. ETC. 
 
 PHILADELPHIA: 
 BLANCHARD AND LEA, 
 
 185G.
 
 Entered, according to the Act of Congress, in the year 1845, by 
 
 LEA AND BLANCHARD, 
 
 in the clerk's oflBce of the District Court for the Eastern District of Pennsylvania. 
 
 
 ' » • «
 
 T^^ 
 \^X 
 
 100 
 
 PREFACE BY THE EDITOR. 
 
 » 
 
 The very full and accurate exposition presented by Dr. Watson of the 
 present state of pathology and therapeutics, in reference to nearly all of 
 the diseases embraced in these Lectures, has rendered it unnecessary to 
 augment materially the size of the work by the addition of frequent and 
 extended notes. In regard, however, to a few of the forms of disease 
 more particularly interesting to the American physician, the account 
 S given by the Author will be found somewhat defective, while he has omitted 
 ^o to notice one or two affections endemic in the United States, his lectures 
 being chiefly confined to a consideration of the diseases most prevalent in 
 ^ Great Britain. It is to remedy these deficiencies that the Editor, in pre- 
 paring the present edition, has mainly directed his attention. In the notes 
 •^ he has added to Dr. Watson's lectures on diarrhoea and dysentery,' he has 
 1^ endeavoured to fill up the very brief sketch presented in the text, of the 
 'N. chronic forms of those diseases ; he has attempted, also, to supply, in part, 
 r^ the omissions of the Author, by his notes on the history, pathology and 
 * treatment of typhoid pneumonia, remittent fever, &c. 
 ! The intrinsic merits of Dr. Watson's Lectures are sufficient to ensure 
 "^ for them a favourable reception. If, by the few notes he has been induced 
 to append to the present edition, the Editor has succeeded in adding in 
 some slight decree to their value, he will be amply repaid for his labour. 
 
 CO 
 
 o 
 
 I 
 Philadelphia, September, 1845. 
 
 In passing through the press a new edition of Dr. Watson's Lectures, the 
 Editor has only to remark that he has corrected some few errors which 
 escaped attention in the last, while he has added some additional notes 
 where the subject appeared to require them. 
 
 Philadelphia, August, 1847. 
 
 a2 (H) 
 
 r"^>/i
 
 ADVERTISEMENT 
 
 TO 
 
 THE FIRST EDITION. 
 
 The following Lectures were put together, with unavoidable haste, dur- 
 ing the Medical Session of 1836 — 37, in which they were first delivered. 
 They were repeated, with slight variations, for four successive years ; the 
 Author always meditating, but never finding time to accomplish, their 
 thorough reconstruction and revision. They were afterwards printed, to 
 fulfil a rash promise, in the pages of the Medical Gazette : and they are 
 now published, in a collected form, at the request, formally conveyed to 
 him in writing, of many who had heard or read them, including several 
 of his colleagues at King's College. 
 
 Writing for mere beginners, and without any thought of future publica- 
 tion, the Author took no pains to note autnorities as he went along. He 
 may often, therefore, have used, without acknowledgment, not only the 
 facts and reasonings, but sometimes, perhaps, the very words of others 
 This omission he regrets, but is now unable to supply. Neither has he 
 leisure to correct, if that were desirable, the colloquial and famihar style 
 in which the Lectures were originally composed. 
 
 Should they attract the notice of any who are no longer in statu pupil- 
 lari, he would request such readers to bear in mind for whom these les- 
 sons were intended. They do not profess to present a formal and complete 
 treatise on the Practice of Physic, much less to exhaust the various subjects 
 upon which they touch. His chief hope is that they may prove useful as 
 a text-book for students. 
 
 As they are passing through the press, such additions and alterations 
 have been introduced as the Author would have made had he continued to 
 deliver the Lectures orally. 
 
 Henrietta Street, Cavendish Square, 
 September, 1843. 
 
 (7)
 
 AUTHOR'S ADVERTISEMENT 
 
 TO 
 
 THE SECOND EDITION. 
 
 The dnexpected exhaustion of the former edition of these Lectures 
 within the space of a twelvemonth, has left but little opportunity to the 
 Author, whose leisure is small, for such revision as might render them 
 more worthy of the encouragement they have received. Some errors 
 liave been corrected, but in substance, as well as in form, the Lectures 
 are nearly the same as before.
 
 CONTENTS. 
 
 LECTURE I. 
 
 InTROSUCTOBT ...^.^ .....^ FAQS 17 
 
 LECTURE IL 
 
 Pathology — meaning of the term. Pathology, general and special. Morbid alterations of 
 the solid parts of the body. Alterations in bulk. Hypertrophy — law of its production — 
 its effects. Atrophy — its causes and consequences. Changes in form. Alterations in 
 consistence. Induration — its various kinds 25 
 
 LECTURE III. 
 
 Softening; its causes and varieties. Transformations of Tissue; Changes of situation — in 
 the Chest, of the Lung, of the Heart — in the Abdomen and Pelvis, Hernia, Intussuscep- 
 tion, Prolapsus 33 
 
 LECTURE IV. 
 
 Morbid alterations of the Fluids, especially of the Blood. Changes in its quantity and distri- 
 bution. General and Local Plethora. Poverty of Blood. Active Congestion — its Phe- 
 nomena — state of the Vessels, as seen by the Microscope. Mechanical Congestion. Pas- 
 sive Congestion. Relations of these forms of Congestion to Inflammations — to Hemorrhages 
 — to Dropsies SB 
 
 LECTURE V. 
 
 Different modes of Dying. Pathology of Sudden Death. Death by Anaemia ; its Course, 
 Phenomena, and Anatomical Characters. Death by Asthenia; its Course, Phenomena, 
 and Anatomical Characters. Syncope. Death by Inanition. Death by Apnoea: Death 
 by Coma : their Course and Phenomena, and the Anatomical Characters common to both. 
 Application of the Principles obtained from the investigation of the Phenomena of Sudden 
 death, in elucidating the Symptoms and Tendencies of Disease 48 
 
 LECTURE VL 
 
 Causes of Disease: distinction between predisposing and exciting causes. Enumeration of 
 causes, as connected with the Atmosphere — Food and Drink — Poisons — Exercise — Sleep 
 — Mental and Moral Conditions — Hereditary Tendencies — Malformations. Temperature. 
 Effects of Heat and of Cold 57 
 
 LECTURE Vn. 
 
 Causes of Disease, continued. Laws by which the operation of Cold upon the Bodily Health 
 is regulated. Circumstances that favour its injurious Effects, and respect, first, the Body 
 itself; secondly, the manner in which the Cold is apphed. Modifying influence of certain 
 states of the Mind — of Sleep— of Habit. Means of protection. Influence of the different 
 Seasons. Impurity of the Air. Its influence in the production of Disease [no/el. Heredi- 
 tary tendencies to Disease 68 
 
 LECTURE VIIL 
 
 Symptoms. Their Uses in relation to the Diagnosis, the Prognosis and the Treatment of 
 Diseases. Signs, as distinguished from Symptoms. Pathognomonic, Commemorative, 
 Direct and Indirect Symptoms. Examples of Symptoms as they consist of uneasy Sensa- 
 tions, disordered Functions, or changes of Sensible Qualities 79 
 
 LECTURE IX. 
 
 Inflammation. Its Morbid and its Salutary Effects. Sketch of the Local and Constitutional 
 Phenomena of Inflammation as it occurs in External Parts. Examination of the Symp^ 
 toms of Inflammation ; Pain ; Heat ; Redness ; Swelling. State of the Capillary Blood- 
 
 Tessels and of the Blood [note] in a part inflamed - 93 
 
 (9)
 
 10 CONTENTS. 
 
 LECTURE X. 
 
 Inflammation, continued. Buffy Coat of the Blood. Terminations or Events of Inflamma- 
 tion. Resolution — Delitescence — Metastasis. Effusion of Serum. EtTusion of Coagulable 
 Lymph, or Fibrin. Organization of this Lymph. Suppuration. Ulceration 103 
 
 LECTURE XI. 
 
 Mortification, as an event of Inflammation. Inflammatory Fever. Hectic Fever. Typhoid 
 Fcer Modification of Inflammation by differences of Tissue ; Areolar Tissue ; substance 
 of Glands and Solid Viscera ; Serous Membranes ; Synovial Membranes ; Tegumentary 
 Membranes — Skin — Mucous Membranes; Muscular Tissue ; Arteries; Veins; substance 
 of the Brain 118 
 
 LECTURE XIL 
 
 Varieties of Inflammation: Acute and Chronic; Latent ^ Specific. Scrofulous Inflammation. 
 Tubercles. Forms of Tubercles [no^e]. Relative frequency of Scrofulous Disease in 
 different Organs. Signs of the Strumous Diathesis ^ - 124 
 
 LECTURE XIIL 
 
 Cancer; its Species or Varieties. Scirrhus; Encephaloid Cancer; Colloid Cancer. Its 
 
 mode of Growth and dissemination. Habitudes of the several Varieties. 
 Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting 136 
 
 LECTURE XIV. 
 
 Treatment of Inflammation, continued. Recapitulation. Bleeding. Purgatives. Mercury. 
 
 Antimony. Digitalis. Colchicum. Opium. 
 Local Remedies. External Cold. External Warmth. Counter-Irritation 149 
 
 LECTURE XV. 
 
 Hemorrhage : — most commonly by Exhalation. Habitual Hemorrhages. Vicarious Hemor- 
 rhages. Idiopathic Hemorrhages. Active and Passive. Symptomatic Hemorrhages. 
 Usual Situations of Hemorrhage. Symptoms and Diagnosis. Principles of Treatment. . 159 
 
 LECTURE XVI. 
 
 Dropsy : its General Pathology. Passive Dropsy ; Cardiac and Renal. Active, Acute, or 
 Febrile Dropsy. Prognosis; and General Principles of Treatment in Dropsies 168 
 
 LECTURE XVIL 
 Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults 180 
 
 LECTURE XVIH. 
 
 Purulent Ophthalmia, continued. Gonorrhoeal Ophthalmia. Purulent Ophthalmia of Infants. 
 Strumous Ophthalmia - 190 
 
 LECTURE XIX. 
 
 Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous Ophthalmia. 
 General Remarks on Conjunctival Inflammations. Iritis: its Symptoms and Treatment 
 Causes of Iritis 199 
 
 LECTURE XX. 
 ntis concluded. Rheumatic Ophthalmia. Amaurosis 209 
 
 LECTURE XXL 
 
 Diseases of the Brain and Nervous System. Difficulties of the subject. Short Revievr of 
 some points in the Physiology of the Brain and Nerves. Peculiarity of the Cerebral Cir- 
 sulation. Pressure 220 
 
 LECTURE XXII. 
 Symptoms of Cereoral Diseases. Inflammation of the Dura Mater and Arachnoid, from
 
 CONTENTS. li 
 
 external injury ; from Disease of the Bones of the Ear, and of the Nose. Inflammation 
 
 of the Pia Mater 229 
 
 LECTURE XXIII. 
 
 Acute and general Inflammation of the Encephalon. Period of Excitement. Modes in 
 which the disease may commence. Period of Collapse. Treatment. Delirium tremens. 249 
 
 LECTURE XXIV. 
 
 Delirium Tremens, concluded; treatment [note']. Chronic Inflammation of the Brain. 
 Softening, Suppuration, Abscess, Induration, Tumours in the Brain. . .^ .^ ^ . . 247 
 
 LECTURE XXV. 
 
 Hypertrophy of the Brain [note] ; Atrophy. Acute Hydrocephalus ; Premonitory Signs ; 
 DiSerent Modes of Attack ; Stages of the Disease ; Anatomical Characters ; Causes... 259 
 
 LECTURE XXVI. 
 
 Acute Hydrocephalus, continued. Prognosis and Mortality of the Disease. Treatment ; 
 Blood-letting ; Purgatives ; Cold ; Mercury ; Blisters. Prophylaxis. Spurious Hydroce- 
 phalus. Chronic Hydrocephalus, or Dropsy of the Brain. Shape of the Head and Face. 
 Anatomical Conditions. Symptoms 271 
 
 LECTURE XXVIL 
 
 Treatment of Chronic Hydrocephalus ; Internal Remedies : Mechanical Expedients ; Band- 
 ages. Tapping. Meningitis Encephalica [note]. Symptoms of Spinal Disease. Inflam- 
 matory conditions of the Spinal Marrow. Cerebro-Spinal Meningitis [note] 28^ 
 
 LECTURE XXVIIL 
 
 Inflammatory and Structural Diseases of the Spinal Cord, continued. Treatment. 
 Apoplexy. Its General Symptoms and Diagnosis. Different forms of the attacks. Predis- 
 position to Apoplexy — Natural, and accidental. Precursory Symptoms 298 
 
 LECTURE XXIX. 
 
 Apoplexy continued. Symptoms characterizing the Apoplectic State. Pressure the ordinary 
 Physical cause. Hemiplegia. Affection of Involuntary Muscles. Anatomical Characters. 
 Situation of the Clot of Blood. Disease of the Cerebral Blood-Vessels 307 
 
 LECTURE XXX. 
 
 Apoplexy continued. Relations between the Symptoms and the Appearances found in the 
 brain after death. Exciting Causes. Prognosis. Treatment 321 
 
 LECTURE XXXL 
 
 Spinal Hemorrhage. Paraplegia. Facial Palsy and Facial Anaesthesia ; their Symptoms, 
 Prognosis, and Treatment. Other Forms of Local Paralysis, and Local Anaesthesia .... 332 
 
 LECTURE XXXII. 
 
 Tetanus. Its Symptoms and Varieties. Causes. Diagnosis. Pathology. Treatment : 
 Opium ; Blood-letting ; the Warm Bath ; the Cold Bath ....^ ^ 345 
 
 LECTURE XXXIIL 
 
 Treatment of Tetanus continued. Wine ; Mercury ; Purgatives ; Digitalis ; Tobacco ; Musk ; 
 Prussic Acid ; Belladonna ; Carbonate of Iron ; Oil of Turpentine ; Strychnia ; Surgical 
 Expedients ; General Rules. Hydrophobia 355 
 
 LECTURE XXXIV. 
 
 Hydrophobia concluded. Various Questions considered respecting the Disease as it appears 
 in the Human Subject, and respecting Rabies in the Dog. Pathology of tbi* Disiwrder. 
 Treatment. Preven,ive Measures .--.«_ , . . . « ... ,.,.* —^...^ . , 86A
 
 12 CONTENTS. 
 
 LECTURE XXXV. 
 
 Epilepsy. Its Symptoms and varieties ; duration and recurrence of the paroxysms ; periods 
 of life at which they commence ; warnings. Efiects of the paroxysms, immediate and 
 ultimate. Pathology. Anatomical characters 379 
 
 LECTURE XXXVL 
 
 Epilepsy continued. Recapitulation. Exciting causes. Simulated epilepsy. Diagnosis. 
 Prognosis. Treatment : during the fit ; during the Intervals ; during the Warnings .... 388 
 
 LECTURE XXXVn. 
 
 Chorea. Symptoms ; Pathology ; Complications ; Causes ; Treatment. Chronic Chorea. 
 Other Nervous Disorders to which the same name has been applied 399 
 
 LECTURE XXXVIIL 
 
 Paralysis Agitans. Mercurial Tremor. Hysteria ; Two Forms of Hysteric Paroxysm ; 
 Diagnosis from Epilepsy; Class of persons most liable to Hysteria ; Diseases apt to be 
 simulated by Hysteria ; Treatment ; Prevention. Salaam Convulsions [note] 410 
 
 LECTURE XXXIX. 
 Catalepsy. Ecstasy. Neuralgia; Tic Douloureux ; Sciatica; Hemicrania 424 
 
 LECTURE XL. 
 
 Intermittent Fever. Phenomena of an Ague Fit. Species and varieties of Intermittents. 
 Predisposing causes. Exciting cause. Malaria : known only by its effects ; places which 
 it chiefly infests ; conditions of its production ; its efiects upon the human body ; influence 
 of soils in evolving it 1 435 
 
 LECTURE XLL 
 
 Ague, continued. Speculations respecting its periodicity. Habits and properties of the 
 malaria ; most noxious at night ; lies near the ground ; is carried along by winds; cannot 
 pass across water ; attaches itself to trees ; is diminished by the increase of cultivation and 
 of population. Ultimate effects of the poison on the body. Ague formerly thought salu- 
 tary. Prognosis. Propriety of stopping the disease - • . 447 
 
 LECTURE XLII. 
 
 Treatment of Intermittent Fever ; during the paroxysm ; during the intermissions. Prophy- 
 laxis 457 
 
 LECTURE XLIIL 
 
 Epistaxis. Bronchocele ; Cretinism ; their Phendmena and probable Causes. Medical antf 
 Surgical Treatment of Bronchocele 467 
 
 LECTURE XLIV. 
 
 Cynanche Parotidffia. Spontaneous Salivation. Aphthae; pathology of [rjo/e]. Cynanche 
 Tonsillaris 479 
 
 LECTURE XLV. 
 
 Acute Laryngitis. Symptoms. Treatment ; Blood-letting. Tracheotomy, Mercury, Antu 
 mony. Anatomical Characters of the Disease. Causes. Secondary Laryngitis. QEdema 
 cf the Glottis. Chronic affections of the Larynx 491 
 
 LECTURE XLVL 
 
 Cynancne Trachealis : Symptoms ; Pathology ; Prognosis ; Treatment. Tracheotomy [note]. 
 Child-crowing, or Spurious Croup. Spasmodic Laryngitis [no/e]. Nocturnal periodic 
 Cough [note] . . ..^ ^ - - - ^ - 50S 
 
 LECTURE XLVn. 
 
 Diseases of the Thorax. General observations. Dyspnoea. Cough. Methods of exploring 
 the physical conditions of the Chest, by the senses of sight, touch and hearing 517
 
 CONTENTS. 13 
 
 LECTURE XL VIII. 
 
 Catarrh ; its varieties. Acute Bronchitis. Dry sounds attending the Respiration ; Rhonchus 
 and Sibilus ; Moist sounds ; Large and Small Crepitation : how these are produced, and 
 what they denote. Treatment of Acute Bronchitis. Peripneumonia Notha. Sudden 
 Infraction of a large Bronchus 528 
 
 LECTURE XLIX. 
 
 Influenza. Symptoms and progress. Conjecture as to its Cause. Treatment. Hay Asthma. 
 Chronic Bronchitis. Its varieties. Morbid Anatomy of these affections 539 
 
 LECTURE L. 
 
 Hooping-cough : symptoms ; duration ; complications ; pathology; treatment. Pneumonia ; 
 its stages and morbid anatomy; auscultatory signs 552 
 
 LECTURE LL 
 
 Pneumonia, continued ; its general symptoms ; pain, dyspnoea, cough, expectoration. Course 
 of the disease. Prognosis. Treatment. Pneumonia in Children [note] . .^ 564 
 
 LECTURE LIL 
 
 Pleurisy. Its anatomical characters ; false membranes ; liquid effusion ; effects of these upon 
 the shape and contents of the Chest, and upon its healthy sounds. Symptoms of Pleurisy 579 
 
 , LECTURE LIIL 
 
 Pleurisy, continued. Recapitulation of symptoms ; of diagnostic signs. Causes of Pleurisy. 
 Pneumothorax ; its condition, and signs. Treatment of Pleurisy. Empyema. Paracen- 
 tesis Thoracis. Typhoid Pneumonia [note'j ^ 590 
 
 LECTURE LIV. 
 
 Pulmonary Hemorrhage ; its varieties ; its connection with pulmonary consumption, and 
 with disease of the heart. Pulmonary Apoplexy. Prognosis in Haemoptysis. Symptoms 
 Treatment 608 
 
 LECTURE LV. 
 
 Pafmonary Emphysema ; vesicular and interlobular. Anatomical characters of vesicular 
 Emphysema ; physical signs ; general symptoms ; causes ; treatment. Interlobular Em- 
 physema ; its anatomical characters, symptoms, cause, and cure. CDdema of the Lungs. 
 Phthisis Pulmonahs 618 
 
 LECTURE LVL 
 
 Phthisis, continued. Vomicae ; adhesions of the pleurae ; ulceration of the larynx and trachea 
 — of the intestines ; fatty liver ; auscultatory signs of a vomica ; gurgling ; cavernous 
 respiration, pectoriloquy. General Symptoms of Phthisis : cough, expectoration, dyspnoea, 
 pain, hectic fever, diarrhoea, wasting, oedema, aphthae 62tt 
 
 LECTURE LVIL 
 
 Phthisis, continued. Diagnosis. Forms and varieties of Phthisis. Ordinary duration. Age 
 at which it is most frequently fatal. Influence of sex, and of occupation. Question of 
 contagion. Treatment, Curability of [no/e] 641 
 
 LECTURE LVIIL 
 
 Melanosis of the Lung ; true, and spurious. Accidental intrusion ot solid substances into 
 the air-passages (J52 
 
 B
 
 J4 ■ CONTENTS. 
 
 LECTURE LIX. 
 
 Diseases of the Heart ; usually partial. Changes in its muscular texture. Mechanism of 
 those changes. Natural dimensions of the Heart. Natural sounds. Modifications of 
 these by disease. Review of the physical and general signs that accompany Cardiac 
 Disease 660 
 
 LECTURE LX 
 
 Diseases affecting the muscular texture of the Heart, and their treatment. Changes to which 
 the valves of the Heart are subject. Effects and diagnosis of those changes. Angina 
 Pectoris - 671 
 
 LECTURE LXL 
 
 Pericarditis ; its frequent connection with Acute Articular Rheumatism. Rheumatic Car- 
 ditis. Anatomical characters of acute inflammation of the pericardium ; of the Endocar- 
 dium. General symptoms. Auscultatory signs. Relations of Carditis with Rheumatic 
 Fever ^ 682 
 
 LECTURE LXn. 
 
 Treatment of Acute Pericarditis and Endocarditis : blood-letting; mercury; blisters. Chro- 
 nic and partial inflammation of the pericardium. Disease of the Aorta. Thoracic Aneu- 
 risms ; their various situations and symptoms ; plan of treatment 697 
 
 LECTURE LXHL 
 
 Diseases of the Veins. Phlebitis ; adhesive and suppurative ; consecutive scattered Abscesses. 
 Treatment of Inflammation of Veins. Effects of the gradual obstruction of large Venous 
 Trunks 707 
 
 LECTURE LXIV. 
 
 Asthma : its nature ; complications ; exciting causes ; and treatment. Diseases of the 
 CEsophagus ; Inflammation of Infants [no/e] ; Stricture; Spasm: Dilatation 716 
 
 LECTURE LXV. 
 
 Diseases of the Abdomen ; sometimes diflacult to identify. Method i>f investigating these 
 diseases ; by the eye, the hand, the ear. Inflammation of the Peritoneum : its symptoms ; 
 and causes. Puerperal Peritonitis. Peritonitis from Perforation -^ 727 
 
 LECTURE LXVL 
 
 Treatment of Acute Peritonitis ; Bleeding, Mercury, Opium. Chronic Peritonitis ; Granular 
 Peritoneum. Ascites; Ovarian Dropsy; Diagnosis of these diseases. Other forms of 
 Abdominal Dropsy 736 
 
 LECTURE LXVIL 
 
 Pathology of Chronic Ascites ; of Ovarian Dropsy. Treatment of these two disorders. In- 
 ternal remedies ; Extirpation of the ovarian sac ; Paracentesis Abdominis 744 
 
 LECTURE LXVm. 
 
 Acute Gastritis ; symptoms ; anatomical characters ; treatment. Acute Gastritis of Infants 
 [note]. Chronic Iriflanmiation of the Stomach; thickening of the Mucous Membrane ; 
 Ulceration : symptoms and treatment of the disorder. Cancer of the Stomach 763 
 
 LECTURE LXIX. 
 
 Hemorrhage from the Stomach : sometimes from a large vessel, usually by exhalation. 
 Idiopathic Hsematemesis. Vicarious HjEmatemesis. Hsmatemesis from gastric disease 
 for injury: Irorn disease in other organs. Melsena. Haematemesis from a morbid state 
 of the blood. General phenomena of Hsmatemesis. Diagnosis. Treatment 76i
 
 CONTENTS. 15 
 
 LECTURE LXX. 
 
 Dyspepsia. Physiology of Digestion. Symptoms of Dyspepsia. Treatment and Prevention, 
 Dietetic and Medicinal 774 
 
 LECTURE LXXI. 
 
 Enteritis : its symptoms ; causes ; treatment. Mechanical occlusion of the Intestinal Tube. 
 Colic. Colica Pictonum ; its symptoms, complications, treatment, and prevention 784 
 
 LECTURE LXXIL 
 
 Diarrhoea. Chronic Diarrhoea [notej. Sporadic Cholera. Epidemic Cholera. Cholera 
 Infantum [note] 798 
 
 LECTURE LXXIIL 
 
 Dysentery: Morbid Anatomy [note] ; Chronic [notty Diarrhoea Adiposa. Intestinal Con- 
 cretions. Worms 814 
 
 LECTURE LXXIV. 
 
 Entozoa, continued. Hydatids. Trichina Spiralis. The Guinea Worm. Strongulus Gigas. 
 Origin of Entozoa. Question of Spontaneous Generation. General Symptoms of the 
 presence of Intestinal Worms, Particular symptoms, and remedies, of the common Round 
 Worm, of Thread Worms, of Tape Worms 829 
 
 LECTURE LXXV. 
 
 Diseases of the Liver. Acute Inflammation. Abscess of the Liver. Causes and Treatment 
 of Acute Hepatitis. Chronic Hepatitis. Jaundice. Its symptoms, causes, species, and 
 pathology [note'] 841 
 
 LECTURE LXXVL 
 
 Treatment of the various species of Jaundice. Diseases of the Gall-bladder ; of the Spleen ; 
 of the Pancreas. Diseases of the Kidneys. Nephritis and Nephralgia. Phenomena 
 constituting a "fit of the Gravel." Dillerent kinds of Gravel. Diseased states of the 
 UTine. Description and Remedies of the Lithic, Pliosphatic, and Oxalic Diathesis 854 
 
 LECTURE LXXVIL 
 
 Suppression of Urine. Diabetes : Qualities of the Urine ; symptoms ; anatomical appear- 
 ances ; general pathology of the disease ; treatment. Diuresis 866 
 
 LECTURE LXXVIII. 
 
 Albuminous Urine. Means of detecting the Albumen. What it imports. Anatomical 
 characters of Bright's Kidney. Symptoms to which this renal disease gives rise. Nature 
 of the Affection ^77 
 
 LECTURE LXXIX. 
 
 Anasarca ; its consideration resumed. Distinction of Chronic General Dropsy into Cardiac 
 and Renal. Characters and signs of each of these varieties. Treatment 88T 
 
 LECTURE LXXX. 
 
 Chylous Urine. Haematuria ; its diagnosis, general and particular ; Local Disorders of the 
 Urinary Organs on which it depends ; treatment. Abdominal Tumours 897 
 
 LECTURE LXXXL 
 
 Acute Rheumatism ; symptoms ; varieties ; treatment. Chronic Rheumatism ; phenomena , 
 
 plan of cure. 
 Gout : description of a paroxysm ; progress of the disease ; general state of the health in 
 
 gouty persons ; causes of the disease ; diagnosis between Gout and Rheumatism 906
 
 16 CONTENTS. 
 
 LECTURE LXXXII. 
 
 Pathology of Gout. Prognosis. Prejudices respecting the disease. Treatment : during the 
 paroxysms ; during the intervals. Cutaneous diseases 91'1 
 
 LECTURE LXXXin. 
 
 Exanthemata. They are contagious ; sometimes epidemic. Period of the eruption ; period 
 of incubation. Theory of contagious Febrile Diseases. Continued Fever 925 
 
 LECTURE LXXXIV. 
 
 Continued Fever, continued. Phenomena of the second week ; Delirium, an Eruption, 
 DiarrhcEa : of the third week ; Recovery, or death in the way of Coma, of Apnoea, of 
 Asthenia. Symptoms that usher in those modes of death ; morbid changes found after 
 them °3' 
 
 LECTURE LXXXV. 
 
 Varieties of Continued Fever. Its causes, exciting and predisposing. Prophylaxis 946 
 
 LECTURE LXXXVL 
 
 Continued Fever, concluded. Treatment. Bilious Remittent Fever [note]. Small-pox. 
 Its essential symptoms. Distinction into discrete and confluent. Periods and modes in 
 which it proves fatal o . 957 
 
 LECTURE LXXXVn. 
 
 Small-pox, continued. Inoculation. Vaccination. Their comparative advantages. Treat- 
 ment of Small-pox .-^ 978 
 
 LECTURE LXXXVIIL 
 Chicken-pox. Measles. Scarlet Fever 991 
 
 LECTURE LXXXIX. 
 
 The Plague. Erysipelas. Erysipelas in Infants [no/e]. Erythema Nodosum. Urticaria. 
 Prurigo. Scabies 1004 
 
 LECTURE XC. 
 
 Herpes ; Eczema ; Pompholix ; Lepra ; Psoriasis ; Impetigo ; Boils ; Carbuncle ; Purpura ; 
 
 Scurvy. Conclusion of the Course 1017 
 
 Vkv^x ^ 1031
 
 LECTURES 
 
 PEINCIPLES AND PRACTICE OF PHYSIC. 
 
 INTRODUCTORY LECTURE. 
 
 Gentlemen : — In approaching any new course of systematic inquiry, there are 
 certain points concerning which the inquirer should always be careful to satisfy 
 himself. He should comprehend, distinctly, what it is that he proposes to learn ; 
 its subject-matter, and its objects : he should consider whether he is about to adopt 
 the most easy, direct, and effectual means for obtaining his purpose ; and whether 
 he is qualified, by the possession of the requisite preliminary information, for pursu- 
 ing his inquiries with intelligence and profit. To these points, and to some others, 
 as they are connected with the duties with which I have been entrusted in this col- 
 lege, I wish briefly to direct your attention on the present occasion. It will be my 
 endeavour to furnish you, at the outset, with clear notions of the nature and the ends 
 of that branch of study upon which you are now about to enter; to explain why it 
 is taught, and how far it may be taught, by oral discourses ; to point out to you what 
 may reasonably be expected from me, and what, to render my attempts prosperous, 
 will be required on your parts. Something also it is expedient you should know 
 beforehand respecting the general order and arrangement of the course ; and a short 
 explanatory comment upon some of the terms that we shall constantly be employing, 
 will clear the way for the succeeding lectures, which forming, more strictly than the 
 present, a part of the series, will also be more strictly didactic in their character. 
 
 The subject of our study is that wonderful thing, the animal body — and more par- 
 ticularly the human body; its construction and qualities; its actions and its suffer- 
 ings ; its derangements ; its decay. 
 
 In this study, which affects the mind with a strong feeling of curiosity, not un- 
 mixed with awe, you have already advanced a certain way : for you have observed 
 the outward form and configuration of the body ; examined its internal composition 
 and structure ; and learned what is known of its various endowments, the working 
 and the uses of its several parts. 
 
 This amount of knowledge was indispensable to j'our further progress. But it 
 forms a portion only of what you assemble here to learn : or rather it is the neces- 
 sary preparation for that ulterior knowledge which it is your main purpose to acquire. 
 The sublimer speculations springing naturally from the researches in which you 
 have as yet been engaged, have not, I trust, been unregarded. You cannot have 
 looked into the mechanism of that intricate but perfect work, — you cannot have con- 
 templated its fullness of exquisite contrivance, its endless examples of means adjusted 
 to ends; its prospective expedients against future needs, its compensations for inevi- 
 table disadvantages, its direct provisions for happiness and enjoyment, — without 
 receiving the profoundest conviction of the being and the attributes of its Maker. Il 
 is upon human anatomy that Paley, in his unrivalled argument for Natural Theology, 
 " takes his stand ;" and sixteen centuries before him, Galen !.ad felt that, in writing 
 3 b2 (17)
 
 18 INTRODUCTORY LECTURE. 
 
 his aniUomical treatises, he was composing a hymn to the Deity ; that a declaration 
 so plain of the wisdom, the power, and the goodness of God, was an act of piety 
 and praise. But beyond, though not above, these higher objects of a diligent inves- 
 tigation of man's bodily fabric, we have another and still a nobler end; and it is my 
 business to take you one step nearer to that end. Hit} erto you have been told of 
 structure and of function. Henceforward our theme must be of health and of dis- 
 ease. Of health, that we ma)"^ understand disease; of disease, that we may, under 
 Providence, restore health. Our objects are to preserve the one ; to prevent, remove, 
 or mitigate the other. 
 
 What then do these contrasted terms denote? 
 
 Health we regard as a standard condition of the living body. But it is not easy 
 to express that condition in a few words, nor is it necessary. My wish is to be 
 intelligible rather than scholastic; and I should probably puzzle myself as well as 
 you, were I to attempt to lay down a strict and scientific definition of the term health. 
 It is sufficient for our purpose to say, that it imphes freedom from pain and sick- 
 ness ; freedom also from all those changes in the structure of the body that endanger 
 life, or impede the easy and effective exercise of the vital functions. 
 
 It is plain that health does not signifj^ any fixed and immutable condition of the 
 body. The standard of health varies, in different persons, according to age, sex, 
 and original constitution ; and in the same person even, from week to week, or from 
 day to da}', within certain limits it may shift and oscillate. 
 
 Neither does health necessarily imply the integrity of all the bodily organs : it is 
 not incompatible with great and permanent alterations, nor even with the loss, of 
 parts that are not vital ; as of an arm, a leg, or an eye. 
 
 If we can form and fix in our minds a clear conception of the state of health, we 
 shall have no difficulty in comprehending what is meant by disease, which consists 
 in some deviation from that state : some uneasy or unnatural sensation of which the 
 patient is aware ; some embarrassment of function perceptible by himself, or by 
 others; or some unsafe, though hidden condition, of which he may be quite uncon- 
 scious : some mode, in short, of being, or of action, or of feeling, different from those 
 which are proper to health. 
 
 I use the word disease generically. Various terms in our language bear nearly 
 the same meaning, and endeavours have been made to appropriate some of these 
 more distinctively. Thus the word disorder has sometimes been apphed to simple 
 derangements of function, where no alteration of structure is seen, or can reasonably 
 be inferred to exist ; while the term disease has been restricted to maladies, which 
 are attended with appreciable change of texture, or which run a short and definite 
 course. I see no great utility, but, on the contrary, some risk of confusion, in tying 
 ourselves rigidly down to such distinctions: indeed, we cannot always make them. 
 During life it is often no easy thing to determine .i|jhether the parts, of which the 
 functions are disturbed, preserve their integrity of structure or not : and even when 
 the peccant organ is placed before our eyes after deam, and the most careful scrutiny 
 fails to discover in it any fauhiness of texture, there may still be ground for suspect- 
 ing that some material change, too subtle for detection by our senses, may have been 
 wrought in its finer and more delicate orsfanization. I shall take care to point out 
 to you, as we go along, the cases in which we can trace organic change, and the 
 cases in which we cannot ; but, for the sake of simplicity, I shall call all deviations 
 irom the healthy standard, whether of function or of structure, by the generic term 
 disease ; and to avoid the perpetual and tiresome recurrence of the same word, I 
 shall not scruple to employ the several terms disorder, complaint, malady, distemper, 
 illness, as its synonyms. 
 
 The number of these deviations from the standard of health, (in other words, the 
 whole number o( diseases,) if we include all their differences in Idnd and in degree, 
 is scarcely calculable ; and the first thing requisite towards investigating the laws 
 that govern their phenomena, is, that we should break them into groups, and dispose 
 them according to some principle of order. 
 
 Now, there are various methods in which this first broad classification of diseases 
 miffht be framed.
 
 INTRODUCTORY LECTURE. ' 19 
 
 The most cursory examination of the animal economy suffices to show that it is 
 made up, not merely of separate parts, but of several distinct systems. There is 
 one set of organs foi the mechanical circulation of the blood ; there is an apparatus 
 expressly designed for the repeated exposure of the blood to the air ; a system for 
 regulating the movements and the feehngs of the body; another for receiving, pre- 
 paring, and appropriating its nourishment ; another for the elaboration of matters 
 that are useful or essential to its functions ; another for carrying off its impuritiqs, 
 and for removing its superfluous or effete materials ; and another for the continuance 
 of the species. 
 
 Now each of these systems is liable to changes of structure and interruptions of 
 function, peculiar to itself; and these peculiarities must be taken into account, what- 
 ever may be the order adopted in treating of diseases in detail. But I shall not 
 divide the subject, as some have done, into diseases of the circulating system — dis- 
 eases of the respiratory system — diseases of the nervous system — and so on ; for 
 this, among other reasons, that there are many forms of disorder that effect all these 
 systems in common, or simultaneously, and comparatively few that are strictly con- 
 fined to any one of them. 
 
 Neither, in the lectures which I am about to commence, shall I classify diseases 
 according to the several tissues of which the animal frame is composed. In speak- 
 ing of diseases in general, it will, indeed, be both proper and necessary to explain in 
 what manner the same morbid process may be modified by the nature of the special 
 tissue affected. But as the entire body is more or less penetrated and pervaded by 
 the intermixture of several of these tissues, so no useful nor lucid arrangement of 
 diseases could be founded on this basis. 
 
 Nor shall I attempt to construct a nosological system by grouping together certain 
 sets of symptoms, and calling each set, in its collective form, a disease. 
 
 To say the truth, I shall consider convenience and usefulness, in frammg my 
 plan, rather than an appearance of scientific precision; and if I make one principle 
 of arrangement more prominent than another, it will be that which relates to the 
 anatomy of regions, — the place and situation of organs. At the same time, I shall 
 not omit to borrow in part from some of those other methods to which I have just 
 been referring. 
 
 Before, however, we treat of the nahire of particular diseases, it will be requisite 
 to give some general account of the different waj-s in which the various parts of the 
 body are liable to be altered in structure, or disordered in function ; and before we 
 speak of the signs of particular diseases, it Avill be proper to take a general view of 
 symptoms, and of their ascertained relations with the several forms of altered struc- 
 ture : for doubtless you are aware that, although diseases are not constituted by 
 symptoms, they are, in the living body, disclosed by symptoms. Sometimes the 
 symptoms are outward signals which alone reach our senses, and through which 
 internal changes declare themselves ; and we then have to decipher and to interpret 
 those signals. Sometimes we see the morbid changes themselves on the surface of 
 the body, or in parts within our ken. Some internal changes we can appreciate as 
 surely by the touch, or by the sense of hearing ; and of some we infer the existence 
 from alterations in the chemical or in the sensible qualities of the natural excretions. 
 
 After death, diseases are often to be traced by visible changes of structure in the 
 internal parts of the body. These changes are extremely interesting, as illustrative 
 of morbid processes : they throw light upon what is past ; they afford some guidance 
 for the time to come. But, for obvious reasons, those signs which reveal diseases 
 during life are, practically, of chief moment. In trutli, the great object of our art 
 is to prevent or postpone the disclosure of the others. The instruction afforded by 
 the dead body comes too late to be of use in that particular case. 
 
 I have already intimated that the morbid physical conditions irom which the symp- 
 toms flow, are not always to be detected, either before or after dissolution. Neither, 
 when they are detected, is their connection with the symptoms always evident.^ 
 
 Besides inquiring into the modes in which the various organs and textures of the 
 body may be spoiled, and into the signals or symptoms by which the presence of 
 disease may be ascertained, it will \^ fcypedient to premise something, in a genen*
 
 20 INTRODUCTORY LECTURE. 
 
 manner, of the causes of disease, both with a view to its cure, and, what is much 
 better, to its prevention. We shall also find it very useful to institute a short inquiry 
 into the different ways in which death may take place — the different processes of 
 dying. 
 
 There is one morbid condition or process, to which all parts of the body are 
 liable, and which contributes so largely and so frequently to alterations both of tex- 
 ture and function, that it claims our especial attention when discussing the more 
 general facts and doctrines of pathology : I allude to that change, or series of 
 changes, which we comprehend under the term injlammation. 
 
 It will be necessary, therefore, in the preliminary part of the course, to give a 
 general account of inflammation ; and this account must chiefly be drawn from those 
 of its phenomena which are most famihar to us — which we can see and handle; 
 those which we witness when the disorder is seated in or near the surface, in the 
 skin, in some of the mucous membranes, or in the subjacent areolar tissue. Then 
 we shall pursue the examination of its peculiar phenomena as they are presented in 
 the other tissues of the body — the mucous, serous, fibrous, parenchymatous, muscu- 
 lar, and nervous tissues ; and here the general principles of treatment applicable to 
 inflammation may be laid down, with the modifications required according to the 
 tissues interested. 
 
 In this part of the course may also be conveniently discussed the modifications ot 
 inflammation, and of morbid conditions generally, by the influence of certain diathe 
 ses, or peculiar dispositions of the body. Some constitutional morbific tendencies 
 we shall find to be innate or hereditary ; such are the scrofulous and the cancerous 
 dispositions : others, again, are plainly acquired, as that in which the whole system 
 is tainted for a longer or shorter period by the venereal poison. 
 
 Hemorrhages, also, and serous accumulations, or dropsies, as they are liable to 
 occur in all parts of the body, require to be treated of generally, before they pass 
 under our notice in the hst of particular maladies. There are certain facts and rea- 
 sonings common to all inflammations, to all hemorrhages, to all dropsies. By com- 
 bining these "generalities" into one comprehensive statement, we help the memory, 
 avoid needless repetitions, and find room for the exposition of principles. 
 
 Diseases themselves, in the mass, are sometimes distinguished according as they 
 are local, or general. 
 
 Taking these epithets in their popular sense, we should say that local diseases are 
 those which occupy a definite portion only of the body ; general diseases, those 
 which pervade the whole body. 
 
 But let us endeavour to obtain clear notions upon these points. 
 
 Certainly there are many diseases which, occupying a definite portion onl}'- of the 
 body, leave all the remaining parts, and the system at large, healthy both in texture 
 and in function. Such diseases we have no hesitation in calling local. 
 
 Again, there are many other diseases which, occupying a definite portion only of 
 the body, yet occasion a manifest and serious disturbance in the functions of various 
 other parts, and (it may perhaps be said) of the whole system. Inflammation of a 
 small portion of the frame may give rise to much secondary or symptomatic fever, 
 but here also we properly speak of the disease as being local ; the secondary' general 
 disorder resulting from the local and primary, following it in point of time, and sub- 
 siding upon its cessation. 
 
 But there are still other forms of disease which show themselves, not like inflam- 
 mation now in this and now in that part, but in many or most parts of the body at 
 the same time. I will take the complaint called purpura, characterized by the uni- 
 versal appearance of purple spots, as an example of what I mean. It is in truth a 
 hemorrhage afl^ecting many or all the tissues of the body simultaneously. For this 
 reason it is commonly regarded as a general disease. 
 
 But if we look somewhat closer into the matter, we shall, I think, perceive that 
 most, if not aU, of those which have been thus reputed general, are, in fact, reduci- 
 ble to the class of local diseases. The fluids are as much parts of the body as the 
 »ohds ; and if it be true, as I believe it is, that the essential and primary change in 
 purpura is a change in the blood, its characteristic phenomena will be apt to present
 
 INTRODUCTORY LECTURE. 21 
 
 themselves wherever there is blood circulating — that is, throughout the whole syj- 
 tem. The disease is local, inasmuch as its original seat is in that particular fluid, 
 the blood : it appears to be general, because the morbid blood is everywhere present. 
 
 The same observations apply to a large class of febrile contagious diseases ; to 
 that state of the general system which is sometimes called anaemia ; also to certain 
 spasmodic affections, where the seat of the actual disorder is in the whole nervous 
 system. 
 
 What are called general diseases, therefore, are those in which the whole of some 
 one system that pervades the entire body happens to be similarly deranged. Whe- 
 ther diseases can ever be truly called general in any more strict or absolute sense 
 than this, is much to be doubted. 
 
 I have mentioned dropsy as a malady which, like hemorrhage or inflammation, 
 may occur in various parts of the body separately. It may also extend at once to 
 all parts capable of receiving and retaining serous effusions : i. e., besides filhng the 
 large serous cavities, the effused fluid may occupy the universal areolar tissue. 
 But even this apparently general dropsy will be found, upon careful investigation, 
 to resolve itself, in most cases at least, into local disease within the thorax, or the 
 abdomen. 
 
 The diseases which, in the sense now explained, may be called general, I shall 
 arrange among the diseases of those parts of the system from which they have been 
 ascertained, or may be presumed, to arise. 
 
 The first part, then, of the course will embrace an outUne of general pathology, 
 with an especial reference to those morbid conditions which fall to the care of the 
 physician. In its relations to surgery and to midwifery, pathology will be more 
 particularly taught by the respective professors of those distinct though kindred 
 departments of medicine. Do not, however, imagine that I take no interest in 
 these, or that there can be any thing different in the principles upon which the 
 several branches of pathological knowledge are founded. The truth is, that you 
 cannot, if you would, separate the one from the other. You can neither understand 
 what may be called medical, without learning much which as strictly belongs to 
 surgical pathology ; nor can you be ignorant of either, without being in many 
 important respects deficient in the other also. But the open field of pathology is of 
 wide extent, and although we may, and must, survey the whole, yet its artificial 
 divisions, its enclosures and allotments, will be cultivated best, and most improved, 
 by a division of labour. 
 
 Afterwards, separate diseases are to be described and considered ; all such, at least, 
 as admit of being individuahzed, or presented under a definite shape. And here, I 
 repeat, I shall chiefly pursue an anatomical order, as being comprehensive and inar- 
 tificial, and as tending to facilitate diagnosis. The diseases of parts which lie near 
 each other are the most liable to be confounded. 
 
 I shall begin, therefore, with the diseases of the parts that appertain to the head 
 and spinal cord, and then proceed in succession to those of the parts belonging to 
 the neck, the thorax, and the abdomen ; to those of the joints, the muscles, and the 
 skin. I shall not hesitate, however, to deviate from this order, whenever, by doing 
 so, I can promote your convenience or advantage. 
 
 With that portion of the course which relates to particular diseases, I shall also 
 interweave certain pathological considerations, applicable not so much to the whole 
 body as to the several great systems of which it is made up. Thus, when I come 
 to the brain, I shall speak of the functions pecuhar to the nervous system, and of 
 the obstructions and disturbances to which those functions are obnoxious, by way of 
 preface to a detailed examination of the various afflictions of the several parts of 
 that system. Before discussing the diseases of the chest, I shall bring before you, 
 in a general view, the manner in which the great functions of respiration and of 
 circulation are liable to be impeded, or otherwise disordered. As preparatory to 
 the consideration of the diseases of the abdomen, I shall treat, in the same way, of 
 the function of nutrition; and of waste, which implies an interruption of those 
 functions. 
 
 Still ihere would remain certain diseases, which would not necessarily find a
 
 22 INTRODUCTORY LECTURE. 
 
 place m this arrangement, inasmuch as their seat is uncertain or only guessed at. 
 Ague is one of these. Cholera, perhaps, another. It is quite unimportant where- 
 abouts in the course such maladies are considered. I feel no concern about any 
 imputations of imperfect or clumsy arrangement with which the plan that I propose 
 to adopt may appear chargeable. I had rather not be cramped and hampered by 
 attempting what abJer heads than mine have failed to achieve, and what, in truth, 
 I beHeve, in the present state of our science, to be impossible, a complete methodical 
 system of nosology. My object will be to furnish as much instruction and informa- 
 tion as I can, in the way that seems most likely to be practically useful to you. 
 
 Ague I shall take leave to include among the disorders of the nervous system ; 
 and with it, the important subject of malaria will necessarily engage much of our 
 attention. 
 
 The great question of contagion I shall consider in connection with continued 
 fever, which I rank among that remarkable class of diseases, the contagious exan- 
 themata of Cullen. 
 
 Of sympathetic and of hectic fever, I must opeak when upon the subject of 
 inflammation. 
 
 This, then, is a sketch of the method I propose to follow. In the earlier lectures, 
 with the general pathology, I shall endeavour to lay down principles. To these 
 principles I shall continually refer, as occasions offer, both in those prefatory remarks 
 with which I purpose to introduce the diseases belonging to the several great sys- 
 tems that contribute to form the body ; and also in what I shall subsequently have 
 to say concerning those diseases themselves in detail. In this way I hope to com- 
 bine the advantage of repetition, which was the peculiar advantage of two short 
 courses in a season, with that of greater completeness, which forms the recom- 
 mendation of a single extended course. The same great advantage of repetition — 
 or I should rather say of recapitulation — will be further aimed at in the stated exa- 
 minations of the class. 
 
 Such being a summary of the topics to be embraced in the ensuing series of 
 lectures, and of the order in which I hope to take up those topics, it seems proper 
 that I should now say a few words in explanation of the scope and objects of the 
 course. The prospectus informs you that it will comprehend the Principles and 
 Practice of Physic. What are the true import and promise of these words? 
 
 By ihc principles of medicine are meant those general truths and doctrines which 
 have been ascertained and estabUshed, slowly, indeed, and irregularly, but still 
 with considerable precision, by the continued observation of attentive minds through- 
 out the entire progress of medicine as a science. These principles I profess to teach 
 you. The practice of medicine, or the particular application of those general facts 
 and doctrines I shall describe to you ; but I cannot profess to teach it in this room : 
 nor can you learn it, except in a very imperfect sense, from my description of it. 
 Ft is the science that I shall here endeavour to unfold. Skill and facihly in turning 
 that science to useful purposes I am unable to impart. These are qualities that do 
 not admit of being communicated from one mind to another. The practice of 
 physic, like every other practical art, is to be learned by its repeated exercise ; by 
 habit ; by carrying its various acts into direct effect again and again ; or, if they 
 happen to require no manual dexterity, by looking on, and seeing them done again 
 and again. There is this capital difference, however, between the art of healing 
 and some other arts : that the blunders of early attempts may be both grievous and 
 irremediable — may hurt or spoil the goodly and precious machine they are intended 
 to repair. There is this also peculiar to our art — that it proceeds upon observations 
 made at the very time when its exercise is wanted ; and that it requires skill in ob- 
 serving as well as skill in acting. You will find what, perhaps, previously to 
 posmve trial, you might not suspect, that the senses — the eye, the ear, the touch — 
 nowever sharp or delicate they may naturally be, require a special course of training 
 and education before their evidence can be trusted in the investigation of di>^ease. I 
 do not know that these views are capable of being rendered plainer by illustration ; 
 I'or you must have observed a similar distinction between the science and the art in
 
 f 
 
 INTRODUCTORY LECTURE. 23 
 
 various other branches of human knowledge. The principles of navigation may- 
 be thoroughly comprehended by a person who scarcely knows a rudder from a cable, 
 and who would not be trusted, nay, who would not trust himself, with the conduct 
 of the simplest boat. A man may master tlie beautiful science of astronomy — may 
 acquire the power of working upon paper its sublimest and most abstruse problems 
 — and yet remain in complete ignorance of the method of adjusting and using a 
 telescope, and unable to ascertain for himself the position or the movements of a 
 single star. But place such a person night after night in an observatory — let him 
 notice and imitate the proceedings of some one already skilled in examining the phe- 
 nomena of the heavens — and he will soon acquire the requisite tact and facility him- 
 self. Just so it is with that branch of knowledge with which we are concerned. It 
 is in the wards of a hospital, or in the domestic chamber — it is among the sick and 
 the dying — and there alone — that you can either thoroughly or safely learn to prac- 
 tise physic. 
 
 In what, then, you may fairly ask, consists the value or the use of lectures on the 
 practice of physic, if the practice of physic cannot be taught by lectures ? 
 
 The main object of systematic lectures, explanatory of the principles, and descrip- 
 tive of the practice of medicine, is to prepare the hearer for observing, to the best 
 advantage, the actual phenomena of disease, and the power of remedies over it. 
 They are intended to fit him for seeing with intelligence — to enable him to read, and 
 understand, and interpret, the book of nature when it is laid open before him — in 
 short, to qualify him for clinical study. One man shall travel into a foreign land, 
 knowing nothing beforehand of its scenery or its climate, of its natural productions, 
 its manufactures, or its works of art, and ignorant alike of the manners, customs, 
 history, laws, and language of its inhabitants ; another shall visit it after having fur- 
 nished his mind Avith information on these subjects by reading, and by conversing 
 with men who have already passed over the same ground. Supposing the visit to 
 be limited in each case to a certain, but not long period of time, and I need not ask 
 your opinion as to which of these travellers will reap the greatest harvest of enjoy- 
 ment and of profitable knowledge from his journey. Not less striking is the dif- 
 ference, in point of instruction and of interest, perceived by different students, upon 
 their admission to the bedsides of the sick, according as they have been well or ill 
 prepared for the multiform spectacle of bodily suffering then first displayed before 
 them. There are persons, indeed, who seriously, and I make no doubt in perfect 
 good faith, warn the student against bringing to the contemplation of disease any pre- 
 conceived opinions ; who tell him that he must come with a free and unprejudiced 
 mind, and see, and note, and judge of all things for himself. I also would have him 
 exercise, and ultimately abide by, his own judgment ; but surely if every man were 
 to depend upon his own unassisted observation for his knowledge of disease, every 
 man would be marvellously ignorant, and the science of medicine would stand still, 
 or cease to be. " If no use be made (says Dr. Samuel Johnson) of the labours of 
 past ages, the world must remain always in the infancy of knowledge." In truth, a 
 person who, without any previous information concerning diseases, should betake 
 himself to a hospital with the design of impartially and resolutely investigating their 
 phenomena, such a person, however clear and strong his intellect might be, would 
 find himself, for a long time, more puzzled than instructed by what he saw around 
 him He would be perplexed by the shifting and seemingly contradictory characters 
 presented by the same malady in different patients ; or in the same patient at dif- 
 ferent times ; and not less so by the outward resemblance of disorders essentially un- 
 like. He could not but be confused by the multitude of symptoms that crowded 
 upon his attention on every side ; and at a loss to distinguish important facts from 
 those which, for the chief ends of his pursuit, were trivial, or useless. 
 
 The business, therefore, of a lecturer upon the Principles and Practice of Medi- 
 cine, or, as it is sometimes worded, the Nature and Treatment of Diseases, is first 
 to fix upon some order in Avhich to treat of the various subjects comprised in hi? 
 course. The simpler and less artificial his arrangement, the better. The chief use 
 of this classification is to facilitate the recollection of particular facts ; and I hava 
 already told you that if I can distribute and connect the multifarious forms of diseasti
 
 24 INTRODUCTORY LECTURE. 
 
 in such a manner as that they shall appear plain to your understanding, and take a 
 secure hold upon your memory, I shall not trouble myself nor you with a vain search 
 after that phantom — a perfect methodical nosology. " In all such classifications," 
 writes Lord Brougham, "we should be guided by views of convenience rather than 
 by any desire to attain perfect symmetry ; and that arrangement may be best suited 
 to a particular purpose which plants the same things in one order, and separates 
 them and unites them in one way, when an arrangement which should dispose those 
 thmgs differently might be preferable, if we had another purpose to serve." 
 
 Having settled this framework of his discourses, the next aim of the lecturer must 
 be to collect and arrange from the voluminous and bewildering records of medicine, 
 and from the necessarily more slender stores of his personal experience, whatever it 
 may seem of consequence that his hearers should know concerning each distinct 
 form of disease, as it comes before them for consideration : to state all the facts which 
 are well ascertained, and which tend to explain its symptoms, to elucidate its origin, 
 to identify its nature, to direct its treatment, to accomplish its prevention : to sift the 
 true facts from the false, the important from the trivial, the essential from the acci- 
 dental : to analyze the relations of these facts, and ascending from particulars to 
 generals, to point out those great principles and precepts which constitute the keys 
 both to the knowledge and to the management of all diseases of the same kind. It 
 may even sometimes be his duty to notice and discuss mere theoretical opinions ; to 
 express his own sentiments upon disputed or undecided questions ; and to admonish 
 his audience against the danger of being led away by ingenious refinements, by the 
 speciousness of novelty, or the boldness of speculation, from the more secure and 
 settled results of careful observation improved by patient thought. 
 
 These duties of a lecturer on medicine are metaphorically, but aptly, expressed in 
 the following passage from Lord Bacon : — 
 
 " Formica colHgit, et utltur, ut faciunt empirici ; aranea ex se fila educit, neque 
 a particularibus materiam petit, ita faciunt medic speculativi ac mere sophistici ; apis 
 denique ca^teris se melius gerit. Ha3c indigesti e floribus mella colligit, deinde in 
 viscerum cellulis concocta maturat, iisdem tamdiu insudat, donee ad integram perfec- 
 tionem perduxerit." 
 
 I may venture to paraphrase it thus : — 
 
 The lecturer must not be the ant, collecting all things indiscriminatdy from all 
 (juarters, as provender for his discourses ; 
 
 Nor the spider, seeking no materials abroad, but spinning his web of speculative 
 doctrine from within himself; 
 
 But rather the bee, extracting crude honey from various flowers, storing it up in 
 the recesses of his brain, and submitting n to the operation of his internal faculties, 
 until it be matured, and ready for use. 
 
 Such, gentlemen, are the main objects which I shall endeavour to keep steadily 
 in view during the series of lectures I am about to commence ; and I should ill 
 deserve the chair I have the honour to occupy, if I did not feel the great responsi- 
 bility under which I speak to you. The subjects with which we have to deal are 
 not niatters of mere speculative curiosity or intellectual amusement — to be taken up 
 to-day and dismissed perhaps with unconcern to-morrow — but they involve ques- 
 tions of life and death. The opinions you are now to form or to embrace, are for 
 the most part the opinions upon which in after Hfe you will confident!}'' and con- 
 stantly be acting. The comfort or the misery of many families may probably hang 
 upon the notions that each of you will carry from this place. Therefore it is that I 
 feel myself to be engaged in a very serious undertaking. Doctrines and maxims, 
 good or bad, flow abroad from a public teacher as from a fountain, and his faulty 
 lessons may become the indirect source of incalculable mischief and suffering to 
 hundreds who have never even heard his name. These reflections fill my mind 
 with an almost painful sense of the obligation imposed upon me, by my present 
 office, of closely sifting the facts, and of carefully examining the principles to be 
 derived from "those facts, which I propose to employ for your instruction and 
 cruidunce
 
 PATHOLOGY. 25 
 
 But amid all the responsibilities, gentlemen, both of teacher and of learner, the 
 profession which you and I have chosen, or Aviiich circumstances have prescribed to 
 us, is a noble profession, and worthy the devotion of a hfetime. If you fit your- 
 selves now for its high functions, and pursue it hereafter in earnestness and truth, it 
 will probably conduct you to an honourable competence, and it will assuredly prove 
 a salutary school of mental and of moral discipline. Trials, no doubt, belong to it, 
 and difficulties ; but it has also privileges and immunities peculiar to itself. Afford- 
 ing ample scope and exercise for the intellect, it is conversant with objects that tend 
 to elevate the thoughts, to chastise the feehngs, and to touch the heart. I have 
 already reminded you how it brings beneath our minute and daily notice that most 
 remarkable portion of matter, which is destined for a season to be the tabernacle of 
 the human spirit, and which, apart from tho*^ singularly interesting thought, excites 
 increasing wonder and admiration the more closely we investigate its marvellous 
 construction. The sad varieties of human pain and weakness with which our daily 
 vocation is familiar, should rebuke our pride, while they quicken our charity. To 
 us are entrusted, in more than ordinary measure, opportunities of doing good to our 
 afflicted fellow-creatures — of showing love towards our neighbour. Let us bev^rare 
 how we idly neglect, or selfishly abuse, a stewardship so precious, yet so weighty. 
 The profession of medicine, having for its end the common good of mankind, knows 
 nothing of national enmities, of political strife, of sectarian dissensions. Disease 
 and pain the sole conditions of its ministry, it is disquieted by no misgivings con- 
 cerning the justice and honesty of its client's cause ; but dispenses its pecuhar 
 benefits, without stint or scruple, to men of every country, and party, and rank, and 
 religion, and to men of no religion at all. And like the quality of mercy, of which 
 it is the favourite handmaid, "it blesseth him that gives and him that takes;" read- 
 ing continually to our own hearts and understandings the most impressive lessons, 
 the most solemn warnings. It is ours to know in how many instances, formino- 
 indeed a vast majority of the whole, bodily suffering and sickness are the natural 
 fruits of evil courses ; of the sins of our fathers, of our own unbridled passions, of 
 the malevolent spirit of others. We see, too, the uses of these judgments, which 
 are mercifully designed to recall men from the strong allurements of vice, and the 
 slumber of temporal prosperity; teaching that it is good for us to, be sometimes 
 afflicted. Familiar with death in its manifold shapes, witnessing from day to day 
 its sudden stroke, its slow but open siege, its secret and insidious approaches, we are 
 not permitted to be unmindful that our own stay also is brief and uncertain, our 
 opportunity precarious, and our time, even when longest, very short, if measured by 
 our moral wants, and intellectual cravings. 
 
 Surely, gentlemen, you will not dare, without adequate and earnest preparation, 
 to embark in a calling like this ; so capable of good if rightly used, so full of peril 
 to yourselves and to society if administered ignorantly or unfaithfully. And even 
 when you have made it, as you may, the means of continual self-improvement, 
 and the channel of health and ease to those around you, let not the influence you 
 will thus obtain beget an unbecoming spirit of presumption ; but remember that, in 
 your most successful efforts, you are but the honoured instruments of a superior 
 power — that, after all, "It is God who healeth our diseases, and redeemeth our life 
 from destruction." 
 
 LECTURE II. 
 
 Pathology — meaning of the term. Pathology, general and special. Morbid 
 alterations of the solid parts of the body. Alterations in bulk. Hypertrophy 
 — law of its production — its effects. Atrophy — its causes and consequences. 
 Changes inform. Alterations in consistence. Induration — i/s various kinds. 
 
 I PROPOSE to devote several lectures, in the commencement of the course, to 
 
 pathology, as it relates to medicine. 
 
 o
 
 26 ALTERATIONS OF SOLIDS. 
 
 And I must first of all explain to you what I mean by the word Pathology. 
 
 Many persons speak of pathology as if it were the same thing with morbid 
 anatomy. That is not the sense in which I purpose to use the term. Pathology is 
 morbid anatomy, but it is something more. 
 
 A knowledge of pathology (in the full and proper acceptation of the word) 
 implies indeed a knowledge of altered structures and of diseased conditions; — but 
 it implies also an explanation of these — a knowledge of what precedes them, and a 
 knowledge of what results from them. 
 
 It comprehends, therefore, the following particulars : — 1. A knowledge of the 
 material changes to which the several parts of the living body are subject : 2. A 
 knowledge of the processes or actions whereby these changes may be wrought : 3. 
 A knowledge of the causes which may set these processes on foot: and 4. A 
 knowledge of the consequences of the same changes, or of the symptoms they 
 occasion. 
 
 On some of these points our actual knowledge is still scanty and imperfect. Yet 
 a good deal of valuable information concerning each of them has been collected ; 
 and this I shall endeavour to place before you as distinctly, and at the same time in 
 as small a compass, as I can. 
 
 Pathology is general or special. General pathology treats of the morbid condi-* 
 lions which are common to the entire system, or to the whole of each of the several 
 tissues that pervade and compose the system. Special pathology contemplates par- 
 ticular diseases. An acquaintance with general pathology prepares us for, and con- 
 ducts us to, that which is special ; and w'hen I say that the eariier lectures of the 
 course will be given to a consideration of the leading facts and doctrines of patho- 
 logy, you will of course understand me to speak of general pathology. 
 
 I shall begin by inquiring what are the changes to which the component parts 
 of the hving frame are liable : and I speak chiefly of sensible changes ; leaving 
 unnoticed for the present those conditions which are perceptible only through the 
 microscope. 
 
 There are, then, various ways, capable of intelligible description, in which the 
 different parts of the body may be sensibly altered by disease. 
 
 The solid garts may be altered in bulk; inform; in consistence ; in their inti- 
 mate texture, i. e., in the qualities and arrangement of their component particles ; 
 and in situation. 
 
 The fluid parts may also be altered in quantity ; in quality ; and in place. 
 
 And many of these alterations may exist in combination wilh each other. 
 
 Let us first consider the solids. 
 
 They may be simply altered in bulk without any change of texture ; and that in 
 two ways. They may become larger than natural, or smaller than natural. In the 
 one case the change is called hypertrophy, in the other atrophy. 
 
 We find the best illustrations of hypertrophy in the muscular system. The 
 huge fleshy masses visibly prominent in the arm of a blacksmith or a pugilist, 
 and in the leg of an opera dancer, afford familiar examples of it. In these cases 
 the increased bulk, although it may be unsightly, as being out of proportion to other 
 parts, is not disease, and does not interfere with the most perfect health. By con- 
 stant exercise the muscles acquire preternatural volume, and weight, and power. 
 It seems to be a law which prevails extensively in the animal economy, that increase 
 of function should lead to augmentation of bulk. The function of the muscular 
 system is contraction, and more frequent and energetic contraction begets an ad- 
 dition of substance. But the same principle obtains in various other parts and 
 tissues. It is especially noticeable in some of the organs that are double. If one 
 kidney wastes, or is spoiled by disease, an increase of function is thrown upon the 
 oiher, and by a beautiful law of compensation, the sound organ, without any alter- 
 ation of its peculiar fabric, enlarges. The same is observed to be the case wilh the 
 lungs The law resembles, somewhat, one that is familiar to political economists, 
 and is expressed by them in the maxim — that the supply of a marketable com- 
 modity is regulated by the demand for it. If, in respect to a muscle, increase of 
 force be habitually needed, the necessity generates the requisite addition of bulk,
 
 ALTERATIONS OF SOLIDS. Zi 
 
 which implies an augmentation of force. One kidney becoming inefficient, it is 
 necessary that the other should secrete a larger quantity of urine ; and this faculty is 
 obtained by the enlargement of the secreting organ. 
 
 I say this law is of extensive operation in the living body : but it is not universal. 
 [t does not hold, for instance, in respect to the organs of the special senses. One 
 eye does not become hypertrophic when the other is blind ; nor one ear grow larger 
 or longer because the other is deaf. And we see at once why the law in question 
 does not apply in such cases. These organs differ from such as I mentioned before 
 — from muscular and glandular parts — in this : that increase of their size would not 
 further or facilitate the purpose they are designed to serve. A muscular arm will 
 strike a harder blow and lift a heavier weight, in proportion to the greater bulk of 
 its muscles : but we should gain nothing in distance or distinctness of vision by the 
 enlargement of an eye ; nor should we hear more acutely or more clearly if our ears 
 were of twice the ordinary magnitude. 
 
 Hypertrophy of this unmixed kind — unattended by any change of texture — (and 
 It is 10 this that the term should as much as possible be restricted) — is believed to 
 depend upon more active nutrition of the part (vrtsp *pcK|»;.) More materials are laid 
 down in the part by the blood, and assimilated, than are received back from the part 
 into the blood to be taken out of the body. The nutritive process preponderates over 
 the re-absorbent. That hypertrophy does thus result from an excess in the process 
 by which parts are nourished and built up, and not from a defect in the process by 
 which they are continually unmade and removed, is rendered probable by the fact 
 that an increased quantity of nutrient blood is sent to the hypertrophied part ; its 
 arteries grow larger : this we perceive by comparing these vessels with others where 
 no accession of bulk has occurred. This opinion is further strengthened by the 
 converse effect produced upon an hypertrophied part (the thyreoid gland, for in- 
 stance), by tying its principal nutrient artery. The magnitude of the bronchocele 
 diminishes. It is curious that no such alteration of size has been noticed in the 
 nerves supplying the hypertrophied parts. 
 
 Now these examples of hypertrophy clearly have not the nature of disease. But 
 hypertrophy is often plainly connected with disease, while still it is not itself a 
 morbid process. Thus we have it in the hollow contractile organs, the office of 
 which is to propel fluids : — in the heart when the progress of the blood suffers some 
 mechanical impediment : in the bladder when the urine, and in the intestinal canal 
 when its contents are somehow hindered in their natural course ; or when, from 
 some undue stimulus or irritation, these parts respectively are urged for a long time 
 together to excessive, or too frequent action. I show you preserved specimens ot 
 each of these changes. You will find that muscular tissue may become apparent, 
 under the influence of disease, where very slight traces of it, or none at all, were 
 visible before. We sometimes observe this in the air-tubes, the trachea and bronchi, 
 when the respiratory functions have been long embarrassed ; and in the gall-blad- 
 der, when the exit of the bile has been chronically obstructed. And it is worth 
 remarking that this new, or greatly exaggerated appearance of muscular tissue, 
 which is the consequence of disease in the human body, is a part of the natural and 
 healthy structure in the corresponding organ of some of the inferior animals. 
 
 The several instances of hypertrophy that I have now been mentioning, if they 
 are to be looked upon as morbid, are morbid in a particular and limited sense — 
 morbid, merely as being associated with disease, but not so either in their own pro- 
 cesses or in their tendencies. Many, indeed, of the writers who notice them, speak 
 of the hypertrophy as constituting a source of disease, and a cause of danger to the 
 patient. But I shall have occasion to show you hereafter that in most cases it is 
 really a compensatory change, and conservative of life ; — a resource of nature by 
 which impending danger is postponed, and existence prolonged. 
 
 It may be said of hypertrophy, that its relation to disease depends very much 
 upon its seat. As regards the muscular system — in the voluntary muscles it is 
 generally innocent, in the involuntary it is generally connected with disease ; 
 sometimes as a cause, much oftener as a consequence, sometimes as both cause 
 and consequence. One way in which hypertrophy may manifestly be a cause of
 
 28 HYPERTROPHY. 
 
 disease is by the pressure'of an enlarged organ upon the parts in its neighbour- 
 hood, and a consequent interference with the functions or the sensations of those 
 parts. 
 
 I am not sure, whether to those among you who are beginners, I make myself 
 understood. An example or two will render my meaning obvious. 
 
 It often happens that the aortic orifice of the left ventricle of the heart becomes 
 narrow and constricted, in consequence of disease in the semilunar valves there 
 situate. Under these circumstances it is requisite, for the due propulsion of the 
 obstructed blood, that the ventricle should contract with increased force : and its 
 walls become, accordingly, thicker and stronger. Here the hypertrophy of the left 
 chamber is evidently a consequence or effect of the disease that previously existed 
 at its outlet. 
 
 On the other hand, when the thyreoid gland is enlarged, it sometimes presses so 
 much upon the parts that lie behind it, as to impede the breathing, or the swallow- 
 ing. In this case the hypertrophy is the cause of consecutive disease. 
 
 Hypertrophy is exceedingly common in other tissues as well as in the mus-* 
 cular. Of its affecting the glandular system we have good examples in what I 
 have just mentioned, the true bronchocele ; in certain forms of enlarged prostate ; 
 in the thymus gland not unfrequently. Of a state of the brain which is considered 
 to constitute hypertrophy, I shall speak more particularly when we come to the 
 morbid conditions of that organ. Hypertrophy is also said (I am not certain with 
 how much propriety always) to occur in the cutaneous, mucous, and vascular 
 systems, in the bronchial, mesenteric, and mammary glands, in the liver, spleen, 
 and pancreas. Of these parts I suspect that the enlargements to which the term 
 hypertrophy has been sometimes applied, most frequently combine some alter- 
 ation of texture with the increase of size, and therefore are not strict examples of 
 hypertrophy. 
 
 You ought to be aware that hypertrophy of one or more of the component tissues 
 of an organ may exist, while the others either remain unaltered, or are changed in 
 some other way. It frequently happens that when one component part is thus over- 
 nourished, it is so at the expense (as it would seem) of another which becomes atro- 
 phied. There are parts of the heart upon which a certain quantity of fat is usually 
 deposited. It is not uncommon to meet with this fat in excess, and at the same time 
 to find the muscular texture of that organ pale, flabby, soft, and wasted. What has 
 been deemed hypertrojihy of the female breast consists, almost always, I believe, in 
 excessive development of its adipose tissue, without any enlargement of the gland 
 itself — or even with its diminution. 
 
 Hypertrophy of the adipose tissue is often general througiiout the body, producing 
 obesity ; and this may become so extreme as to amount to disease, when it is called 
 by nosologists polysarcia. I have seen one fatal instance of this kind. The mother 
 of a large family, whom I long knew as a slender and elegant woman, began sud- 
 denly to grow fat ; and in about fifteen months, without any other discoverable 
 malady, she gradually enlarged into a corpulent unwieldy monster. At length her 
 legs and thighs became a3dematous as well as fat, her lips blue, hei breath was 
 short, and her pulse feeble. One night she was found dead in her bed. The body 
 was not examined ; but her death was mainly owing, as I believe, to fat collected 
 upon the heart, oppressing its movements, and at last stopping them altogether. 
 
 [n the majority of cases the size of an hypertrophied organ is augmented ; it has 
 a larger superficies than is natural : and therefore I have introduced hypertrophy to 
 your notice among the alterations to which parts are hable in balk. 
 
 But it is not always so. There may be hypertrophy of an organ without enlarge- 
 ment — in at least three different ways : — 
 
 1st. In hollow organs, where the additional substance is deposited cenlrically, and 
 the hypertrophy takes place at the expense of the cavity : 
 
 2dly. In any organ, whereof the hypertrophy is confined to one or more tissues, 
 while the others are proportionably wasted ; and, 
 
 3dly. Hypertrophy may even be consistent with no alteration of shape, or increase 
 of bulk in any direction, the organ occupying exactly the same <;p^ce, and preserving
 
 HYPERTROPHY. 29 
 
 the same absolute dimensions as before, but becoming more full of component par 
 tides, more compact, heavier. This state is well exemplified in certain cases of 
 hypertrophy of bone : the spongy or cancelous texture of the bone disappears ; its 
 specific gravity is increased ; it becomes hard, firm, and like ivory. The structure 
 appears, to the eye, to be changed, yet remains the same, except in respect of its 
 density. 
 
 I have told you that hypertrophy is usually a conservative and salutary change. 
 We shall meet with many illustrations of this as we proceed. But I may take the 
 present occasion for pointing out to you some of the beneficial tendencies of this 
 change when it takes place in bone. For, since the diseases of the bones do not 
 belong to my province, I shall have no other opportunity. 
 
 You probably know that in the disorder called rickets, occurring principally during 
 childhood, the bones are soft and deficient in their more solid ingredient ; so that 
 they bend under the weight of the body, or the contraction of the muscles attached 
 to them. After a certain period this disproportion in the constituent particles of the 
 osseous tissue ceases ; but the bones are permanently distorted, and, therefore, less 
 adapted to their office, and less strong, than if they had remained straight. Now the 
 natural remedy that ensues is very striking and beautiful. The bent bones become 
 hypertrophied in certain places ; they grow thicker, denser, harder, and consequently 
 strong, at the very concave part where the stress of the pressure is the greatest. 
 
 The following experiment showed the same thing in a somewhat different man- 
 ner. An inch of the middle part of the fibula of a quadruped was cut out. A long 
 time afterwards the animal was killed. The tibia was then found to have become 
 considerably larger exactly in that part of it which corresponded to the defect in the 
 fibula.* 
 
 The same principle appears still more conspicuously in a case of disease related 
 by Cruveilhier. He saw in the hospital at Limoges a young man who had lost 
 (from necrosis with suppuration) the middle third of his tibia; of the larger of the 
 two bones of the leg. The lost bone had not been reproduced, but the fibula, the 
 naturally slender bone, had become thick and strong enough to support the whole 
 weight of his body. 
 
 I was explaining to you that hypertrophy may exist without enlargement. On 
 the other hand there may be enlargement without any change of structure, and yet 
 no hypertrophy. The liver and spleen are apt to acquire a considerable increase of 
 bulk from mere congestion and distension of their vessels by blood. An immense 
 spleen will shrink into its proper size in a few hours, after" hemorrhage from the sto- 
 mach, whereby the gorged venous system of the abdomen has been relieved. Dr. 
 Townshend mentions a remarkable example of the same kind respecting the liver. 
 The inferior cava has been compressed by an aneurismal tumour, so that the pas- 
 sage of blood from the liver was greatly impeded. Under these ciioumstances the 
 liver became so large as nearly to reach the crest of the ilium. Suddenly the aneur- 
 ism burst, the pressure was taken from the cava, the hepatic veins weie allowed to 
 empty themselves, and before the bod} was opened for inspection, the 'iver had 
 nearly resumed its natural situation and dimensions. 
 
 Of the causes of hypertrophy little more is known than I have already told you. 
 The most important circumstance for you to remember is, that increase of function 
 produces increase of nutrition. This is nearly a general fact ; but whether the con- 
 verse proposition be as generally true — whether hypertrophy of a part always de- 
 notes increased activity in its function — is much less certain. If that were ascer 
 tained, we might hope to discover the actual office of certain parts of the body, the 
 uses of which we do not yet understand (of the thyreoid gland, for example), by 
 investigating the circumstances under which they become subject to hypertrophy. 
 In Mr. Mayo's Outlines of Human Pathology, a case is related of hypertrophy of 
 the tongue, in a young child, treated by Mr. Hodgson, of Birmingham. It would 
 seem to be impossible to account for this by any increased energy in the known 
 functions of that member. 
 
 * Mr. Stanley's Lectures, Coll Si'rg. 
 c3
 
 30 ATROPHY. 
 
 A few isolated facts, bearing upon some points connected witn tins inquiry, hav3 
 been nnade out. 
 
 In the first place, certain localities appear to be influential in the profluction of 
 certain forms of hypertrophy. Thus bronchocele is verj' frequent among the inha- 
 bitants of certain districts ; especially in close or marshy valleys at the feet of high 
 mountains. Its real cause is to be sought in some condition, hitherto undetermined, 
 of the air in those places, or of the water, or of both. 
 
 2dly. Certain congenital or acquired conditions of the body tend to produce local 
 hypertrophy. In that peculiar diathesis which we call the strumous — and of which 
 I shall have much to say hereafter — certain parts of the body, as the upper lip, and 
 the extremities of the long bones, undergo a kind and degree of enlargement thai 
 seem properly to fall within the definition of hypertrophy. 
 
 3dly. Certain habits of life have a distinct effect in promoting certain forms of 
 hypertrophy. Full diet, with bodily inactivity, leads to hypertrophy of the adipose 
 tissue. So general is this tendency, that we confidently act upon it in the fattening 
 of animals. Shut a healthy pig up in a small st}^, and give him as much food as 
 he is willing to eat, and you insure his rapid pinguescence. If you cannot so cer- 
 tainly attain the same result by similar means in the human animal, it is chiefly, I 
 believe, because moral causes, and especially mental anxiety, will effectually coun- 
 teract those means. A healthy man, with a quiet mind, using habitually a full nu- 
 tritious diet, and leading a sedentary life, will fatten, I apprehend, as unfaihngly as 
 a calf, or a turkey. Sometimes, indeed, fat accumulates to an enormous extent, in 
 spite of abstinent habits, and very active exercise. 
 
 4thly. It is a curious fact that the removal of certain parts of the body, as the 
 testicles from male animals, and the ovaries from females, increases the disposition 
 to accumulate fat. The same tendency appears to be given, for a time, by the 
 extirpation of the spleen. 
 
 Of the curative methods that hypertrophy may require it would be premature to 
 speak at present. 
 
 The bulk of parts may be also augmented in various other ways. The hollow 
 organs may be inordinately distended by an undue accumulation of their natural 
 contents : or by matters that do not enter them in health. The solid organs may 
 have their size increased by the presence of matter foreign to their natural composi- 
 tion, collected in their interior, or distributed through the insterstices of their proper 
 tissues, or deposited upon their surface : and in either case the functions of the part 
 itself may be disturbed or suspended; or the functions of parts immediately con- 
 tiguous to it may sustain damage from its pressure ; or the functions of distant parts 
 connected with it by dependency of ofliice may be disordered ; or all these conse- 
 quences may exist together. Numerous examples of them all will hereafter be 
 brought under your notice. 
 
 Let us next attend to that condition which is the opposite of hypertrophy — to 
 atrophy, namely, in which parts become notably smaller than natural, without other 
 altemtion of texture. 
 
 The two conditions contrast strongly with each other in their nature and origin, as 
 well as in their physical character. 
 
 Hypertrophy depends essentially upon an increase — atrophy upon a diminution 
 or defect, of the nutritive functions. You will find that atrophy plays an important 
 part in altering the bodily organs, both in heakh and in disease. 
 
 Of the effect of atrophy in causing alterations consistent with health, I shall merely 
 remind you of some instances, that you may the better comprehend its morbid 
 operation. 
 
 There are parts of the body, as you well know, destined for a temporary purpose 
 only. Upon the cessation of their especial function they dwindle, or disappear. We 
 have examples of this in the thymus gland, in the supra-renal capsules, and in those 
 parts of the mechanism of the circulation which are pecuKar to the fostal state. The 
 atrophy here begins as soon as the child is born, and is not only consistent with, but 
 necessary to, its perfect health. As life advances, we see the same principle at
 
 ATROPHY. 31 
 
 work, remodelling from time to time those structures of which the office has only a 
 limited duration. After the child-bearing period in women is over, when the func- 
 tions of the ovaries expire, these organs shrink, through atrophy. It is so with the 
 testes of old men. Indeed, atrophy, to a certain extent, pervades all parts of the 
 system in old age ; the muscles diminish in size, the whole body is less plump, the 
 bones lose a portion of their substance, and become brittle. 
 
 Even in the period of foetal life this process, by which parts are starved and 
 stunted, sometimes displays itself. But here it is no longer compatible with the 
 integrity and well-being of the system. The arrest or retardation of the nutritive 
 function produces changes of great interest, and gives rise to various kinds of mon- 
 strosity. Harelip — fissure of the palate — certain malformations of the heart — are 
 familiar examples of the consequences of intra-uterine atrophy. 
 
 Atrophy, considered as a morbid change, is conspicuous, no less than hypertrophy, 
 in the muscular system. We see it in the voluntary muscles, whenever a limb 
 remains long in a state of inaction — whether from palsy depending upon disease in 
 the brain or spinal cord ; or from pain connected with disease of a joint ; or from 
 perversion of the will, as in the self-inflicted penance of the Fakir. The same law, 
 therefore, obtains here, which w^as previously announced; the development of a part 
 is proportioned to the activity of its function. In most cases, I believe, the atrophy 
 will be found to resolve itself into a deficient supply of healthy arterial blood. Build- 
 ing materials are not provided, or are provided inadequately. Mere inaction will 
 produce atrophy ; but it is probable that the inaction operates simply by abridging 
 the flow of arterial blood to the muscle. If (as some suppose) what is called a 
 change in the innervation of a part tends sometimes to occasion its atrophy ; if, for 
 example, the altered state of the nervous influence has some share, beyond the inac- 
 tion which it produces, in causing the atrophy of a paralyzed limb — it stiJl acts, I 
 conceive, indirectly, and by reducing somehow the supply of healthy arterial blood. 
 The nerves belonging to palsied and atrophied muscles are said not to diminish in 
 size. It is with the arterial circulation, certainly, that atrophy is most concerned. It 
 is upon a diminution of the number of the smaller, and perhaps also of the capacity 
 of the larger arteries, that senile atrophy depends. We find atrophy of the brain 
 accompanying certain diseased conditions of its main arteries. So the testicles 
 wither when the spermatic artery is tied for the cure of varicocele. 
 
 Pressure of any kind, exercised either upon the large arterial trunks, or upon the 
 capillary vessels, so as to lessen without completely preventing the supply of blood, 
 will be found to give rise to atrophy, whenever the due quantity of blood is not fur- 
 nished by the establishment of a collateral circulation. Chronic inflammation is 
 sometimes attended by the wasting of the part which it occupies. It acts, in all 
 probability, by unfitting the capillary arteries for transmitting the requisite quantity 
 of blood. Various diseases, by which the supply of nutriment to all parts of the 
 body is checked at its source in the digestive organs, or by which some unnatural 
 drain upon the system is kept up — by which, in short, the quantity of the nutrien* 
 fluid is diminished, or its quality impaired — produce a greater or less degree of 
 g^enera/ atrophy ; but to this universal wasting we usually apply the term emaciation. 
 
 Atrophy, then, such at least as is morbid in its nature, may be the consequence of 
 inaction, of compression, of chronic inflammation, and of various diseases ; but in all 
 cases the defect of nutrition which constitutes the atrophy seems to be resolvable into 
 a diminished supply of healthy blood through the arteries. 
 
 As in hypertrophy, so likewise in atrophy, the change may be limited to some 
 one or more of the component tissues of a part ; and by these altered proportions of 
 its constituent tissues the appearance of the part may be remarkably modified. 
 
 So, also, as hypertrophy may exist without any increase of absolute size, atrophy 
 may occur without any decrease : as in the heart, when the cavities are dilated in 
 the exact degree in which their walls become thinner. Bones, externally sound in 
 appearance, have had their specific gravity so greatly reduced by internal atrophy, 
 tliat they would float upon water like a cork. 
 
 It is a curious fact — which I mentioned in other terms before — that an atrophied 
 part is sometimes plentifully encompassed by fat. But this is by no means a neces-
 
 32 INDURATION. 
 
 sary accompaniment. Why it happens in one case, and not in another — whether 
 the adipose hypertrophy is ever the cause of tlae atrophy associated with it, or tho 
 atrophy the cause of the hypertrophy : — these are questions which, in the presem 
 state of the science of medicine, do not admit of any positive soUuion. 
 
 It is scarcely necessary to observe that the changes of bulk which we have been 
 considering, imply often, though not always, changes o[ form also. You will have 
 one or two of the chambers of the heart greatlj enlarged, while the others remain of 
 their natural size. Of course this altered proportion modifies the shape of the organ 
 
 Signal changes of form are produced also by inflammation, by pressure, and in 
 various other ways. But, after all, modifications of figure are rather to be consi- 
 dered as accidents of disease than among its important elements : and I pass on to 
 other alterations. 
 
 Various parts of the body are liable to be changed in consistence. They may 
 become harder and firmer than before: or they may become softer. To' the state 
 of increased or unnatural hardness the term induraiion has been applied : the same 
 word is used also to express the process of hardening. To the state of diminished 
 consistence we give the name of softening. The French pathologists, who first 
 noticed this condition as an element of disease, call it ramolUssement. 
 
 You are already aware — those of you who have attended the lectures of the pro- 
 fessors of midwifery and of anatomy — that a slow process of natural and healthy 
 induration is going on throughout the body from the earliest period of uterine life to 
 extreme old age. 
 
 There are several ways in which wnnatural induration may take place. 
 
 Induration of an organ may happen, without any other alteration of its proper 
 tissue, in consequence of inordinate fullness of its blood-vessels. This is apt to occur 
 in the lungs, or liver, whenever the free exit of blood from these organs is in any 
 way impeded. They become stretched, tense, resisting, hard. 
 
 In Uke manner induration of the hollow organs, or of cellular parts, will arise 
 /without any change of their texture) from an undue accumulation of fluids within 
 <nem ; — of bile, for example, in the gall-bladder ; of urine, in its receptacle ; of gases 
 in the stomach and intesti^ies ; of serosity in the cellular tissue. 
 
 In either of these kinds of induration the unnatural hardness may be temporary 
 only, or it may be the permanent accompaniment of other disease. It is necessary 
 that you should be aware of its occurrence, and of its nature. I say of its nature, 
 because this is not always understood. In the induration arising from the last cir- 
 cumstance I mentioned, viz., from infiltration of the cellular tissue with the serous 
 or albuminous parts of the blood — from oedema, in short — the hardness has some- 
 times been erroneously ascribed to some other morbid condition. Dr. Carswell has 
 shown that in the curious disease of new-born children who are said to be skin-bound, 
 the hardness of the surface is the consequence of simple osdema of the subcutaneous 
 cellular tissue. The same phenomenon is remarkable in oedema of the tongue. I 
 believe the induration belonging to oedema will be found to be the greater, in propor- 
 tion as the efiusion is recent, and has taken place rapidly. 
 
 Again, induration may accompany, and be a consequence of, simple hypertrophy. 
 Of this I have already shown you examples ; especially in the eburnation (as it has 
 been called) of hypertrophied bone. 
 
 Induration of an organ may also result from the compression of its fluid, and the 
 C07/jpression of its solid parts. We see this extremely well in the lung, when it has 
 been thrust and flattened against the vertebral column by fluid effused into the pleura ; 
 or when it is still more tightly bound down by an investing layer of plastic lymph. 
 In this way, therefore, induration may be consistent with atrophy. That the natural 
 structure of the hardened lung is not always lost in these cases we know, because 
 vv^e can restore, to a certain extent at least, its bulk and spongy feel, by forcibly 
 mflating it. The spleen sometimes exhibits the same kind of induration, under the 
 constrictive force of an investing false membrane. I am mentioning samples only 
 of these changes. 
 
 More frequently induration depends upon the presence, in the internal texture of
 
 SOFTEiMNG. 33 
 
 parts, in the little spaces left between their compotent tissues, of fluid or solid matters 
 which are not found there in the healthy state. Bony or earthy particles are some- 
 times laid down, and the part thus changed is said to be ossified. There are few 
 ])arts of the body in which this kind of induration does not occasionally take place. 
 It is especially common in the coats of arteries, and in the subserous tissues. Blood, 
 or fluids separated from the blood, may fill and obhterate the natural interstices, and 
 concreting, tend to solidify and harden the part which they occupy. What is called 
 hepatization of the lung is a good instance. [ need not tell you that the healthy 
 lung is spongy and crepitant under pressure : in this altered state it no longer crackles 
 between the fingers ; its spongy character is lost ; it resembles liver in its compact- 
 ness and colour, and it is therefore said to be " hepatized." This is a consequence 
 of inflammation ; and induration of this kind is a very common consequence (as we 
 shall see) of- the same morbid process in various other parts and organs. Another 
 instance of induration of the pulmonary substance we have in what is badly called 
 pulmonary apoplexy. This is independent of inflammation. Blood is collected and 
 coagulates in a part of the lung which should contain air — in the vesicle of one or 
 more of its lobules ; the lobules thus gorged with blood become even harder and 
 firmer than when hepatized ; but by a different process. 
 
 In the instances last mentioned, fluids after escaping from their proper vessels. 
 i. e., in technical phrase, after being extravasated, pass into the solid form, and thereby 
 render the parts which they pervade harder and more firm. But fluids may con- 
 crete and harden ivithin their proper vessels, and so lead to another form of indu- 
 ration. Thus the blood, under certain circumstances, coagulates in the hving veins 
 — nay, sometimes even in the heart itself: and we may hereafter have to consider 
 the conditions under which this coagulation is liable to occur, and the serious conse- 
 quences which it involves. The bile, again, as you probably know, sometimes 
 concretes, by a rude kind of crystallization, into what are called gall stones : and 
 the passage of these calcuK through the narrow ducts that connect the gall bladder 
 with the bowel, is apt to be attended with pain the most intense. The formation of 
 urinary calculi is not exactly of the same kind. 
 
 Numerous specimens of all the changes I have been describing are on the table 
 before you. You may examine them at leisure after lecture, or in the museum. 
 
 I have j'et to notice another source of unnatural induration, in the deposition or 
 growth of irregular masses of matter within me body, differing remarkably from any 
 of the solids or fluids that enter into its healthy composition. These unnatural for- 
 mations vary considerably in their nature and appearance, and in their consistence 
 at different periods. Sometimes they exist in distinct and separate masses, ana 
 whether hard or soft in themselves, cause induration by their pressure upon surround- 
 ing textures : sometimes they are diffused through or among the natural tissues of a 
 part, which thus they indurate. All the varieties of tubercle, and of cancer, and 
 other forms of disease which have been styled mahgnant, fall under this head. 
 
 These new and morbid products play a fearful part in disorganizing the bodily 
 frame, and in embittering and shortening life. They will necessarily occupy much 
 of our attention in the progress of the course. At present I merely point them out 
 as illustrations of the manner in which the consistence of parts may be increased. 
 
 LECTURE III. 
 
 Softening ; its causes and varieties. Transformation of Tissue ; Changes oj 
 situation — in the Chest, of the Lung, of the Heart — in the Abdomen and Pelvis. 
 Hernia, Intussusception, Prolapsus, 
 
 We were occupied with that branch of pathological inquiry which relates to the 
 various ways in which the several parts and organs of the living body are liable l(t 
 be sensibly ahered by disease. 
 3
 
 31 SOFTENING. 
 
 We considered the changes to which the solid parts are subject in bulk and form f 
 and that aheration of their consistence which constitutes hardening or induration. 
 
 The opposite condition to this is softening, diminished consistence, a less degree 
 of cohesion of parts and tissues than is natural. 
 
 This is also a state of Avhich it is important that you should comprehend the 
 nature, and causes, and varieties ; and the share that it often has in breaking down 
 the structure of organs, and in destroying life. 
 
 There is scarcely anj^ tissue of the living body in which softening may not take 
 place. I shall here, however, as before, mention a few illustrations only of its occur- 
 rence, taking those instances in which the phenomenon is most evident, or is best 
 understood. 
 
 Softening is perhaps never more strikingly obvious to our senses than when it 
 affects the brain or spinal cord. We find portions of these organs manifestly softer 
 than the rest. You are familiar with the usual consistence of the adult brain : you 
 will find it sometimes reduced, in places, to the consistence of cream : a gentle stream 
 of water suffered to fall upon the softened pulp suffices to wash it away, and a cavity 
 is left in its place. 
 
 The cellular tissue — or rather let us call it, with Professor Todd, the areolar tissue, 
 since minute anatomists now affirm that all the tissues in their embryonic state are 
 cellular — the areolar tissue is another part in which softening is exceedingly com- 
 mon, although the change is not so readily perceived. This is the great connecting 
 tissue of the body; and we are made sensible of its diminished consistence when 
 parts which it unites become separable with unusual ease. Thus you may some- 
 times, by exerting a very slight degree of force, strip off' a serous membrane from 
 the parts which it invests, or a mucous membrane from the surface hned by it. This 
 ready separation is a consequence of the diminished consistence of the subserous, 
 or the submucous, areolar tissue. The membranes themselves, in such cases, may 
 be in a perfectly natural state. 
 
 Muscles, again, are often palpably softer than they should be : the fleshy substance 
 of the heart, for example. Here the muscular fibre may itself have undergone a 
 change of consistence ; or the muscle may simply appear to be softened, in conse- 
 quence of the softening of the threads of areolar tissue by which its fibres are tied 
 together. 
 
 The mucous membranes very frequently present the phenomenon of softening. 
 This is more commonly seen in the stomach than elsewhere. Instead of being 
 raised from the subjacent tissues in large flakes, the mucous membrane, when seized 
 between the forceps, breaks off" in small fragments ; or it may be crushed and mashed 
 by the pressure of the finger, or washed away in shapeless pulp by a little current 
 of water. This condition of its hning membrane is usually limited to parts of the 
 stomach ; but occasionally it is general. 
 
 Even the bones are liable to this change of consistence. There is a disease called 
 mollifies ossiiim, in which the bones even of adults become soft and pliant, and 
 capable of bending in any direction. There is a deficiency in their earthy consti- 
 tuents ; atrophy of that particular tissue. Indeed, softening is often a concomitant 
 or a result of atrophy. 
 
 The accidental products to which I adverted when speaking of induration — espe- 
 cially some of the varieties of cancer — are sometimes remarkably soft, resembling 
 brain in consistence and appearance, or cream, or jelly. But in these cases we can 
 scarcely consider the change as an example of softening of the textures of the 
 body ; it rather consists in the addition of parts that are themselves soft and half fluid. 
 
 Now softening may occur under very different circumstances. One very general 
 cause of softening is inflammation. Every part, I believe, that is inflamed, under- 
 goes, in the first instance, a diminution of its consistence. This appears to be almos* 
 the necessary consequence of stagnation of the blood, the effusion of serosity, and 
 ihe suspension of healthy nutrition. These are circumstances to which I shall 
 recur. I cannot avoid alluding occasionally to things with which you are supposed 
 i(i be as yet but little acquainted, and which will engage our particular attention aa 
 the course advances.
 
 TRANSFORMATION OF TISSUE. 35 
 
 It would be a great mistake, however, to suppose that all softening results from 
 previous inflammation. Doubtless it often proceeds directly and simply from defi- 
 ciency of nutrition, and is thru closely allied, as I said before, to atrophy. Thus 
 softening of the brain is, sometimes, due to inflammation : we meet with it where 
 the inflammation has been unequivocal, and was caused by external injury; but 
 sometimes also it is quite independent of inflammation, and is owing to disease of 
 the cerebral arteries, whereby the brain, or a portion of it, is deprived of its full 
 supply of arieritil blood, and ceases to be properly renovated : hence a loosening of 
 its texture, a separation of its component particles, an approach to the fluid state. I 
 shall, of course, hereatler endeavour to point out to you more particularly the means 
 we possess of distinguishing these two forms of cerebral softening ; they constitute 
 morbid conditions of the highest interest. 
 
 I may observe, that we have an illustration of the principle now laid down, in that 
 general softness, flaccidity, and slight cohesion of parts, noticeable in children, and 
 others, who are imperfectly nourished. We find this general absence of the natural 
 firmness coincident with paleness, and a thin watery condition of the blood. Ma- 
 gendie kept animals upon food unsuitable to them, containing no azote, and incapa- 
 ble of supplying sufficient nourishment ; and one curious consequence that followed 
 was a loss of substance in the cornea, which melted down and disappeared. 
 
 There is another source of softening which requires to be mentioned — I mean the 
 gastric juice, which has the power of dissolving not only food that is submitted to its 
 action, but the mucous membrane of the stomach itself, and even all its tissues and 
 coats. This cause of softening operates, however, in the dead body only ; but hs 
 effects have often been mistaken for the consequences of disease ; and therefore it 
 will be necessary for me hereafter to call your attention to the circumstances under 
 which they may be expected, and to the means we possess of discriminating them 
 from similar changes, which are more properly called morbid. 
 
 Upon the v/hole, it may be said that every form and kind of softening in the living 
 body — whether it proceed from inflammation, from disease of the arteries, from 
 insufllcient sustenance, or from altered qualities of the blood — may ultimately (like 
 atrophy) be resolved into suspended or defective nutrition. 
 
 Furthermore, as there is a hardness of parts resulting from repletion and disten- 
 sion, so there is a softness rather than a softening, from their emptiness and flac- 
 cidity : as of the breast immediately after the child has sucked ; of the abdomen 
 soon after delivery ; of the integuments in those who, having been fat, have w^asted, 
 either from disease or from advancing age ; and so on. 
 
 On former occasions, T thought it right to lay before you the views of M. Andral 
 ^vhich appear to have been adopted also by Dr. Carswell) respecting what has been 
 called the transformation of tissues. " In the proper place of one natural tissue 
 (I remarked) we sometimes find another, which last is thus toinatural in regard to 
 its situation, but natural in all other respects. The new tissue is such as we meet 
 with elsewhere in the body, but it is not such as properly belongs to the place it 
 occupies. Either the original tissue has been gradually converted into the new, or 
 the original tissue has disappeared, and the new tissue has been substituted for it : 
 that, for example, which should be cartilage we sometimes find to be bone." 
 
 "In most cases the tissue that has been changed or displaced is in one of the twi< 
 following predicaments : 
 
 " Either its natural function has been for a long time suspended ; 
 
 " Or, it has been accidentally called upon to fulfil a purpose for which it was not 
 originally designed. 
 
 " In the former case it gradually approximates towards areolar tissue, which at 
 length is all that remains. 
 
 " In the latter, it assumes the characters of that other tissue of which it has taken 
 up the office." 
 
 Now the analogy which M. Andral thought he could perceive between changes 
 of this kind, and those changes which occur during the growth and progressiva 
 developement of the human body, does not in reality obtain. More recent and more
 
 36 TRANSFORMATION OF TISSUE. 
 
 exact microscopical researches have shown that the several tissues do not comnience 
 by being areolar tissue — which is the sense in which M. Andral uses the word 
 cellular — and therefore, that in the dwindling of any given tissue into the areolar, 
 there is no return, as he had supposed, towards the primitive state of the tissue so 
 wasting. A muscle remaining for a long time in complete inaction, loses bulk, but 
 does not pass from the condition of muscular into that of areolar tissue : when wasted 
 to the utmost, it still retains its proper anatomical elements. The areolar tissue is 
 quite as complex and advanced a tissue as the muscular. There is no true conver- 
 sion of the one tissue into the other. It is commonly stated, indeed, that when a 
 muscle comes accidentally to invest a dislocated joint, the dislocation remaining unre- 
 duced, it assumes by degrees the characters, together with the uses, of those tissues 
 which naturally inclose the joint, and is converted from muscular into fibrous or 
 ligamentous tissue — ^just as in the vegetable kingdom, the cut branch of a willow 
 tree, planted in the earth, takes up the office, and gradually acquires the form and 
 properties of a root. But here again the analogy is more fanciful than real. The 
 formation of a false joint implies no actual conversion of tissues. The muscular 
 fibres shrink and disappear, while the areolar tissue augments, and is transformed 
 only into the fibrous ; these two, the fibrous and the areolar, being essentially and 
 primarily the same tissue. 
 
 The change from cartilage to bone approaches more nearl}'' than any other to 
 actual transmutation ; but even this resolves itself into a simple increase of one of 
 the natural constituents of both the tissues concerned ; phosphate of Hme, which 
 exists in healthy cartilage. 
 
 A curious and common change is the so-called transformation of other tissues into 
 adipose tissue. The fat, however, does not take the place of the natural elements 
 of the tissue. It is deposited among them, and wastes them, yet they still remain, 
 and are easily distinguishable. If you examine a fat heart — such as is not unfre- 
 quently met with in very fat persons — you av ill generally find a combination of 
 hypertrophy of the adipose tissue with atrophy of the muscular, rather than any 
 conversion of the one into the other. The fat is deposited around and between the 
 attenuated muscular fibres, and the two may usually be separated from each other. 
 It would seem that here the converse of one of the propositions which I lately men- 
 tioned holds good — of the proposition, namely, that suspension of the function of a 
 tissue leads to its degeneration into adipose or areolar tissue. In the instance before 
 us, the increase of adipose tissue tends to lessen, and at length to destroy, the function 
 of the part. What is called the fatty liv^er affords another instance of this morbid 
 accumulation. The altered liver is of a light tawny colour, of diminished specific 
 gravitj', retains the impression of one's finger, is tender, and tears easily ; it greases 
 the knife that cuts it, or bibulous paper in which it is wrapped. B}^ boiling it you 
 may obtain a concrete oil, which has all the characters of fat. The change is 
 wrought b}'' an enormous augmentation in quantity of the fat which is a natural 
 constituent of the texture of the liver, and which thus comes to prt'dominate immea- 
 surably over all its other elements. 
 
 What is very curious in respect to this morbid condition of the liver is, that we 
 can produce it, at will, in some at least of the lower animals. You know thai the 
 ^"■foie gras^^ procured from certain birds, is an article of great luxury among epi- 
 cures. It is obtained by a very cruel process. Geese or ducks are confined in 
 baskets just large enough to contain them, but not large enough to allow them any 
 motion ; they are kept continually in the dark also ; sometimes even, I am afraid, 
 iheir eyes are put out, but this I should imaa^ine to be a useless and superfluous 
 piece of cruelty, it being the absence of light, and not the absence of the power of 
 vision, which helps to bring about the desired efTcct. At the same time the birds 
 are sedulously crammed with food. Under this discipline their livers acquire the 
 reouisite size, and greasiness, and the true flavour. 
 
 An ingenious tiieory has been constructed, in reference to the modus operandi of 
 this process. The excessive supply of nutriment tends, no doubt, of itself, as it 
 always does, to the production of fat ; the constrained state of inaction interfeies 
 pjobably with the right and healthful formation of blood, a matter in which the liver
 
 TRANSFORMATTON OF TISSUE. 37 
 
 is believed to be a good deal concerned ; then we know, by experience, that the 
 privation of hght has the effect of blanching animals as well as vegetables, and thus 
 further interferes with the due renovation of the blood. In this way, the trans- 
 formation of the liver into a fatty mass has been sometimes attempted to be explained. 
 To what extent the explanation is correct, I will not pretend to say: but it is worth 
 remarking that the fatty liver is very frequently met with in persons who die of con- 
 sumption ; and in that disease there are various causes in operation tending to 
 modify the constitution of the blood. 
 
 The history of these unfortunate fowls is not barren of instruction in respect to 
 the more limited bad effects of full diet, want of exercise, and a short allowance of 
 day-light, upon the " featherless biped" man. 
 
 These accumulations of fat are morbid changes. The transformations that are 
 effected in false joints are evidently methods of accommodation and repair. The 
 same may be said of the transformation — which is not conversion — of areolar tissue 
 into synovial membrane. Synovial membrane consists chiefly of condensed areolar 
 tissue. Sir B. Brodie, in his book on Diseases of the Joints, gives instances of 
 synovial membranes being formed, where none before existed. " In a young lady 
 who had attained the age of ten or twelve years, labouring under the inconvenience 
 of a club-foot, a large bursa was distinctly to be felt on that part of the instep whicn 
 came in contact with the ground in walking. In another young lady, who had 
 apparently recovered of a caries of the spine, attended with a considerable angular 
 curvature, a bursa appeared to have been formed between the projecting spinous 
 process and the skin." 
 
 In like manner we find that sinuses, fistulous openings and tubes, in various parts, 
 become lined, through the intervention of the areolar tissue, with a surface which in 
 its appearance and in its properties resembles the mucous membranes. Like them 
 it is with difficulty made to take on adhesive inflammation : and therefore it is that 
 sinuses of this kind, and chronic abscesses, are often so troublesome to the surgeon, 
 and require to be laid open before they can be abohshed. 
 
 On the other hand, the mucous membranes, under peculiar circumstances, 
 approximate to the skin in their physical aspect and quahties. When, for instance, 
 a portion of the mucous lining of the rectum, or of the vagina, protrudes externally, 
 is permanently exposed to the air, and subject to the friction of clothes or of neigh 
 bouring parts — that is to say, when it is placed under the same conditions as the 
 skin — it assumes somewhat the characters of the skin : it gradually loses its red 
 colour and approaches the tint of the skin, ceases to pour forth mucus, becomes dry, 
 obtains even a sort of permanent cuticle, acquires firmness and density, and is less 
 sensible to the contact and pressure of foreign substances. It is impossible not to 
 perceive the beneficial nature of this transformation. 
 
 The greater number, then, of those interesting changes in the living body which 
 have been classed under the head of transformations of tissue, have a restorative 
 tendency. They exemplify the working of what the older pathologists discerned, 
 and called the vis mcdicatrix nufrirx. This is a phrase that has been much sneered 
 at; but (as I conceive) very unjustly, and sometimes ignorantly. It is simply a 
 short formulary expressive of a great general truth, viz., that the animal frame is so 
 constituted as to contain within itself the elements of repair, and of conservative adap- 
 tation. To a certain extent it is a self-mending machine. Surely this is an admirable 
 provision, and clearly indicative both of wise contrivance and of beneficent design. 
 
 The intimate texture of parts may be further altered — not simply by some modi- 
 fication or reconstruction of the ordinary tissues, but — by an absolute disappearance 
 or confusion of all regular structure. This is usually a consequence either of the 
 effusion, in the natural interstices of the parts, of fluids, which afterwards pass inro 
 the solid state, or it is a consequence of the growth of solids which do not belong to 
 the healthy body. In this sketch of general pafhology I must content myself with 
 thus briefly alluding to this source of morbid change. 
 
 I may as well observe here, that the alterations with which we have hitherto been 
 occupied, of the solids of the body, fall, almost all of them, under ihS head of 
 lesions of nulrilion, QiS the French pathologists spe^k. That is to say, the}- "m 
 
 D 
 
 <^v- at* in ./.('■v—.-f-
 
 38 LESIONS OF KUTRITipN. 
 
 mence, and have their priinilive seat, in that process and place where the blood, 
 havinij reached the capillar)^ system of vessels, performs its special purposes, ^ It is 
 in or Throuorh the capillaries that the fluids and solids accomplish their vital union. 
 Each solid receives from the blood, and assimilates with its proper substance, ma- 
 terial particles, identical in their nature with those of which it already consists. 
 Each solid gives up also to the blood, and so dismisses other particles, which before 
 formed a portion of itself, but which have become unfit or superfluous. Now any 
 departure from this continual building up and pulling down — any excess or defect 
 of the particles added, or of the particles subtracted — any irregularity in the manner 
 in which they are deposited — any variation from their right consistence, or in their 
 kind and quality — in short any deviation from the regular process, as I have briefly 
 described it — is called a lesion ofnuirition. 
 
 The few changes already spoken of, and not included among the lesions of nu- 
 trition, are : — 
 
 The distension of the hollow organs by an undue accumulation of fluids within 
 them ; 
 
 The coagulation of the fluids in their proper vessels, excluding, however, the 
 capillaries ; 
 
 The escape of the fluids, as such, out of and beyond their containing vessels ; and 
 
 The solution of tissues, after death, by the chemical agency of the gastric juice. 
 
 None of these, properly speaking, constitute lesions of nutrition, although they 
 sometimes lead to them. 
 
 Lastly, let us take a glance at the changes of situation to which the solid parts of 
 the body are liable. They are sometimes of very serious import. 
 
 These changes of place — sometimes the consequence of disease, sometimes its 
 cause, and not unfrequently the cause of death — respect chiefly the viscera; and 
 most especially the viscera of the chest, abdomen, and pelvis. I omit dislocations of 
 joints, as belonging exclusively to surgery. 
 
 In the chest, a whole lung may be displaced, and compressed against the ver- 
 tebral column, bj' blood, or serum, or air, effused into the cavity of the pleura. An 
 alteration of this kind, whereby one half of the respiratory apparatus is rendered 
 incapable of its peculiar function, cannot be otherwise than full of peril. 
 
 The very same causes operating on the left side of the thorax will dislocate the 
 heart, thrust it over to the right of the sternum, where it may be felt, and heard, and 
 seen, to pulsate. This again cannot happen without greatly disturbing the vital 
 function of circulation, and putting hfe in jeopardy. 
 
 Yet neither of these serious displacements is necessarily fatal. Both admit, 
 under certain circumstances, of remedial treatment : as I hope to prove to you 
 hereafter. 
 
 In the abdomen and pelvis, the various forms of hernia may be adduced as 
 involving very dangerous changes in the place and relative position of part?. 
 Portions of the intestinal tube are apt to pass through accidental openings in the 
 diaphragm^-or between the edges of the linea alba surrounding the navel — or out 
 at the abdominal ring — or through some other natural or accidental aperture. I 
 need not tell you how fearfully life is compromised when, in consequence of such 
 faulty position, the bowel becomes constricted — when its contents can no longer 
 pass onwards, and inflammation, or gangrene, is present or impending. Even 
 when there is no strangulation, the mere displacements to which the escape of 
 the contents of the abdomen and pelvis from their natural limits gives rise, may be 
 productive of much discomfort, deformity and hazard. Of this the historian Gib- 
 bun presented a remarkable example. He had an immense scrotal hernia ; so 
 large it was, that it hung down very nearly as low as his knees. After his death it 
 was found that almost the whole o^the omentum, and the greater part of the colon, 
 had descended into the scrotum, and had dragged the stomach after them ; so that 
 Us pyloric orifice lay close to the abdominal ring. 
 
 Akin t» hernia is that partial displacement of the bowel in which a portion of it 
 passes, not through any natural or accidental opening, but into the bowel itself;
 
 CHANGES IN THE BLOOD. 39 
 
 just :is one portion of the finger of a glove is sometimes pulled into the remaining 
 part, by the withdrawal of one's hand. The containcf/ portion of intestine is liable 
 to be nipped and strangulated by the contain/;?^ portion — and all the peril of hernia 
 results, with much less chance of relief by art. This state of things is called intus- 
 susception. 
 
 Exactly of the same nature, though less alarming, is prolapsus of the rectum, or 
 of the vagina. Here, also, a portion of the tube passes into the contiguous portion ; 
 but being near the extremity of the canal, the inverted part protrudes externally, and 
 becomes, in most cases, a source of distress and suffering, rather than of danger. 
 Inversion of the uterus is another example. 
 
 Thus much, then, of the changes to which the solid parts of the body are subject, 
 in bulk, inform, in consistence, in texture, in situation. 
 
 You cannot fail to perceive the injurious effects which many of these changes in 
 the various solids are calculated to produce upon the movements and working of the 
 living machine ; how some of them must impede or derange its natural action ; 
 some stop that action altogether. 
 
 Now, the fluid parts of the body are liable also to alterations, which, if they 
 are not always so obvious as those of the solids, are certainly not of less moment. 
 
 You are probably aware that for many centuries, the fluids were supposed to be 
 the primary agents in every form of disease ; that all maladies were attributed to 
 some acrimony or peccant state of the humours ; and that, however else the the- 
 ories of medicine might vary and fluctuate, the humoral pathology, till a compara- 
 tively recent period, ran through almost all of them. At length, the absurdity of 
 the hypotheses, and still more the dangerous practice, which this doctrine gene- 
 rated, began to be manifest, and led to its total abandonment. Rather more than a 
 century and a half ago, the foundation of the opposite doctrine appears to have been 
 laid, by the writings of Glisson in this country, and by those of Baglivi in Italy ; and 
 presently the notion came to prevail throughout the schools, that all the morbid con- 
 ditions of the body had their exclusive origin in the solids. The pendulum of 
 opinion swung at once, as is usual, into the opposite extreme of error. It promises, 
 in our time, to settle at the proper medium. Ine old extravagances of the humoral 
 doctrine still, indeed, find favour among the ignorant, and are commonly adopted by 
 the quack : circumstances which illustrate the fact that the mischievous influence of 
 unsound theories survives the duration of the theories themselves. The scientific 
 physician of the present day can only wonder how exclusive solidism, or exclusive 
 humorahsm, should ever have found advocates. 
 
 LECTUUE IV. 
 
 Morbid Alterations of the Fluids, especially of the Blood. Changes in its quan- 
 tity and distribution. General and Local Plethora. Poverty of Blood. Active 
 Congestion — its Phenomena — State of the Vessels, as seen by the Microscope. 
 Mechanical Congestion. Passive Congestion. Relations of these forms of 
 Congestion to Inflammation — to Hemorrhages — to Dropsies. 
 
 After running over the principal alterations to which the solid parts of the body 
 are liable, we were beginning to inquire into those no less important morbid changes 
 which are apt to take place in its fluid constituents. 1 reminded you that, respect- 
 ing the whole of this subject, pathologists had passed from one extreme of opinion to 
 another : that, for a very long period, the humoral pathology prevailed in the 
 schools, and that in times not very remote from our own, it was entirely superseded 
 by the opposite doctrine of exclusive solidism. It is strange that either miscon- 
 ception should have so long maintained its ground. 
 
 Jf we consider the definite relation subsistinc: between the solids and the fluids of
 
 40 CHANGES IN THE BLOOD. 
 
 the body, and the unceasing agencies which ihej mutually exercise on each other- 
 how, for instance, on the one hand, all the solids are originally built up, and are 
 afterwards perpetually nourished and sustained by materials furnished from the 
 blood — how again, on the other hand, some of the solids are continually employed 
 in the reciprocal office of feeding and renewing the blood, while others are as con- 
 stantly at work in decompounding it by the various secretions — we cannot avoid 
 perceiving that distinctions of the kind I have mentioned, founded upon mere differ- 
 ences of consistence, are futile. Flesh and blood are almost convertible terms : their 
 composition, the chemists tell us, is identically the same. To use the strong expres- 
 sion of Borden, Le sang est de la chair coidante. You may be certain that no 
 notable alteraiion can take place in the solids of the body which will not soon affect, 
 in some way, its fluids ; and that every important change in its fluids must lead to, 
 or proceed from, a corresponding and proportionate modification of its sofids. The 
 long dispute between the solidists and the humoralists was altogether baseless and 
 unprofitable. 
 
 The animal fluids are — the blood, the fluids that enter the blood, and the fluids 
 that proceed from the blood. 
 
 The fluids that enter the blood are of two kinds. 
 
 1. Those by which it is renewed and enriched. 
 
 2. Those w^hich enter it in order that they may be conveyed out of the body. 
 Now, although we cannot doubt that any considerable modification or defect of the 
 
 fluids that feed and renovate the blood, and particularly of the chyle, must have a 
 direct influence upon its composition and quality, we really know but little about 
 them, except in their effects. We seldom have any means of procuring these, the 
 first products of nutrition, so as to examine them, or to test their qualities; yet we 
 can perceive causes that are likely to deteriorate or deprave those fluids (unfit ali 
 ment, impure air), and we know that, under the continued operation of such causes, 
 the blood, replenished by these fluids, is actually and sensibly modified. 
 
 Again, we cannot doubt that some of the matters derived from the body itself, and 
 taken into the blood in order to be conveyed awa^^ may, and often do, directly alter 
 and contaminate the blood, and act as poisons upon the system : matters, for in- 
 stance, absorbed from the parts of the body that are diseased, or dead and putrefying ; 
 in this way, doubtless, disorders which were at first strictly local, may come to affect 
 the whole economy : — matters, again, which, though harmless while merely transi- 
 tory, and in minute quantity, become noxious when retained and accumulated in the 
 blood, in consequence of fauity or deficient action of the organs destined to eliminate 
 them from the circulating fluid. The injurious effects of some of the substances 
 which thus become deleterious, — as urea, of which the blood, during heakh, is con- 
 tinually purified by the kidneys; and bile, which is naturally separated therefrom 
 by the liver; and carbonic acid, which if is the office of the lungs to excrete — will 
 furnish topics of interesting inquiry here-ifter. 
 
 The fluids that leave the blood ma}^ bt considered under a threefold division. 
 
 1. Those which are directly expende J in the growth or maintenance of parts, 
 some of them becoming fixed and solid, and others retaining their fluid condition. 
 Of these, the principal alterations have been briefly pointed out among the lesions 
 of nutrition. 
 
 2. Those that are employed in aid of some definite function of the body : as the 
 saliva, the gastric juice, the bile, the pancreatic secretion, the tears, the synovia of 
 the joints, and so on. Now these may be secreted in excessive abundance, or in too 
 scanty quantit3% or of imperfect quality, or not at all; and all, or an)% of these 
 deviations from the healthy standard, may be the result of very serious disease, or 
 may cause very serious disease ; and they will be spoken of hereafter when the dis- 
 orders of the parts or functions connected with each shall be discussed. 
 
 '3. Those which are separated from the blood merely to be excreted, as the urine, 
 :.crtain secretions from the bowels, and from the bronchi and skin. Some of these 
 are extremely worthy of study, as furnishing, in their altered qualities, indications 
 'if disease ; but they require no particular consideration in this part of the course. 
 
 Dismissing, therefore, for the present, all further account, as well of the fluids that
 
 PLETHORA. 41 
 
 concur to form the blood, as of the fluids that issue from the blood, let us inquire 
 what morbid changes the blood itself is liable to undergo. 
 
 The blood, then, is subject, first, to remarkable variations in its quantity, both in 
 respect to the whole system, and in respect to particular organs and tissues. 
 
 2. Closely connected with these differences of quantity is the variety which 1;^ 
 observable in regard>to the proportions between the several proximate constituents 
 of the blood. The changes that occur of this kind are sometimes strikingly evident 
 to our senses. For example, we not unfrequently perceive that the blood drawn 
 from a vein is thinner, manifestly more watery, less rich in fibrin, and in colouring 
 matter, than blood of the standard quality. 
 
 3. Again, independently of mere alterations in the relative proportions of its 
 proximate constituent parts, the blood is liable to great change in its chemical com- 
 position, and, therefore, in its physical quality. This appears to be the case in sea- 
 scurvy, and in the analogous disease called purpura, and it is doubtless so in many 
 other complaints. 
 
 The composition of the blood cannot fail to be affected by a deficient supply of the 
 elements of nutrition from without ; by diseases of the digestive organs, interfering 
 with the process of chylification ; by diseases of the organs of respiration, interfering 
 with its change from venous to arterial ; by diseases of other channels of excretion — 
 the bowels, the biliary apparatus, the skin — interfering (as I have already hinted) 
 with its appointed purification ; by foreign contaminating matters, finding entrance 
 (as they may when in solution, or in a gaseous form) through artery, vein, or any 
 membranous substance, such as bladder and intestine : lastly, thfe composition of the 
 blood may be altered, there is good reason to believe, by certain states of the nervous 
 system. 
 
 But contenting myself with having indicated these latter changes, or sources of 
 change, I shall defer giving a more particular account of any except those that relate 
 to the quantity and the distribution of the blood. 
 
 I say the blood may undergo important alterations in its quantify. It may exist 
 in too great abundance throughout the body ; and it may exist in too great abun- 
 dance in certain parts only of the body. These states have been recognized for 
 ages. Sometimes they are called respectively general and partial plethora: some- 
 times general and local congestions of blood ; people speak also of irregular deter- 
 minations of blood to different organs ; and, of late, the term hypersemia, first 
 invented by M. Andral, in France, has been imported into this country, and much 
 adopted here. All these words and phrases mean, in truth, the same thing; and 
 their frequent recurrence in medical works, is, of itself, sufficient evidence of the 
 frequency and importance of the conditions which they express. 
 
 If we comprehend rightly this subject of plethora or congestion, we shall be pre- 
 pared to understand some most important morbid states, of which it seems to be in 
 many, if not in all cases, the earliest approach — the initial step. Inflammation, 
 hemorrhage, dropsy, all acknowledge and imply a previous condition of congestion. 
 "There is probably," says Dr. Alison, "no kind of diseased action of which any 
 part of the living body is susceptible, which is not connected, sooner or later, with 
 increased afflux of blood towards that part, either as its cause or its effect ; and the 
 immediate object of all our most powerful remedies is to act on these irregularities 
 of the circulation." 
 
 That the blood may be differently distributed in the capillaries at different times, 
 we know by the variable colour of the surface, which depends upon the varying 
 degrees of fulness of the cutaneous blood-vessels. The phenomenon of i)hishing, the 
 red cheek of anger, the heightened colour of the skin under brisk exercise, are fami- 
 liar facts illustrative of partial plethora of the capillaries, consistent with health. 
 
 There are reasons (which I shall hereafter lay before you) for believing that a 
 similar sudden accumulation of blood, taking place in internal parts, may sensibly 
 disturb their functions ; causing transient fits of giddiness, insensibili'v, and some- 
 times depth itself, when the congestion affects the cerebral blood-vessels; and attacks 
 
 D'2
 
 42 » GENERAL PLETHORA. 
 
 of difficult breathing when the capillaries of the puhnonary tissue are conceined; 
 and even these attacks, for aught that I know, may end fatally. 
 
 It oftt'n happens that when certain portions of the surface, as the cheeks, are 
 visibly redder and fuller of blood than usual, or when such symptoms as I have just 
 referred to denote the probability of some internal congestion, other parts of the sur- 
 face, as in the extremities, are visibly paler : and there are, at the same time, cor- 
 esponding and palpable differences of temperature. 
 
 Perha})s it may not be so obvious that the whole quantity of blood, throughout the 
 bodv, is sometimes in excess. 
 
 That in the adult state, when the growth or increase of the body has been com- 
 pleted, blood may be made in greater abundance, and more rich in the materials of 
 nutrition than the wants of the body require, is not only conceivable, but true. We 
 are able to assign circumstances in which this is likely to happen, and we find that 
 under such circumstances it actually does happen. Full living, and a sedentary 
 life, are causes likely to occasion general plethora — and they do occasion it. The 
 full diet, so long as the digestive powers are perfect, provides more chyle, conducts 
 into the blood a larger quantity of its proper pabulum. The sedentary life precludes 
 that freer circulation of the blood, and that more liberal expenditure of it through the^ 
 skin, and by means of the other organs of secretion, which would occur under more 
 active habits. Persons thus circumstanced are apt to grow fat; the adipose tissue 
 seeming, in these cases, to form a kind of safety valve for the diversion of the super- 
 fluous blood. Such persons have turgid and florid cheeks, red lips, red mucous 
 membranes, and (ncft uncommonly) ferrety eyes. Their entire vascular system is 
 preternaturally distended. If you open a vein, you find that they bear a large 
 abstraction of blood without fainting, and are even refreshed by it ; and the blood 
 drawn separates into a large and firm mass of coagulum, with but little serum. 
 Keeping to the nomenclature we have already employed, we might say that there 
 is here liypertrophy of the blood. 
 
 When inflammation arises in the subjects of this general plethora, it runs high, 
 and requires active treatment. But they are not, as you might naturally exj^ect 
 them to be, and as many writers state them to be, peculiarly prone to sufler inflam- 
 matory complaints. There is a general fullness of the vascular system, but no irre- 
 gularity, nor any necessary tendency to irregularity, in the distribution of the blood. 
 
 You will observe that the relative proportion of the more solid to the more fluid 
 constituents of the blood is increased in these cases of general plethora : the blood is 
 not only more abundant, but it is richer also in fibrin, and in red particles. 
 
 The means to be adopted for redressing this unnatural and unsafe condition of the 
 circulation, are those which common sense would suggest. The removal of a por- 
 tion of the superfluous blood, a more restricted diet, a larger allowance of active 
 exercise. 
 
 It will be worth our while to contrast this state of general plethora with its 
 opposite — that in which the blood is scanty and poor — what Andral calls (though 
 with questionable propriety) anaemia. Oligscmia is the cacophonous but more 
 exact name assigned to it by Gendrin ; hut poverty of blood is the ordinary English 
 phrase for it, and the best of the three. This is a state which we can produce at 
 will, by abstracting blood from the body in moderate quantity, but repeatedly, and at 
 short intervals. It occurs, also, frequently, in spontaneous disease, and from various 
 causes ; from a privation of the materials destined to replenish the blood ; and in 
 cases in which these materials appear to be turned to little account, as in chlorotic 
 girls. We see it in those who habitually and frequently lose a certain quan'iiy of 
 blood, in disease; in persons, for example, who are subject to piles, and who bleed 
 daily from the rectum ; still oftener in women who sufler repeated hemorrhagi's from 
 the uterus. When the drain has been long-continued, these persons become very 
 pa)'^; even those parts which are naturally most red, as the lips and tongue, become 
 almost white,' their faces look like wax; and if still you draw blood from a vein, 
 and allow it to coagulate, you v/ill have a small clot floating in an abundance of 
 ferum, and that small clot will be of a light rosy colour; showing a great diminution 
 *n the proportion of fibrin ; and a still greater deficiency of the red particles. The
 
 ANEMIA. 43 
 
 blood, as they say, is " turned into water." It is a curious pathological fact, that the 
 red particles require more time for their restoration than the other constituents of the 
 blood. And I may mention to you now, what I shall have to repeat, that — in con- 
 junction with the obvious curative measures comprised in arresting tbe habitual loss 
 of the vital fluid, and in aflbrding sufficient nutriment to the system, — the prepara- 
 tions of iron, and the respiration of pure air, have signal efficacy in renewing the rea 
 particles, and giving back again their native hue of redness to the cheek and lips. 
 
 In general plethora every part is preternaturally full of blood, and the blood itself 
 is full of the elements of nutrition. General plethora, therefore, implies, in one 
 sense, local plethora of every organ and tissue. In strictness, however, local plethora 
 is only predicable of a part that contains more than its share of red blood. 
 
 Now the converse of this is not true, as it might be expected to be, of the opposite 
 condition. A deficiency in the whole mass of blood contained in, and circulating 
 through the body, does not protect the parts of the body from congestion — from 
 having an undue quantity of blood sent to them. Far from it. Local determinations 
 of blood are very common in persons in whom the mass of that fluid, and the pro- 
 portion of its nutritive materials, have been considerably diminished by disease, or 
 by hemorrhage. 
 
 This remarkable tendency. Tinder such circumstances, to an unequal distribution 
 of the blood in the capillaries, admits (I think) of this explanation. A due supply 
 of healthy blood is requisite for the steady and equable performance of the function? 
 of the brain and nerves. When this supply is defective, or uncertain, those functions 
 become disordered and irregular, and, in their turn, influence the various solids, dis- 
 turb their action, and derange the balance of the circulation. That the capillary 
 blood-vessels may be filled to excess, or completely emptied, by causes operating 
 through the nervous system — by moral emotions, for example — we are sure from 
 the phenomena just now adverted to, the blush of shame or anger, the paleness of 
 fear ; and there can be no doubt that morbid congestions, which sometimes are 
 separated from those that are consistent with health by very slight shades of difTer- 
 ence, are often determined through the agency of the same nervous system. And 
 persons endowed Avith great sensibility or irritability of the nervous system are very 
 liable to partial and irregular congestions of blood. 
 
 But this is not the only way in which local congestion may arise. 
 
 We can produce it, upon the surface of the body at least, at pleasure, and that m 
 various ways ; by friction, by exposing the parts to a high temperature, by certain 
 stimulating applications, mechanical (as a cupping-glass), or chemical (as a mustard 
 poultice) : we produce an injection of the small cutaneous blood-vessels ; there is, 
 evidently, more than the usual quantity of blood attracted to the part, or detained in 
 the part — a degree of redness, which soon subsides if the cause of it be withdrawn 
 in time. 
 
 Congestion thus occasioned is not inflammation, but it is the first obvious Step 
 towards that complex process ; and for this reason it deserves all your attention. 
 Apply the exciting cause a little longer, or increase, in a slight degree, its intensity, 
 and the phenomena of inflammation begin to manifest themselves. 
 
 I said we can produce local congestion when we please upon the sinface of the 
 body; but there can be no doubt that a similar state may be produced by analogous 
 causefi, in internal parts. Look at this representation of the stomach of a dog (one 
 of Dr. RoupelV s plates). You see one portion of it of a bright red colour, actively 
 and vividly congested. This was the consequence of a dose of alcohol. We may 
 be certain that something of the same kind is the result of every visit to the gin 
 shop. 
 
 Local congestion thus produced, or of this kind, is said to be active. M. Andial, 
 whose nomenclature has come much into fashion of late years, calls it sthenic, or 
 active hyperemia. The arteries, perhaps, have more to do with it, in the first 
 instance, than the veins. But it is in the capillary vessels, which are distinct from, 
 and interposed between the minute arteries and veins, that further changes aro 
 wrought, when the process advances a stage bej'ond mere local plethora. What
 
 44 LOCAL PLETHORA. 
 
 has been observed, by the aid of the microscope, with res^ject to the blood-vessek, 1 
 will endeavour to describe to you. 
 
 I take the account I am about to give you chiefly from Kaltenbrunner, a German 
 pathologist, who has recently investigated the subject experimentally, and whose 
 observations are believed to have been most carefully and skilfully conducted, and 
 their results no less faithfully narrated. His observations were made upon the 
 circulation as it appeared in the web of a frog's foot, under a powerful microscope. 
 It would be idle, and something like committing a fraud upon you, were I to lay any 
 stress upon my own knowledge or experience in this matter, for I cannot pretend to 
 any great skill in the use of that instrument, and my opportunities of noticing, by 
 its help, the phenomena of the circulation, have been too few to render their results 
 of much value. Yet it may be in some degree satisfactory to you to know that I 
 am not blindly repeating the remarks of others, and that what I have witnessed is 
 perfectly in accordance with the statements of Kaltenbrunner, and affords me a strong 
 assurance of his accuracy and fidelity. There is another reason, too, why I con- 
 sider him the more trustworthy — he has no theories to which he might be disposed 
 to bend or accommodate his facts. 
 
 Before I detail to you his account of the phenomena of congestion, I may briefly 
 describe the scene which presents itself when the web of a frog's foot is looked at 
 through a good microscope. It is a most beautiful and wonderful spectacle, and 
 particularly interesting to those who, like ourselves, are desirous of gaining some 
 insight into the healthy and diseased states of the circulation. It is a sight which I 
 hope and believe you also will have many opportunities of seeing in this place. 
 You perceive, then, occupying the circular field of the instrument, a number of 
 blood-vessels, through which the blood, with its globules, is in active motion : and 
 you see at once that there are three different kinds of vessels before you. First, 
 you notice the blood shooting with great velocity along tubes which divide and sub- 
 divide into smaller and smaller branches, each branch (speaking generally^ going 
 off at an obtuse angle : these are plainly arteries. Then, in another part of the field 
 of view, you see the blood moving in the contrary direction, more slowl}', in larger 
 trunks, which are formed by the continual union and accession of smaller and 
 tributary vessels of the same kind, that meet, for the most part, at acute angles : 
 these you know to be veins ; and all the intermediate and surrounding surface in 
 view is occupied with other vessels or channels, which connect themselves with the 
 ultimate ramifications of the arteries on the one hand, and with the primary radicles 
 of the veins on the other, but which differ from both arteries and veins in these par- 
 ticulars — that they interlace and anastomose in all parts, in a very irregular manner, 
 and at all angles, and that they retain everywhere .the same uniform size ; they 
 neither collect into larger and larger trunks, nor separate into smaller and smaller 
 branches, but are disposed like the threads forming the meshes of a net, except thart 
 the interstices are irregular in size and shape. These are the true capillaric^ inter- 
 mediate between the arteries and the veins, and perfectly distinct in character from 
 each, but communicating and continuous with both. 
 
 If now you press upon the animal's leg, so as to obstruct the circulation a little, 
 the motion of the blood is retarded, especially in the capillaries. You see the red 
 globules slowly following one another. These so-called globules are not really little 
 spheres, but circular discs, or flat cells. You may sometimes see one of them 
 sticking to the side of a capillary channel, and damming up the current ; other glo- 
 bules accumulate behind it, till at last they all pass on again together. 
 
 Now Kaltenbrunner irritates the web by pricking it, and soon afterwards the 
 following appearances present themselves : — There is an increased afflux of blood 
 to the part, so that arteries, veins and capillaries receive a column of blood two or 
 ♦.hrfe times as great as usual ; the velocity of the blood is accelerated ; the distended 
 sides of the vesseis seem to tighten round the stream of blood which they contain. 
 With this alteration of the circulation, the natural functions of the part begin to be 
 modified. The change of the blood from arterial to venous is interrupted. The 
 globules, passing with great rapidity through all the vessels, retain the characters of 
 arterial globules even when they arrive at the veins ; they present a bright colour.
 
 ACTIVE CONGESTION. 45 
 
 Show a tendency to stick together, and often form little clots, which pass through the 
 capillaries, and become visible in the veins. 
 
 One of the natural functions of the web is the secretion of a kind of lymph; but 
 this secretion is now suspended. The parenchyma itself begins to be shghtly tumid, 
 and assumes a brighter tint than common. 
 
 All these phenomena begin from a circumscribed spot, of which the circumference 
 gradually expands as the affection increases ; and they cease insensibly at that 
 circumference. 
 
 This is active congestion. 
 
 A certain period always intervenes between the first action of the irritant cause, 
 and the commencement of true congestion. This period, the occurrence of which 
 you will be good enough to bear in mind, Kaltenbrunner calls the period of incuba- 
 tion ; the period in which the congestion is hatching. 
 
 Active congestion, as such, does not continue long. It either passes on into 
 inflammation, as I shall hereafter explain, or it begins to decrease. When it has 
 been very sHght, the quantity of blood, and the rapidity of its movement, diminish 
 gradually from the circumference towards the centre ; and in this way the conges- 
 tion insensibly vanishes. 
 
 But, in other cases, Avhen it has not been so slight, the congestion terminates by 
 an evident crisis, which Kaltenbrunner thus describes : — The blood, receaing from 
 the circumference of the congested part towards the centre, gives out, by exhalation, 
 a liquid. The exhalation takes place by fits, and here and there, through the sides 
 of the capillary tubes, and generally on the surface of the organ. The moment of 
 exhalation is very transient; but it is repeated often, and in different spots, until the 
 congestion has disappeared. It is evidently critical, for the congestion is reheved 
 and extinguished in proportion as the exhalation is repeated. 
 
 I shall follow these consequences of active and continued local congestion no 
 further at present ; but merely remind you again that the changes I have last men- 
 tioned constitute the earliest appreciable modification of structure leading or belonging 
 to inflammation. What we thus may see (and it is what I myself have had some 
 opportunities of seeing) in the transparent textj^res of animals, we reasonably infer 
 to take place, under analogous circumstances, in those parts of the body which are 
 internal and opaque, and consequently hidden from our view. 
 
 I will just observe, also, that as active congestion is the parent of inflammation, so 
 it sometimes causes hemorrhage, and is relieved by it. But, comparing this form of 
 congestion with another which I am about to mention, the connection of hemorrhage 
 with it is, relatively, unfrequent. 
 
 One obvious mode of remedying this congestion is the mechanical abstraction of 
 blood from the loaded part. But it is seldom that this measure alone suffices ; and 
 sometimes it would be ultimately hurtful to adopt it. The state of the constitution 
 may be such, that the disposition to local plethora would be increased by the loss 
 qf blood. Undue susceptibility and disordered action of the nervous system are apt 
 to be aggravated by bleeding; and in proportion as the nervous functions are irregu- 
 larly performed, does the tendency to unequal distribution of blood in the capillary 
 vessels augment. We have daily examples of this in hysterical young women. It 
 IS not, therefore, the mere congestion that we have to consider ; we must look deeper, 
 for its cause. Leave a small thorn in the finger : the blood will be collected there in 
 consequence of its irritation, and will continue to collect in spite of depletion. But 
 extract the thorn, and your remedial measure of taking away blood is at once suc- 
 cessful. So it is also with internal congestions of blood — of which the exciting and 
 sustaining cause is not always so well known. 
 
 Contrasted, in some important particulars, with active congestion such as I have 
 been describing, is that morbid fullness of the capillary vessels which arises when 
 the return of the blood from them towards the heart through the veins, is impeded 
 by some mechanical obstacle. With this mechanical congestion the veins are 
 exclusively concerned. 
 
 Congestion of this kind may be strictly local. It may be confined to a smglo 
 limb, when the principal venous trunk belonging to that limb -s compressed, or
 
 46 PASSIVE CONGESTION. 
 
 Otherwise diminished in size ; and when no collateral and compensatory channels 
 for the returnirtg blood have been established. If there be disease of the liver, of 
 such a nature as to prevent a free passage of the blood through that organ, conges- 
 tion will ensue in all those parts of the capillary system from which the blood is 
 conveyed by the veins that ultimately concur to form the vena porta?. The force of 
 gravity alone is sufficient to produce venous congestion, and consequently conges- 
 tion of the capillaries, in parts of the body in which, under ordinary circumstances, 
 the circulation through the veins is aided, instead of being opposed, by that force. 
 If, for instance, the head be suffered to hang downwards for a certain lime, we see 
 the unequivocal signs of such congestion in the tumid condition and the purplish red 
 colour of the lips, cheeks, eyelids, and ears. When an impediment to the free 
 transmission of blood exists in the heart itself, a tendency to stagnation is produced, 
 first in the vence cavse, then in the smaller ramifications by which these veins are 
 fed, and at length in the general system of capillary vessels ; and thus even general 
 congestion may proceed from a fixed mechanical cause ; the parts that are the most 
 vascular being also the most readily and the most completely gorged. 
 
 There is yet a third form of local congestion, differing, in some respects, both 
 from active and from mechanical congestion. The capillaries become loaded, and 
 the course of the blood in them is languid and sluggish, without any previous 
 increased velocity of the blood in the arteries, and independently of any mechanical 
 obstacle in the veins. To this form of congestion the term passive is applied. 
 Andral denominates it passive or asthenic hyperagmia. I will tell you the class of 
 facts from the observation of which the real existence of this passive plethora has 
 been ascertained. 
 
 In persons enfeebled by age, or by disease, the lower parts of the legs, the insteps 
 and ankles, and the skin which forms the surface of old scars, are often habitually 
 purplish, or violet coloured. There is congestion of dark blood in those parts. 
 You may, perhaps, be ready to ascribe this to the mere influence of gravity upon 
 the blood, but this cannot be the whole explanation, because the force of gravity is 
 the same with all persons, and at all ages. A horizontal position of the limb will 
 perhaps diminish the hvid redness, or may even sometimes entirely remove it. But 
 the depending position ought not to cause it, and wonlu not cause it, if the blood- 
 vessels were in a healthy condition. Neither can the difference of posture be any 
 source of irritation to the congested part. The capillaries themselves appear to 
 have lost, in a great degree, their natural elasticity ; they easily dilate under the 
 pressure of the blood, which, being thus retarded, accumulates in the part. The 
 employment of friction, or some stimulating application, will often remove this con- 
 gestion. 
 
 I say all this is often to be noticed when there has been no cause of irritation 
 operating upon the part, and no preceding state of active congestion. But it is 
 important to mark the very frequent connection that exists between these con- 
 trasted conditions. The one very often succeeds the other : the vessels become 
 dilated under the force of the active hypersemia, and, the irritation ceasing, they do 
 not at once recover their tone, but remain passively loaded and distended. They 
 are frequently left in the same state upon the subsidence of inflammation. 
 
 Take another illustration from what you may any day witness in respect to indo- 
 lent ulcers. You will find that the large, flabby, and livid granulations which they 
 present, may be made to contract, and to assume a more healthy and florid hue, by 
 local stimulants ; these evidently act by quickening the previously languid circula- 
 tion, and unloading the congested capillaries. 
 
 Observe, again, what not unfrequently happens in regard to the eye ; a little 
 crgan, indeed, but one that supplies us with more striking lessons in patnology and 
 therapeutics than any other portion of the body. You know that the conjunctiva 
 and sclerotica, through which, while healthj'-, colourless fluids alone circulate, are 
 traversed, under various forms of disease, by innumerable vessels bearing red blood. 
 Now it is notorious that, in certain cases, the application of any stimulating sub- 
 stance to the surface of the organ wiU increase the existing redness, multiply the 
 number of visible vessels, and aggravate the complaint. These are cases of active
 
 PASSIVE CONGESTION. ' 47 
 
 congestion, dependent upon irritation that is still subsisting. But it is equally well 
 known to practical men that the blood-vessels of the eye are Kable to congestion of a 
 very different kind. They are seen to be distended, somewhat tortuous, almost vari- 
 cose, and the redness has a browner tinge, and is less vivid, than in the former case. 
 In this kind of vascular fullness — or in this stage of it, for it sometimes succeeds to 
 active congestion, — emollient applications do harm rather than good, while strongly 
 astringent and even irritant substances will often promptly dissipate the vascularity. 
 These, again, are cases illustrative of congestion of the asthenic or passive character. 
 The strong topical irritants restore to the feeble and relaxed vessels their natural elas- 
 ticity, stimulate them to contract upon their contents, and to force onward the red 
 blood, which they cease to admit from the arteries ; and the redness vanishes. 
 
 In the production of active congestion the arteries appear to be principally con- 
 cerned : in the production of mechanical congestion, the veins: in passive conges- 
 lion, the capillaries — which, strictly, are neither arteries nor veins, but lie between 
 the arteries and the veins — are the vessels chiefly in fault. 
 
 If we turn our thoughts from the visible textures of the body to those which are 
 hidden internally, we shall find reason to believe that these also are equally liable tn 
 similar conditions of passive congestion. Take those exceedingly vascular organs, 
 the Jungs, through which the whole of the blood circulating in the living body nas 
 to pass. The lungs, as might be expected, are very liable to congestion and engorge- 
 ment of their capillary vessels. Ofc-times this is clearly active, and the result of 
 some irritating cause. But it is not always so. Many of you recollect the epidemic 
 disorder called the influenza, which was so prevalent here in the spring of 1831, 
 and again in the early part of 1837. Among the most constant and striking charac- 
 ters of the disease were the symptoms of pulmonary catarrh ; and it was remarkable 
 how long, ih some persons, these symptoms persisted. After the pulse had regained 
 its natural frequency of beat, and when all fever had ceased, the patient would con- 
 tinue to breathe with constraint and some labour, to wheeze a little, to cough, and to 
 expectorate mucus. As all febrile disturbance had subsided, and no further benefit 
 seemed to flow from adhering to what is called the antiphlogistic system, it was a 
 reasonable conjecture that this disappointing obstinacy of some of the symptoms 
 might depend upon a lingering but passive congestion of the pulmonary mucous 
 membrane. And the nature of ihejuvantia showed the correctness of this con- 
 jecture. Tonics and stimulants, so far from aggravating the pectoral symptoms, 
 speedily removed or abated them. 
 
 You cannot fail, I think, to perceive the important bearing of these distinctions 
 between active and passive congestion upon our notions of disease and our choice 
 of remedies. These distinctions are not to be discovered by the knife of the anato- 
 mist. You must take care not to confound a knowledge of pathology, in the proper 
 sense of that word, with a knowledge of morbid anatomy. Pathology comprehend;; 
 not only the visible changes of structure which accompany disease, and are disclosed 
 by death, but the processes by which those changes are effected in the hving body, 
 and the laws which govern those processes. 
 
 There is one important law ascertained in respect to both active and passive con- 
 gestion : viz., that it is apt to recur; that those parts are most likely to suffer it (or 
 inflammation, which implies it) that have suffered it before. We may often turn 
 our knowledge of this general fact to good account, in what is termed the jirophy- 
 laxis of disease — in devising means for warding off disorders. 
 
 I have stated that active and passive congestion sometimes occur in succession, 
 the latter being a sequel of the former. So, also, it may be said of passive and of 
 mechanical congestion, that they often exist together. If the capillaries of a part or 
 organ be much enfeebled, the mechanical effect of the gravity of the blood may suf- 
 fice to bring them into a state of congestion. It is thus that Andral explains the 
 occurrence of a gorged condition of the posterior portions of the lunrrs (evinced by 
 symptoms during life, as well as by inspection of those parts after death), in persons 
 who, having laboured under no previous pulmonary affection, have been confined to 
 a supine position by long-continued disease or debihty. This state of the capillaries 
 is called by Lerminier the "engorgement of position ;" and by Laennic, "th'^ pneu-
 
 48 CONDITIONS OF LIFE. 
 
 moiiia of the dying." It neither proceeds from irritation, nor has it the essential 
 characters of inflammation ; although it is ajit to be considered an evidence of inflam- 
 mation by the mere morbid anatomist. 
 
 Again, as active congestion, when continued or intense, is antecedent and con- 
 ducive to inflammation, so is mechanical congestion, when it reaches a certain point, 
 the prolific source of hemorrhage, and the almost constant precursor and immediate 
 cause of a large class of dropsical accumulations. 
 
 I spoke a little while ago of general plethora, as a state in which the whole mass 
 of blood circulating in the body is excessive in quantity, and rich in quality — full of 
 fibrin and of colouring matter, thick with globules. But the blood, as a mass, may 
 be in excessive quantity, yet poor in its materials, serous, deficient in globules, and 
 fibrin, and colour; and in this condition of the blood, also, as we shall hereafter see, 
 dropsies are apt to arise. 
 
 We have now, therefore, laid the foundation for the better understanding of those 
 three great classes of disease — InJIammations, Hemorrhages, and Dropsies. 
 
 There is no region or organ of the body exempt from these diseased conditions 
 and their consequences ; and of each of them some general account must be given, 
 Defore we come to consider the special diseases incident to the several parts and 
 organs. 
 
 But previously to entering upon this general account of inflammation, of hemor- 
 rhage, and of dropsy, we have still some other preliminary matters of importance to 
 discuss. The causes and modes of death. The causes of disease. A sketch of the 
 nature, classification, and import of symptoms. 
 
 Our inquiries hitherto have related to the manner in which the physical condi- 
 tions of the various parts of the body are capable of being altered, and their functions 
 disturbed or suspended, in disease. But how it happens that some of these altera- 
 tions of structure, or interruptions of function, are incompatible with the further con- 
 tinuance of life, and put a stop to the working of the whole machine, is an inquiry 
 nf no less interest, though of a somewhat difl"erent kind. 
 
 LECTURE V. 
 
 Different modes of dying. Pathology of Sudden Death. Death by Amemia; 
 its Course, Phenomena, and Anatoinical Characters. Death by Asthenia ; its 
 Course, Phenomena, and Anatomical Characters. Syncope. Death by Inani- 
 tion. Death by Apnoea: Death by Coma: their Course, and Phenomena, and 
 the Anatomical Characters common to both. Application of the Principles ob' 
 tainedfrom the investigation of the Phenomena of Sudden Death, in elucidating 
 the Symptoms and Tendencies of Disease. 
 
 I. PROPOSE to devote the present lecture to the following inquiry: — Wherefore it 
 IS, and how it is, that some of the corporeal changes which we have been consider- 
 ing, or the diseased conditions connected with those changes, come to be incompatible 
 with the further continuance of life ? how it is that they put an end to the working 
 of the living animal machine ? why the machine should not continue to work, though 
 perhaps imperfectly, notwithstanding such changes ? 
 
 When our watches stop, we take them to a watchmaker to ascertain why they 
 have stopped. The watchmaker knows that there are various ways in which the 
 movements of the instrument may have been arrested. The main spring may have 
 broken ; or the little chain that connects the barrel with the fusee may have parted ; 
 or the teeth of some of the wheels may have become inextricably entangled ; or the 
 watch may have ceased to go (as the saying is) simply because it has not been wound 
 up. Now the examination which the watchmaker undertakes in respect to the 
 watch, I am desirous of making in respect to the human body. I am going to 
 inquire mto the several processes and modes of dying — the steps, or ways, by which
 
 CONDITIONS OF LIFE. 49 
 
 the vital functions of the body are extinguished. A very Httle experience in the 
 sick chamber, or in the wards of a hospital, will suffice to teach you that, although 
 all men must die, all do not die in the same manner. In one instance the thread of 
 existence is suddenly snapped ; the passage from Hfe, and apparent health perhaps, 
 to the condition of a corpse, is made in a moment : in another the process of dissolu- 
 tion is slow and tedious, and we scarcely know the precise instant in which the 
 solemn change is completed. One man retains possession of his intellect up to his 
 latest breath : another hes unconscious, and insensible to all outward impressions, 
 for hours or days before the struggle is over. 
 
 We seek to assertain the laws and mechanism of these mysterious differences. 
 The inquiry is not one of merely curious interest, but has a direct bearing upon 
 the proper treatment of disease. It will teach us what we have to guard against, 
 ■what we must strive to avert, in different cases. In speaking of particular diseases, 
 I shall constantly refer to the facts and reasonings which I am now about to lay 
 before you. 
 
 In pursuing this inquir}', we need not go into any deep physiological disquisition 
 respecting the conditions that are essential to hfe. It is sufficient for our purpose to 
 remark that life is inseparably connected with the continued circulation of the blooa. 
 So long as the circulation goes on, life, organic Ufe at least, remains. When the 
 blood no longer circulates, life is presently extinct : and our investigation of the dif- 
 ferent modes of dying resolves itself into an investigation of the different ways in 
 which the circulation of the blood may be brought to a stand. 
 
 Observe the ample provision that is made, in the construction of the body, for car- 
 rying on and maintaining this essential function. First, there is an extensive hy- 
 draulic apparatus distributed throughout the frame, and consisting of the heart and 
 othcT blood-vessels. Next, there is a large pneumatic machine, forming a consi- 
 derable part of the whole body, and composed of the lungs, and the case in which 
 they are lodged. Lastly, the power by which this machine is to be worked and 
 regulated is vested in the nervous system. Each of these systems must continue in 
 action, or the circulation will stop, and hfe will come to an end. The functions ihey 
 respectively perform are, consequently, called vital functions : and their main organs 
 — the heart, the lungs, the brain (by which I understand the intercranial nervous 
 mass) — are denominated vital organs. The functions of any one of the three being 
 arrested, the functions of the other two are also speedily extinguished. But the 
 phenomena of dying vary remarkably according as the interruption begins in the one 
 or the other organ. Hence Bichat, who in his Recherches siir la vie et la mort, laid 
 the foundation of the distinctions I am about to describe, spoke of death beginning 
 at the head, death beginning at the heart, and death beginning at the lungs. This 
 nomenclature is, however, unsatisfactory and insufficient, as you will presently per- 
 ceive. 
 
 That the heart may continue to propel the current of the blood, two things are 
 necessary : first, a certain power or faculty of contraction ; and, secondly, a suffi- 
 cient quantity of blood in its chambers, to be moved, and also to stimulate theni to 
 contract. If this, the proper stimulus to the internal surfaces of the heart, be with- 
 held, or much deficient, it will soon cease to beat. There are plainly, therefore, 
 two ways in which death might be said to begin at the heart ; and these require to 
 be distinguished. 
 
 The respiration is entirely subservient to the circulation of the blood. The two 
 organs, the heart and lungs, respond intimately to each other. The whole of the 
 blood is sent by the right heart to the lungs, simply that it may there be submitted 
 to the chemical action of the atmosphere. The respiratory apparatus is added to 
 the body for the sole purpose of thus repeatedly ventilating the blood. 
 
 To this purpose also (setting aside all accidental impediments) two things are re 
 quisite ; first, circumfused air to enter and depart at short intervals ; and, secondly, 
 alternating movements of the chest to cause its entrance and exit. 
 
 Now these movements, although they admit of being regulated by the will, are 
 essentially involuntary. The ordinary acts of respiration depend upon a certain con- 
 4 E
 
 50 DEATH BY ASTHENIA. 
 
 dition of the medulla oblongata. If this condition fails, the mechanical part of the 
 respiratory process, and, consequently, the chemical part also, ceases. 
 
 The respiration hangs, therefore, directly upon the nervous system. 
 
 On the other hand, the action of the heart is not directly or necessarily dependent 
 upon any constant nervous mfluence conveyed to it. The circulation goes on in an 
 acephalous foetus ; it may be kept up, by maintaining artificial respiration, in a deca- 
 pitated animal ; nay, even when both brain and spinal cord have been abstracted from 
 the body. 
 
 But though the nervous influence is not necessary to the movements of the heart 
 — further than as it is necessary to the respiration, and to the introduction of nutri- 
 ment — it has been clearly ascertained that very sudden and extensive injury or shock 
 to the nervous system may instantly paralyze the heart, and so stop its action. 
 
 There are certain states, then, of the brain and nerves which, without directly 
 afTecting the heart, bring the motions of respiration to a pause : and there are cer- 
 tain states of the brain and nerves Avhich act directly on the heart and arrest its pla3^ 
 That is, there are two different ways in which death might be said to begin at the 
 head. 
 
 Hence, I say, the nomenclature employed by Bichat is defective and inaccurate. 
 
 In order to see clearly the steps by which the circulation, and with it life, finally 
 terminates, in the various forms of dying, we must study the problem under its sim- 
 plest forms. We must examine the cases in which the vital functions are, each in 
 their turn, suddenly stopped, by some known cause, operating upon this or that vital 
 organ. We must take advantage of tlie experiment (if I may so call it) which is 
 performed before our eyes whenever a healthv man is cut off at once by external 
 violence, or by poison, acting directly upon a particular organ or system of organs. 
 The inquiry might be assisted, and, indeed, it has been mainly carried on, by ex- 
 periments made upon living animals of a similar conformation with man. But the 
 pathology of sudden death is happily now too well understood to require any further 
 recurrence to that painful mode of " interrogating nature." 
 
 Death, as it takes place in disease, is usually complicated. Many parts are affected, 
 and different functions languish, and various disturbing causes are in operation, at 
 the same time. Occasionally, however, the process of dissolution is as simple and 
 obvious as in death produced by violence ; and in most cases some primary and pre- 
 dominant derangement may be traced of this or that vital function ; and a tendency 
 is more or less clearly manifest to one or the other of the modes of dying, which we 
 may now proceed to consider in succession. 
 
 And first let us examine that form of death which is caused by a want of the 
 due supply of blood to the heart. This is caUed, with much propriety, death by 
 anaemia. 
 
 The best examples of death taking place in this way are those in which it is the 
 consequence of sudden and profuse hemorrhage. The circulation fails, not because 
 the heart has lost its power of contraction, but because blood does not arrive in its 
 chambers in sufficient quantity. 
 
 We assure ourselves of this in two ways. In the first place, when the body of 
 an animal is examined immediately after death from sudden and copious loss of blood, 
 the heart is not found dilated and full of blood, as it would be if it had ceased to act 
 from a Avant of {)ower to contract upon its contents ; but it is found empty, or nearly 
 so, and contracted. Secondly : this conclusion is confirmed by the reverse expe- 
 riment : by the effect, I mean, of the transfusion of blood. It is a fact well ascer- 
 tained, first by experiments made upon animals, and afterwards by most happy trials 
 upon the human subject, that in cases of apparent death from violent hemorrhage 
 the suspended functions may be restored by conveying a timely supply of blood into 
 the vessels of the seemingly dead animal from the veins of a hving animal of the 
 same species. Now it is quite clear that this introduction of fresh blood could be 
 of no avail in a case where the heart was unable to act upon the blood which had 
 already reached it. 
 
 The phenomena which attend this mode of dying are paleness of the countenance 
 tjid hps, cold sweats, dimness of vision, dilated pupils, vertigo, a slow weak irregular
 
 DEATH BY INANITION. 5J 
 
 pulse, and speedy insensibility. With these symptoms are frequently conjoined 
 nausea, and even vomiting, restlessness and tossing of the limbs, transient delirium : 
 he breathing is irregular, sighing, and, at last, gasping ; and convulsions generally 
 occur, and are once or twice repeated, before the scene closes. 
 
 It is thus that women often die, in whom "flooding" happens after childbirth. 
 Sometimes the sudden bursting of an aneurism occasions this form of death. It is 
 common on the field of battle, and in accidental injuries whereby large blood-vessels 
 are wounded. Internal hemorrhage, depending upon diseases to be hereafter 
 described, may also prove fatal in the same manner. 
 
 This, then, is one form of death beginning at the heart. Another form, the con- 
 verse of this, but spoken of also as death beginning at the heart, is that in which 
 there is no deficiency of the proper stimulus to the heart's action, but a total failure 
 of contractile power in that organ. This is well denominated death by asthenia. 
 
 Death occurring in this way is not uncommon. The effects of some kinds of 
 poison furnish a good illustration of it. There are certain substances which, applied 
 to some part or other of the bod}', speedily extinguish fife : and when, after their 
 fatal operation, the thorax is opened, each chamber of the heart is found to be filled 
 with its proper stimulus, upon which it has been unable to contract. 
 
 This was distinctly made out by Sir Benjamin Brodie, in his able and scientific 
 investigation of the effects of different poisons. You may read with advantage his 
 papers on this subject in the Philosophical Transactions for 1811 and 1812. He 
 ascertained upon examining the chest after death occasioned by the upas antiar, that 
 the heart was not empty, but full, there being purple blood in its right, and scarlet 
 blood in its left cavities. These are the anatomical characters of this kind of death ; 
 and they prove that the action of the heart does not cease from a defect of stimulus, 
 but from a loss of its contractile power. 
 
 The state of suspended animation common to both these forms of dying — (the 
 ultimate external phenomena being nearly the same in each, and the result in 
 each being the simple failure of the circulation) — is often expressed by the term 
 syncope. 
 
 Besides the essential distinctions between them already mentioned, there is this 
 further point of difference. In death by anramia, the suspension of the functions of 
 the nervous system arises from a lack of blood which should be sent to the brain 
 from the heart. Hence the well-known effect of mere position. Syncope is sooner 
 produced by venesection when the person bled is sitting up than when he is recum- 
 bent : and the first remedy for the fainting state is to lay the patient flat upon the 
 ground, or even to place his head a little lower than the trunk of his body. In the 
 one posture the current of the blood towards the head is impeded by the force of 
 gravity ; in the other it is not. In sudden death by asthenia this order is reversed ; 
 the nervous system is the part first affected, and through it, consecutively, the heart. 
 This appears from the fact that sudden death by asthenia is sometimes produced by 
 causes which we know to act primarily upon and through the nervous system ; by 
 strong mental emotion — as intense grief, joy, terror. Cases of fatal concussion, 
 where the brain is jarred by some bodily shock — and death occurring almost instantly 
 from blows on the epigastrium — are of this kind. Lightning and electricity kill too, 
 when they kill at all, in the same way. And we shall hereafter see that certain 
 varieties of apoplexy, and several other diseased conditions, destroy life by suddenly 
 arresting the contractile power of the heart. 
 
 When death by asthenia occurs more slowly, from disease, the phenomena are 
 somewhat different. The pulse becomes very feeble and frequent, and the muscular 
 debility extreme ; but the senses are perfect, the hearing is sometimes even painfully 
 acute, and the intellect remains clear to the last. The tendency to death of this form 
 is remarkably manifest in acute inflammation of the peritoneum, in what is called 
 malignant cholera, and in cases of extensive mortification. 
 
 Akin to this form of dying is that in which the living povvers are slowly exnausted 
 by fingering and wasting disorders, as in many cases of phthisis, in diabetes, and in 
 dysentery ; or by hemorrhages moderate in amount, but frequently repeated ; or by 
 any other long-continued drain upon the system. The death is partly, however, t(j
 
 52 DEATH BY APNCEA. 
 
 be ascribed to a deficient supply of the natural stimulus to the heart's action. The 
 type of these mixed modes of dying is seen in death by starvulion, which may be 
 considered intermediate between death by anaemia, and death by asthenia. Death 
 from inanition can never be sudden. The blood, renewed no longer from without, 
 and fed only by absorption from the system itself, diminishes gradually in quantity, 
 while its quality deteriorates. Gradually also the contractile power of the heart, eis 
 well as of the muscles generally, is weakened ; and from these combined causes its 
 movements at length cease. Accordingly after death by starvation the heart is not 
 found to be so much contracted, nor so nearly empty, as after death by sudden and 
 copious hemorrhage. 
 
 Certain diseases of the throat or the cesophagus, prohibiting the introduction of 
 food ; of the stomach, preventing its retention ; of the digestive organs generally, 
 hindering its assimilation, are fatal in this manner. 
 
 We have yet to consider how death is produced by the suspension of the respi- 
 ratory function — in other words, by a want of the due arterialization of the blood. 
 
 There are two perfectl}^ distinct modes in which this cause of death may happen ; 
 distinct, i. e., in regard to the steps of the process, although identical in regard to 
 the ultimate result. 
 
 1. When the access of air to the lungs is suddenly denied by some direct obsta- 
 cle to its entrance. 
 
 2. When the muscular actions required for breathing cease in consequence of 
 insensibility, caused by disease or injury of the brain. 
 
 The first of these two forms of dying is commonly called death by ctspJiyxia. 
 The second is conveniently termed death by coina. Bichat spoke of them respect- 
 ively as death beginning at the lungs, and at the head. 
 
 It is of much importance to get rid, when we can, of improper names. They are 
 ver}' apt to warp our notions concerning the real nature of the things they are 
 intended to express. This term asphyxia, which is in every body's mouth, is very 
 inappropriate, if we look to its etymology, to the kind of death which it has come to 
 denote. It signifies, you know, literally, pulselessness, the want of pulse ; and there- 
 fore it might express any kind of death whatever ; or if applied to any particular 
 mode of dying, it would seem to belong to that we have just been considering, 
 namely, death beginning at the heart. And you will presently see that it is pecu- 
 liarly inapplicable to all those cases where death results from the non-arterialization 
 of the venous blood. Its current signification has, I am afraid, been too long estab- 
 lished by custom, to allow of its being restored to its proper meaning without much 
 confusion. But at any rate, I can and shall avoid its use, and adopt in preference 
 the generic term o/j;2ffa (privation of breath) as justly expressive of the mode of 
 death to which the word asphyxia is commonly given by authors. The generic 
 English term is suffocation. 
 
 The entrance of air into the lungs may be prevented in various ways : by stop- 
 page of the mouth and nostrils {smothering): — by submersion of the same inlets in 
 some liquid {droivning); or in gases which, though not in themselves poisonous, 
 contain no oxygen ; such are hydrogen and azote : — by mechanical obstruction of 
 the larynx or trachea from within, as by a morsel of food (choking), or from with- 
 out, as by the bowstring [strangulation; both these varieties are included in the term 
 thiottling): — by forcible pressure made at once upon the chest and abdomen, pre- 
 venting all movement of the ribs and of the diaphragm ; this happens sometimes to 
 workmen employed in excavating, who are buried, their heads excepted, by the falling 
 of a mass of earth ; it was near happening, Dr. Roget tells us, to an athletic black 
 man, of whose body a cast was attempted to be taken, as an academic model, by one 
 operation, and in one entire piece. "As soon as the plaster began to set, he felt on 
 a sudden, deprived of the power of respiration, and to add to his misfortune, was 
 cut off from the means of expressing his distress ; his siniation was perceived just 
 in time to save his hfe ;" in this way the victims of Burke and Hare were stifled ; 
 and the same immovable state of the lung-case is sometimes produced in tetanus, or 
 oy the poisonous influence of strj'chnine, all the respiratory muscles being fixed in 
 ri^ i spasm . — b) paralysis of the same muscles, from injury or disease of the spina'
 
 DEATH BY APNCEA. 53 
 
 cord above the origin of the nerves that give oif the phrenic nerve, and therefore 
 above the origin of the intercostal nerves also ; or from section of the phrenic and 
 intercostal nerves : — lastly, by such breaches in the walls of the thorax as admit air 
 freely to the surface of bolh lungs, and spoil the pneumatic machine, as a pair of 
 bellows is spoiled when deprived of its valve. Of course the same consequences 
 ensue when both pleurce become filled with liquid of any kind. 
 
 Whenever the privation of air is sudden and complete, the following external phe- 
 nomena present themselves. — Strong but vain contractions occur of all the muscles 
 concerned in breathing, and struggling efforts to respire are made, prompted by that 
 uneasy sensation which every one has experienced who has tried how long he can 
 hold his breath, and which, when unappeased, soon rises to agony : this extreme 
 distress is transient, being almost immediately succeeded by sensations, not unplea- 
 sant, of vertigo, and then by loss of consciousness, and convulsions : at length all 
 effort ceases, a few irregular twitchings or tremours of the limbs alone perhaps 
 remaining; the muscles relax, and the sphincters yield: but still the movements of 
 the heart, and even the pulse at the wrist, continue for a short time after all other 
 signs of hfe are over; there is no asphyxia (properly so called) till the very last. 
 
 During this process, which does not occupy more than tw^o or three minutes, the 
 face at first becomes flushed and turgid, then Hvid and purplish, the veins of the 
 head and neck swell, and the eyeballs seem to protrude from their sockets ; at length 
 the heart ceases to palpitate, and life is extinct. 
 
 The internal changes which correspond with, and cause these outward symptoms, 
 have been carefully studied, and accurately, though slowly and lately ascertained. 
 They all proceed from the prevention of the chemical alteration naturally produced 
 in the blood, within the capillary vessels of the lungs. The blood, continuing venous, 
 passes at first in considerable quantity through the pulmonary veins, into the left 
 side of the heart, and thence through the arteries, to all parts of the body. This 
 venous blood, however, is inadequate to sustain, or sufficiently to excite, the functions 
 of the parts it thus reaches. In the brain the effect of the unnatural circulation is 
 felt at once ; and shown by the convulsions and insensibility that ensue. The motion 
 of the blood in the pulmonary capillaries is also, from the first, impeded, and its 
 current gradually retarded, until it stagnates altogether ; the lungs remaining full, 
 the right chambers of the heart distended, and therefore less capable of contracting. 
 Meanwdiile the black blood, flowing more and more tardily and scantily into the left 
 chambers, leads, by its unnatural quality, as well as its deficient supply, to feeble 
 contractions ; and this side of the heart is comparatively empty. 
 
 In this state, even after |.he heart has ceased to beat, but not long after, if the i ause 
 which has excluded the air be withdrawn, and fresh air readmitted — in other words, 
 if artificial respiration be instituted — the blood in the pulmonary capillaries under- 
 goes the required change, becomes arterial, begins again to pass onwards, and by 
 degrees the circulation is restored, and the patient saved. 
 
 In this mode of death the circulation is first arrested, and death truly begin.., in 
 the lungs. 
 
 When the carcass of an animal, that has thus perished of apnosa, is immediately 
 afterwards examined (so speedy an inspection of the human body being, for obvious 
 reasons, seldom practicable or proper), the left side of the heart is found to contain a 
 small quantity of dark blood, while its right cavities are greatly distended, and the 
 lungs, the cavce, and the whole venous system, are gorged with blood of the same 
 character. These are, in few words, the anatomical characters of sudden death by 
 apncea. 
 
 The pathology of this mode of dying has, I say, been thoroughly understood only 
 of late. It will not be uninteresting, and may, I think, be useful, to trace briefly 
 the successive steps by which the true explanation has been attained. Haller was 
 of opinion that the quiescence of the lungs, consequent upon the cessation of the 
 alternate movements of the thorax, formed a mechanical impediment to the further 
 transit of the blood through them; and that death resulted from obstruction of the 
 circulation in Ihe lungs. He was partly right ; but he erred in supposing that thir 
 stream of blood was arrested absolutely, and at once, and by a mechanical obstacle 
 
 e2
 
 54 DEATH RY APNCEA. 
 
 Apnoea, with all its peculiar phenomena, occurs, when atmospheric air is excluded, 
 although the lungs continue to play ; as in persons who breathe azote or hj^drogen 
 gas. It was clearly shown by Dr. Goodwyn, in his Essay upon the Connection of 
 Life ivith Respiration, that the unaerated blood passed through the lungs and entered 
 the left auricle and ventricle of the heart ; but he thought that it went no further. 
 His notion was that arterial blood is the only stimulus which can excite the contrac- 
 tion of the left cavities of the heart, and that, when venous blood arrives in them, 
 the organ becomes motionless ; and no blood being sent to the brain, the person dies. 
 Had this theory been true, the left chambers would be found full of blood after death 
 (which they are not), and the mode of dying would not have differed essentially from 
 that which we have already considered as death by asthenia. The well-devised 
 experiments of Bichat carried the investigation a step further, and proved that the 
 unaerated blood not only reached the heart, but was propelled by the contractions of 
 that organ to every part of the body, through the arteries. Having applied a liga- 
 ture upon the trachea of a living animal, he made a small opening in one of its 
 carotid arteries. Presently the slender stream of blood that issued began to lose its 
 florid tint, and to assume the dark colour of venous blood; but it continued to floic, 
 and the afflux of this dark blood upon the brain was marked by convulsions and 
 insensibihty. Bichat conceived, therefore, the erroneous belief that the blood under- 
 went no obstruction in its passage through the lungs, but that, remaining unpurified 
 and venous, it acted as a poison upon every part to which it was carried by the 
 arteries — first upon the nervous S3'stem, and ultimately (passing through the coronary 
 arteries) upon the muscular substance of the heart itself. There are, however, two 
 well-known facts, which, upon this theory, would be inexplicable — the comparative 
 emptiness of the left chambers of the heart, and the restoration of the suspended 
 functions by the timely performance of artificial respiration. The air could never 
 reach and revivify or depurate the venous blood, stagnating in the capillaries of the 
 heart. It was reserved for Dr. Kay to correct the unsound parts of Bichat's doctrine, 
 and to show that the blood begins to stagnate in the capillaries of the lungs, in con- 
 sequence of its failing to undergo the change from venous to arterial ; and that the 
 movements of the left heart are brought to an end, principally by the deficient supply 
 of blood from the lungs. His experiments tend, moreover, to prove that venous blood 
 circulating through the arteries has no directly poisonous operation, but is capable, 
 though much less effectually than arterial blood, to support, in some degree, the 
 irritability of the muscles. A muscle will continue to contract longer when supplied 
 with venous blood by its arteries, than when supplied with no blood at all. Doubt- 
 less, in death by apnoea, the movements of the heart are weakened, partly in conse- 
 quence of the imperfect stimulus afforded by the venous blood that penetrates its 
 substance ; but the main cause of the failure of the circulation seems to be the diffi- 
 culty with which the non-arterialized blood finds its way through the capillaries of 
 the lungs. This theory is consistent with all the phenomena observed. For a 
 detailed account of the experiments and reasonings upon which Dr. Kay's conclu- 
 sions are founded, I must refer you to his work on Asphyxia. 
 
 Sudden death by apncea is not very often witnessed as the result of disease. It 
 sometimes is caused by a spasmodic closure of the rima glottidis. It is no uncom- 
 mon consequence of accidents, in which the upper cervical vertebra? are broken or 
 displaced. I ii:ive seen several instances of death rapidty produced, with all the 
 symptoms of sudden suffocation, generally in intoxicated persons, in whom the chink 
 of the glottis has been found closely plugged by a fragment of meat, which "had 
 gone the wrong way." 
 
 But there are numerous forms of more chronic disease, in which the tendency to 
 death by apnoea is plainly discehiible, sometimes for a long while before their fatal 
 lermmation arrives. And the phenomena are similar in character to those which are 
 noticed when the struggle is short. We hear the patients complain of the " want of 
 breath ;" we see how they labour to satisfy this want, when it becomes urgent, by 
 the elevated shoulders, the dilating nostrils the energetic action of all the muscles 
 ihat are auxiliary to the respiration; we perceive by the dusky and loaded coun- 
 tenance, the hvid lips, and ears, and eyelids, that the blood is but imperfectly arte
 
 DEATH BY APNGEA. 55 
 
 rialized. The diminislied capability of such blood to support the functions of the 
 brain is made evident by the vertiginous sensations, and the delirious thoughts of the 
 gasping sufferers ; and after death we find the same distension of the right chambers 
 of the heart, while the left are nearly empty — the same gorged condition of the 
 pulmonary arteries and venous system generally, which constitute the anatomical 
 characters of this mode of dying. These appearances are even more constandy 
 visible in the dead body, when apncea has been gradually produced, than after sudden 
 suffocation ; simply, I believe, because they are more permanent. After sudden 
 death, however caused, the blood seldom coagulates; and the venous turgescence 
 consequent upon rapid apncea, although great at first, has time to subside and disap- 
 pear before the body is examined. 
 
 In protracted cases, death does not take place purely in the way of apncea ; the 
 heart is weakened, and the nervous influence impaired by the continued circulation 
 of imperfectly arterialized blood ; but the symptoms belonging to apncea are plainlj'- 
 predominant. 
 
 When (as is most common) the privation of air is incomplete, and a scanty and 
 insufficient supply is admitted, morbid changes take place in the lungs themselves ; 
 the air-tubes and cells become charged with serous fluid, which operates as an addi- 
 tional cause of suffocation. The saine phenomenon is observed when the par vagum 
 is divided on both sides. 
 
 Death by apnoea in disease is extremely common. It may be produced by any 
 thing which narrows the chink of the glottis ; by warts that sometimes grow there, 
 by oedema of the submucous tissue of the larynx, by inflammatory tumefaction of 
 its lining membrane: it may result from the presence of what are called false mem- 
 branes in the windpipe and bronchi, such as are formed in the distemper named 
 croup : it may be the consequence of disease situate in the substance of the lungs 
 themselves, rendering them incapable of receiving the requisite quantity of air ; of 
 this we have examples in pneumonia, and in pulmonary apoplexy : or it may pro- 
 ceed from disorders of the pulmonary mucous membrane, the air-passages becoming- 
 blocked up with excessive and unnatural secretions, as in bronchitis. Phthisis is 
 sometimes fatal in the way of apna-a; more commonly it tends to death by asthenia. 
 Diseases of the pleurce attended with effusion, and causing pressure upon the lungs : 
 diseases of the heart and great thoracic blood-vessels, afiecting the quantity of blood 
 in those organs ; even certain abdominal maladies, accompanied by sweUing, and 
 thrusting the diaphragm upwards — terminate by the same mode of dissolution. 
 
 Death by coma, akhough common enough, and of much importance to be under- 
 stood, need not detain us long. Certain morbid states of the brain (it is unnecessary 
 at present to inquire into their nature and origin) produce stupor, more or less pro- 
 found ; the sensibility to outward impressions is destroyed, sometimes wholly and at 
 once, much oftener gradually; the respiration becomes slow, irregular, stertorous ; 
 all voluntary attention to the act of breathing is lost, but the instinctive motions con- 
 tinue; the stimulus conveyed by the pulmonary branches of the eighth pair of 
 nerves, and probably by certain branches too of the fifth, still excites, though per- 
 haps imperfectly, the reflex power of the medulla oblongata, Avhich sustains the 
 involuntary movements of the thorax. At length this function fails also — the chest 
 ceases to expand — the blood is no longer aerated — and thenceforward precisely the 
 same internal changes occur as in death by apnosa. 
 
 You will observe that the extinction of organic life takes place in exactly the 
 same manner in both cases : the difference between the two forms of dying being 
 this — that in death by apnoea, the chemical functions of the lungs cease first, and 
 then the circulation of venous blood through the arteries suspends the sensibility; 
 whereas, in death by coma, the sensibility ceases first, and in consequence of this tin. 
 movements of the thorax, and the chemical functions of the lungs, cease also. So 
 that the circulation of venous blood through the arteries is in the one case the cause, 
 and in the other the effect, of the cessation of animal life. 
 
 The causes that destroy the sensibility leave no constant or necessary traces >r 
 their operation. The essential anatomical characters of death by coma, and of deain 
 by apnoea, are therefore the same.
 
 56 APPLICATION' OF PRINCIPLES. 
 
 Death occurring in the way of coma has this pecuHar kind of interest belonging 
 to it, that it may sometimes be efTectually obviated by a mechanical expedient. The 
 circulation ceases because the actions of respiration cease — and the failure of the acts 
 of respiration arises from a suspension of the nervous power. If it be merely a 
 suspension — if the nervous functions are within the verge of recovery — organic life 
 may be sustained by the performance of artificial respiration, until the insensibility 
 has passed away ; and thus the danger to life, which depended on that insensible 
 state, may be escaped. 
 
 .Many years ago, in the course of those researches to which I have already 
 referred, Sir Benjamin, then Mr. Brodie, was led to think that by continuing the 
 respiration artificially in animals labouring under the influence of narcotic poisons, 
 the heart might be kept in action until the stupefying but transitory effect of the 
 poison upon the brain had gone off. This idea he soon brought to the test of 
 experiment, and the result was such as to justify his ingenious reasoning. He. 
 inserted some woorara into a wound which he had made in a young cat. After a 
 certain time the respiration had entirely ceased, and the animal appeared to he dead, 
 but the heart could be still felt beating. The lungs were then artificially inflated 
 about forty times in a minute. The heart continued to beat regularly. When the 
 artificial breathing had been kept up for forty minutes, the pupils of the cat's eyes 
 were observed to contract and dilate upon the increase or diminution of light, but the 
 animal remained perfectly motionless and insensible. At the end of an hour and 
 forty minutes there were slight involuntary contractions of the muscles, and every 
 now and then there was an efTort to breathe. At the end of another hour the animal, 
 for the first time, showed some signs of sensibihty when roused, and made spon- 
 taneous efforts to breathe twenty-two times in a minute. The artificial breathing 
 was, therefore, now discontinued. She lay, as in a state of profound sleep, for forty 
 minutes longer, when she suddenly awoke, and began to walk about. 
 
 Sir Benjamin Brodie had indeed been anticipated in this happy proposition for 
 recovering persons apparently dead after taking narcotic poison, after submersion, 
 and the like, — although he does not seem to have been aware of it. The experiment 
 had once been tried before, and on the human subject, and with success, though not 
 upon such scientific principles. The case is given by Mr. Whately, in the Medical 
 Observations and Inquiries, vol. vi. A man who had swallowed an immense 
 quantity of solid opium, and who seemed to be dead, was restored by the patient 
 continuance, on the part of his medical attendants, in a process of artificial breathing 
 
 It is seldom that we can hope for success from this expedient in the treatment of 
 disease ; simply because, in most cases, the injury of the nervous system which has 
 produced the insensibility is irretrievable. 
 
 In most forms of apoplexy, and of hydrocephalus, death occurs in the way of 
 coma. Sometimes, however, as I mentioned before, the lesion of the nervous sub« 
 stance is so extensive and sudden, as to operate like a shock, and cause death by 
 asthenia. The tendency to death by coma is also strongly pronounced in sundry 
 afTections of the brain, both acute ond chronic. These will form subjects for oui 
 consideration hereafter. 
 
 The several modes of dying, then, in cases of sudden death, are clearly enough 
 made out. Let me briefly sum up the conclusions at which we have arrived. Life 
 cannot be maintained without the circulation of arterial blood : and whenever a 
 person dies, he dies either because no blood circulates through his arteries, or 
 because venous blood circulates through them. 
 
 When it comes to pass that no blood is circulated through the arteries, we say 
 that death occurs in the way of syncope; and this is of two kinds. In the one there 
 IS not blood enough received by the left side of the heart to stimulate its chambers to 
 contract, or to be sent onwards by their contraction ; in the other, there may be 
 blood enough, but the heart has not sufficient power to contract upon it. 
 
 Also there are two ways in which death may be brought about in consequence of 
 the circulation of th'^ venous blood through the arteries. In one of .hese, the first 
 step is tlic sudden shutting out of air from the lungs ; the blood which arrives m
 
 CAUSE OF DISEASE. Sf 
 
 those organs is not aerated, or rendered arterial, but circulates again as venous blood, 
 producing a failure of the animal functions, and weakening the muscles, till it finally 
 stagnates in the capillaries of the lungs themselves. In the other, the animal func- 
 tions are the first to suffer — insensibility occurs — the power which governs the 
 movements of respiration is withheld — the breathing ceases — and organic life is 
 extinguished as in the former case. 
 
 I trust you even already perceive that a right understanding of these matters is 
 calculated to throw both light and interest upon our study of the symptoms and of 
 the tendencies of disease. It will enable us to aim with more precision at ful- 
 filling the indication so often inculcated by Cullen, of " obviating the tendency to 
 death." In this sketch I have merely been able to hint at the important bearings 
 of such views upon our practice. My attention was first called to them by the 
 lectures of my respected instructor. Dr. Alison, who was accustomed to illustrate 
 them by reference to the phenomena of one large class of disorders. All the 
 modes of dying that I have described are apt to take place in fevers. Some- 
 times we have to combat the one, sometimes the other tendency. The disease 
 often proves fatal in the way of coma ; this happens principally when the brain 
 has been a good deal affected, when there have been much headache, delirium, 
 and stupor ; sometimes, when the lungs have been seriously implicated, hfe is 
 extinguished in the way of suffocation or apnroa : and occasionally fever seems to 
 terminate fatally in the way of syncope, especially when the stress of the disorder 
 has fallen upon the bowels, when there has been continued diarrhea, and ulcer- 
 ation of the intestinal glands. Or if death does not occur precisely in these ways, 
 at least it resembles more in different cases, sometimes one form of dying, sometimes 
 another. 
 
 It is notorious that very different remedies, and even different plans of treatment, 
 have been strongly recommended, in fever, by different practitioners. One probable 
 reason of this is, that one plan has been found the most proper to avert the fatal 
 event in one form of the disease, and one in another. The tendency to a particular 
 mode of death will prevail in, and characterize, a whole epidemic. We shall resume 
 these considerations hereafter : in the mean time the facts we have been reviewing 
 may teach us the danger of applying, with too much confidence, the experience we 
 may have gained of one epidemic to the treatment of another ; and the risk we are 
 sometimes liable to, of misjudging, and criticising unjustly, the practice recom 
 mended by other physicians, because it does not appear to accord with the results of 
 our own observation. 
 
 LECTURE VI. 
 
 Causes of Disease : distindmi between predisposing and exciting causes. Enu- 
 meration of causes, as connected with the Atmosphere — Food and Drink — 
 Poisons — Exercise — Sleep — Mental and Moral Conditions — Hereditary Ten- 
 dencies — Malformations. Temperature. Effects of Heat and Cold. 
 
 The causes of disease are commonly arranged under three heads — as predis- 
 posing, exciting, or proximate. 
 
 Of these three, the last mentioned, or the proximate cause, is nothing else than 
 the actual disease itself — the actual condition of that part of the body from which 
 the whole train of morbid phenomena essentially flows. When we know that part, 
 and that condition, we name the disease accordingly. It may be inflammation of 
 the lungs; or softening of the brain. When we do not, we call the complaint 
 after the group of symptoms by which it is characterized : intermittent fever, 
 perhaps ; or marasmus. The term " proximate cause" is, therefore, an unnecessary 
 term : it is, moreover, to learners, a puzzling term, and tends to give to the study of 
 the disease a scholastic and repulsive aspect. I wish you to get into the habit of 
 contemplating the whole science of medicine under its simplest and plainest form
 
 58 CAUSE OF DISEASE. 
 
 I am sure we may very well abolish the term " proximate cause" altogether ; and 
 having now given an explanation of its meaning, for your guidance when you meet 
 with it in books, I shall never employ it, in these lectures, except perhaps in a quo- 
 tation, again. 
 
 In strictness of language, one event is held to be the cause of another event which 
 follows it, when the first being absent, the second never occurs ; and the first being 
 present, the second never fails to occur, unless some other event intervene to prevent 
 it. But the causes of disease will not bear to be spoken of after so strict a 
 fashion. We perceive that certain external circumstances [qux nos circumstant) 
 often precede such and such diseases ; and that the diseases seldom happen when 
 the same circumstances are not previously observable ; and we begin to regard 
 those circumstances as exciting causes of those diseases. We find that the dis- 
 eases are much more frequent among persons known to have been exposed to 
 the agency of the presumed causes than among persons who are not known to 
 have been so exposed. The evidence at first is presumptive only. But the more 
 unifonn their conjunction, and the more rare their disjunction, the more confi- 
 dently do we assign to the two consecutive events the relation of cause and efl^ct. 
 By this kind of observation a number of exciting causes of disease have been clearly 
 estabhshed to be such. 
 
 But recollect, certain circumstances being present, such and such diseases do 
 often, not alwuys, follow. Some persons are more Hable to be afl^ected by the ope- 
 ration of many of these ascertained causes than others are; and the same persons 
 are more liable to be influenced by the same cause at one time than at another. 
 And special circunastances, existing in particular cases, will be found to account for 
 this variable operation of known exciting causes upon the bodily health. These 
 special circumstances may properly be called predisposing causes. Thus, of twenty 
 persons exposed to the same noxious influence — to the combined agency of wet and 
 cold during a shipwreck, for example — one shall have cala: ih, another rheumatism, 
 a third pleurisy, a fourth ophthalmia, a fifth inflammation of the bowels, and fifteen 
 shall escape without any illness at all. A man does that with impunity to-day, 
 which shall put his life in jeopardy when he repeats it next week. It is not, there- 
 fore, the exciting cause o/one that in all cases determines the dis-..se. Something 
 — nay much, or all — will frequentl}^ depend upon the conditio . of the body at the 
 time Vv-hen the exciting cause is applied ; and this condition of the body, which 
 we cai\l predisposition, will depend upon circumstances then or previously in ope- 
 ration ; and these circumstances are, in our language, predisposing causes. 
 
 Do not confound, as many seem to do, the predisposition mth the circumstances 
 creating it. The predisposition is a certain state of the body — the predisposing 
 cause of what produces that state. The cause of the predisposition is the predis- 
 posing cause of the disease. A predisposing cause may therefore be defined to be 
 any thing whatever which has had such a previous influence upon the body as 
 to have rendered it unusually susceptible to the exciting cause of the particular 
 disease. 
 
 It is sometimes difficult, or impossible, to say of a given cause whether it ought to 
 he ranked among the exciting or among the predisposing causes ; whether it has 
 prepared the system for being affected by some other agent, or whether it has itself 
 produced the disease ; but for the most part the distinction is real, and sufficiently 
 well marked, and of great importance to be attended to. 
 
 Disease may sometimes be averted, even in despite of strong and fixed predis- 
 "^osition to it, if we know, and can guard against, the agencies by which it is 
 capable of being excited. A man may inherit a proclivity to consumption, yet 
 fortunately escape that fatal complaint by timely removal to a warm and equable 
 chmate, and by other suitable precautions ; that is, by avoiding whatever tends to 
 rouse the dormant tendency into action. On the other hand, disease may often 
 be warded ofl', notwithstanding the presence and application of its exciting cause, 
 when its predisposing causes are ascertained and can be prevented. In proportion 
 js the body is weakened or exhausted, it yields more readily to the pernicious 
 influence of contagion, or of malaria ; but by obviating all causes of debility, and
 
 CAUSE OF DISEASE. 0» 
 
 fortifying the system, we walk with comparative security amid surrounding pes- 
 tilence. 
 
 Diseases sometimes occur when no exciting cause, when no cause at all, has been 
 apparent. All that we can say of such cases (which are not, however, very fre- 
 quent) is, that the causes have not hitherto been discovered. 
 
 Now the ascertained causes of disease are many and various. Whatever minis- 
 ters to life, health, or enjoyment, may become the medium, under changing circum.- 
 slanccs, of pain, disease, or death. The atmosphere, in which we are constantly 
 immersed, is full of dangers. Both the organic and the inorganic world of matter 
 around us abound in poisons ; they lurk in our very food, which becomes pernicious 
 when taken in excess, or Avhen it consists of certain substances, or certain admix- 
 tures of substances ; so that there really was much truth, as well as some humour, 
 in the startling motto to Mr. Accum's book on adulterations — " There, is death in 
 the pot. ''^ Our passions and emotions also, nay, even some of our better impulses, 
 when strained or perverted, tend t6 our physical destruction. The seeds of our 
 decay are Avithin as well as around us. 
 
 Let us enumerate, however, a httle more particularly, the various known sources 
 of disease, with the view of making, afterwards, a few practical comments upon 
 some of them. 
 
 r shall pass over, in this enumeration, nearly all chemical and mechanical inju- 
 ries ; inasmuch as these belong to surgery. 
 
 If we look to atmospherical causes, we shall find that those varieties in the state 
 of the air which proceed from mere differences of degree in its natural qualities may- 
 be productive of disease. Such are, extremes of heat and of cold ; sudden variations 
 of_temperature ; excessive moisture or excessive dryness ; different electric condi- 
 tions ; differences of pressure, as measured by the barometer; a deficiency of light. 
 
 Again, the atmosphere may be a source of disease in consequence of its being 
 loaded with impurities. Malaria, contagions of various kinds, and noxious gases in 
 general, may be considered as so many poisons. 
 
 Under the head of nutriment we may place the use of food of which the quality 
 is bad and hurtful ; this cause also strictly belongs to the class of poisons. Again, 
 an insufficient supply of healthy food ; and still more common causes are excess in 
 eating, and intemperance in drinking. 
 
 The numerous poisons which are not comprehended under either of the foregoing 
 heads are also prolific sources of disease. 
 
 Another great class among the causes of disease might be formed by considering 
 together the influence of various trades and avocations which are directly injurious 
 to the health of those who pursue them. 
 
 We know, by ample experience, that a certain amount of bodily exercise is essen- 
 tial to good health. We see the evil consequences of much overstepping that 
 amount, in tlie deformities and disorders which result from labour too severe, or too 
 long continued. But a much more numerous train of complaints follow the opposite 
 state — that in Avhich, from indolence, or from necessity, but little exercise is used. 
 
 Excessive indulgence in sleep on the one hand, and long-continued want or inter 
 ruption of repose on the other, are apt to give rise to serious maladies. 
 
 Very many diseases have a mental origin. Excessive intellectual toil — the domi- 
 nation of violent passions — the frequent recurrence of strong mental emotions — 
 vicious and exhausting indulgences, — each and all will sap the strength, and 
 grievously impair the health of the body : and perhaps there is no cause of corpo- 
 real disease more clearly made out, or more certainly effective, than protracted 
 anxiety and distress of mind. 
 
 When we add to this catalogue of the sources of disease all those morbid tenden- 
 cies which are hereditary — and those which flow from original malformation, and 
 are congenital — we shall have a tolerably complete list of the manifold dangers to 
 which our mortal frames are continually liable. 
 
 There are several points of view under which the consideration of these causes 
 of disease might be shown to be interesting. We might inquire, for example, which 
 of them are commonly predisposing, which exciting causes; and what are the cir-
 
 60 , CAUSE OF DISEASE. 
 
 cumstances which are found to render the same agent at one time merely a predis- 
 posing, and at another time an exciting cause. 
 
 We might also separate, with some advantage, those causes of disease to which 
 the human body is often and necessarily exposed, from those which consist in agen- 
 cies that are of local or temporary existence only. But without multiplying these 
 artificial distinctions, I shall take occasion to advert to them either when speaking 
 more in detail of particular causes, or when speaking of the disorders they have 
 produced. 
 
 In our investigations into the causes of disease, great caution is necessary in order 
 to avoid being misled by individual cases. The circumstances capable of influ- 
 encing the bodily health are so various — so many of them are apt to be in operation 
 at the same time — and so little power have we of excluding them, one after the 
 other, so as to ascertain the exact efficacy of each — that our observations respecting 
 their relative or their actual effects are open to much fallacy. We endeavour to 
 escape this source of mistake by repeating and multiplying our observations. But 
 it is by tracing diseases as they affect considerable masses of men, placed as nearly 
 as possible under the same external circumstances, that we gain the surest and most 
 satisfactory evidence in respect to the causes of disease. And hence it is that the 
 experience of the medical officers of our fleets and armies is so valuable. Dr. Alison 
 has well remarked, that all the circumstances of the whole number of men whose 
 diseases fall under the notice of military and naval practitioners are, in many respects, 
 exactly alike: the men are generally healthy adults in the first instance — the cir- 
 cumstances in which they are placed are thoroughly known to the observer — and, 
 indeed, are often to a certain degree at his disposal ; they are often suddenly changed 
 also ; and changed sometimes as to one portion of the whole mass of individuals, 
 while they remain unchanged as to another portion ; so that his opportunities of 
 observation partake in some measure of the nature of experiments, and being made 
 upon a large scale, they are especially interesting and conclusive. In point of fact 
 a great deal has been learned, with absolute certainty, upon this subject. 
 
 Hitherto I have simply enuinerafcd the principal causes of disease : — but con- 
 ceiving a bare enumeration of this kind to be of but little use, I shall inquire some- 
 what more nearly into the nature and mode of operation of several of them 7ioiv ; of 
 others I prefer to speak in connection with the particular diseases to which they 
 give rise. 
 
 You will not consider the inquiry superfluous. To know the cause of a disease 
 is sometimes to be able to cure, often to be able to prevent it. In some cases the 
 cause is beyond our power, but an acquaintance with its nature may teach us how 
 to moderate or to remedy its consequences. There are many diseases also over 
 which medicine has very little control, but the causes of which, when ascertained, 
 may be avoided, or extinguished. Such causes, when they do not happen to be 
 removable by individual efforts, are often susceptible of extinction by the united 
 measures of a community. And for this reason it is very desirable that correct 
 opinions respecting the causes of disease should be widely diffused among the public ; 
 — and there is now no way in which information of this kind is so likely to be made 
 generally known, as by communicating it to medical students who are about to 
 scatter themselves in ail directions over the face of the land. 
 
 I shall proceed, then, in the first place, to the consideration of heat and cold, as 
 external agencies capable of producing disease. 
 
 The range of atmospheric temperature compatible with human life is very con- 
 siderable. Its limits are probably juit those extremes of heat and cold that belong 
 to the lower strata of the air in the different parts of the planet on which man is 
 desdned to exist. Under the burning sunshine of the tropics, and amid the pro- 
 found frost of the polar regions, we alike find human dwellers. These different 
 degrees of external temperature impress indeed peculiar physical characters upon 
 those who are subjected to them, but they do not, of necessity, extinguish life, or 
 even cause disease. It requires more care, however, to preserve life under intense 
 cold than under intense heat. In some parts of India the temperature ranges for a
 
 CAUSE OF DISEASE. 61 
 
 long time together from 80 to 100, and even 110° of Fahrenheit's thermometer: I 
 believe it sometimes reaches 120°. "VVe can form some estimate of this heat by 
 remembering the oppressive effect of the lowest of these temperatures — that of 80° 
 — to which the thermometer sometimes rises in this country in the hot weather of 
 summer. But these tropical cHmates are very thickly peopled. In the arctic coun- 
 tries, on the other hand — in the northernmost parts of America, for example — where 
 the sun appears above the horizon for a short part of the year only, and where the 
 thermometer sinks to 40 or 50° below zero — we still find inhabitants, indeed, but 
 they are few, and thinly scattered. This mainly depends, no doubt, upon the scanty 
 supply of human food in those parts of the world ; but something also is to be 
 ascribed to the depressing influence of extreme cold upon the vital powers. Indeed, 
 the deficiency of human food is itself owing to the restraining effect of a low tem- 
 perature upon organic life. Under a degree of temperature a little greater than that 
 at the equator— or a little less than the lowest around the poles — it seems probable 
 that man would soon perish. And in this fact we have one striking instance of the 
 adaptation of external nature to the physical constitution of the human race. 
 
 But for a short time — and imder certain circumstances — man is capable of 
 enduring a very much higher degree of heat than the open and general atmosphere 
 ever attains even in the hottest portions of the earth. Whether he could continue 
 to exist, even for a little while, under a much more intense cold than ever occurs 
 naturally on the surface of the globe, is more questionable. 
 
 It was long believed that the human body could not be safely exposed, even for a 
 short time, to a degree of heat much exceeding that which is met with in hot chmates. 
 This opinion, which we now know to have been erroneous, was strengthened by the 
 result of some experiments made by the celebrated Fahrenheit himself, and related 
 by Boerhaave in his Chemistry. Some animals were shut up in a sugar-baker's 
 stove, where the mercury stood at 14G°. A sparrow died in less than seven minutes, 
 a cat in rather more than a quarter of an hour, and a dog in about twenty-eight 
 minutes. The noxious air of the stove had probably more to do with the speedy 
 deaths of these animals than the heat. The truth, upon this subject, may be said to 
 have been discovered by accident. In the year 17G0 and 1761, jVIM. Duhamel and 
 Tillet were appointed to devise some means of destroying an insect which consumed 
 the grain in the province of Angoumais in France. They found that this could be 
 done by subjecting the corn, and the insects contained in it, in an oven, to a degree 
 of heat great enough to kill the insect, but not so great as to hurt the grain. In 
 order to ascertain the precise heat of the oven, they introduced into it a thermometer 
 placed upon the end of a long shovel. The mercury, when the thermometer was 
 withdrawn, was found to indicate a degree of heat considerably above that of boiling 
 water. But M. Tillet was aware that the thermometer had sunk several degrees as 
 it was drawn towards the mouth of the oven. While he was puzzled to invent 
 some way of determining more exactly the actual degree of heat, a girl, who was 
 one of the attendants of the oven, offered to go in, and to mark with a pencil the 
 height at which the mercury stood. And she did enter the oven, and remained 
 there two or three minutes, and then marked the thermometer at 100° of Reaumur, 
 which nearly equaUcd 2G0° of Fahrenheit. M. Tillet then began to express some 
 anxiety for the safety uf the girl, but she assured him that she felt no inconvenience, 
 and remained in the even ten minutes longer, during which time the mercury 
 reached the 288th degree ^f Fahrenheit's scale — denoUng 76° of heat above that 
 of water when it boils. When she came out her complexion was considerably 
 heightened, but her respiration was by no means quick or laborious. This experi- 
 ment was afterwards repeated Another girl remained in the oven as long as the 
 former had done, at the same temperature, and with the same impunity. Nay, she 
 even breathed, for the space of five minutes, air heated to about 325° of Fahrenheit 
 — or 113° above that of boiling water. 
 
 The publication of these facts naturally excited the curiosity of scientific men, and 
 other experiments were soon instituted. Dr. Dobson, of Liverpool, and several 
 other persons with him, shut themselves up in the sweating room of the public hos- 
 pital there, the air having been heated till the quicksilver stood at 224° of Fahren-
 
 62 CAUSE OF DISEASE. 
 
 heit. They did not experience any oppressive or painful sensation of heat. Dr. 
 Fordyce and Dr. Blagden made some remarkable trials of the same kind. They 
 entered rooms artificially heated to a very high degree, sometimes naked, and some- 
 times with their clothes on, and bore the extraordinary temperature of 240°, and 
 even 200°, for a considerable time, with very little inconvenience. In all these 
 experiments it was found that the animal heat, as ascertained by thermometers placed 
 under the tongue, or grasped in the hand, was scarcely increased at all ; and the 
 respiration but little affected; but the pulse was very much quickened. The fre- 
 quency of Dr. Blagden's pulse in one instance was doubled. You may read -i 
 detailed account of these experiments in the Philosophical Transactions ', but to 
 give you a more lively notion of the degree of heat to which the bodies of these 
 gentlemen were exposed, I may tell you that their watch-chains, and other pieces of 
 metal about them, became so hot that they could scarcely be touched; when they 
 breathed upon the thermometer, the mercury immediately sank several degrees ; 
 each act of expiration produced a pleasant feeling of coolness in the nostrils, and 
 they cooled their fingers by breathing upon them. In and by the same heated air 
 which they respired, eggs were roasted quite hard in twenty minutes, and beef-steaks 
 were dressed in thirty-three minutes ; and when the air was blown upon the meat by 
 means of bellows, it was sufficiently cooked in thirteen minutes. 
 
 It is ascertained, then, beyond all doubt, that the human body is capable of 
 sustaining these very high degrees of temperature, for a short time, without 
 detriment. 
 
 Facts of this kind may, perhaps, appear to you rather curious than useful. Man 
 is never submitted to any natural heat of the air even approaching towards that to 
 which the authors of the experiments I have been describing voluntarily exposed 
 themselves. But a knowledge of extreme cases always tends to throw light upon 
 those that lie between the extremes ; and the direct resuhs arrived at in these philo- 
 sophic inquiries are not barren of practical utility to members of our profession. It 
 is not long ago that a man was found almost dead in an oven ; he expired a quarter 
 of an hour after he was taken to one of the borough hospitals ; and an inquest was 
 held upon his bodj'-. The newspaper report of the case (which is the only one I 
 have seen) states the temperature of the oven to have been about 120° — a candle 
 was melted by it in half a minute. Now prior to the trials just mentioned, exposure 
 to such a degree of heat would have been held a sufficient cause of death. We now 
 know (and it would be discreditable if we could not support our opinion in a court 
 of law, or before a coroner, by a reference to authentic facts) that something else 
 must have concurred in extinguishing life ; and, in fact, it turned out that the man 
 was drunk when he went into the oven. 
 
 But what are the effects, upon the human frame, of a high, yet less excessive, 
 temperature of the air? 
 
 One very constant effect of heat is that of stimulating the organic functions of 
 the body. We have seen that the temporary application of great heat accelerates 
 remarkably the action of the heart : the pulse was uniformly found to be much 
 increased in frequency in the persons who made trials of their powers of endurance 
 in heated rooms. We have evidence to the same purpose in the annual changes 
 that take place in the vegetable kingdom at a given place, the summer renewing its 
 foliage ; the winter checking and repressing it; and still more in the superior luxu- 
 riance of vegetation in warm climates as compared with cold. And the same 
 observation applies to those functions which animals possess in common with plants. 
 Towards the poles both man and the lower animals are smaller than at the equator. 
 Linnaeus remarks that the hares, partridges, and other animals which inhabit the 
 northern climes, are considerably smaller in size than the same species in more 
 southern climes. And Mr. Tooke, in his Vierv of Bussia, observes, "As we ap- 
 proach nearer to the north pole, both the animal and vegetable productions of nature 
 become more and more stunted. The ordinary stature of the Samoyedes seldom 
 exceeds four or five feet, and their whole exterior corresponds Avith their dwarfish 
 si^e." The stature of the native inhabitants of hot cHmates does not, I behevc, 
 fixceed that which is proper to the temperate zone ; but if, as is generally beheved.
 
 I 
 
 CAUSES OF DISEASE. 6-$ 
 
 the human body, like plants and fruits, grows faster, and npens sooner, in proportion 
 as we approach the equator, this must be attributed to the stimulus of heat acting 
 upon the or£!;anic life. 
 
 On the other hand, and in some sort as a contrast with this, we may observe that 
 considerable heat, when applied for some time together, has a sedative or depressing 
 influence upon the animal functions, i. e., upon the nervous system ; causing lan- 
 guor and lassitude, want of energy, a disinclination to exertion both bodily and 
 mental. 
 
 Under favourable circumstances, and where due precaution is exercised, it is pro- 
 bable that a very high degree of natural temperature of the atmosphere may be 
 borne with impunity. Sir James M'Grigor informs us (in his account of the passage 
 of the army in 1801 from India to Egypt), that during the march over the sandy 
 desert of Thebes, where the heat was uniform, though the thermometer in the sol- 
 diers' tents was as high as 118°, the health of the troops was equal to that which they 
 had enjoyed in any former period in India. 
 
 But there are some forms of disease w^hich are distinctly traceable to heat as their 
 cause. 
 
 The effect of hot weather in promoting the cutaneous perspiration is notorious. 
 By the same influence the hepatic function is rendered more active. Dr. James John- 
 son first, I think, distinctly pointed out the sympathy or consent that obtains between 
 the liver and the skin, under varying conditions of external warmth. Whatever 
 may be the explanation of the fact, experience has taught us that a high atmospheric 
 temperature, when its operation is continued for some time, has a marked influence 
 upon the liver, increasing the quantity of bile that is secreted, and altering its sen 
 ?ible qualities ; and this disturbance of function is not unfrcquently followed by in- 
 flammation of the gland itself. In this country we witness, almost annually, the 
 effects of a succession of sultry weather, in those attacks of vomiting and diarrhoea 
 which are so common towards the latter end of summer, and in the autumn, espe- 
 cially when the season happens to have been unusually hot ; and which result, appa- 
 rently, from the excessive quantity or a morbid state of the bile. The English 
 cholera (a totally different disorder from that which has of late years been called, 
 most improperly, the cholera), is, as you know, so frequent and general in some 
 years, as to be fairly considered and termed an epidemic disease. In tropical cli- 
 mates the same morbific operation of external heat is still more conspicuous ; leading 
 not only to violent disorder of the stomach and intestines, with the evacuation of 
 large quantities of vitiated and acrid bile, but also to acute inflammation of the liver 
 going on to suppuration, and the formation of large abscesses. These last diseased 
 conditions are extremely rare in this latitude. The yellow complexions of those 
 who return to England after a long residence in India, are to be attributed to that 
 disordered state of the liver, and of its functions, to which such persons are prover- 
 bially subject, and which has in them been brought on by the influence of a hot at- 
 mosphere, operating for a long space of time together. Hepatic affections, acute or 
 chronic, are among the chief diseases to which Europeans, at least, are liable in that 
 eh mate. 
 
 We have here an example of the distinction I wish you to notice between predis- 
 posing and exciting causes. The heated atmosphere stimulates unduly the secreting 
 function of the liver. Now a secreting organ is never so apt to be affected by any 
 exciting cause of inflammation as when the process of secretion is going on. This 
 law, which I mention by anticipation, depends, no doubt, upon the increased afflux 
 cff blood that accompanies the act of secretion. The excessive activity of the hepatic 
 function constitutes thus a predisposition to inflammation of the liver. The hot at- 
 mosphere, which creates this predisposition, holds the place of a predisposing cause 
 in respect to the inflammation that ensues ; but the exciting cause is exposure to 
 cold : one of the most common and best ascertained exciting causes of inflammation 
 in general. You are not to imagine that there can be no such thing as exposure to 
 cold in a climate where the temperature of the air is habitually above 80°. Dr. 
 James Johnson, in his book on Tropical Climates, observes that on the coast of 
 Coromandel the temperature is steady by day, and the nights are hot : but yet, he say.".
 
 64 CAUSES OF DISEASE. 
 
 nothing IS more common than exposure to cold in this place. The European soldier 
 or sailor, after the heat occasioned by his employments in the day, strips off bis 
 clothes, and lies opposite a window or port, his shirt wet with perspiration, to enjoy 
 the sea breeze at night. And the same author tells us that the application of cold 
 after or during perspiration, commonl}- produces an attack of hepatitis in some one 
 of its various forms. Now the effect of that kind of exposure here described does 
 not depend upon the actual temperature, but upon the sensation that is produced, 
 and the sensation depends upon the relative temperature ; and there can be no doubt 
 that, under the circumstances mentioned by Dr. Johnson, a strong sensation of cold 
 would be occasioned, even by a sea breeze as warm as 80°, or warmer. Changes 
 of temperature seem to be as readily felt at one part of the thermometric scale, as at 
 another, and in whichever direction they take place. Dr. Walsh states, that while 
 sailing along the coast of Brazil, after having been long accustomed to a temperature 
 of 72°, a strong breeze set in from the sea, and the thermometer fell to 61° ; (i. e., 
 to a point which we should here call temperate ;) " but," he says, " the sense of cold 
 from the sudden transition of temperature was quite painful. After bearing it for 
 some time, shivering on deck, it became intolerable, and we all went below, put on 
 warm clothing, and dreadnoughts — and again appeared with thick woollen jackets 
 and trowsers, as if we had been entering Baffin's Bay, and not a harbour under one 
 of the tropics." 
 
 It is interesting to compare this statement with Capt. PaiTj'-'s account of a change 
 of temperature at the opposite extreme of the scale, and in the other direction. Having 
 previously said that the thermometer had fallen to 13° below zero in the night of the 
 21st of October, he goes on thus : — " The wind veering to the southeast on the 24tli 
 and 25th, the thermometer gradually rose to 2:3°. I may possibly incur the charge 
 of affectation in stating that this temperature was much too high to be agreeable to 
 us ; but it was nevertheless the fact, that everybody felt and complained of the 
 change. We had often before remarked that considerable alterations of the tempe- 
 rature of the atmosphere are as sensibly felt by the human frame at a very low part 
 of the scale as in the higher. The difference consists only in this, that a change from 
 40° upwards to about zero, is usually a very welcome one ; while from zero up- 
 wards to the freezing point, as in the instance just alluded to, it becomes, to persons 
 in our situation, rather an inconvenience than otherwise." 
 
 Besides the more gradual effects of great heat, direct or indirect, upon the human 
 body, it sometimes operates distinctly as an exciting cause, and gives rise to more 
 sudden attacks of illness. Persons who are exposed to the direct beams of a hot sun, 
 especially during any labour or active exercise, are apt to be affected by what is 
 called the sun-stroke, the coup de soleil, insolation : they fall down insensible, and 
 often die in a very short time. This disorder is common among troops in long 
 marches in India. It is a complaint of which the cause has long been known by 
 the inhabitants of hot climates. There is a case of it related in the Bible. "And 
 Manasses was her husband, of her tribe and kindred, who died in the barley harvest. 
 For, as he stood overseeing them, and bound sheaves in the field, the heat came upon 
 his head, and he fell on his bed, and died in the city of Bethulia." 
 
 Pathologists are not agreed respecting the intimate nature of this distemper; noi 
 about the manner in which it destroys life. Some regard it as a sort of apoplexy : 
 and hold that death takes place in the way of coma. But the most approved reme- 
 dies of apoplexy — bleeding and other eA'acuations — have not proved successful in 
 relieving it. The natives of India prefer the pouring of cold water upon the head 
 to every other curative measure. Our army sergeants also found that stimulants — 
 rum and water, for instance — answered better than depletion. I have never seen 
 this affection, but I should conjecture that it is more akin to the state we call concus- 
 sion than to true apoplexy. It would appear that the sun's rays act upon the brain 
 hke a shock. The nervous system is suddenly and extensively influenced, and the 
 heart's movements arrested, as in syncope. One of Sir Benjamin Brodie's experi- 
 ments is in favour of this opinion. He placed a rabbit in a basket in an oven, the 
 jemperatuie of which was not more than 150", and it died in a few minutes, without
 
 CAUSES OF DISEASE. G5 
 
 any apparent suffering. The heart was afterwards found distended with blood, on 
 both sides, as after death by asthenia. 
 
 Great heat tends also to the production of certain cutaneous diseases : it is said 
 that kw Europeans escape, on their first settUng in tropical cUmates, an eruption of 
 pimples, attended with almost intolerable itching and pricking, and lasting for some 
 weeks. It is called in India the prickly heat. 
 
 Before considering that most prohfic source of disease which is familiar to the 
 commonest observation in sudden transitions of temperature, let us inquire what are 
 the ascertained effects of extreme cold upon the human frame. Of course I use the 
 term cold in its popular acceptation, as if it were something positive, instead of sig- 
 nifying the mere privation of heat. It is much more convenient to speak of it in 
 this way, and there is no risk of your being misled by my doing so. 
 
 Now this inquiry is of more practical interest to us than that which is concerned 
 with the immediate effects of extreme heat. Even in this climate medical men are 
 not unfrequently called upon, in cases of injury or death produced by intense cold, 
 either to remedy the morbid conditions it has caused, or to explain the mode and 
 probability of its operation in extinguishing life. 
 
 The effects of cold, as might well be imagined, are in many respects the direct 
 opposites of the effects of heat. When its application is continued, it acts as a 
 sedative upon the organic functions both of animals and of plants. This appears 
 from the shrinking of the external parts : the superficial arteries become unable to 
 transmit the blood in the usual quantity through the integuments. Hence the skin 
 becomes pale, and contracting round the sebaceous glands and the hair-bulbs, exhi- 
 bits a roughness which is compared to that of the skin of a plucked goose, and is 
 technically called cutis anserina. By the same contraction of the smaller vessels, 
 and repressed circulation, the extreme and projecting parts are diminished in size. 
 Thus, rings which are tight on the fingers while the body is warm, drop off in cold 
 weather — and even the shoes fall from the feet during extreme exposure. The 
 heart with the whole arterial system becomes weak. I have already, when speaking 
 of the contrasted operation of heat, illustrated the withering influence of a continued 
 low atmospheric temperature upon the organic functions, by referring to the dwarfish 
 size of both men and the lower animals, as well as of plants, in cold regions. We 
 have evidence of the same fact in the tardy development of the functions, and par- 
 ticularly, as many travellers affirm, of the sexual functions, in cold climates as corn- 
 pared with hot ; and in the winter torpor of certain animals, which is very analogous 
 with the state of trees and shrubs in that season. 
 
 I need not tell you that to judge of the effects of mere coldness of the atmosphere 
 we must take the case of the atmosphere at rest. The air is a bad conductor of 
 caloric, and for that reason, a much lower, as well as a much higher degree of 
 temperature, can be borne when it is in a state of quiescence, than when fresh por- 
 tions of it are perpetually brought into contact with the surface of the body by 
 currents of air. " With the thermometer," says Captain Parry, "at -55°," (a most 
 fearful degree of cold, you will observe, 55° below zero, i. e., 87° below the freezing 
 point,) " with the thermometer at -55°, and no wind stirring, the hands may remain 
 uncovered for ten minutes or a quarter of an ho'ur without inconvenience ; while 
 with a fresh breeze, and the thermometer nearly as high as zero, k\v people can 
 keep them exposed so long without considerabk pain." And speaking in another 
 place of the cold, when the thermometer was 49° below zero ; 9 or 10°, that is, 
 below the point at which mercury freezes, he says, " The weather being quite cahn, 
 we walked on shore for an hour without inconvenience, the sensation of cold de- 
 pending: much more on the degree of wind at the time, than on the absolute tempe 
 rature of the atmosphere as indicated by the thermometer. In several of the accounts 
 given of those countries, in which an intense degree of natural cold is experienced, 
 some effects are attributed to which it certainly did not come under our observation 
 in the course of this winter. The first of these is the dreadful sensation said to be. 
 produced in the lungs, causing them to feel as if torn asunder when the air is 
 inhaled at a very low temperature. No such sensation was ever experienced by us. 
 5 f2
 
 66 CAUSES OF DISEASE. 
 
 though in going from the cabin into the open air, and vice vcrsct, we were constantly 
 in the habit, for some months, of undergoing a change of from 80° to 100°, and in 
 seviM-a. iuftunces 120' of temperature, in less than one minute: and what is still 
 more extraordinary, noc a single inflammatory complaint (beyond a slight cold, 
 which was cured by common care in a day or two), occurred during this particular 
 period." 
 
 But when the cold air is in motion, in other words, when there is wind, so that 
 fresh portions of cold air are brought, successi'vly. \n '^mtact with the surface ; or 
 when It is accompanied with moisture, or occurs under other circumstances favour- 
 able to its operation, and to be spoken of more particularly presently ; then cold of a 
 much inferior degree of intensity may very speedily occasion partial or total death. 
 By partial death I mean the loss of vitality in certain parts of the body only — the 
 ears, nose, fingers, toes, and feet. The parts thus affected are said to be frost-bitten: 
 and the mode of managing such accidents falling Avithin the province of surgery, I 
 shall confine my remarks almost entirely to the case where general death — death in 
 its full and ordinary meaning — is either brought about, or impending, in consequence 
 of exposure to cold. 
 
 One of the earliest effects of extreme cold upon the system at large has been said 
 to be a remarkable and overpowering drowsiness. But I believe you will find that 
 most or all of the persons in whom this torpor has been noticed had not only been 
 exposed to severe cold, but had been using also a great deal of exercise : and per- 
 haps the drowsiness ought to be ascribed, in some measure at least, to that exercise. 
 They who attribute it to the cold alone explain the comatose state in this way. They 
 say that the chilling of the surface and extremities drives the blood inwards, causes 
 it to accumulate internall}^ and increases the flow of blood towards the head. One 
 thing, however, is certain, viz., that drowsiness is not a necessary consequence of 
 exposure to severe cold, although it is a very common consequence. Dr. Currie, in 
 his Medical Reports, gives a very interesting account of the shipwreck of an Ame- 
 rican vessel on the coast of Ireland. Most of the crew, fourteen in all, were im- 
 mersed, to a considerable depth, for twenty-three hours, in water of which the 
 temperature was believed not to exceed 33 or 34° of Fahrenheit : and he states 
 expressly that none of the men were drowsy, and that in no one of the three that 
 perished was death preceded by sleep. 
 
 The overpowering tendency of cold when combined with fatigue (and perhaps, 
 under certain circumstances, of intense cold alone), to induce sleep, was strikingly 
 exemplified in what befel Dr. Solander among the hills of Terra del Fuego. The 
 story, as given in Captain Cook's Voyages, is well known. Sir Joseph Banks and 
 Dr. Solander had been out botanizing. On their return towards the ship, after 
 various hardships, and after having travelled through swamps for a considerable 
 way, the weather, which had been very fine, became gloomy and cold, with sudden 
 blasts of piercing wind, accompanied by snow. Finding it impossible to get back 
 to the ship before the morning, they resolved to push on through another swamp 
 that lay in their way, into the sheher of a wood, where they might build a wigwam 
 and kindle a fire. Mr. Banks (as he was then) undertook to bring up the rear. Dr. 
 Solander, who had more than once crossed the mountains that divide Sweden from 
 Norway, and who well knew that extreme cold, especially when joined with fatigue, 
 produces a torpor and sleepiness that are almost irresistible, conjured the company 
 to keep moving, whatever pain it might cost them, and whatever relief they might 
 be promised by an inclination to rest. " Whoever sits down" said he, " will sleep, 
 and whoever sleeps will wake no more." Thus at once admonished and alarmed, 
 they set forwards; but they had not gone far before the cold became suddenly so 
 intense as to produce the effects that had been most dreaded. Dr. Solander was the 
 first who found the inclination, against which he had warned others, invincible, and 
 ne insisted on being suffered to lie down. Mr. Banks entreated and remonstrated 
 with him in vain : down he lay upon the ground, ahhough it was covered with 
 snow, and it was with much difficulty that his friend kept him from sleeping. Rich- 
 mond, also, one of the black servants, began to linger in the same manner. When 
 lie was told that if he did not go on he would in a short time be frozen to d^ath, bis
 
 CAUSES OF DISEASE. 67 
 
 answer was that he desired nothing but to lie down and die. The doctor said he 
 was willing to go on, but that he must first take some sleep ; although but a short 
 time before he had told the company that to sleep was to perish. Mr. Banks and 
 the rest found it impossible to carry them, and there being no remedy, they were 
 both at length suffered to lie down, being partly supported by some bushes ; and in 
 a few minutes they fell into a profound sleep. Soon after some of the people who 
 had been sent forward returned with the welcome news that a fire was kindled about 
 a quarter of a mile on the way. Mr. Banks then endeavoured to wake Dr. Solander, 
 and happily succeeded ; but, though he had not slept five minutes, he had almost 
 lost the use of his hmbs, and the flesh was so shrunk, that his shoes fell from his 
 feet. He consented to go forward with such assistance as could be given him ; but 
 no attempts to relieve poor Richmond were successful. He, together with another 
 black left with him, died. 
 
 In many instances, before this complete torpor comes on, intense cold has a curi- 
 ous effect upon the nervous system, blunting the sensations, and confusing the intel- 
 lect, and giving to the person exposed to it the appearance of one intoxicated. It is 
 very necessary that you should be aware of this, for there is too much reason to 
 beheve that poor wretches who have been picked up by the constables in the streets 
 at night, during periods of hard frost, have been supposed to be drunk, when, in 
 truth, they were only stupefied by the cold. Such a mistake is most likely to be 
 fatal to them : instead of receiving the attention and treatment proper for persons in 
 their condition, they are hable to be laid aside, by themselves, to sleep off their sup- 
 posed debauch, and the morning finds them corpses. It is not at all improbable that 
 some of you may be called upon to investigate such cases : and as actual instances 
 are more readily impressed upon the memory than any general description, I will 
 read you a short history illustrative of what I have just been saying, from Captain 
 Parry's Journal. 
 
 " John Pearson * * * had his hands severely frost-bitten, having unfortunately 
 gone without mittens, and with a musket in his hand. A party of our people most 
 providentially found him, although the night was very dark, just as he had fallen 
 down a steep bank of snow, and was beginning to feel that degree of torpor and 
 drowsiness which, if indulged, inevitably proves fatal. When he was brought on 
 board his fingers were quite stiff, and bent into the shape of that part of the musket 
 which he had been carrying : and the frost had so far destroyed the animation in 
 his fingers on one hand, that it was necessary to amputate three of them a short 
 time after." 
 
 It is what immediately follows this, that I was desirous of pointing out to your 
 attention. 
 
 "The effect which exposure to severe frost has in benumbing the mental as well 
 as the corporeal faculties, was very striking in this man, as well as in two of the 
 young gentlemen who returned after dark, and of whom we were anxious to make 
 inquiries respecting Pearson. When I sent for them into my cabin, they looked 
 wild, and spoke thick and indistinctly, and it was impossible to draw from them a 
 rational answer to any of our questions. After being on board for a short time, the 
 mental faculties appeared gradually to return with the returning circulation ; and it 
 was not until then that a looker-on could easily persuade himself that they had not 
 been drinking too freely. To those who have been much accustomed to cold coun- 
 tries, this will be no new remark, but I cannot help thinking (and it is with this view 
 that I speak of it) that many a man may have been punished for intoxication, who 
 was only suffering from the benumbing effects of frost : for I have more than once 
 seen our people in a state so exactly resembling that of the most stupid intoxication 
 that I should certainly have charged them with that offence, had I not been quite 
 sure that no possible means were afforded them on Melville Island to procure any 
 thing stronger than snow-water." 
 
 When persons in this state are suffered to sleep, and the operation of the cyld 
 continues, they become less and less sensible to external impressions, until death 
 closes the scene.
 
 CAUSES OF DISEASE. 
 
 LECTURE VII. 
 
 Causes of Disease, continued. Laws by tvhich. the operation of Cold upon the 
 Bodily Health is regulated. Circumstances that favour its injurious Effects, 
 and respect, first, the Body itself; secondly, the manner in which the Cold is 
 applied. Modifying influence of certain states of the Mind — of Sleep — of 
 Habit. Means of protection. Influence of the different Seasojis. Impurity 
 of the Air. Hereditary tendencies to Disease. 
 
 In the last lecture I commenced the consideration of some of the causes of 
 disease. 
 
 We learned, by the evidence of authentic facts, that the human body is capable of 
 bearing a very high degree of external temperature, for a short time, without detri- 
 ment — and even without much inconvenience ; and we learned — also by the testi- 
 mony of facts — that the body is equally well calculated to endure, under favourable 
 circumstances, a very low degree of atmospheric temperature — or, to speak in 
 popular language, a very intense degree of cold. 
 
 It appears also that a high, but not extreme, atmospheric temperature, when long 
 continued, has a stimulating effect upon the organic functions, and a depressing or 
 sedative effect upon the animal functions of the body. Long-continued heat predis- 
 poses the body to be injuriously influenced by exposure to cold : the diseases apt to 
 follow such exposure, under such circumstances, being derangement of the hepatic 
 functions — violent disturbances of the stomach and bowels, with a copious discharge 
 of vitiated and acrid bile — and acute inflammation of the hver itself. As more 
 direct consequences of exposure to extreme heat — in other Avords, as examples of 
 disorders of which extreme heat sometimes proves an exciting cause — I mentioned 
 the coup de soldi, and the eruption called the prickly heat. 
 
 With respect to external cold, I pointed out to you its depressing effects upon the 
 organic functions of the body — and, when it becomes very intense, indeed, its directly 
 sedative influence upon the animal functions also — producing a state resembling 
 intoxication, overpowering drowsiness, and coma, especially when the cold has had 
 an auxiliary in fatigue ; and, ultimately, death itself. 
 
 I hardly need say that the effect of external cold upon the body, within certain 
 limits of intensity and duration, is totally different from all this. When it is not 
 intense — or when, though intense, it is applied for a short time only — or when its 
 refrigerating and sedative properties can be sufficiently counteracted by exercise and 
 warm clothing — cold becomes a tonic; stimulating, refreshing, and invigorating both 
 mind and body. Instead of benumbing, it heightens the sensibility ; instead of 
 stupefying, it clears and sharpens the faculties, and bestows alacrity and cheerful- 
 ness ot spirit; and in this way, among others, cold becomes a very important curative 
 agent. 
 
 Here also, therefore, the contrast obtains; a high external temperature relaxes and 
 depresses — a low one, under the circumstances just mentioned, braces and enlivens. 
 
 Nevertheless, exposure to cold is one of the most common causes of various com- 
 plaints. Many or most of the internal inflammations acknowledge cold as their 
 ordinary exciting cause. Acute rheumatism has, perhaps, no other external origin. 
 Apoplexy and palsy, and dropsy, are its frequent consequences. "With the excep- 
 tion," says Dr. Bateman, in his Observations on the Diseases of London, " with the 
 exception of a small number of diseases occasioned by unwholesome occupations, 
 and by the contagions, the great mass of human malai-^ in this metropolis is refer- 
 able to the climate or state of the seasons, and to intemperance : but, of these two 
 causes, the vicissitudes of the weather, especially its cold, are by far the most prolific 
 bources of mischief." 
 
 It must, therefore, to every one who is engaged, or likely to be engaged, in the 
 practice of physic, be a matter of first-rate importance, and of great interest, to asce-- 
 ta'n the circumstances under which the application of cold is the most prejudicial, or
 
 I 
 
 CAUSES OF DISEASE. .69 
 
 has the greatest influence upon the body — as well as the means by which the bad 
 effects of exposure to cold may often, in a great degree, be prevented. 
 
 There are some short but valuable hints upon this subject in Cu lien's First 
 Lines. The late Dr. Currie, of Liverpool, was, however, the first person who dis- 
 tinctly pointed out the laws that regulate the operation of cold as a cause of health 
 and disease. 
 
 Of the circumstances which favour the morbific effects of cold, some relate to the 
 condition of the body itself, some to the particular manner in which the cold is 
 applied. The former are predisposing circumstances; the latter accessory. We 
 will glance at these in succession. 
 
 It has long been a popular, as well as a professional axiom, that sudden vicissi- 
 tudes of temperature are dangerous ; that a previous hot state of the body augments 
 the hurtful effect of cold, whether applied externally or internally. But the proposi- 
 tion thus broadly stated is not universally true. It is well known that the inhabitants 
 of Russia are in the habit, while reeking from their vapour baths, of rolling imme- 
 diately in the snow, or plunging into cold water, without suffering from the change. 
 Sir Charles Blagden, describing some of the experiments which I mentioned in the 
 last lecture, says, " During the whole day we passed out of the heated room (of 
 which the temperature ranged from 240° to 2(50°), after every experiment, imme- 
 diately into the cold air without any precaution. After exposing our naked bodies 
 to the heat, and sweating most violently, we instantly went into a cold room, and 
 stayed there even some minutes before we began to dress, yet no one received the 
 least injury." And Captain Scoresby, speaking of the arctic regions, tells us that 
 he has often gone from the breakfast-room of the vessel, where the temperature was 
 50° or 60°, to the mast-head, where it was only 10°, without any additional clothing, 
 except a cap — " yet," says he, " I never received any injury, and seldom much 
 inconvenience from the uncommon transition." 
 
 It is plain, therefore, that the proposition which assigns danger to sudden vicissi- 
 tudes of temperature requires limitation. The effects of a sudden descent from one 
 point to another in the scale of atmospheric temperature vary according to the state 
 of the body at the time. Without going into any physiological discussion respecting 
 the source of animal heat, I may just remind you of the faculty of evolving heat 
 possessed by man and the warm-blooded animals ; by which faculty very nearly the 
 same degree of inward temperature is steadily maintained under very different 
 degrees of outward temperature. If the external temperature be lower than that of 
 the body, the caloric thereby carried off' is speedily replaced, in a healthy adult, by 
 this evolution of heat from within, aided by clothing, or by exercise. When the 
 external temperature approaches the standard heat of the body, sweat soon breaks 
 forth, and the superfluous heat is removed by evaporation : for so constant is the 
 internal evolution of caloric, that an atmosphere which does not as constantly abstract 
 any of it is excessively incommoding : an external temperature of 98°, which is 
 about the average heat of the blood in man, is, as you know, extremely oppressive. 
 The terms hot, warm, cool, cold, as applied to the surrounding air, are regulated by 
 the sensations that it produces upon the avepage of persons. If the heat be carried off 
 as fast as it is generated, and no faster, no particular sensation is felt, and the bodily 
 powers are neither stimulated nor exhausted. This equilibrium is maintained (sup- 
 posing that no extraordinary exertions are made), when the thermometer stands at 
 62°, or thereabouts. We call that point in the scale temperate. All degrees above 
 that point, up to 70, are reckoned 7varm ; all above 70, hot. Descending in the 
 scale, we speak of the temperature denoted by any degree between the 60th and the 
 50th, as being cool ; and every lower degree of temperature is cold. 1 am speaking 
 of the average of healthy men : for remarkable diversities occur among individuals in 
 respect to the epithets Avhich they assign, under the guidance of their sensations, tu 
 particular degrees of the thermometric scale ; their sensations differing according to 
 the power which their constitutions respectively possess of evolving heat. Now if 
 this power of evolving heat, thus inherent in the system, be entire, and active, aiid 
 persistent — if it have not been weakened by any of those circumstances which ai«3 
 known to have the effect of weakening it — no peril need attend even violent 'liters-
 
 /O CAUSES OF DISEASE. 
 
 tions of external temperature. Unusual heat of the body at the time when the cold 
 is applied, so far from implying danger, is really the condition of safety, provided the 
 heat is steady and permanent. You may read, in Dr. Currie's book, numerous 
 instances of the cold affusion being employed in the hot stage of fever, and particu- 
 larly in cases of scarlet fever, not only with impunity, but with great benefit to the 
 patient. The same holds true of the application of cold when the body has been 
 heated by exercise — and, indeed, whatever may have been the cause of the increased 
 heat — provided always that that cause remains steadily in action, that there is no 
 local disease, and that the body is not fatigued, and fast losing its heat. But if a 
 person be already exhausted and weakened by exercise — if he be sweating and 
 rapidlv parting with his heat — and especially if the exercise be over, and he remain 
 at rest immediately after and during the application of the cold — then it becomes 
 highly perilous, and likely to produce internal mischief. 
 
 The more correct statement, therefore, respecting the application of cold is, that 
 it is dangerous — not when the body is koi — but when the body is cooling after 
 havi7ig been heated. 
 
 This principle obtains alike, I say, whether the cold be applied externally or 
 internally; to the surface of the bodj', or to the mucous membrane of the stomach. 
 Very many instances are recorded of death taking place immediately after a copious 
 draught of cold water. I beheve it will be found that in all these cases, the body 
 after having been much heated and enfeebled by severe exertion, was losing its 
 preternatural heat from profuse perspiration, and, in general, from the cessation also 
 of the exertion by which this heat was accumulated. Celsus was aware of the 
 danger: " ex labore sudanti frigida potio perniciosissima est." The fatal influence 
 of cold water thus apphed was experienced, on a large scale, among the troops of 
 Alexander the Great, upon their reaching the banks of the River Oxvis, thirsty, 
 fatigued, and perspiring from their toilsome march of forty-six miles across the 
 scorching sands of the desert. According to Quintus Curtius, Alexander lost more 
 of his soldiers on that occasion than in any one of his battles. " Sed qui intempe- 
 rantius hauserant intercluso spiritu extincti sunt; multoque major horum numerua 
 fuit, quam ullo amiserat prrelio." Dr. Currie relates a striking example, which fell 
 under his own observation, of sudden death thus produced. A young man had been 
 playing a severe match at fives, and had violently heated himself. When it was 
 over he sat down on the ground panting for breath, and covered with perspiration. 
 In this state he called to a servant to bring him a pitcher of cold water just drawn 
 from a neighbouring pump. After holding it in his hand a little while, till he 
 recovered his breath, he put it to his mouth, and drank a large quantity at once. He 
 laid his head on his shoulder, and bent forwards ; his countenance became pale, his 
 breath laborious, and in a few minutes he expired. 
 
 I may take the opportunit}'^ of telling you that the remedies to be administered, 
 when life is in jeopardy from this cause, are warmth to the epigastrium ; and lauda- 
 num in free doses. 
 
 If death does not speedily follow the external or internal application of cold to the 
 body under the untoward circumstances I have described, inflammation of some 
 internal part is very apt to arise. 
 
 By attending to the principles now laid down, you will be enabled to furnish those 
 whom it may be your business to advise with many useful suggestions, and to cau- 
 tion them against some common mistakes : mistaKes which have had their origin in 
 the unqualified credit given to the maxim, that sudden vicissitudes of external tem- 
 perature, and exposure to cold while the body is hot, are dangerous ; whereas these 
 things are dangerous under certain circumstances only. Thus, you may tell the 
 sportsman that wet feet, or a wet skin, need cause him no apprehension, so that he 
 continue.* in active exercise ; and changes his clothes, and avoids all further appU- 
 cation of cold, as soon as his exercise ends. You may admonish the bather that 
 after walking in a hot day to the river's side, he had better not wait to cool himself 
 a httle oefore he plunges into the stream ; and in like manner you may venture to 
 counsel the young lady who has heated herself with dancing, not to linger in the 
 entrance hall till the glow has somewhat subsided, but to make the best of her way
 
 CAUSES OF DISEASE. 71 
 
 to her carriage, and thence to her bed ; and you may tell your male friends, who 
 happen to be similarly circumstanced, that the best thing they can do is to walk 
 briskly home in their great-coats. The main points to be remembered are, that "the 
 heat which is preternaturally accumulated by exercise is held with little tenacity, is 
 dissipated by profuse perspiration, and is speedily lost when to this perspiration is 
 added a state of rest after fatigue ;" and that, in these circumstances, the application 
 of cold is most apt to be prejudicial. 
 
 Among the circumstances which favour the morbific effects of cold, and relate to 
 the condition of the body itself, is to be included — for reasons that must now be 
 obvious to you — whatever has the effect of weakening the system, and so diminish- 
 ing its capability of evolving heat. The most common of these debilitating circum- 
 stances are enumerated by Cullen — " fasting, evacuations, fatigue, a last night's 
 debauch, excess in venery, long watching, much study, rest immediately after great 
 exercise, sleep, and preceding disease." All these, you will observe, tend to lessen 
 the vigour of the circulation, and to depress the power of generating heat. Con- 
 sistent with the same principle is the fact ascertained by Dr. M. Edwards, that the 
 faculty of evolving heat is very feeble in old persons, and in the newly born ; it 
 being in these classes that we find the greatest number of victims to the power of 
 cold. 
 
 The bad effects of cold upon the system depend partly upon the intensity of the 
 sensation it produces — but still more upon the duration of that sensation. We are 
 seldom the worse for a momentary sensation of cold, however lively it may have 
 been ; whereas even slight feelings of chilliness, if long protracted, are apt to termi- 
 nate in some form of disease. 
 
 By the help of this principle we may explain most of the circumstances which, 
 relating to the manner in which the cold is applied, have been found by experience 
 to aggravate its hurtful influence. 
 
 Cold is more likely, cxteris paribus, to prove injurious when it is applied by a 
 wind, or current of air. The sensation of cold is sustained by the continual acces- 
 sion of fresh particles of frigid air to the surface of the body. Some striking facts 
 in illustration of the refrigerating and depressing effects of a stream of cold air were 
 mentioned in the last lecture. 
 
 Again, the injurious operation of cold is augmented, when it is accompanied with 
 moisture. Wetness is notoriously the worst way in which cold can be applied. The 
 contact of wet or damp clothes with the skin both increases and prolongs the sensa- 
 tion of cold. For the same reason, a cold foggy atmosphere is more prejudicial than 
 a clear, and therefore drier one, of the same temperature. The heat of the body is 
 abstracted more rapidly than it is generated from within, and if it be not replaced 
 by exercise, or cordials, the balance of the circulation is deranged, and internal mis- 
 chief often follows. 
 
 The same principles serve to illustrate the effect of certain other circumstances, 
 adverted to by Cullen, as being counteractive of the morbific tendency of exposure 
 to cold: "passions engaging a close attention to one object," — "that state of the 
 body in which sensibility is greatly diminished, as in maniacs," — and "the power 
 of habit." These circumstances are worthy of a moment's notice. 
 
 Impressions which are unheeded are unfelt and inoperative. As it is scarcely 
 possible, when the attention is engrossed by bodily pain, to carry on any connected 
 train of thought — so on the other hand the senses become impassive in proportion 
 as the mind is fixed upon some absorbing subject of reflection, or enchained by some 
 powerful emotion : impressions made upon the organs of sense are no longer taken 
 notice of; the corresponding sensations, if they are excited at all, are not remem- 
 bered, and the effect of such impressions is as if they had never been ; they are no! 
 followed by the usual consequences. Persons gasping for breath in spasmoaic 
 asthma will remain for hours at an open window, with scarcely any clothing during 
 severe frost, and without suffering from the cold ; their attention is so anxiously and 
 exclusively bestowed upon the distress in their breathing, that the coldness of the an 
 is unnoticed and unperceived, and has no sensible effect. 
 
 For where the greater malady is fixed 
 The lesser V anstrr.o Mt.
 
 72 CAUSES OF DISEASE. 
 
 The morbific effect of cold upon the system is certainly modified by the degree of 
 attention that is paid to the sensation it excites. 
 
 Upon the veiy same principle may be explained the impunity with which some 
 maniacs undergo exposure to cold — even when suffering no fever which might 
 regenerate the lost heat. "I have seen," says Dr. Carrie, "a young woman, once 
 of the greatest delicacy of frame, struck with madness, lie all night on a cold floor, 
 with hardly the covering that decency requires, when the water was frozen on the 
 table by her, and the milk that she was to feed on Avas a mass of ice." 
 
 Sleep is enumerated by Dr. Cullen among those conditions of the body which 
 diminish its power of resisting cold. And certainly cold is very readily caught (as 
 the phrase is), when its causes are present, during sleep. But while we sleep sensa- 
 tion is in a great measure suspended. This would seem, therefore, to furnish a 
 contradiction to the principle that the effect of cold upon the bodily health depends 
 upon the strength and the duration of the sensation excited by it. Dr. Alison — I 
 speak from recollection of his observations heard many years ago — disposes of this 
 difficulty by affirming that the sleeper who thus suffers, does really feel, and is con- 
 scious of, the sensation of cold, and that it mingles with and probably suggests his 
 dreams. Lord Brougham, in his Discourse of Natural Theology, gives a very 
 lively picture of dreams so excited — drawn, as 1 should guess, from his own expe- 
 rience. Probably somethingf of the same kind has occurred to most of us. " Every 
 one knows (he says) the effect of a bottle of hot water, applied during sleep, to the 
 soles of the feet : you instantly dream of walking over hot mould, or ashes, or a 
 stream of lava, or having your feet burnt by coming too near the fire. But the 
 efl^ect of falling asleep in a stream of cold air, as in an open carriage, varies this 
 experiment in a very interesting, and indeed instructive manner : you will, instantly 
 that the wind begins to blow, dream of being upon some exposed point, and 
 anxious for shelter, but unable to reach it ; then you are on the deck of a ship, 
 suffering from the gale — you run behind a sail for shelter, and the wind changes, so 
 that it still blows upon you ; you are driven to the cabin, but the ladder is removed, 
 or the door locked. Presently you are on shore in a house with all the windows 
 open, and endeavour to shut them in vain ; or, seeing a smith's forge, you are 
 attracted by the fire, and suddenly a hundred bellows play upon it, and extinguish it in 
 an instant, but fill the whole smithy with their blast, till you are as cold as on the road." 
 
 Certain it is, that though while sleeping we are not sensible of, or (what perhaps 
 is the same thing) do not remember, ordinary impressions, we are nevertheless con- 
 scious of unusual sensations ; so that the facility with which we take cold during 
 sleep is no real exception to the general law, that the sensation produced by cold is 
 concerned in its injurious effects. 
 
 The last of the accessory circumstances mentioned by Cullen is " the power of 
 habit." No one can doubt the effect of custom in enabling the body to resist the 
 operation of cold, who has had opportunities of observing how differently an 
 inclement temperature is borne by persons whose employments oblige them to 
 live much under the open sky, as shepherds, sailors, stage-coachmen ; and by such 
 as pursue in-door occupations — mechanics, tailors, shopmen, and the like. Pro- 
 bably the sensibihty of the surface is blunted by habitual exposure. We may 
 believe too that the purer air breathed by the out-door labourer, and his more active 
 life, confer a more vigorous state of health, and endow him with an ampler faculty of 
 evolving animal heat. The fact is unquestionable ; and we may sometimes turn 
 our knowledge of it to good account, in gradually fortifying the system against the 
 influence of cold that cannot be avoided. An ill-directed application of this prin- 
 ciple has led, however, to grave errors, and cost many lives. You will now and then 
 hear parents talk of hardening their children, by causing them to brave all sorts of 
 weather, by teachintr them to be indifferent about variations of temperature, to sit 
 in winter time Avithout a fire in the room, and to despise great-coats, flannel, 
 and other additions to their usual dress. Fearing to render them effeminate by 
 wver care and cockering, they run into the opposite and more dangerous extreme. 
 
 Tins process is often attempted with children originally delicate, and to such it is 
 doubly hazardous. During the early periods of life the inherent protective power
 
 CAUSES OF DISEASE. 73 
 
 of evolving heat is comparatively feeble ; and in this climate it requires to be care- 
 fully cherished. 
 
 The experiment of hardening should never be tried on any child or person who 
 is ailing or unsound ; who shows any sign of present disease ; or any marked dis- 
 position to future, and especially to scrofulous, disease. Whenever it is tried it 
 must be conducted in conformity with the principles already laid down. The subject 
 of the experiment must be sufficiently clothed, and he must not fail to use such ex- 
 ercise during the exposure as may be requisite to excite and sustain the adequate 
 generation of animal heat. An abiding sense even of chilliness must never be aimed 
 at nor permitted. 
 
 The most direct and certain mode of fortifying the body against injury from ac 
 cidental exposure to cold, is afforded by the use of the cold bath, and especially of 
 the shower bath. When this is regularly taken in the morning, the surface of the 
 body becomes inured to a degree of cold greater than it is Hkely to encounter during 
 the remainder of the day. It is fortunate that we have an easy criterion of the pro- 
 priety of continuing this expedient. When the sense of cold does not remain long, 
 and is followed by a glow of warmth, the cold shower bath is sure to do good. If, 
 however, after the bath, the person suffers headache, and continues to be chilly, 
 languid, and uncomfortable, it should at once be given up as useless, and even 
 hazardous. 
 
 By observing these simple rules, a healthy child may be made hardy also, without 
 the risk which their neglect would impose, of damage to his bodily fabric, and of 
 abbreviating, by what was meant to prolong, his mortal span. 
 
 Closely connected with the effects of temperature upon the health is the influence 
 of the different seasons of the year. A few remarks upon that influence, as it is 
 witnessed in our own climate and country, may properly conclude our present 
 subject. 
 
 It is open to the commonest observation that the general health of the community 
 fluctuates with the changing seasons. Catarrhs, and coughs, and pectoral complaints 
 of all kinds, are most apt to commence, or to grow worse, in the winter and spring 
 months ; while bowel-complaints are more numerous and distressing in the summer 
 and autumn. The mucous membranes of the air-passages sympathize with the skin 
 under the agency of external cold ; those of the stomach and intestines under that of 
 continued atmospheric heat. 
 
 The thoracic disorders are more serious and fatal than the abdominal. Various 
 other maladies are likewise aggravated by cold, or by vicissitudes of temperature. 
 Hence the mortality of the winter is always larger than that of the summer ; unless, 
 mdeed, this rule happens to be disturbed by the intervention of some widely- 
 spread epidemic. I am not sure that the superior salubrity of the hotter over the 
 colder portion of the year is generally acknowledged, even in this age of enlight 
 ment. 
 
 It is the cold that, more than any other element of the weather, occasions the 
 difference. 
 
 There are two small pubhcations by the present Dr. Heberden, to which I 
 would direct your attention, as being singularly instructive upon these points. 
 One you will find in the eighty-sixth volume of the Philosophical Transactions : 
 Of the influence of Cold vpon the Health of the inhabitants of London. The other 
 is a separate pamphlet : Observations on the Increase and Decrease of differoxt 
 Diseases. 
 
 From a number of tables, framed chiefly upon the weekly bills of mortality, Dt- 
 Heberden (in the last-named paper) draws the conclusion that the whole number 
 of deaths is greatest in Januarj', February, and March, and least in June, July, and 
 August. This is contrary to the notions of the ancients, and perhaps of many of the 
 moderns iJso. Celsus says, " Tgitur saluberrimum ver est ; proxime deinde ab hoc. 
 hiems ; periculosior testes; autumnus longe periculosissimus." 
 
 The (iifference of place may perhaps account for this difference of opinion. Celsui 
 'ived m Rome. That city, and the surrounding district, abound in malaria; a caus« 
 
 a
 
 74 CAUSES OF DISEASE. 
 
 of disease which, happily, is now scarcely known in London, but which, wherevei 
 it exists, operates most powerfully and most extensively during the autumn. The 
 comparative healthiness of the several seasons may doubtless be disturbed, and 
 even reversed, by endemic peculiarities of this kind. 
 
 In his paper in the Philosophical Transactions, Dr. Heberden compares the number 
 of deaths that took place in London in January, 1795, which was an unusually 
 severe month, Avith the number that occurred in January, 1796, which was an un- 
 commonly mild month. Of those two successive Avinters one Avas the coldest, and 
 the other the Avarmest, of Avhich any regular account had been kept in this counlr}'. 
 In the month of January, 1795, the thermometer, upon an average, stood at 2;^° in 
 the morning, and 29°.4 in the afternoon; ahvays, you Avill observe, beloAv the 
 freezing point. In the same month in 1796, it stood at 43^.5 in the morning, and 
 at 50° in the afternoon ; ahvays much above the freezing point. The average differ- 
 ence in the tAvo months AA-as more than 20°. 
 
 In the fiA^e AA-eeks beginning upon January 1st, 1795, there Avere 2823 deaths: 
 in the five AA'eeks beginning upon January 1st, 1796, there were only 1471. The 
 difference, 1352, is enormous. The mortality in the former year was nearly double 
 of that in the latter. 
 
 One object Avhich Dr. Heberden had in vieAv in making this comparison Avas to 
 disabuse his countrymen of the notion that, in Avinter, frosty Aveather is more favour- 
 able to health than mild Aveather ; a notion Avhich has been embodied in the pro- 
 verb, that " a green Christinas makes a fat churchyard." 
 
 It is very instructive to remark in Avhat classes of persons the injurious effects of 
 the severe Aveather of winter is most felt. The increased mortality Avas found to be 
 chiefly among the very young, and the very old ; in other Avords, among those in 
 whom the recuperative poAver of generating heat is the feeblest. 
 
 In January, 1795, there AA'-ere in London 717 deaths of persons above sixty years 
 old, Avhile in January, 1796, there Avere only 153 such deaths; or scarcely more 
 than one-fifth of the former number. 
 
 I have often been struck by the unusual length of the neAA-spaper obituaries during 
 periods of hard frost ; and by observing how man}' of the individuals Avhose deaths 
 they record were far adA'anced in years. Dr. Heberden remarks that among per- 
 sons older than sixty, the tide of mortality, as measured by the AA"eekly bills, folloAA's 
 regularly the degree of coldness of the weather; so that any one accustomed to 
 examine these lists may form a tolerably accurate judgment of the severity of any 
 of our Avintcr months, by noting the ratio of the mortality in persons aboA'e sixty. 
 
 The deaths from asthma (under Avhich vague term all kinds of pectoral disorder 
 attended with shortness of breath appear to have been included) Avere 249 in Janu- 
 ary, 1795; only 29 in January, 1796. In the former of these months there Avere 
 825 deaths attributed to consumption ; in the latter, 342. 
 
 All this accords AA'ith what I mentioned before of the effect of cold AA'eather in 
 producing or exasperating diseases of the respiratory organs. 
 
 One of the conclusions deduced by Dr. Heberden from his examination of the 
 bills of mortality is, that "the number of deaths bj' palsies and apoplexies is in this 
 country al\A'ays greatest in Avinter." There are intelligible reasons for this. When 
 the surface is chilled, and the blood driven out of the superficial vessels by the cold, 
 it must accumulate in internal parts, and so press Avilh increased force toAA-ards the 
 head. And there is another reason for the frequency of these affections in the 
 winter season : it is, as Ave have seen, the season of pectoral complaints, and of em 
 barrasscd respiration. DA'spncra and fits of coughing greatly impede the return of 
 the blood from the head through the \'eins : and cerebral congestion tends m the 
 production of cerebral hemorrhage, especially Avhen the arteries of the bnuii are 
 diseased ; and they often are so. Accordingly Ave find that in January, 1795, there 
 were fifty-tAvo deaths from apoplexy and palsy ; Avhile in January, 1796, the num- 
 ber AA-as only thirty-one. 
 
 Since these lectures were first deliA^ered, three Jinnnal Reports of the Registrar- 
 General of Births, Marriuges, and Deaths in England, have been printed, and 
 liberally circulated, by the obliging attention of Mr. Lister, among the members of
 
 CAUSES OF DISEASE. 75 
 
 our protession. Much of the practical information afforded by these interesting 
 vohinnes is rendered accessible, even to a cursory reader, by Mr. Farr's able analy- 
 sis of the registered facts ; which amply illustrate and confirm most of the inferences 
 drawn by Dr. Heberden from the old tables of mortality. 
 
 For example, under the head of "Influence of the seasons," Mr. Farr shows, by 
 numerical statements, especially in the ildrd Annual Report, that in London the 
 degree to which the mean monthly temperature descends in December, January, or 
 February, determines, to a great extent, the mortality of the winter. 
 
 Again, " The causes of death which prove most fatal in the cold months belong 
 principally to the pulmonary class, and the cerebral diseases of the aged: those 
 which prove most fatal in summer belong to diseases of the bowels." 
 
 The mean temperature of the external atmosphere in London is 505°. In pro- 
 portion as the mean temperature of the day and night falls beneath that point, the 
 mortality progressively increases. 
 
 "The rise in the mortality," says Mr. Farr, "is immediate ; but the effects of the 
 low temperature go on accumulating, and continue to be felt thirty or forty days 
 after the extremities of the cold have passed away. The cold destroys a certain 
 number of persons rapidly; and in others occasions diseases which prove fatal in a 
 month or six weeks. The practical lesson taught by these facts is obvious. A 
 great number of the aged, and of those afflicted with difficulty of breathing, cannot 
 resist cold sunk so low as 32^. The temperature of the atmosphere in which they 
 sleep can never safely descend lower than 40°: for if the cold that freezes water in 
 their chamber does not freeze their blood, it impedes respiration, and life ceases 
 when the blood heat has sunk a few degrees below the standard." 
 
 The immense body of authentic facts thus yearly accumulating in these Reports 
 constitute most valuable contributions to the science of vital statistics ; and cannot 
 fail to throw hght upon the sources, and to point towards the prevention, of many 
 very dangerous and destructive disorders. To ascertain the causes of any disease, 
 and to display them before the public mind, are, I repeat, large steps towards the 
 ultimate removal of such as human endeavours are competent to remove. 
 
 You may trace the influence of the seasons, not only in the prevalence of parti- 
 cular diseases in certain portions of the year, but also in the character of other dis- 
 orders that are liable to occur in all periods of the year alike ; in the character, for 
 example, of fevers. In the majority of cases of continued fever, you will find that 
 the pectoral symptoms are most troublesome in the spring, and the abdominal symp- 
 toms in the autumn. It is said, also, but I do not know that this is so generally true, 
 that affections of the head, in continued fever, are more frequent and severe in the 
 winter than at other periods of the year. 
 
 Mere impurity of the air — by which I mean impurity that does not result from 
 the admixture of any specific poison, such as the marsh poison, and the various con- 
 tagions — is a powerful predisposing cause of disease. The prejudicial effect of im- 
 pure air is seen, on a large scale, by comparing the inhabitants of great towns, in 
 respect of health and longevity, with those who live in the country. If we again 
 refer to Mr. Farr's calculations, founded upon the returns made to the Registrar- 
 General, we find it stated, in the third Annual Report, that in cities, as contrasted 
 with rural districts, the deaths from consumption are increased 24 per cent. ; those 
 from typhus 55 per cent. ; those from childbirth 59 per cent. ; and so of several 
 other disorders. " The diseases chiefly incidental to childhood are twice as fatal in 
 the town districts as they are in the country." The mean duration of life in the 
 two classes of districts differs nearly 17 years ; being in the proportion of 55 years 
 {country) to 38 years (toivns). 
 
 These differences we can explain only by attributing them to the weakening influ 
 ence of impure air, and the want of sufficient exercise: for, as Dr. Alison has 
 remarked, "it is hardly possible to observe separately the effect on the animal eco- 
 nomy of deficiency of exercise, and deficiency of fresh air, these two causes being 
 very generally applied together. But it is perfectly ascertained on an extensive 
 Bcale, in regard to the inhabitants of large and crowded cities as compared with th«
 
 76 CAUSES OF DISEASE. 
 
 rural population of the same climate, that their mortalitj' is very much greater, 
 especially in early life — and the probability of life very much less." There is one 
 circumstance which shows that impure air is the more noxious agent of the two, 
 namely, the great comparative mortahty, in towns, of children under two years of 
 age, even although they get as much exercise as their time of life would allow of 
 anywhere. 
 
 The noxious and depressing influence of vitiated air is made strikingly manifest 
 by the effect of removal to a purer atmosphere. We are continually obliged to 
 recommend " change of air" to our patients. We advise them to go out of London, 
 that their recovery from acute disorders may be accelerated, and that they may 
 regain the degree of general strength which is necessary to the cure of many chro- 
 nic complaints ; of all those especially that require the use of tonic medicines, among 
 which class of remedies no one is so effectual, in constitutions that have been weak- 
 ened by a town life, as migration to the clear and pure air of the country. 
 
 It is necessary, however, to remember that although impure air has most unques- 
 tionably a very hurtful effect upon the general health, there is no specific diseas*^ 
 which can be distinctly traced to it as an exciting cause. It is as a predisposing in- 
 fluence that the impurity operates. For instance, it never generates (as I believe) 
 continued fever, yet it will most certainly aggravate the sjmiptoms, and favour the 
 propagation, and augment the mortality, of that, and of other diseases, in a great 
 degree. If there be" any diseased condition that is strictly the product of impure air, 
 it is scrofula. Scrofula (as I shall presently show you) depends in part upon here- 
 ditary constitution ; it partly arises also from exposure to cold and wet ; but there is 
 much reason for beheving that impure air is a very powerful agent in caUing scrofula 
 into action, and in aggravating the strumous diathesis. 
 
 [This statement of Dr. W. is not strictly correct. That specific disease is produced by im- 
 pure air is a fact established by the most abundant and conclusive testimony. Wherever we 
 find individuals crowded together in localities where filth is accumulated, and a free venti- 
 lation is prevented, there, also, we find diseases to prevail, evidently dependent upon the 
 impure and stagnant state of the atmosphere ; though other causes, no doubt, conspire to their 
 development, and to augment their malignancy. It cannot, certainly, be denied, that it is to 
 the impurity of the air, produced by decomposition of the exhalations and excretions of indi- 
 viduals regardless of personal and domestic cleanliness, when crowded together in confined 
 apartments, that we are to refer the production of the typhus fever, so apt to prevail under 
 such circumstances, as well as the typhoid character of most of the diseases with which such 
 individuals may become aflected from other causes. Typhus fever, we know, is particularly 
 liable to be produced in camps, barracks, hospitals, prisons, besieged fortresses, and on board 
 of ships, whenever in such situations a number of persons are crowded together, and cleanli- 
 ness and ventilation are neglected ; and it is seldom, if ever, generated when the sources of 
 impurity are carefully removed, and a free and constant ventilation secured. 
 
 The dependence of yellow fever upon an impure state of the atmosphere is shown by the 
 fact, that it is almost exclusively confined to towns or other situations where the population 
 is dense, and many causes exist calculated to impair the purity of the atmosphere; and by its 
 being very generally confined, when it occurs in cities, to the vicinity of the wharves and 
 docks, into which the common sewers empty and various impurities are allowed to accu- 
 mulate, and which, when acted upon by heat, cannot fail to give rise to a miasm, by which 
 the purity of the surrounding atmosphere is very materially impaired. 
 
 In regaird to the agency of an impure air "in calling scrofula into action, and in aggravating 
 the strumous diathesis," the evidence is by no means so strong as the language of Dr. W. 
 would imply. Dr. Phillips, h\ his late work on the Nature and Causes of Scrofula, has 
 examined this question with a great deal of care; his conclusions are, that '-if we regard 
 scrofula in the widest signification of the term, so as to include all diseases in which a 
 tubercle-like deposit seems to determine the loss of life, namely, phthisis, scrofula, and tabes 
 mesenterica, the result may be thus stated : — The mortality from those diseases is larger in 
 towns than in country districts, but it is not found that the densest portion of a town is that 
 in which the mortality is the largest. Thus, in the four districts in London in which the 
 crowding is the greatest, the average deaths from these affections is under 0.46, whilst in four 
 othfr districts, in which there is less crowding, the average deaUis amount to 0.51. and in 
 Fietiinal Green they are under 0.40. If we now narrow the question to the influence of a 
 residence in towns and bad air in developing scrofula alone, the result may be thus stated : — 
 In the four years' mortality included in the fifth report of the Registrar-General, namely, from 
 i?,38 to loll, in a district comprising towns having a population of 3,759,186, the deaths 
 from scrofula amounted to 758 ; and in a district having a rural population o£ 3,440,501 '^uls,
 
 CAUSES OF DISEASE. 77 
 
 the deaths amounted to 1333 ; or, to state the question more simply, the proportion of deaths 
 from scrofula to 1,000,000 living was, in the town districts, 50 per annum, and in the country 
 districts, 97. And if, with scrofula, tabes mesenterica be included, the numbers would stand 
 as 122 deaths in towns to IGO deaths in the country. Again, let us observe the south-eastern, 
 the south midland, and the south-western districts ; there the mortality from scrofula amounted 
 to 1 in 12,000, whilst in the densely-packed factory districts of Yorkshire, Lancashire, and 
 Cheshire, the mortality from scrofula will be seen to be less than half the preceding mor- 
 tality from the same cause, namely, about 1 in 25,000. And suppose we go one step further, 
 and compare one portion of the metropolis with another, we find that the total deaths from 
 scrofula in the metropolis, when compared with the population, are as 5-6 to 100,000 living, 
 whilst in tlie most densely populated districts, comprising the East and West London Union, 
 the Strand, Holborn, or St. Giles, Whitechapel, and Bethnal Green, the proportion is as 51 to 
 100,000; Bethnal Green being represented by 4-8, and Whitechapel by 4-7 to 100,000 living. 
 So in the low, dense, and poor districts of Bethnal Green, Poplar, Stepney, Whitechapel, 
 Shoreditch, Westminster, Bermondsey, Rotherhithe, and Lambeth, with a total mortality 
 amounting to 21,522, the deaths from scrofula are 45, or 1 in 478; while in the district em- 
 bracing Kensington, St. George's, Hanover Square, and St. Marylebone, with a total mortality 
 amounting to 14,734, the deaths from scrofula are 30, or 1 in 490. Thus the difference in 
 these districts is scarcely appreciable ; but if we compare the western districts of the me- 
 tropolis with those of Bethnal Green, Shoreditch, and Whitechapel, we find that the propor- 
 tion of deaths from scrofula to the general mortality in the former is as 1 to 490, and in the 
 latter to as 1 to 1000. Again, if from considering the influence of localities, we turn to the 
 csomparative mortality of the sexes, it will be found that 20 per cent, more boys die of scro- 
 fula than girls ; and yet it must be admitted that girls are more exposed than boys to the 
 eifects, whatever they may be, of crowded rooms, and exclusion from out-door employ- 
 ments.'" — C] 
 
 I have entered the more fully into the consideration of certain states of the atmos- 
 phere, its extremes and its variations of temperature, and its impurity, as causes of 
 disease, because there is no part of the course in which I could more conveniently 
 introduce them. Most of the other causes of disease, enumerated in my last lec- 
 ture, will be discussed in connection with the disorders to which they give birth : 
 malaria, for example, when I speak of ague ; contagions, when we come to the 
 exanthemata and to continued fever ; epidemic influences, with epidemic distem- 
 pers ; improper or insufficient diet, and intemperance generally, with indigestion, 
 and the disorders of the alimentary canal ; and so on. There is, however, one re- 
 markable predisposing cause of disease, a few observations upon which may serve 
 to fill up the little that remains of the present hour. I mean, that disposition to cer- 
 tain diseases which is apt to descend from parents to children : hereditary tendencies 
 to disease. 
 
 We must distinguish between susceptibility of disease, and a tendency to disease. 
 In one sense all persons are born with a predisposition to most forms of disorder. No 
 one is protected by nature against inflammation when the causes of inflammation 
 come into play. Poisons of various kinds, and specific contagions, which indeed are 
 poisons, operate with tolerable uniformity upon cill men alike. 
 
 But there are certain complaints which we may separate in this respect from the 
 others : which complaints some persons have a tendency to, and some have not. 
 The tendency is sometimes strong and evident, sometimes feeble and faintly marked ; 
 sometimes it displays itself in the midst of circumstances the most favourable lo 
 health, sometimes it requires for its development conditions the most adverse and 
 trying. To mention some of these diseases : scrofula, which I soon shall describe 
 more particularly, gout, mania, and (I believe I may add) spasmodic asthma. 
 
 Not only is a disposition to these complaints strikingly pronounced in some per- 
 sons, but other persons appear wholly free from such a tendency — nay, even devoid 
 of the susceptibility of them. Gout, in those capable of it, may be acquired by 
 habits, as it may be repressed and prevented by the opposite habits. The habits 
 that, in certain persons, bring it on, are the intemperate use of the luxuries of the 
 table, and an indolent or sedentary manner of life : but there are many people in 
 whom no amount of rich living or idleness will generate gout. So there are some 
 m whom no exposure to impure air, cold, and wet, and no privations — in other 
 words, no appliance of the influences calculated to bring the strumous diathesis into 
 play — will ever produce any form of scrofula ; will ever render them consumptive 
 
 g2
 
 78 CAUSES OF DISEASE. 
 
 for instance, Consumption being one of the most common and fatal shapes of scro- 
 fulous disease. There are many who endure the utmost distress and excitement 
 of mind, yet never become insane. There are many who never become afliicted 
 with asthma, although surrounded by the most powerful exciting causes of that 
 complaint. 
 
 Now with respect to these diseases, and perhaps a few others, it is matter of tact 
 that they occur much more frequently in persons, some one or more of whose an- 
 cestors have suffered from them, than in other persons : the tendency is transmitted, 
 is hereditary. 
 
 That the circumstances of the parents do influence the physical characters of the 
 children, no one can doubt : it is matter of daily observation ; and one of the best 
 possible illustrations of the fact is to be found in what are called family-likenesses. 
 We see children resembling their father, or their mother ; or both parents at once, as 
 mulaltoes. 
 
 It has been suggested that the similarity in features and expression, and even in 
 moral chamcter, which cannot be denied to exist, may be ascribed to training and 
 imitation. But allowing something to that cause, it cannot be all. It was, I re- 
 member, a common remark when I was at Cambridge, that the followers and 
 admirers of a very good man, the late Mr. Simeon, appeared to come at last to re- 
 semble him. So man and v/ife are sometimes fancied to grow like each other. That 
 is, the same prevailing cast of thought and feeling, the idem sentire et idem velle, 
 may give such an habitual expression and character to the countenance, as shall con- 
 stitute, to superficial observers, a likeness. But there are family-hkenesses which 
 will not admit of such an explanation as this : similarities in the shape or size, or 
 disposition of peculiar features. Every one has heard of, or may remark in por- 
 traits, the hereditary thick lip of the imperial house of Austria. Many persons now 
 living have had the opportunity of tracing the lineaments of our own royal family 
 through at least three generations. The sisters of one of our English dukes are re- 
 markably handsome young women, and bear, to this day, a striking resemblance to 
 the portraits of their beautiful ancestress, the celebrated Nell Gwyn. And inde- 
 pendently of the general cast of features, we trace these family-likenesses in minute 
 or unequivocal particulars, as the colour of the hair and eyes, the shape of the limbs, 
 the stature of the body, and so on : nay, in more decided peculiarities than these, 
 in points of unusual formation. You have heard, probably, of the American calcu- 
 lating boy, Zerah Colburn. A great number of individuals of his family, descended 
 from a common ancestor, had six fingers and six toes instead of five. The pecu- 
 liarity was transmitted through four successive generations ; and probably, could his 
 pedigree have been further traced, through many more. I am myself acquainted 
 with a gentleman who had the misfortune some years ago to have a bastard child 
 laid to his charge. At first he had some misgivings on the subject, and suspected 
 that he might have no title to the credit (or I should rather say to the discredit) of 
 the imputed paternity ; but all his scruples Avere satisfied when he found that the 
 child had six fingers on each hand, for he had himself possessed two small super- 
 numerary fingers, which had been amputated when he was an infant. Haller gives 
 an account of a web-footed family, descended from a mother in whom that configu- 
 ration existed. There is now living in London a musical composer of some celebrity, 
 in whose person nature has played a similar freak ; and whose father, grandfather, 
 and great-grandfather, were all web-footed before him. Beyond this point his infor- 
 mation does not reach. I am indebted for the knowledge of this instance to one of 
 my former pupils, Mr. Cooper, of Grafton street. 
 
 Now there is one very curious circumstance observable in regard to these family- 
 likenesses, namely, that they may fail to appear in the child, and yet appear in the 
 grandchild ; may skip over a generation or two ; may, after lying dormant, break 
 out, as it were, in some collateral branch of the family tree. 
 
 This not only proves that certain physical peculiarities may be transmitted, but it 
 discloses this remarkable property, that peculiarities no/ /Jossfsser/ by the parent may 
 nevertheiesi ue transmitted by him. And this evidently opens a wide field for the 
 operatioi oi^ hereditary tendencies. A person is not to consider himself as neces-
 
 SYMPTOMS. ■''9 
 
 sarily free from a disposition to consumptioa or gout, because his parents have ne-er 
 shown any symptoms of those disorders. 
 
 When one parent only bears the transmissible tendency, the disease appears to be 
 most apt to break out in the children who most resemble that parent in their physical 
 conformation and appearance. Yet this is a most universal rule. I am acquainted 
 with a gentleman who had lost several brothers or sisters by phthisis. The fatal 
 disposition is known to exist on his mother's side, while his father's pedigree is be- 
 lieved to be quite free from it. All the children that have hitherto become consump- 
 tive have resembled the mother in bodily configuration and features, except this 
 gentleman, who is like his father's family, but who, nevertheless, labours under un- 
 equivocal consumption.* 
 
 It becomes a very interesting, and a very important question, whether acquired 
 peculiarities can be transmitted. I have been told, by a gentleman attending the 
 class, that he knew a man who, having been accidentally deprived of sight, after- 
 wards propagated bUnd children. I believe, however, such an event to be uncom- 
 mon. Dr. Prichard is of opinion that all original or connate bodily peculiarities 
 lend to become hereditary, while changes in the organic structure of the individual 
 from external causes during hfe, end with him, and have no obvious influence on his 
 progeny. Although this general law is probably true, I doubt whether it be yet 
 sufficiently established by a reference to actual facts. 
 
 I need scarcely say a word respecting the importance to medical men, and indeed 
 to all men, of a knowledge of these hereditary dispositions. Such knowledge ourrht 
 to regulate, in some degree, the choice of persons wishing to marry. Where both 
 parents have a decided tendency to any complaint, there will be a double probability 
 of a diseased offspring. Lawful intermarriages between members of the same 
 family are often highly objectionable on the same score. Any inherent defect or 
 . morbid propensity is aggravated by what cattle-dealers call " breeding in and in." 
 
 Again, if it be known that in any family an hereditary proclivity exists — to gout 
 and gravel, for instance, or to consumption — this knowledge ought to warn every 
 individual of that family sedulously to avoid the causes which foster and develop 
 these diseases ; and medical men, possessed of the requisite information, may give 
 most valuable advice and instruction on these points. 
 
 LECTURE VIII. 
 
 Symptoms. Their Uses in relation to the Diagnosis, the Prognosis and the 
 Treatment of Diseases. Signs, as distinguished from Symptoms. Pathog- 
 nomomic, Commemorative, Direct and Indirect Symptoms. Examples of Symp- 
 toms as they consist of uneasy Sensations, disordered Functions, or changes of 
 Sensible Qualities. 
 
 We are perpetually reading and talking about symptoms ; and no wonder, for 
 symptoms are the signals by which we learn that disease is present ; the evidence 
 upon which our whole art proceeds. We are always, therefore, observing symp- 
 toms, analyzing them, striving to interpret their meaning, to ascertain what they 
 signify. Without a knowledge of symptoms we can have no knowledge of the art 
 of physic. Sagacity in penetrating the import of symptoms constitutes a great pan 
 of the skill of an able physician. We shall find it useful to take a cursory view of 
 semeiology, and to famihurize our thoughts with some of the cardinal symptoms 
 themselves, before we speak of them in connection with particulai diseases. 
 
 What do we mean by a symptom ? XvixTttuifia — " Something that happens concur 
 rently with something else." Symptoms, they say, are coincidences, but this i& 
 merely translating the word svuHtufw/ta into English through the Latin. Symptoms 
 
 • This gentleman, an eminent London physician, has died since this lecture was given
 
 so SYMPTOMS. 
 
 are sometimes defined to be morbid phenomena — " any thing (5bserved in a patient 
 out of the course of health." But in forming our estimate of disease we must often 
 lake into account functions that are regular and undisturbed : tliese have been said 
 to furnish negative symptoms. For my own part, if I were called upon to dclino a 
 symptom, I should say, " Every thing or circumstance happening in the body of a 
 S'ck person, and capable of being perceived by himself or by others, which can be 
 made to assist our judgment concerning the seat or the nature of his disease, its pro- 
 bable course and termination, or its proper treatment: every such thing or circum- 
 stance is a symptom^ 
 
 And 1 wish you to take notice at once, that it is for the three purposes just adverted 
 to, that we cultivate the study of symptoms, viz.: — 
 
 First, To ascertain the seat and the nature of the disease under which our patient 
 is labouring : in technical language to form the diagnosis. 1 am no great friend to 
 technical phrases where they can be avoided without inconvenience ; but in some 
 cases short terms of art save us a great deal of tiresome periphrasis and circum 
 locution. 
 
 A second object of the study of symptoms is to enable us to foresee and foretell 
 the probable course and issue of the disease ; in other words, to frame the prognosis. 
 
 And a thii'd, and paramount use of a knowledge of symptoms, is to direct oui 
 treatment of the disease. 
 
 I suspect that the immense importance of the first mentioned of these three 
 objects — the diagnosis or recognition of disease, is not always clearly seen, either by 
 students or practitioners of medicine. Sometimes we are obliged to prescribe for a 
 malady, although we are in great uncertainty, perhaps in total ignorance, respecting 
 its nature or its situation. But this is always unsatisfactory. On the other hand, 
 when we have ascertained where and what the disease is, we apply with much 
 more confidence, precision and comfort, those rules for its relief which w^e have 
 picked up by our own observation, or have been taught by others. This, however, 
 is a very limited view of the importance of an exact and true diagnosis. Diagnosis 
 forms the indispensable basis of all advances in physic as a practical art. There is 
 a common saying, that the knowledge of what a disease is, is half its cure. In one 
 sense this may sometimes be true, but in another sense it is not so. Almost all that 
 we know concerning the proper treatment of the sick is originally derived from 
 observation, not of the nature of diseases, but of the ejects of remedies. That 
 rhubarb will purge, and opium lull to sleep, and loss of blood occasion faintness, are 
 truths which experience alone could suggest, aid successive trials alone confirm. 
 They are purely empirical truths. No one could guess them beforehand. No skill 
 in the discrimination of disease has even a tendency to teach them. In some few 
 cases, indeed, we see that certain mechanical derangements exist, which are mani- 
 festly capable of mechanical relief. When parts of the body are displaced, as in 
 hernia and dislocations ; or when distension and pressure are evidently produced by 
 accumulated fluids ; the mechanical remedies are at once suggested by the physical 
 and obvious faults. But with such exceptions, diagnosis does not, of itself, afford us 
 any direct information as to the cure of diseases; but it does this — it defines and 
 fixes the objects about which observation is to be exercised, and experience collected. 
 When Ave can once identify a given diseased condition, we obtain the privilege of 
 watching the behaviour of that diseased condition, again and again, under the opera- 
 tion of therapeutic measures ; and from that time the increase of our knowledge 
 concerning the appropriate management of that particular disease becomes progressive 
 and sure. The term experience is obviously misapplied, and the results of all 
 observation are vitiated, when any doubt exists about the sameness of the objects 
 contemplated. It is mainly to this imperfection in the diagnostic part of medicine 
 that we must attribute the uncertainty and variation, both of doctrine and practice, 
 which have brought so much suspicion, and reproach, and ridicule upon the science 
 we profess. False experience, if I may use such a term, has greatly hindered the 
 progress of the heaUng art ; and false experience springs from false diagnosis. A 
 man will tell you that he has cured a score of cases of advanced phthisis ; but he 
 has deceived himself : they were not cases of true phthisis, but simply cases of
 
 SYMPTOMS. SI 
 
 chronic inflammation, with puriform discharge of the mucous membrane of the 
 bronchi. He publishes an account of his success, and of his plan of treatment ; and 
 thus he deceives others also : and thus he retards the science which he fondly and 
 conscientiously beheves he is promoting. Accuracy of diagnosis, then, cannot be 
 too highly estimated, nor too diligently sought after. It has been wonderfully im- 
 proved within the last twenty years. 
 
 'Ihe prognonis, or foreknowledge of the course and event of diseases, has but 
 httle connection with the promotion of the art of healing ; but it is not on that 
 account less worthy of our attention. Both physician and patient find their advan- 
 tage in the capability of the former to determine whether a disease be remediable — 
 to foresee the changes that may be expected in its progress — to predict the manner 
 in which it will terminate. Knowledge of this kind opens to us a fair and honour- 
 able source of credit and reputation ; and it begets a degree of confidence towards 
 us, which is beneficial, not merely to ourselves, but to our clients. Our influence 
 over a sick person, and the efficacy of many of our remedial measures, are remark- 
 ably mcreased by the reliance he places on our skill, and by our apparent acquaint- 
 ance with the nature of his complaint. It is often of material consequence, in another 
 point of view, that the fatal character of a disease should be plainly perceived. A 
 sick man, made aware of his danger, is furnished with a motive and an opportunity 
 for arramjmg his worldly affairs, in the settlement of which the future comfort and 
 happiness of his family may be very deeply concerned ; for making his will ; and 
 also for more solemn preparation for the awful change that awaits him. For these 
 reasons medical men have, in all periods, endeavoured to read, in the phenomena 
 presented to them by diseases, the event to which those diseases severally tend. To 
 form an accurate opinion on this head is, however, one thing — to divulge it, ano- 
 ther. There is always some risk of losing, instead of gaining credit, by strong state- 
 ments, and confident predictions of the death or the recovery of a patient. If you 
 give an unfavourable prognosis, you have a good chance of losing your patient alto- 
 gether; his friends argue very naturally, that you are not inAUUble, that you may be 
 wrong, that i^ you know of no means of safety for him, some other practitioner may, 
 and they will grasp at v/hatever straw comes near them. Do not suppose that this 
 is merely a selfish view of the matter : it is often of much moment to the patient 
 himself, that he should not be tempted to put his life under the charge of impostors, 
 who will feed his hopes, and promise largely, and torture him perhaps with their 
 discipline, and have no mercy upon his pocket. Many an instance have I known 
 of persons dying of consumption, who, when given over by their regular attendants, 
 have been brought to London at considerable expense, exchanging the many com- 
 forts of home for the inconveniences of a hired lodging, that they might be cured 
 by that ignorant and cruel and rapacious quack, iVlr. St. John Long. There are 
 other reasons, too, why we must sometimes conceal the truth from our patients. It 
 often happens that a person is extremely ill, and in great danger, but may yet reco- 
 ver if he is not informed of his peril. To agitate a person in these circumstances 
 by telling him he is likely to die, is to lessen, perhaps to destroy, his chance of 
 recovery. You kill him if you take away his hope of hving. It must be confessed 
 that the duty of the medical man in these cases is very painful and embarrassing: 
 the patient and the patient's friends are urgently inquisitive to know whether there 
 is any danger ; or whether he is not yet out of danger. The rule which I have 
 always adopted in circumstances of this kind, when I see clearly that the case is 
 hopeless of cure, is to fix as well as I can upon that person among the family c" 
 friends of the patient to whose prudence the real state of the matter may be the 
 most safely confided. If I think that there is a possible chance of recovery, and 
 that a knowledge of his danger by the patient would diminish that chance, of course. 
 I urge the necessity of speaking to him with assumed cheerfulness and confidence ■ 
 if I see that the case is absolutely and inevitably mortal, either soon or at some littL 
 distance of time, I leave it to the discretion of the person with whom I communicate 
 to disclose or conceal my opinion as he or she may think best. There are, I bekevc. 
 practitioners, who make it a point, on principles of worldly policy, never to speak
 
 82 SYMPTOMS. 
 
 des])airingly of a patient ; but 1 cannot regard such a rule of conduct as honest, or 
 justifiable, or consistent with one's Christian duty. 
 
 Now I would have you observe that symptoms do not serve equally or indiffer- 
 ently the three several purposes that I have spoken of. The same symptom or set 
 of symptoms may indeed at once reveal the nature of the disease, arid foreshow it3 
 result, and indicate its treatment. When we have discovered what the disease is, 
 we may want no further information to tell us how it will terminate, or how we are 
 to prescribe for it. A man previously sound and well, shivers, then becomes hot, 
 and afterwards sweats, and then reverts to his natural state of comfort and good 
 heahh : and the same series of phenomena recur every other day. We pronounce 
 the disease to be ague ; we predict that, in this climate at least, the patient will 
 recover ; and we give him quinia ; all upon the strength of the same set of symp- 
 toms. But this is not necessarily the case : certain symptoms may disclose to us what 
 the malady is, and where it is situated ; other symptoms teach us whether our patient 
 is hkely 'o survive or not ; and a still different set instruct us what is the proper 
 method of cure to be attempted. We see a number of httle pustules scattered over 
 his skin, and we know that our patient is labouring under small-pox. His chance 
 of recovery will be singularly different, according as the spots upon his face run 
 together, or remain separate and distinct from each other ; and we investigate the 
 state of his pulse, and his breathing, of his bowels and his brain, before we can ven- 
 ture to prescribe for him. Those s3'mptoms, or combinations of symptoms, which 
 disclose the place and nature of the disease, we call signs of disease ; those which 
 teach us what to do, we call indications of treatment. We speak also of prognos- 
 tic signs. By keeping these distinct ends of the study of symptoms in mind, Ave 
 shall be enabled to group them to advantage, and to avoid huddling confusedly 
 together symptoms that speak, not indeed a different language, but upon a different 
 topic. The ancients, who knew but little of the intimate nature of diseases, but 
 who paid great attention to symptoms, have laid down most admirable rules in 
 respect to prognosis : which shows not only that the prognostic signs are more 
 easily made out, in many cases, than the diagnostic, but also that they may be inde- 
 pendent of them. 
 
 I have just spoken of symptoms as being, signs. These words are not, however 
 exactly synonymous, ahhough they are frequently employed as if they were so. 
 Even those medical writers who admit a distinction between them, have not alwaj's 
 succeeded in clearly pointing out the difference. Signs are deduced from symptoms, 
 by arranging and comparing them, and noticing the circumstances under which they 
 occur. Symptoms are obvious to all persons alike — to the nurse as well as to the 
 physician : signs, for the most part, are such to medical eyes alone. Let me try to 
 make this plainer by the help of an illustration. Symptoms may be considered as 
 resembling so many words. When taken separately, or when put together at ran- 
 dom, the words have no force or siiinification. Arrange them in due order, reduce 
 them mto a sentence, and they convey a meaning. The sentence is a sign or 
 expression of something which is thus revealed. Symptoms become signs when 
 their import can be interpreted. 
 
 A certain crackling sound, of which T shall have much to say hereafter, is heard 
 (we will suppose) in some part of a patient's lung, by the ear applied outside his 
 thorax. The sound is a symptom ; any one who listens may perceive it. It is 
 even so far a sign that it denotes the unnatural presence of a liquid in the lung, and 
 the passage of air through that liquid. But the liquid may be one of several — 
 mucus, or serum, or pus, or blood : we cannot tell by the sound alone which of 
 these it is. But if we learn that the person in whose lung the sound is audible has 
 been ill for a day or two only, that he has pain in his chest, cough, embarrassed 
 breathing, and fever, we conclude that he is labouring under that serious disease, 
 inflammation of the lung. The crackhng sound alone could not assure us of this ; 
 nor without the addition of this sound could the pain, the laboured breathing, the 
 cough, or the fever. Taken collectively, the symptoms constitute a diagnostic sign, 
 luid bespeak the existence of pneumonia. 
 
 Sometimes a symptom, or set of symptoms, becomes a sign, by its relation to whaJ
 
 SYMPTOMS. 83 
 
 has gone before and what follows it. To adhere to our illustration, the meaning 
 becomes evident from the context. By comparing, at short intervals, in the sup- 
 posed case of pneumonia, the extent and character of the sounds heard during respi- 
 ration, we ascertain whether the disease be advancing or receding; and thus con 
 vert the sounds, or their variations from day to day, injo a prognostic sign. 
 
 We always strive, then, to penetrate beyond the symptoms to the disease of which 
 they are significant. But we do not always succeed in this, and when we do not 
 (as in the case of ague), we are driven to the necessity of regarding the combina- 
 tion of symptoms as the disease. 
 
 You will often hear of pathognomonic symptoms. A pathognomonic symptom 
 is one which, when it occurs, settles infallibly the nature of the malady ; becomes a 
 positive sign or token of a particular morbid condition. But there are very few 
 symptoms, if there be any, which, taken singly, can ever be said to be strictly pa- 
 thognomonic signs ; yet a symptom which in itself possesses httle or no value may 
 become very significant when conjoined with others. 
 
 Much light is often thrown upon symptoms by what the French call commemo- 
 rative circumstances — that is, by a knowledge of the previous history and condition 
 of the patient. For example, a person may have palpitation and other marks of dis- 
 ordered action of the heart, and doubts may exist whether these symptoms depend 
 or not upon organic disease of that organ. The question is often determined in the 
 affirmative, by our learning that the patient has had one or more attacks of acute 
 rheumatism of the joints. 
 
 There are some other general division of symptoms, which it is useful to attend 
 to. Thus some symptoms are said to be direct, and others to be indirect symptoms. 
 Direct symptoms relate to the very part which is affected ; indirect symptoms are 
 such as " declare themselves through the medium of some other parts, or through 
 the medium of the constitution at large." There are some cases in which the direct 
 symptoms are of much more value than the indirect ; and there are other cases in 
 which those which are indirect are the most important; and there are yet many 
 more which require for their elucidation a knowledge of both the direct and the 
 indirect symptoms. 
 
 Again, there are many symptoms of which we receive no information, except 
 through the statements made by the patient himself; and there are many others of 
 Avhich we learn the existence by means of our own observation, by the exercise of 
 our several senses. The relative importance of these varies too in different cases. 
 Of course those symptoms which we are able to ascertain for ourselves ar^ the most 
 trustioorthy ; but both sorts of symptoms shed mutual light upon each other. We 
 should constantly be making mistakes if we relied solely upon what our patients tell 
 us. On the other hand, the value of the information we derive from their state- 
 ments is made apparent by the difficulty we are apt to experience in investigating 
 the diseases of children ; of those who are dumb ; or, what is much the same thing, 
 who speak no language that we understand. 
 
 Now, setting aside that notice of the healthy functions which is sometimes neces- 
 sary in order to determine the relative value and meaning of other symptoms, and 
 regarding those symptoms only which consist of morbid changes, they may all be 
 classed under three heads: 1. Uneasy, unnatural, or impaired sensations: 2. Dis- 
 ordered or impeded functions : and 3. Alterations of structure or of appearance ; 
 changes of sensible qualities. When these last come within the direct cognizance 
 01 our senses, they are called, usually, physical signs. 
 
 Uneasy or altered sensations we can only be aware of through the testimony of 
 the patients themselves. The symptoms belonging to the other classes fall, gene- 
 rally, under our own notice. 
 
 Uneasy or altered sensations comprehend a large class of morbid symptoms. By 
 their occurrence persons sometimes become conscious that they are unwell before 
 any other symptoms are observable. Of all the uneasy sensations pain is the most 
 common and the most important. It rarely happens that it is not felt, at one period 
 or another, in inflammatory disorders ; and it very often occurs, and is very acuK; 
 too, when there is no inflammation at all. I shall have occasion, in a subsequent
 
 84 SYMPTOMS. 
 
 lecture, to lay before you the criteria between pains that accompany inflammalicn. 
 and pains that are independent of it. Upon that point of distinction the whoio ques- 
 tion of treatment commonly depends ; and it is often a most difficult point to de- 
 termine. 
 
 There are many different kinds and degrees of pain. Different kinds of morbid 
 action are accompanied by different kinds of pain ; and the same kind of morbid 
 action — inflammation, for example — produces different modifications of pain, accord- 
 ing as it affects different parts. The pain that belongs to inflammation of the lungs 
 differs from that which is felt in inflammation of the bowels. Bones, muscles, ten- 
 dons, ligaments — the bladder, the kidney, the uterus — all modify, in a manner pecu- 
 liar to themselves, the pain that is produced in them by injury or disease. Differ- 
 ent epithets are given to the different varieties of pain — i. e., persons endeavour to 
 explain how they feel by likening their sensations to something which they have 
 felt before, or fancy they have felt. Thus we hear of s/iurp pain — shooting pain- — • 
 dull pain — gnawing pain — burning pain — tearing pain ; and so on. 
 
 If pain be felt in a part only when it is touched, i. e., when pressure is made 
 upon it, the heightened sensibility is called tenderness : — the part is said to be ten- 
 der. This is a very important kind of pain, as we shall see hereafter. A part may 
 be both painful and tender: or painful without being tender: or tender without 
 being otherwise painful. 
 
 Pain often takes place, not in the part really affected by disease, but in some dis- 
 tant part. Inflammation of the liver or diaphragm will cause pain of the right 
 shoulder : the mechanical irritation of a stone in the bladder produces pain at the 
 extremity of the urethra : inflammation of the hip-joint occasions pain in the knee : 
 disease of the heart is often attended with pain running down the left arm : many 
 headaches result from irritation of the stomach. We call these instances of inai/ic:; 
 or sympathetic pain. Some of them admit of no very obvious explanation : — others 
 have been ascribed to connections between the sentient nerves of the two parts; 
 "especially when the part really injured is internal, and that to which the feeling is 
 referred is external, and both derive their sentient nerves from the same larger 
 branches." You will perceive that a due estimation of these sympathetic pains is 
 of no small importance. 
 
 I may observe of pain in general, that it is differently felt — or at any rate differ- 
 ently complained of — by persons of different constitutions and temperaments. There 
 are even, I fancy, national differences in this respect. I have been present, as you 
 may believe, at a great number of surgical operations, and I have been struck with 
 the different degrees of patience with which the same operation has been borne by 
 Irishmen and by Scotchmen. The Irishman, generally speaking, either feels more 
 acutely, or gives more free vent to his feelings in cries and exclamations : the Scotch- 
 man, on the contrary, most commonly preserves a resolute silence. In complaints 
 that are attended with low spirits, and hypochondriacal symptoms, there is reason 
 to believe that the pain spoken of often depends, in a great degree, upon the eager 
 attention that is paid to it. The accounts given by such patients of their suflerings 
 are always to be received with a grain of allowance ; and this is often an embar- 
 rassing circumstance in practice. Patients take it ill if they do not seem to be im- 
 phcitly credited ; and yet if they are not convinced that much of what they suffer 
 depends on their great attention to it, they will never get well. You will often find 
 that they cease to feel pain — i. c, they forget to attend to their complaints — when 
 their attention is otherwise strongly arrested ; as by conversation, or music. I ad- 
 verted to this principle in my last lecture. 
 
 Besides pain, in all its modifications, there are man 3^ other, and very interesting, 
 uneasy sensations. Itching is an uneasy sensation nearly allied to pain. As severe 
 mechanical irritation will cause pain, so a slighter degree of it will cause itching. 
 Itching occurs in many cutaneous diseases, and it gives a name to one of them, 
 whicn is emphatically called the itch.- And the Latin word signifying the same 
 sensation, prurigo, is made use of to denote other forms of disease of which itching 
 is the most prominent symptom. It often affects some one of the natural outlets of 
 the body. It occurs about the rectum, from the motions of little Avorms that nestle
 
 UNEASY SENSATIONS. 85 
 
 in the lower part of that gut. This prurigo podicis, which does not always depend 
 on the cause just mentioned — and the prurigo pudendi in the female — are some- 
 times most distressing complaints ; harassing the patients continually, preventing 
 sleep, excluding them from society, and requiring medical treatment. Acrid 
 matters in the intestines will sometimes produce a kind of itching there ; and the 
 call to void the fajces is perhaps more akin to itching than to any other sensa- 
 tion : sometimes, indeed, it amounts to ])ain. The tickling often felt in the wind- 
 pipe, and provoking the person to cough, appears to be of the same nature. 
 Tingling and pricking are sensations which have also some analogy with itching. 
 Nausea is another uneasy sensation. It is sometimes a dir'ect symptom of disease 
 or disorder of the stomach, to which the sensation is referred. Sometimes it is a 
 very important indirect symptom, taken in conjunction with others, of disease in 
 some part at a distance from the stomach — in the kidney, for example, or in the 
 brain. The nausea which is so troublesome to pregnant women is another in- 
 stance of a morbid sensation sympathetic of irritation in a distant organ. 
 
 Another example o." an uneasy sensation we have in giddiness, or dizziness — 
 technically, vertigo. It sometimes results from disease within tlie head; some- 
 times it is an indirect consequence of disorder of the stomach ; or of mere de- 
 bility and an approach to syncope. 
 
 Patients will also complain of an undefinable sensation which they usually 
 call sinking — a sensation which is referred to the epigastric region. This is 
 frequently a source of much distress to hysterical women ; and it is occasionally 
 the forerunner of death at the close of severe diseases which have a tendency to 
 end fatf Ily in the way of syncope. 
 
 Many other symptoms might be mentioned which belong to this class of uneasy 
 sensations, and for our knowledge of the existence of which we must depend upon 
 the accounts given us by the patients themselves. Sensations of weight; and of 
 tightness and fullness ; drowsiness, tenesmus, strangury, heartburn ; and various 
 depraved conditions of the special senses. In the majority of diseases the appetite 
 is lost or impaired ; but sometimes excessive hunger accompanies and denotes 
 disease. We sometimes derive the first suspicion of the existence of diabetes from 
 the preternatural keenness of the appetite. Thirst is a very constant and striking 
 symptom in all febrile and inflammatory disorders ; and in the disease just now 
 mentioned, diabetes, it frequently constitutes the whole distress of which the patient 
 is sensible. The appetite may be perverted, as well as deficient or excessive. 
 Chlorotic girls will eat cinders, sealing-wax, slate-pencil, and such trash. So women 
 who are pregnant either have or pretend to have inordinate longings for particular 
 kinds of food — longings which are evidently fostered by encouragement. They are 
 not, I believe, common at present in this country ; and they are less frequently heard 
 of among the poor, who have not the means of gratifying them, than in the higher 
 classes of society. 
 
 The class of uneasy sensations you see then is a very large one, and some of the 
 morbid feelings are of very great moment. However, there are not many diseases 
 which consist altogether of uneasy sensations ; and when we find that pain or 
 uneasiness is complained of in any part or organ, we next proceed to inquire whether 
 the functions of that part or organ are disturbed or suspended. If we discover any 
 interruption or derangement of function, we have additional reason for concludino- 
 that the part so affected in its sensations and in its functions is actually the seat of 
 disease. This is an inquiry which we can prosecute with much less assistance from 
 the patient himself; and mostly with no assistance at all ; and even in spite of any 
 erroneous opinions which he may have formed, and is anxious to state upon the 
 subject. The study of disordered functions is of great practical value. 
 
 The functions of the brain and nerves — of the heart and blood-vessels — of the 
 respiratory apparatus — and of the digestive organs — are all of vital consequence. 
 
 Some of the impeded or disordered functions which relate to the brain and nerves 
 are in fact identical with the last class of symptoms, and consist of altered or morbid 
 sensations : sensation being one of the natural functions of those parts. Deprava 
 tions, for instance, of the sense of touch ; numbness ; the total absence of senfation* 
 
 u
 
 86 SYMPTOMS. 
 
 which we call anaesthesia. Symptoms of this kind do not constitute primary dl«r;ases 
 but they often portend or accompany very serious alterations in the brain, or in some 
 part of the nervous system : and it is from that circumstance that they derive the 
 great interest and importance which belong to them. The same may be said of 
 perverted conditions of the other senses. The sense of vision is often impaired, and 
 in various ways and degrees, from mere dimness or imperfection of sight, to total 
 blindness. And this total blindness may occur without any other apparent disease, 
 the humours and fabric of the eye itself being in all evident respects healthy and 
 right ; it may come on, too, so gradually, and increase so slowly, as not to be disco- 
 vered for a long time, even by the patient himself. Mr. Day, the great blacking man, 
 of the firm of Day and Martin, who died not long since, was almost entirely bhnd. 
 He told me he first discovered that the sight of one eye was gone, one day when he 
 attempted to look at a distant object through a telescope. He could see nothing, and 
 he imagined that the little brass plate which slides over the eye-glass had not been 
 withdrawn. There was, however, no such obstacle ; and he too soon found that 
 when the other ej^e alone was closed, he was in total darkness. This state of blind- 
 ness is called amaurosis, and it may depend upon pressure made upon the retina, or 
 upon the optic nerves, or upon the brain at the origin of those nerves. There are 
 other causes also, to be mentioned hereafter, of amaurosis. Its approach is some- 
 times marked by the fallacious appearance of black spots upon the objects the patient 
 is looking at, or floating before him in the air — muscx volitantes. Some of the 
 other depravations of sight are still more extraordinary, and except that they are not 
 uncommon, might almost be considered fabulous. Thus persons sometimes see things 
 around them apparently in motion, when in truth they are not so. This is, in fact, 
 a symptom I have mentioned before — vertigo. If the patient shuts his eyes, and 
 consequently can see nothing, he feels as if he were himself turning round, while 
 in reality he is at rest. Persons in this state fancy sometimes that the bed on which 
 they lie is sinking rapidly down with them into some abyss. A still stranger depra- 
 vation of the sense of vision is that in which a person sees only one half of an 
 object at which he is steadfastly looking. One man, in passing along the street, 
 imagined that every body he met had only one eye. The late Dr. Wollaston was 
 subject to this optical delusion : he frequently found that only one half of the object 
 he looked at was visible : and he wrote an ingenious paper in the Philosophical 
 Transactions to explain this. After his death a tumour was found in his brain, 
 interfering with the optic nerves. The celebrated Mr. Abernethy had once a tem- 
 porary afjection of the same kind, dependent no doubt upon some shght and transient 
 injury of the brain. He was thrown, I believe, from his horse — at any rate he 
 received a violent blow on his head, which stunned him ; and when he had recovered 
 a little, he was taken home in a hackney-coach. On his way he amused himself 
 with reading the names of the tradespeople placed in front of the shops, and he wag 
 greatly surprised to find that one half of each name — the last half — seemed blotted 
 out. He describes this in his lectures, in his whimsical wa)% by taking his own 
 name as an example : " I could see as far as the ne (said he), but I could not see a 
 bit of the thy:'' 
 
 Those very Avonderful cases of spectral illusion which sometimes occur, come 
 within the class of symptoms we are now considering ; they throw a strong light 
 upon many of the well-authenticated ghost-stories — which were in fact merely 
 instances of disease or derangement in the brains of the ghost-seers. It would be 
 out of place to go into any detail upon this interesting subject here. You will find 
 some excellent examples of these spectral illusions in Dr. Hibbert's book on .Ippari- 
 tions, in Sir David Brewster's Natural Magic, and in Sir Waller Scott's Letters on 
 Jlemonolugy. 
 
 The sense of hearing is liable to analogous disorders. Sometimes it becomes pre- 
 ternaturally acute ; and this is a bad symj)tom when it does occur. I was called, a 
 }^ear or two ago, to see a gentleman in the Temple ; he had been taken ill only a. 
 lew hours before, but I found him dying; the pulse was gone from his wrist, and 
 his skin was cold, but his intellect was entire, and he complained of nothing but the 
 distress he felt from the loud noises that were made by those around him, in mo^mgr
 
 DISORDERED FUNCTIONS. S7 
 
 about and in speaking, although, in fact, all noise was as much as possible suppressed, 
 and conversation was carried on in whispers : but his hearing was painfully acute. 
 He died the same evening; I believe of an irregular form of cholera. It is always 
 right that patients should be protected from the irritation which might arise from this 
 source ; for that degree of noise which would not interfere with the sleep of a healthy 
 person will often not only prevent it in a sick man, but bring on delirium, and aggra- 
 vate greatly the disease under which he labours. The custom of strewing the streets 
 with straw before the houses of those who are seriously ill, is, in many cases, a very 
 proper precautionary measure. 
 
 The opposite fault, obtuseness of hearing, is much more common. Deafness is 
 frequently attributable to some physical imperfection in the organ of hearing. But 
 it is with cases in which it has a deeper origin, that the physician is chiefly con- 
 cerned. It often occurs in fever, and is not then thought a bad symptom : it cer- 
 tainly is a much less unfavourable circumstance than morbid acuteness of hearing ; 
 and it probably depends upon a disordered state of the brain, which is not in itself 
 very dangerous. 
 
 What is called tinnitus aurium, is an instance of the depravation of the sense of 
 hearing. It seems sometimes to result from the too strong throbbing of the arteries. 
 It occurs in many disorders, and is not unfrequently a symptom of diseased cerebral 
 vessels, and a precursor of apoplexy or palsy. It is sometimes in itself extremely 
 annoying. Curious and undefinable sounds are heard by some patients — sounds 
 like a rushing wind, like the falling of a cataract, the ringing of a bell, or the beat 
 of a drum. A female patient of mine, in the Middlesex Hospital, last year, who had 
 disease of the bones of the ear, with symptoms that threatened some implication of 
 the brain, affirmed that she heard a perpetual noise in her ear like the singing of a 
 tea-kettle. I have lately been consulted by a gentleman from the country, who had 
 no other complaint than a constant hissing, which worried him greatly, in one ear. 
 Another had watched with curious anxiety, and described to me very graphically, 
 the successive variations which this troublesome symptom underwent in his own 
 person. It began suddenly, with some headache, and had lasted six vveeks. At 
 first it w-as a loud roaring, like that of the sea ; in a few days it came to resemble 
 exactly the w^histling of the wind among the trees in Avinter ; afterwards he could 
 have beUeved that the room was filled with humming gnats ; and finally the noise 
 settled down into the gentle sound of a distant waterfall. It haunted him incessantly. 
 Sir David Brewster relates the case of a lady, subject to spectral illusions, whose ear 
 was mocked by unreal sounds, as her eye by unreal visions. Being in her right 
 mind, and perfectly aware of the infidelity of her senses, she repeatedly heard, not 
 vague noises merely, but voices and sentences, when none were uttered. 
 
 Affections of the intellect — of what are sometimes called the internal senses, are 
 very common and very important symptoms of disease. Incoherence of the trains 
 of thought — palpably false belief — extravagant perv^ersions of the judgment. These 
 affections are sometimes considered as primary diseases themselves ; they very fre- 
 quently accompany certain febrile diseases ; and they are not uncommon in diseases 
 that are unattended with fever. There is more or less derangement of the internal 
 senses from the very beginning of continued fever. The power of attention is im- 
 paired. That kind and degree of mental exertion which would afford gratification 
 and amusement when we are well, become laborious and irksome when we are ill ; 
 and to compel, or to urge the attention, under such circumstances, is injurious. 
 This state is probably only the first degree of delirium, and therefore these slight 
 approaches to derangement of the internal senses are by no means to be disregarded 
 It is curious that the delirium of fever is always most marked during the night ; this 
 seems to be owing to the circumstance that the erroneous notions and wandering 
 thoughts of the patient are not corrected by impressions made upon his externa! 
 senses. You will find, conformably with the same principle, that your patient 
 sometimes ceases to be delirious upon your visiting him : the sight of a new face 
 rouses him for a time, but he soon relapses. 
 
 Voluntary motion is another function connected with the nervous system, and ono 
 which affords a great variety of important symptoms. I Jke the power of the sense*,
 
 88 SYMPTOMS. 
 
 It may be excessive, or deficient, or perverted. Excess of voluntary motion is not 
 common, nor very important. Maniacal patients sometimes exhibit an extraordinary 
 degree of muscular strength ; indeed, in the delirium of fever something of the same 
 kind may be observed. 
 
 But the opposite state, that in which the power of voluntary motion is deficient, 
 muscular debility is exceedingly common. Debility is an original and essential 
 part of fevers. It appears before there has been time for it to be produced by the 
 exhaustion of disease. It is not always proportional to the other symptoms, and 
 does not necessarily imply any great degree of danger. This sudden and early 
 weakness has been a very striking symptom in our two recent visitations of influ- 
 enza. Persons previously in apparent good health would be seized as they walked 
 along the street, and be glad to sit down in a shop, or a carriage, and to get home 
 and go to bed. Young and strong persons would be thus rapidly prostrated. 
 
 In some instances debility does not appear till late in the disease, of which it then 
 forms an important prognostic symptom, and an important guide for our treatment. 
 It shows us that there is a tendency to death by asthenia, and we have to endeavour 
 to keep the patient alive by supporting his strength as well as we can, this being the 
 chief or the only indication. 
 
 Debility is occasionally the principal symptom of the whole disease — as in hemi- 
 plegia, paraplegia, or in more partial palsy, palsy of one limb, even of a finger, or of 
 a single muscle, as of the levator palpebrarum. This, though it may seem trivial in 
 itself, is far from being so in reality ; it often forms a fragment only of a most serious 
 disease. From such partial manifestations of palsy we presage a more general and 
 alarming attack ; as the loosening of a few stones in the wall announces the com- 
 mencing earthquake. A shght degree of paralysis, affecting some of the muscles of 
 the eye, will j)roduce a squint, and consequent double vision ; and this occurs not 
 only in hydrocephalus, when it is a most significant phenomenon, but also as a pre- 
 lude to more extensive palsy. General palsy is sometimes prefaced by a similar 
 affection of the tongue, producing a faltering and indistinctness of speech. 
 
 Spasm is an instance of disturbance and perversion of the power of voluntary 
 motion. It consists in an irregular and violent contraction of muscular parts — 
 involuntary, even when the voluntary muscles are concerned. Cramp is a famihar 
 example of it ; and we have been taught, since the cholera came among us, to regard 
 cramp as sometimes a very formidable symptom : not formidable in itself, but 
 formidable in respect to the condition that gives rise to it. Tonic spasm is the prin- 
 cipal symptom, also, of that frightful disease — frightful in its phenomena and in its 
 frequent fatality — tetanus. The convulsions of epilepsy and hysteria, and the 
 jactitation of chorea, are ordinary examples of the perversion of the function of 
 voluntary motion. Sometimes convulsions bode great danger, sometimes none at all. 
 
 So, also, tremor, which is near akin to spasm, is a sign, frequently, of a morbid 
 state of the greatest peril; while it is sometimes violent without being attended with 
 the smallest hazard. 
 
 If we now turn to the greatest function of respiration, we shall find that it affords 
 a very large number of morbid symptoms, and those of the highest importance. 
 
 Dijspncea, difficulty of respiration, is one of the most prominent of those symp- 
 toms. It may depend upon various causes. In inflammation of the lungs or pleurae, 
 '.here are several circumstances in operation to impede the breathing; for example, 
 pain, which would be enough of itself ; the effusion of lymph into the texture of the 
 lUng, or of serum into the cavitj' of the pleurcp, mechanically resisting the entrance 
 of air. In dyspnoea the breathing is almost always most difficult when the patient 
 is lying flat on his back. One reason for this is plain. In the supine horizontal 
 posture the action of the diaphragm is obstructed by the weight and pressure of the 
 viscera; and the erect position obviates this. Upright breathing, or//iO/)nfl"o, has 
 rome to be considered as a distinct modification of dyspnoea. The patient cannot lie 
 down. 
 
 Sometimes, as in asthma, the difficulty of breathing comes on in separate parox- 
 ysms ; the respiration becomes all at once noisy, wheezing, and laborious. A 
 person who had never seen any cases of this kind would imagine that the patient
 
 DISORDERED FUNCTIONS. 89 
 
 was at the point of death — that it was all over with him ; but the most frightfuJ ot 
 these attacks are seldom attended with any immediate danger. They depend 
 frequently upon organic disease of the lungs, heart, or aorta ; sometimes they seem 
 to be purely spasmodic; sometimes to result from transient congestion of blood in 
 the lungs. 
 
 Cough is a violent spasmodic action. A full inspiration is taken ; then the glottis 
 is closed pretty firmly; and in expiration the air is forced suddenly out, and with 
 it, frequently, mucous or other matters which had irritated the air-passages. It seems 
 to be one of the efforts of nature to expel from the lungs things which ought not to 
 be there. There are several varieties of cough. It is a symptom belonging to so 
 many dangerous complaints — pneumonia, puhnonary consumption, and diseases of 
 the heart — that it always demands strict attention. No one who has once heard it 
 can ever mistake the hooping cough. There is also a startling obstreperous sort of 
 cough, shattering one's ears almost, like the noise of a person coughing through a 
 brass trumpet — which depends upon some peculiar state of the nervous system, 
 imphes no danger, and is more distressing to the bystanders than to the person who 
 utters it. I beheve you may often distinguish the cough of inflammation of the 
 lungs from that of phthisis, and each from the cough of hysteria, by their respective 
 sounds : but we have much better methods of distinguishing them — viz., by the 
 concurrence or the absence of certain other sounds belonging to the breathing, and 
 ascertained by auscultation. 
 
 Sneezing is another morbid symptom, which, though it may appear trifling, is not 
 to be overlooked. It is a very common symptom in catarrhal affections. When 
 sneezing occurs in combination with cough, it affords a presumption that the 
 cough is not phthisical. Sneezing may even happen as a primary disorder, occur- 
 ring in long-continued paroxysms. 1 have at present under my care a young 
 lady of an hysterical disposition, whose main distress consists in violent and pro- 
 tracted attacks of sternutation, which have harassed her almost daily for many 
 months. One of our bishops is subject to very inconvenient fits of this kind. He 
 will begin to sneeze and go on sneezing incessantly for a long time together. I 
 believe that he finds an effectual remedy for these attacks in plunging his head into 
 cold water. 
 
 I say nothing here of those direct symptoms of pulmonary disease which are 
 ascertained by the sense of hearing — by auscultation and percussion. I shall 
 enter fully into that subject hereafter. A systematic account of symptoms, if this 
 were the fitting place for it, which it is not, would require a dozen or twenty lec- 
 tures. In order to perceive the relation of symptoms, taken one by one or in diverse 
 combinations, to the various known forms of disease, you must have some prior 
 knowledge of diseases. But I am oWiged to suppose (however incorrect the 
 supposition may be in respect to some among you), that you are mere beginners, 
 and have still to learn even the rudiments of such knowledge. Different dis- 
 eases may have many symptoms in common. The same symptom may bear a 
 very different import according as it is combined with other symptoms ; or con- 
 nected with this or that disorder. The proper place for a comprehensive and 
 complete review of symptoms would, therefore, be at the etui of a course of lec- 
 tures on the practice of physic. When the various forms of disease had been 
 gone through, in reference to the symptoms belonging to them, then would be the 
 time to take the converse aspect of the case, and to consider ihe long list of symp- 
 toms in reference to the diseases they denote or accompany. All that I am at 
 present attempting, is to give you some general notion of what symptoms are ; to 
 put before you, as samples, a few of the most prominent ; and to show you, even 
 by this cursory and imperfect view of them, of how great importance it is that we 
 should make their relations to each other and to different diseases, and their sig 
 nificaiion, diagnostic, prognostic, and therapeutic, the objects of our most diligent 
 attention. 
 
 I might find matter for two or three lectures, if my present purpose would admit 
 of them, in the symptoms that are drawn from the functions belonging to*the a>- 
 culation. Everybody knows how much importance is attributed to the sta.e of tne 
 
 h2
 
 90 SYMPTOMS. 
 
 arterial pulse. It is expected of us, as a matter of course, that before we th nk of 
 prescribing for a patient we should at any rate feel his pulse. And really the in- 
 fonnalion obtained by that little touch of the wrist is often of the most interesting and 
 instructive kind. But it requires practice and intelligence to appreciate that infor- 
 mation. The qualities that we most attend to in the pulse are its frequency, its 
 regularity, iis fulness, and its force. It is necessary that we should know the number 
 of beats which the heart habitually makes in heakh ; for it varies much in different 
 persons. Its average number of pulsations in a healthy adult is from 70 to 75 ; but 
 there are persons who, when they are quite well, have always a pulse of 80 or 90 ; 
 and there are others in whom the ])ulse seldom rises above 60. In early life the 
 pulse is more frequent, in old age it is more slow, than the standard I have given. 
 Cheteris paribus, its beats are more numerous in the standing than in the sitting pos- 
 ture ; in the sitting than in the recumbent. If we do not inform ourselves of these 
 peculiarities, we may fall into great mistakes. In disease the pulse may acquire a 
 degree of frequency which is scarcely calculable; and the less so because, when 
 it is extremely frequent, it is also extremely feeble ; it will reach 150, 160, or 
 even 200 beats in a minute. In other cases, — as in apoplexy sometimes, and in 
 some organic affections of the heart — the pulse will become extremely slow. The 
 slowest pulse I ever felt was that of a man sixty-eight years old, who was for some 
 time a patient of mine, with diseased heart and dropsy. His pulse was often no more 
 than 25 in the minute. He died suddenly in his chair, and I was very desirous of 
 examining his body, but his widow would not allow it. In the 17th volume of Dun- 
 call's Medical Commentaries a case is related in which the pulse was as slow as 
 nine beats in the minute. We learn a good deal in certain disorders from the vari- 
 ations and JJuctuations of the pulse in respect to frequency — in hydrocephalus, for 
 example, and in continued fever. 
 
 Irregularity of the pulse is another condition which is often full of meaning, and 
 of interest. I hope, as the lectures proceed, to be able to point out the bearings of 
 these several qualities of the pulse upon our views of disease, and especially upon 
 its treatment. At present I must repeat that I pretend to do no more than furnish 
 you with a few samples of the phenomena that characterize disease. Irregularity 
 of the pulse is natural to some persons. I have a brother who enjoys very good 
 health, and whose pulse is habitually irregular ; I have been told that when he was 
 ill with a fever at school, it became regular. I have heard of several precisely similar 
 cases. There are two varieties of irregular pulse — in one the motions of the artery 
 are unequal in number and force, a few beats being from time to time more rapid 
 and feeble than the rest : in the other variety a pulsation is from time to time entirely 
 left out — the pulse is said to intermit. These two varieties may coincide in the 
 same person, or they may exist independently of each other. 
 
 Irregularity of the pulse may be caused by disease within the head ; by organic 
 disease of the heart; by simple disorder of the stomach; or it may be merely the 
 result of debihty and the prelude to the complete stoppage of the heart's action from 
 asthenia. How important it must be to ascertain and construe each of these mean- 
 ings of the same symptom ! It may indicate mortal disease — it may imply no danger 
 at all ; it may afford no clue to any available treatment ; or it may teach us how to 
 ■ward off impending dissolution. 
 
 Another most important quality of the pulse is what is called its hardness, or 
 incompressibility. You find that you can scarcely abolish the pulsation by any 
 degree of pressure ; the blood still forces its way through the artery beneath your 
 finger. Sometimes it is felt to strike a large portion, also, of the finger, and then 
 we say that the pulse is full, or large, as well as hard. When it strikes a very 
 narrow portion of the surface of the finger, it is compared to a thread ; it is a small 
 pulse : and if at the same time it be hard, such a pulse is often described as a wiry 
 pulse. It requires some education of the finger to appreciate with exactness the 
 several varieties of the pulse, even those which are practically important ; for many 
 liave been mentioned by authors which are purely fanciful or useless and unneces- 
 sary refinements. 
 
 ^ow this hard pulse I shall soon have to speak of again, in connection with the 
 
 I 
 
 I
 
 DISORDERED FUNCTIONS. 99 
 
 freatrnent required in inflammation. It is one of the best warrants we have, in 
 many cases, of the propriety of bleeding our patient. It does not occur, however, 
 m all inflammations, and it may occur when there is no inflammation. It may 
 depend upon hypertrophy of the left ventricle of the heart, and then it is beyond 
 the reach of blood-letting as a remedy. It often seems to be connected with a 
 morbid condition of the artery itself, brought on, as Dr. Latham has suggested, by 
 the pernicious habit of dram-drinking. It is, however, at all times considered so 
 much a guide to our practice, that whenever it occurs, it is very necessary to make 
 careful inquiry into its real cause. 
 
 Before 1 conclude this rough review of symptoms, I must point out one or two 
 that belong to the third class mentioned ; viz., changes of sensible quahties. These 
 include variations in the temperature of the body ; in the colour of the surface, and 
 especially of the face ; the diminution or increase of bulk ; the latter, when general, 
 we call corpulence ; when partial, swelling ; and various other symptoms, especially 
 those which are detected by auscultation. 
 
 Wasting, or emaciation, is sometimes the first observable symptom of disease. It 
 occurs in complaints that are not commonly dangerous — as in dyspepsia, and in 
 hypochondriasis, which is often connected with dyspepsia : and when it does appear, 
 it marks the reality of the disease. This wasting happens also in many fatal mala- 
 dies — in phthisis pulmonalis, for example — and in dropsy, although the dropsical 
 enlargement sometimes masks it. It accompanies many acute diseases, and is 
 reckoned an unfavourable symptom ; for it shows that the body is not properly nour- 
 ished. Sometimes the emaciation is so extreme that the integuments give way — 
 the bones of the patient are said to come through his skin. 
 
 We have examples of symptoms that consist in changes of colour, in the flushed 
 face of fever; in the pallor belonging to many diseases; in the contrast exhibited 
 by the white cheek with its central red spot, so characteristic of hectic fever; in the 
 yellowness of the skin and conjunctiva in jaundice ; in the dusky hue of the coun- 
 tenance and the lividity of the lips noticeable whenever the due arterializaticn of 
 the blood in the lungs is interfered with ; and in a long catalogue of cutaneous 
 disorders. 
 
 Various and full of meaning are the conditions and appearances presented by the 
 tongue. A patient would think you careless, or ignorant of your craft, if you did 
 not, at every visit, look at his tongue, as well as feel his pulse. 
 
 Let me once more remind you of the peculiar importance of accustoming your- 
 selves to take notice of the symptoms comprised in the last two classes, and especially 
 in the last class, that you may attain to a quick perception of them. Changes of 
 sensible quahties speak for themselves, and speak the truth. They cannot deceive 
 us, as the verbal statements of even conscientious patients respecting their uneasy 
 feelings might. They direct us in the choice and order of our inquiries : nay, they 
 frequently spare us the necessity of putting many questions ; questions that might 
 be irksome or fatiguing to our patients, or offensive to their natural delicacy, or even 
 hurtful by letting them know our thoughts respecting their disorders. Of the changes 
 in sensible qualities we judge by our own eyes, and ears, and fingers, and often by 
 our noses also ; and the change is sometimes, of itself, perfectly characteristic of the 
 complaint. 
 
 Many more morbid phenomena, or symptoms, or tokens of disease, might have 
 been mentioned ; but I have said enough, I hope, to rouse your attention to the 
 extent and the fertility of this field of study. When we next meet I shall begin to 
 consider one of the special forms of disease to which all parts of the body are liable 
 —a disease that meets us at every turn — I mean injlammalion.
 
 92 INFLAMMATION. 
 
 LECTURE IX. 
 
 InJJammation. Its Morbid and its Salutary Effects. Sketch of the Local ana 
 Constitutional Fhenoinena of Inflammation as it occurs in External Farts. 
 Examination of the Symptoms of Inflammation ; Pain ; Heat ; Redness ; 
 Swelling. State of the Capillary Blood-vessels and of the Blood in a part 
 inflamed. 
 
 Inflammation must needs occupy a large share of the attention of both the sur- 
 geon and the physician. In nine cases out of ten the first question which either of 
 them asks himself upon being summoned to a patient is, " Have I to deal with 
 inflammation here ?" It is continually the object of his treatment and watchful 
 care. It affects all parts that are furnished with blood-vessels, and it affects different 
 parts very variously. It is more easily excited by many external causes, and there- 
 fore it is more common than any other special disease. A great majority of all the 
 disorders to which the human frame is liable begin with inflammation, or end in 
 inflammation, or are accompanied by inflammation during some part of their course, 
 or resemble inflammation in their symptoms. Most of the organic changes of 
 different parts of the body recognize inflammation as their cause, or lead to it as 
 their effect. In short, a very large share of the premature extinction of human life 
 in general, is more or less attributable to inflammation. 
 
 Again, inflammation is highly interesting not only in its morbid phenomena and 
 destructive consequences, but in its healing tendencies also. It is by inflammation 
 that wounds are closed, and fractures repaired — that parts adhere together when their 
 adhesion is essential to the preservation of the individual — and that foreign and 
 hurtful matters are conveyed safely out of the body. A cut finger, a deep sabre 
 wound, alike require inflammation to re-unite the divided parts. Does ulceration 
 occur in the stomach or intestines, and threaten to penetrate through them ? Inflam- 
 mation will often forerun and provide against the danger — glue the threatened mem- 
 brane to whatever surface may be next it — and so prevent that worse and universal 
 inflammation of the peritoneum, and the almost certain death, which the escape of 
 the contents of the alimentary canal into that serous bag would infallibly occasion. 
 
 [We doubt very much the correctness of this statement. Is it true, that wounds are closed 
 and fractures united by inflammation, in the proper acceptation of the term 1 Union of 
 divided surfaces, it is true, may be a resuh of inflammation ; but, that what has been tf rmed 
 by surgeons "union by the first intention," takes place altogether independent of inflamma- 
 tion, and that the occurrence of the latter is calculated to impede or prevent it, must be evi- 
 dent, we think, to any one who will carefully watch its phenomena. Neither is it, we con- 
 ceive, correct to describe the adhesions of the peritoneum which often precede the perforation 
 by an ulcer of the coats of the stomach or intestines, and prevent the escape of the contents 
 of the latter organs into the cavity of the abdomen, as a provision to guard against the uni- 
 versal and fatal peritonitis that would otherwise occur. The inflammation by which the 
 adhesions alluded to are produced, is as strictly a morbid process as that which caused the 
 ulceration of the alimentary canal, and cannot, with any propriety, be viewed as a process 
 setup, in anticipation of the escape of the contents of the alimentary canal into the peritoneal 
 sac, and to guard against the danger that would hence result. The danger is, we admit, 
 occasionally lessened or even entirely prevented by the adhesions, but we have no right to 
 ■lifer from this circumstance, that the adhesions occurred to provide against its occtir- 
 ience--C.] 
 
 The foot mortifies ; is killed by injury or by exposure to cold ; — inflammation, if 
 1L be not anticipated by the knife of the surgeon, will cut off the dead and useless 
 part. An abscess forms in the liver — or a large calculus concretes in the gall- 
 bladder: how is the pus or the stone to be got rid of? If they make their way to 
 the external surface of the organ, as they always tend to do, they enter the cavity of 
 the abdomen, and excite fatal peritonitis. But a natural safeguard arises ; partial 
 'Uflammation precedes and prepares for the expulsion; the liver or the gall-bladder, 
 8s the case may be, becomes adherent to the Avails of the abdomen on the one hand, 
 
 1
 
 INFLAMMATION. Q^ 
 
 or to the intestinal canal on the other; and then the surgeon may plunge his lancet 
 into the collection of pus — or the abscess or the calculus may eat their own way 
 safely out of the body — through the skin, or into the bowel. Inflammation, hmited 
 in extent and moderate in degree, becomes conservative by preventing inflammation 
 more severe and more widely spread, which would be fatal. This is what I mean 
 when I speak of the curative properties of inflammation ; and surely this process, 
 which may save hfe or destroy it, deserves and demands our most careful study. 
 
 But inflammation has a still further and peculiar claim upon our attention. The 
 salutary acts of restoration and prevention just adverted to, are such as nature con- 
 ducts and originates. But we are ourselves able, in many instances, to direct and 
 control the effects of inflammation — nay, we can excite it at our pleasure ; and hav- 
 ing excited it, we are able, in a great degree, to regulate its course. And for this 
 reason it becomes in skilful hands an instrument of cure. This instrument the 
 surgeon employs when, after letting out the water of a hydrocele, he wilfully excites 
 inflammation of the tunica vaginahs, whereby its cavity is obhterated, and the re- 
 accumulation of the fluid rendered impossible. It is by avaihng himself of the same 
 agent that he is enabled to remedy many afliicting deformities : — to unite the cleft 
 lip ; to close up the fissured palate ; to restore the dilapidated nose. There is no 
 other special disease which is thus at our command ; we cannot, if we would, pro- 
 duce a tubercle or a cancer. For all these reasons inflammation possesses a very 
 high degree of interest for us — and for every one who would inquire, with any pros- 
 pect of success, into either the pathology or the treatment of diseases. 
 
 Of the amount of our knowledge respecting the intimate nature of inflammation, 
 [ shall have occasion to say a few words by and by. We first become acquainted 
 with inflammation in its symptoms, and as it displays itself externally. After we 
 know what they are, it may be right, and cannot but be interesting, to inquire how 
 they come about. Now the symptoms which, when they exist together in an ex- 
 ternal or visible part, betoken or denote inflammation of that part, are four in number: 
 pain — redness — heat — swelling; preternatural redness, and 'preternatural heat. 
 These, from the earliest ages, have been recognized as the signals of outward inflam- 
 mation, " Not83 inflammationis (says Celsus) sunt quatuor — rubor et tumor cum 
 calore et dolore." 
 
 No definition, however, or general description, can be made to embrace all the 
 forms in which inflammation presents itself. We can give no useful account of it 
 in the abstract ; and therefore I shall first sketch the phenomena of inflammation 
 under one of its most common external forms ; and taking this as a type of the 
 disease, proceed afterwards to trace its modifications and varieties, and to fill up the 
 picture. 
 
 Let us suppose, then, that a healthy man receives some local mechanical injury — 
 that he falls, for instance, against a window, and gets a piece of glass stuck into his 
 arm. In a short time he begins to have pain in that part of the arm, and this is soon 
 succeeded by redness, and increased heat and swelling. The skin becomes of a 
 bright red colour; the swelling increases. In the immediate place of the injury the 
 swelhng is firm and hard, and exquisitely tender : at some distance from that centre, 
 although there is still swelling, the parts are softer and more yielding. In the seat 
 of the redness and swelling the patient experiences a sense of heat, a burning pain ; 
 the part is sensibly hotter than natural to the touch of a bystander ; and if its actual 
 temperature be measured by means of a thermometer, it will be found to exceed the 
 temperature of the neighbouring surface. The part is injlamed. This is what is 
 called phlegmonous inflammation. ^"Ktyfiovfi is a Greek word, and inflammatio is a 
 Latin word, and they both mean the same thing, viz., a burning, or a flame. Phleg- 
 monous inflammation is, therefore, in truth, a tautological phrase. But custom has 
 assigned a particular signification to the epithet phlegmonous ; — it denotes that kind 
 of violent inflammation in which the affected part seems all on fire ; and chemistry 
 teaches that, philosophically speaking, there is actual and excessive combustion going 
 on in that part.
 
 94- INFLAMMATION. 
 
 If the inflammation reach a certain degree of intensity, other signs of disorder 
 piesent themselves at a distance from the injured spot. The patient usually at first 
 feels chilly and feeble; but soon the temperature of the whole of the surface rises, 
 the skin becomes hot and dry, the pulse more frequent and fuller and harder than is 
 usual ; lassitude comes on, with headache, and wandering pains in the limbs. The 
 patient is unable or unwilling to exert himself, and finds that he is unapt for any 
 mental effort ; he cannot command his attention, gets confused, and restless, and 
 sleeps ill ; he loses his appetite, his tongue becomes white, his mouth is parched, 
 he is unusually thirsty, and the various secretions of the body are deranged and 
 diminished. 
 
 This is wJJammatory fever. This is an indirect symptom of inflammation, mani- 
 festing itself through the medium, of the system at large. Various names have 
 been given to this general derangement of the vascular and nervous systems : con- 
 stitutional disturbance — sympathetic fever — symptomatic fever. It matters little what 
 term is used, provided that we affix alwaj^s the same meaning to it : but inasmuch 
 as the word fever, in this and in other languages, is taken to express a specific dis- 
 ease, it would perhaps be better to employ the term pyrexia, as Cullen and others 
 have done, to denote that secondary febrile state which grows out of, or is associated 
 with prirjary local inflammation. 
 
 Now what is the end of this remarkable state of things ? Wh}^ it may end in 
 one of two or three different ways. Supposing the piece of glass to have been 
 extracted, and proper measures to have been taken for subduing the inflammation, or 
 even supposing that no other measure has been adopted except removing the bit of 
 glass, then it will often happen that the phenomena just described will gradually 
 recede and disappear ; the pain will abate, the redness fade, the swelling diminish, 
 the heat decline, the pyrexia cease; until the part at length regains its usual sensa- 
 tions and its natural appearance. When inflammation subsides in this waj'- it is said 
 to be resolved, to tenTiinate by resolution ; and this is its most favourable and desira- 
 ble mode of terminating, whenever inflammation occurs as a morbid process. 
 
 But in many instances the inflammation does not thus subside. The irritant cause 
 jtill remains in action — or the original intensity of the inflammation has been too 
 great to admit of resolution — or the means proper to abate it have not been used — 
 or ha^e not succeeded. The symptoms already described continue, and are aggra- 
 vated in degree : at length the swelling begins to assume a more projecting and 
 pointed form, and the skin in its centre to look white ; the central part of the swell- 
 ing, formerly so hard, becomes softer — the pain is of a throbbing kind : a pulsative 
 sensation, keeping time with the beats of the heart, is experienced in the part, and 
 often a feeling occurs as if something had given way within it : at last (if art does 
 not interpose) the cuticle breaks, and a yellow cream-like fluid is poured out, which 
 we call pus, and upon its escape there generallj'' ensues a considerable and speedy 
 abatement of all the local symptoms of inflammation — of the pain, the heat, the 
 redness, the tumour. 
 
 This is suppuration. 
 
 Meanwhile, especially if the suppuration be long-continued, and the discharge of 
 pus profuse, the character of the general febrile excitement undergoes a change. 
 Slight but frequent shiverings, or feehngs of chilliness, take place, followed by flushes 
 of heat, which end in perspiration. 
 
 This is hectic fever. 
 
 If the injury has been still more serious, and the inflammation more intense, the 
 part which it has invaded perishes by the violence of the disease : there is a partial 
 death. In that case the vivid red colour alters to a purplish or livid, or even a 
 black, or greenish-black hue, the tension of the part exists no longer, the cuticle is 
 elevated by a sanious fluid, the pain ceases, the part is devoid of all sensation — is 
 dead and putrid, and exhales a pecuhar and offensive odour. 
 
 This is mortificaiion. 
 
 When ttie mjury has been extensive, a corresponding and characteristic change 
 is again observable in the constitutional febrile disturbance. The patient grows 
 more and more feeble, and delirious ; he has involuntary startings of the tendons of
 
 INFLAMMATION. 95 
 
 the voluntary muscles ; his pulse is weak and very frequent ; his tongue becomes 
 dry, brown, tremulous ; his lips are black with accumulated sordes ; his countenance 
 is shrunk, haggard, damp, and ghastly ; his stools and urine escape from him with- 
 out his appearing to be conscious that they do so. 
 
 This is typhoid fever. 
 
 Under more favourable circumstances the dead or mortified part, which is called 
 a slough, separates from the hving parts, and leaves a breach of surface. The sepa 
 ration is effected by a vital process which is denominated ulceration ; but which 1 
 need not now describe. The cavity thus formed gradually fills up, and heals in a 
 peculiar way. 
 
 There is one other circumstance, not to be omitted in this rough outline of the 
 local and general phenomena and effects of inflammation. If during its progress 
 blood be drawn from a vein, it exhibits, after standing and coagulating, the peculiar 
 appearance known by the name of the bifffy coat, i. e., on the surface of the coagu- 
 lum, and to a certain depth in its substance, the colouring matter of the blood leaves 
 the fibrin, which is therefore seen of a yellowish hue, or buff colour. 
 
 Taking the preceding statement as a groundwork, let us look back upon it, and 
 trace its particulars a little more in full. The four characteristic signs of inflamma- 
 tion being pain, heat, redness, and swelling, it will be useful to examine more closely 
 each of these symptoms in its turn. 
 
 The pain varies much in different cases of inflammation, both in degree and in 
 kind. It is differently felt, ceteris paribus, by different persons, according to their 
 natural susceptibihties. It varies from the shghtest degree of sensibility to the utmost 
 agony and torment. Parts which, when sound, are endowed with little or no capa- 
 city of sensation (as tendons, ligaments, cartilage, bone), become often exquisitely 
 sensible under inflammation. The organs of sense are variously affected in this 
 respect. Thus the specific sensibihties of the mouth and nose are blunted by inflam- 
 mation — those of the eye and ear are often rendered painfully acute. There are 
 great diversities also in the kinds of pain. Sometimes it is of a dull aching charac- 
 ter, as in toothache ; sometimes it is a pricking, tingling, smarting sensation — this is 
 the case in some forms of inflammation of the skin, as in erysipelas for example, and 
 in herpes ; sometimes it is sharp and piercing, as if the part were stabbed or cut 
 with a knife — such is frequently the feehng in inflammation of the serous mem- 
 branes, in pleurisy for instance ; sometimes the pain is tensive or stretching ; and 
 sometimes there is scarcely any pain at all. This last chiefly happens in the mu- 
 cous membranes and in the parenchymatous textures of organs. Very often thu 
 pain is a "bulking" or throbbing pain — every beat of the heart makes itself felt in 
 the tender part. The pain of inflammation results, no doubt, from the implication 
 of the nerves in the diseased process. The stretching of the vessels and textures 
 adds to the pain. Everybody who has been plagued by boils (and few escape them) 
 has had proof of this : the pain is most harassing a short time before the ripening 
 little tumour gives way, or is laid open by means of a scalpel ; but as soon as the 
 distension is thus relieved, perfect ease and comfort ensue. It is the same in com- 
 mon earache. It is upon this principle, I beheve, that the differences in regard to 
 pain, which occur in different structures under inflammation, are partly to be ex- 
 plained. Speaking generally, there is more pain felt in external inflammations, and 
 in the inflammation of investing membranes, than in inflammation of the substance 
 of the viscera, or of the lining membranes ; and it has been conjectured that this 
 may be because, in the latter cases, the parts affected have fewer nerves of common 
 sensation. But I do not think this explanation satisfactory. If it were well founded 
 we should not have such exquisite pain in some of the textures already mentioned, 
 which appear to be furnished with very few nerves of common sensation, and 
 scarcely feel at all in their healthy state : tendons, ligaments, and cartilages, I mean 
 I think it will be found that most pain is felt in those parts which are least capable 
 of yielding — in which the tension produced by the swelling, or the tendency to 
 swell, is the greatest. The substance of the liver, spleen, and viscera generally, is 
 soft and yielding — the mucous membranes are spongy in their texture, and oftett 
 attached to the subjacent parts in loose folds, and they allow of an accumulation o-'
 
 96 INFLAMMATION. 
 
 blood within them without becoming much stretched, or very tense. The investmg 
 serous and fibrous membranes are more tightly appHod, and much less capabl^i of 
 yielding : and their inflammation is usually attended with severe pain. 
 
 The pain that belongs to inflammation sometimes precedes any other apparen 
 change. This is specially observable in respect to internal parts. Sometimes the 
 pain is continued and uniform. Sometimes it is continued, but irregular in severity, 
 having periods of great exasperation : sometimes again it is intermittent, and even 
 periodic. 
 
 It is an unsettled question that has often been mooted, whether in inflammation, 
 :he slate of the blood-vessels is determined by that of the nerves, or the reverse. 
 Mere nervous pains are known sometimes to be followed by congestion of the part 
 in which they are felt. Whatever may be the true state of this question of priority, 
 it is certain that the disordered condition of the blood-vessels, when produced, greatly 
 augments the sensibility of the part. We may suppose that this depends, partly on 
 over-distension and stretching of the vessels and fibres, partly on pressure made upon 
 the nerves by the swelling. 
 
 It is important to remark of the pain belonging to inflammation, that it is usually 
 aggravated by pressure: frequently it is not felt at all, except when pressure is 
 somehow made upon the afft'cted part — intentionally by the medical man — or acci- 
 dentally, from the movements or position of the patient. This is tenderness. 
 
 And this is a point which requires a little further notice. I say the aggravation 
 of the pain by pressure is an important circumstance, because it continually helps 
 us to distinguish pain that is inflammatory from pain that is not inflammatory. Thus 
 pain of the abdomen may result from colic, or spasm — from a distension of the intes- 
 tines by air, and a stretching of the textures and nerves belonging to them : and this 
 sort of pain will mostly be relieved by pressure ; you will find patients lying upon 
 their bellies across the back of a chair for the sake of obtaining ease : but if the pain 
 proceed, as it may, from inflammation of the peritoneum — oh! then the gentlest 
 pressure, even that of the superincumbent bed-clothes, causes intolerable torture. 
 The suddenness with which the pressure is made — and its being made on a part 
 only of the suffering organ — these circumstances have much to do with the augment- 
 ation of the pain ; and it is curious, and instructive too, to know that gradual pres- 
 sure, applied uniformly to the whole organ or part under inflammation, is sometimes 
 so far from enhancing the pain, that it relieves or removes it. Dr. Elliotson puts a 
 very good case in illustration of this. " If (he says) you have a blister upon the sole 
 of the foot, or at the ball of the great toe, and you rest gradually upon the part, the 
 pain becomes mitigated, till at last it seems to be almost entirely removed ; but the 
 moment you take off the pressure, and raise the foot from the ground, you feel the 
 part begin to throb — to throb with violent pain." 
 
 Now all this exemplifies what I said just now — that though a deranged condition 
 of the nerves, marked by pain, may, for aught I know, first lead to the vascular full- 
 ness — yet the same fullness, and the distension which it implies, will greatly increase 
 the pain. In fact, the expulsion of the blood by means of well-regulated pressure 
 is made the foundation of certain proposed methods of cure. This has been lately 
 recommended in hernia humoralis, or swelled testicle — what is now more scienti- 
 fically called orchitis. It gives one a sort of horror even to think of pressure being 
 made on the healthy testicle — much more when it is rendered preternaturally sen- 
 sible by inflammation : yet, when properly managed, it is said (by Dr. Fricke, of 
 Hamburgh, and others) not to increase the pain, but entirely to remove it, so that 
 the patient can at once walk about the room ; and the disease is thus ultimately cured. 
 In the same way it has been proposed to cure eiysipelas, and gout, and rheumatism. 
 Without inquiring here into the general merits of this remedial expedient, I may 
 remark that pressure, so employed as to benefit an inflamed part by supporting its 
 strained and oppressed capillaries, must be steady, gentle, continued, and (above all) 
 uniform pressure. All these conditions are strictly supplied in an apparatus recently 
 devised by !>• Arnott ; whose air-press promises to be scarcely less useful to suffer- 
 ing humanity than his earlier contribution to the comfort of the sick — the water-bed. 
 
 It is sometimes necessary to recollect, especially when the existence of internal
 
 HEAT. ' 97 
 
 inflammation is suspected, that all expression of the sense of pam, and probably ail 
 sensation of pain, may be prevented or abolished by ihe presence of stupor or coma. 
 So also, if the nervous connection between the inflamed part and the sensonum be 
 cut ofT, no pain is felt. Limbs in a state of palsy are often (though not always) des- 
 titute of sensibility also ; and inflammation readily occurs in them, but is accom- 
 panied with no pain. 
 
 That mere pain will not constitute inflammation, must, I think, be plain to you. 
 Spasmodic contractions of the muscles, slretchincf and tension of the tissues, a par- 
 ticular state of the nerves, and other conditions which do not imply inflammation, 
 may, nevertheless, be attended with severe pain. 
 
 Let us next consider the heat. 
 
 Of course, as I hinted before, this means prefernatural heat : the temperature of 
 the part exceeds that which belongs to it in health ; but in truth, the heat is not in 
 general so much increased as the sensations of the patient or his heightened sensi- 
 bility would persuade him it is ; nor even so much as a bystander might suppose. 
 The heat of inflammation does not rise above the maximum heat of the blood in the 
 central parts of the body. The natural heat of the blood is about 9S° or 100°, but 
 n fevers and inflammatory diseases it has been known to reach 107°, and the 
 laximum heat of the blood in fever is probably the limit of the temperature as it 
 exists in inflamed parts. The surface of the body, in its natural state, is not quite 
 so warm as the internal parts, and the extremities are generally less warm than the 
 trunk ; so that the contrast between an inflamed and a healthy part, in respect to 
 heat, is greater in the extremities than on the trunk. Thus if a bhstcr be placed 
 upon the chest, the heat of the part inflamed by its application will not exceed that 
 of the neighbouring healthy surface by more than a degree or two ; while a blister 
 applied upon the leg may occasion a difference of five or six degrees. John Hunter 
 took great pains to ascertain the degree of heat produced in inflammation. He ex- 
 cited inflammation in the cavity of the thorax of a dog, and in the vagina and rectum 
 of an ass, and he could not find that the temperature of the parts thus inflamed ever 
 exceeded that of the blood at the centre of the circulation. He did not neglect the 
 opportunities that came before him of making similar observations on the human 
 body. He had occasion to tap a patient in St. George's Hospital for hydrocele : as 
 soon as he had let the fluid out, he introduced a thermometer through the puncture 
 made by the trocar, and placed it in contact with the testicle. He found the tempe- 
 rature to be 92°. He repeated this experiment the next day, when inflammation had 
 set in, and then the thermometer rose to 98|°. So that here an increase of 6?° had 
 taken place in consequence of the inflammation ; but even this, you see, did not go 
 beyond the natural warmth of the blood. 
 
 The increase of heat depends upon the increased influx of arterial blood, and 
 therefore of oxygen, into the part. Animal heat appears to be derived, in all cases, 
 from the mutual action that takes place between oxygen and the elements of the; 
 tissues, their carbon and hydrogen ; the tissues themselves undergoing meanwhile 
 perpetual changes, which, in the natural condition of the body, belong and are 
 necessary to health. In a part that is inflamed this kind of combustion is, I say, 
 excessive in amount ; while unnatural metamorphoses occur in the affected tissues. 
 It is, however, a curious fact, a fact worth remembering, that the heat of inflam- 
 mation does not transgress or surpass that of the blood in the central parts of the 
 body. 
 
 Heat alone neither constitutes nor impHes inflammation : for parts of the body may 
 be made preternaturally hot by holding them before the fire, by friction, by exercise, 
 while there is no inflammation. 
 
 I apprehend that increased heat is essential to inflammation, in some stage or other 
 of its progress, although there are cases in which the augmented temperature is not 
 perceived or appreciated. Sometimes the increase of heat is very slight, and may 
 be easily overlooked, there being, nevertheless, unequivocal inflammation, redness and 
 swelling, which go slowly into suppuration. The heat is often concealed from the 
 observation of the physician or the surgeon, by the situation of the part afl>3Cted, anu 
 it escapes the notice of the sufferer, because the sensibihty to heat is less gencn It v 
 7 I
 
 \)S SWELLING. 
 
 diffused through the bodj' than the susceptibility of common sensation. The heat 
 of inflammation is usually less felt and less complained of by the patient than the 
 pain. A vivid sensalion of heat is pain. 
 
 The redness of inflammation must also be prdernalural in degree, for many parts 
 of the body are by nature, and in health, more or less red. This phenomenon 
 depends upon the greater quantity of blood contained in the vessels of the part, and 
 sometimes also upon the extravasation of a portion of the blood into the affected tex- 
 ture. There is more blood than usual in those vessels which naturally carry red 
 blood ; red blood enters too into vessels which in the healthy state are destined to 
 receive and convey colourless fluids only, or which naturally admit so few of the red 
 particles, that from their paucitj^ and the quickness of their motion, they cannot be 
 seen. We are sure of this from v.-hat takes place in ophthahnia. Doubtless, also, 
 the redness is sometimes increased by the formation of new vessels which admit the 
 colouring particles of the blood in visible numbers. 
 
 That the vessels which naturally circulate red blood are actually distended and en- 
 larged in inflammation, there can be no doubt, John Hunter (whose treatise on in- 
 flammation is a mine in which all succeeding writers have dug), excited inflammation 
 in one of the ears of a rabbit, and then killed the animal. He next injected the 
 head and ears from the aorta, so that the fluid injected, passing through both the 
 carotids, was driven with equal force towards each ear. The arteries of the in- 
 flamed ear were enlarged one-third beyond their natural size, and arteries in it were 
 injected which had no visible counterparts in the sound ear. That the apparent 
 increase in the number of blood-vessels is often owing to the circumstance that red 
 blood enters tubes Avhich already existed, but which did not previously admit the 
 colouring matter, or did not admit it in sufficient quantity to be visible, is evident 
 from the rapidity with which the redness may be produced in many textures : in the 
 eye, for example, it may be effected in a few seconds ; and many of the vessels 
 which become suddenly apparent are evidently continuulions of the trunks that 
 could be seen before. 
 
 There is much variety in the tint of the redness of inflammation, depending on 
 the kind and degree of the inflammation, and on the nature of the part aflected. 
 Sometimes the redness is bright and vivid, as if the part were full of arterial blood : 
 this generally happens in the acuter forms and the earlier stages of inflammation. 
 Sometimes the redness is dark, or livid, or purphsh ; more as if the part were 
 gorged with venous blood : this occurs in some of the chronic or sluggish forms of 
 inflammation, and it is often the case when there is a tendency to gangrene. Some- 
 times the redness is distinctly circumscribed, or in patches ; and sometimes it is dif- 
 fused in a general blush over a large space. 
 
 The redness may, and often does, remain for some time after the inflammation has 
 ceased. 
 
 Now seeing that redness accompanies inflammation of the external parts, we pre- 
 sume that it exists also in internal inflammation : indeed we may convince ourselves 
 that it is so. If a portion of intestine be drawn out through a slit in the parietes of 
 the belly of a dog, and suffered to remain exposed to the air, it will soon inflame ; 
 and inflaming, it grows red. We see also that internal parts are left red after death, 
 which parts we have no other reasons for knowing had been inflamed duiing life: 
 and we infer that redness may have been present during life, although we find none 
 remaining when the body is examined. That when it has been owing to mere full- 
 ness of the natural blood-vessels, it may disappear with parting life we know, because 
 .he same thing happens externally, as in erysipelas and scarlet fever: but in such 
 cases the inflammation has not gone to any great height. 
 
 It is proper to remark that, as the absence of redness is no proof that there has 
 not been inflammation, so its presence is no proof of the contrary. There are many 
 kinds of redness, both within the body and on its surface, that have nothing to do 
 with inflammation : yet some of these are very apt to be mistaken for traces of 
 inflammation. I shall endeavour to instruct you how to avoid such a mistake, when 
 wf come to examine the morbid anatomy of particular forms of disease. 
 
 1
 
 INFLAMMATION. 
 
 Qti 
 
 While inflammation actually exists, redness, of some shade or degree-, is seldom 
 absent, even though the other symptoms may be scarcely apparent. 
 
 Lastly, let us take a glance at the swelling. This also depends, in some degree, 
 upon the distension of the blood-vessels ; but no great amount of swelhng can be 
 attributed to this cause ; and as much as does proceed from it occurs early in the dis- 
 ease. Some, also, and usually almost the whole, of the swelling, results from the 
 presence of matters poured out into the interstices of the affected part. These 
 effused matters are of very different kinds, although they are all modifications of the 
 same hquid, the blood. I mentioned, in describing the condition of the part inflamed, 
 that the central portion of the swelling is, at first, hard and resisting, while, at a 
 greater distance from the centre, the swelling is softer, and yields more readily when 
 pressed by the point of the finger, and, sometimes, even pits a little under that 
 pressure. Now, the central hardness is to be ascribed to an effusion into the areolar 
 texture of the part, of a fluid, which, transparent at first, speedily becomes opaque 
 and more consistent, and at last assumes a sohd form. This is what is commonly 
 called, in this country, coagulable lymph. The softer swelling at the circumference 
 of the tumid part proceeds from the effusion of a thinner fluid of serum into the 
 areolar tissue. Under very violent inflammation, blood, in substance, is poured out 
 into the same parts. When the central portion of the swelhng softens and becomes 
 pointed, this part of the whole enlargement is owing to the presence of a quant'ty 
 of pus. The different hquids that I have now been mentioning are of great import- 
 ance, and play a conspicuous but diversified part in altering textures. Blood, serum, 
 albuminous fluid or coagulable lymph, pus. They are called the products of inflam- 
 mation. We are sure that inflammation has been at work, if we meet with certain 
 of these products. We are not sure that there has been inflammation if we perceive 
 mere redness : — we are not always sure if we find serum only : — we are not sure 
 if we find blood alone : — we are tolerably certain if we discover pus ; we are cer- 
 tain, at least, that there has been inflammation somewhere, though doubts have been 
 started whether the pus is not sometimes conveyed from an inflamed part to other 
 parts of the body. We are quite sure that there has been inflammation in a part if 
 we find coagulable lymph in that part. This often remains, as a monument of the 
 inflanamation, during life ; it frequently becomes organized, furnished with blood- 
 vessels ; and a great number of changes, some reparative, some morbid, depend 
 upon its presence. I shall have to recur to these products of inflammation here- 
 after. 
 
 The degree of swelling in different cases depends partly on the intensity of the 
 inflammation, partly on the nature and texture of the structures affected. 
 
 I need scarcely observe that swelling may exist without any inflammation. Her- 
 nia, simple anasarcous enlargements, dislocations, will occur to you as every day 
 examples of swellings that have no necessary connection with inflanamation. 
 
 On the other hand, inflammation may exist without any appreciable swelling. 
 Inflammation of the sclerotic coat of the eye, for instance, may be present, without 
 aiiy swelling cognizable by our senses. 
 
 We have seen, in this review of the symptoms of inflammation, how much they 
 severally depend, the pain, the swelling, the redness, and the heat, upon the increased 
 influx of blood into the part. 
 
 It may not be uninteresting to pause here for a moment to mquire what has been 
 ascertained in respect to the actual condition of the capillaries of an inflamed part, 
 and of the blood they contain. Much has been learned on these points by patient 
 and minute observation with the microscope, and by reasoning upon the facts thus 
 brought to light. Kaltenbrunner, Gendrin, Miiller, and others, have corrected many 
 erroneous notions which formerly prevailed upon this subject. 
 
 In or Jer to comprehend the minute phenomena of inflammation, you must have a 
 clear conception of the constituent elements of the blood, and of the main changes u 
 is liable to undergo. The rough anatomy, rather than the chemistr)'^ of the blood, L«; 
 what I allude to. 
 
 The blood consists of red particles, or globules, and of a transparent colourlestt 
 fluid called lymph, or fiquor sanguinis. Muller succeeded in separating theso two
 
 100 BLOOD AND BLOOD-VESSELS. 
 
 constituents of the blood b}'- filtering through paper that of a frog, which contains 
 very large red globules. The liquor sanguinis thus obtained separates spontaneously, 
 by coagulation, into two parts, into serum and fibrin, the last having previously ex- 
 isted in solution in the liquor sanguinis. 
 
 When the coagulation is sufl^ered to take place Avithout any attempt to remove the 
 red particles, these are entangled and enclosed in the fibrin as it becomes solid; and 
 the common well-known appearance of clot and serum results. You may even then 
 wash out the red particles from the clot, and leave the fibrin. 
 
 I must now recur to the experiments and observations of Kaltenbrunner. I should 
 have told you, on a previous occasion, that various stimulant substances, mechanical 
 or chemical, when applied to the web of a frog's foot, will produce irregular dis- 
 turbances in the circulation, which irregular disturbances you are not to confound 
 with true congestion : in like manner you must avoid confounding them with the 
 phenomena of inflammation, which are always preceded by those of true conges- 
 tion. Kaltenbrunner ibund, hkewise, that (just as in congestion) a certain interval 
 of time generally happened between the application of the exciting cause and the 
 apparent development of the inflammation. This accords with what we observe to 
 be the case in respect to local injuries, and to those local internal inflammations that 
 are apt to be produced by exposure to cold. There is a pause before the mischief 
 lights up: or (to take the metaphor from the eggs of birds) there is a period during 
 which the inflammation seems to be hatching, and it is called accordingly the period 
 of incubation. Kaltenbrunner describes inflammation to be a regular process — as 
 he had also described congestion to be. 
 
 On looking, then, at the web, to which some violence had been done, he observed, 
 after the first irregular disturbances were over, and when the period of mcubation 
 had elapsed — he found (I say) that an afflux of blood took place to the part about to 
 be inflamed ; the velocity of the blood in the vessels was srreatly accelerated ; the 
 vessels themselves were distended and tense, and therefore disposed to tighten upon 
 the blood they contained — the functions of the part, that is to say, the secretion and 
 absorption of lymph, were interrupted ; the blood underwent an evident change — ■ 
 or it failed to undergo the proper changes : its globules stuck together, and the 
 parenchyma of the web became tumefied. Now all this is just what I represented 
 to you in a former lecture as constituting the state of the blood-vessels under active 
 congestion ; and I also told you, at the same time, that such congestion was just one 
 step short of inflammation. The congestion now described increases, until, at length, 
 this remarkable alteration happens : the capillary tubes, instead of tightening upon 
 their contents, dilate, or grow larger; the circulation, at first so rapid, begins to be 
 delayed in some of the capillaries ; the direction of its motion becomes uncertain ; it 
 oscillates, as it were, irregularly in those vessels, and at last stops altogether, the 
 globules cohering in irregular masses, and thus points of sJagnution are formed ; 
 and these points of stagnation, if the affection goes on increasing, augment in .«ize, 
 and multiply in number. Around them, beyond their circumference, the circulation 
 remains still very rapid, and the congestion persists. This is injlammation — of 
 which the characteristic or pathognomonic feature is the formation of these points 
 of stagnation. 
 
 Now one early consequence of the stagnation of the blood is, that a portion of it 
 transudes through the sides cf the vessels containing it : the serum, or the liquor 
 sanguinis, or even sometimes the blood itself; red particles and all. The effitsed 
 serum remains, or is absorbed, as serum. The fibrin, when it has so transuded, 
 concretes, and thus the interstices of tissue are filled up, and layers of coagulable or 
 coagulated lymph are formed upon the surfaces of inflamed parts, constituting false 
 membranes. Under certain circumstances, already adverted to, other or further 
 changes take place. Microscopic investigation has recently discovered a number of 
 colourless corpuscles floating in the liquor sanguinis. These corpuscles, passing into 
 the interstices of the inflamed tissue, or stagnating in its capillaries, suffer remarkable 
 changes, assume a yellow colour, and are thus transformed into globules of pus. So 
 that pus is nothing else than altered blood. During the inflammatory state, the cor 
 puscles sometimes appear to muhiply with surprising rapidity ; and are poured forth,
 
 BLOOD AND BLOOD-VESSELS. 101 
 
 in their new shape, like a secretion. Pus streams, almost, from certain mucous 
 membranes under inflammation. Whether the colourless corpuscles be independent 
 of the red globules of the blood ; or whether, as some suppose, they are originally 
 derived from the red particles, are questions which must be regarded as being a;//i»c 
 sub judice. 
 
 Certainly much which used to be thought mysterious in the process of inflamma- 
 tion has been rendered more simple and intelligible by modern research. Most of 
 the events or consequences of that process are traceable to the stagnation of the 
 blood in the capillaries, and to the changes which the stagnant blood subsequently 
 undergoes. 
 
 I must not omit to tell you what Kaltenbrunner says about the direct absorption 
 that takes place in the inflamed part. He found that the colouring matter, and the 
 adipose matter, were thus taken away. The web of a frog's foot is speckled over 
 with little stars of five rays, caused by a black pigment. The extremities of these 
 rays gradually disappear until mere black points are left in the places of the stars. 
 He says that he has been lucky enough to catch the exact moment when the blood, 
 circulating rapidly in the canals, has detached a particle from one of the rays, and 
 carried it into the torrent of the circulation. In the sound state, the mesenteric vessels 
 of the rabbit are surrounded with much fat. When the mesentery is inflamed, the 
 adipose cells soon empty themselves : a number of capillary canals are developed 
 upon the walls of those cells, and it is probable that the fat is carried off by the 
 blood circulating in these canals. 
 
 Another curious and interesting sight witnessed by Kaltenbrunner, was the form- 
 ation of new blood canals. He says that in an organ recently inflamed, when th-e 
 circulation is accelerated, globules of blood may be seen to sally, all of a sudden, 
 from some capillary, pass into the surrounding parenchyma, force themselves a 
 channel, and reach another capillary canal. Thus a new capillary channel is 
 formed ; the blood circulates through it ; its formation is often the work of a few 
 seconds only. As the same thing is repeated in different parts, a rich net-work of 
 new capillary canals is added to the original set, whereby it happens that organs 
 which in the sound state are but slenderly furnished with capillary vessels (as the 
 mesentery of the rabbit) present an astonishing number of them under inflammation. 
 
 W^hile new capillary vessels form, the old ones dilate, and assume the appearance 
 of small arteries or veins according as they, are continuous with the arteries, or 
 border on the veins. 
 
 The fact has long been known that when coagulable lymph has been poured out, 
 in inflammation, blood-vessels gradually form in it, whereby it obtains a vascular 
 connection with the surrounding textures, and becomes a living portion of the body : 
 and these microscopic disclosures of the manner in which they form appear to me 
 to possess a peculiar interest. 
 
 I should be making a very wasteful use of your time and of my own, if I entered 
 into the undecided and unprofitable disputes that have been raised respecting the 
 vital conditions of the vessels engaged in inflammation. While some have pretended 
 that the action of the smaU vessels is increased, others assert that it is diminished : 
 that the vessels are in a state of atony. For my own part I have never yet seen 
 any conclusive evidence that the capillaries possess any vital contractile power dis- 
 tinct from their elasticity. And granting them such a power, it is extremely difficult 
 to conceive how any increase in their vital contraction should produce the changes 
 that are observed in inflammation. Certainly we have no warrant that any such 
 contraction takes place, in the results of microsco[)ical examination of the vessels of 
 an inflamed part. The inquiry might be more properly directed, I think, towards 
 the vital conditions of the nerves of the part : but here we are wholly in the dark, 
 
 1 do not think it so evident as some have supposed it to be, that a greater quantity 
 of blood than is natural passes through an inflamed part in a given time. It is quite 
 true — and it is proper that you should be aware of it — that the arterial trunks leading 
 to an inflamed part often pulsate vvith more than ordinary force, and, if opened, pro- 
 iect a jet of blood further than they would naturally project it. It is true also that 
 
 1 2
 
 102 INFLAMMATION. 
 
 a venous trunk leading from an inflamed part will discharge blood faster and more 
 copiously than a corresponding vein leading from a sound part. Mr. Lawrence 
 declares that he has frequently tried this experiment, and always with similar results. 
 Finding it necessary to bleed a patient whose hand and forearm were inflamed, he 
 has directed a vein to be opened in both arms at the same moment ; and he has 
 ascertained that about three times more blood flowed, in a given time, from the vein 
 of the inflamed limb than from that of the sound. But it scarcely follows from this 
 that more blood circulates through the whole of the part actually inflamed : the 
 activity of the circulation in the vessels that remain pervious, and are merely con- 
 gested, around the focus of inflammation, is greatly increased, and more blood circu- 
 lates through the limb: and yet the blood may be stagnant, or scarcely circulate at 
 all, in the very part that is strictly and truly inflamed. However, the fact of this 
 increased afflux of blood towards the parts concerned in the inflammatory process 13 
 an important one. 
 
 LECTURE X. 
 
 Inflammation continued. Bitffy Coat of the Blood. Terminations or Events of 
 inflammation. Fesohifion — Delitescence — Metastasis. Effusion of Serum. 
 Effusion of Coagrdable Lymph, or Fibrin. Organization of this Lymph. 
 Suppuration. Ulceration. 
 
 In the last lecture, after giving a very general sketch of the phenomena of inflam- 
 mation, I particularly considered its four characteristic symptoms, pain, heat, redness, 
 and swelling: and endeavoured to describe the changes that take place in an 
 inflamed part, as they are seen through a microscope. 
 
 There is one very remarkable and important circumstance which is not often 
 absent in cases of inflammation, but which hitherto I have barely mentioned : I 
 mean a peculiar appearance of the blood itself after it has been drawn from a vein. 
 A portion of the fibrin at the upper surface of the coagulum parts with its colouring 
 matter; so that upon the deep red clot there is to be seen a layer of yellowish, or 
 sometimes of a bluish white colour, varying in thickness from a line or two to per- 
 haps three-fourths of an inch. This uppermost whitish layer of the coagulum is 
 called in this country the buffy coat of the blood. Sometimes the surface of the buff^y 
 coat is flat and wide ; but often it is contracted and concave ; i. e., the diameter of 
 the buffy surface is less than the diameter of the lower portion of the clot, and it is 
 hollowed out into a cup-hke form. Accordingly the blood is said, in these circum- 
 stances, to be both buffed and cupped. The formation of this buffy coat appears to 
 be favoured by many circumstances which have nothing to do with the disease under 
 which the person may be labouring ; such as the size of the aperture in the vein, 
 the manner in which the blood flows, the form and size of the vessel that receives it: 
 but it does not occur at all except in certain conditions of the system ; and it belongs 
 so especially to the state of inflammation, that blood having the buffy coat upon it is 
 often spoken of as inflammatory blood, or, with less propriety, as inflamed blood. 
 Both these expressions indeed are incorrect, for inflammation sometimes exists with- 
 out bufiy blood ; and buffy blood sometimes occur without inflammation. The phe- 
 nomenon is, however, upon the whole, a very valuable index of the nature of many 
 cases of disease, and an important guide in their treatment. 
 
 Now this crust, or upper layer, or buffy coat, consists of pure fibrin, mixed with a 
 certain quantity of serum, which M. Gendrin says is fuller of albumen than the rest 
 of the serum. You will not fail to notice the great analogy that subsists between the 
 buffy coat, and the coagulable lymph poured out in inflammation, either into the 
 texture of the part, or (as I shall show you more particularly by and by) upon its 
 surface, forming what are called false membranes. Both in appearance, and in 
 chemical composition, the two seem to be identical; and no doubt exists in my mind
 
 BUFFY COAT OF THE BLOOD. 103 
 
 of their being actually the same substance: the separation in the one case taking 
 place from the blood while contained in its proper vessels ; in the other case from 
 the blood after it has been removed from the body. 
 
 There has been a great deal of speculation among pathologists as to the cause of 
 this buffy coat. From its situation it is piain that gravity has something to do with 
 its formation: that the red particles, leavmg the colourless fibrin before it coagulates, 
 sink downwards by their own weight. But though the subsidence of the red par- 
 ticles is occasioned by their greater specific gravity, their separu'ion from the fibrin 
 is not to be explained upon that principle alone. If it were, then it would follow 
 that the slower the coagulation of the blood, the more time would there be for the 
 sinking of the red particles, and the thicker and more decided would be the buffy 
 crust : and it used to be supposed that this was the true explanation of the phenome- 
 non. Careful observations, however, have shown that the formation of the buffy 
 coat often takes place when the coagulation of the blood is unusually rapid. Dr. 
 Davy and M. Gendrin both state, as the result of much attention to the subject, that 
 the coagulation of blood drawn from a vein during inflammation begins sooner, and 
 is more quickly completed, than that of healthy blood. But certain observations 
 made and published by Dr. Stokes have settled this question. He noted the appear- 
 ance of the blood in twenty-seven cases. In fifteen of these the buffy coat presented 
 itself; in twelve it did not. Now in three of these twelve, the coagulation of the 
 blood did not begin till from tv^enty to forty minutes after it was drawn ; and in four 
 others there was no coagulation for eight minutes. So that theij was plenty of time 
 for the red particles to have left the fibrin, and subsided ; but they did not do so. On 
 the other hand, in twelve out of the fifteen cases in which the blood was buffed, the 
 coagulation took place in five minutes ; and in the remaining three it was delayed 
 only fourteen minutes. 
 
 The slowness of the coagulation, therefore, although it may and doubtless does 
 favour the subsidence of the red particles when they have a tendency to subside, 
 cannot be regarded as the cause of the buffy coat. The red particles very soon begin 
 to subside when they subside at all : you may tell, immediately after it has been 
 drawn, and prior to any coagulation, that blood is about to buff, by a peculiar bluish 
 hue on its surface. A German writer, Shroeder Van der Kolk, has stated observa- 
 tions to the same purpose, showing that in the blood abstracted by venesection during 
 inflammation there is an unusual disposition to a separation of the fibrin from the red 
 particles ; a sort of repulsion between them. This separation takes place in mere 
 films of blood, so thin as not to permit a buffy stratum to lie above a red stratum. 
 The fibrin and the red particles then separate from each other latterly by horizontal 
 movements, and the films acquire a speckled or mottled appearance, quite at, charac- 
 teristic of the state of the blood as the buffy coat itself. 
 
 That the formation of the buffy coat depends, however, upon some vital change 
 in the blood appears probable,, from this — that it will sometimes vary greatly in 
 different portions of blood abstracted at the same bleeding. Thus, if the blood be 
 received into four different cups in succession, it will, perhaps, be buffy in the first, 
 and in none of the others; or it will be buffy in the last only ; or in the second and 
 third only, the first and fourth cups being free from buff. Attempts have been 
 made to explain these rapid variations. Some have fancied that the inflammator' 
 .?tate having been remedied by the removal of a certain quantity of blood, the blood 
 that flows subsequently is, therefore, without the usual index of the presence of 
 inflammation ; but this explanation will not apply at all to those cases in which the 
 portions last drawn are the only portions that exhibit the buffy crust. Others have 
 suggested that the state of the nervous system is principally concerned in these 
 sudden changes ; that the depression caused in the outset of the bleeding by fear, 
 and the faintishness produced towards its termination by the lo^s of blood, may pre- 
 vent the appearance of the buffy coat on the first and last cups, when it shows itself 
 only in those that are intermediate between the first and last. We cannot rely 
 much on those hypothetical explanations : I mention them to impress upon your 
 memory the facts which they are intended to explain.
 
 104 INFLAMMATION. 
 
 There are two or three different forms presented by buffy blood ; and with these 
 you ought to be familiar. 
 
 In one form the buffy coat is thick, tough, contracted, puckered at its circum- 
 ference, and its surface is cupped. There is a complete separation of the red parti- 
 cles, and a strong aggregation of the particles of the fibrin among themselves. The 
 red portion of the coagulum is also, in these cases, round and contracted, of a globu- 
 lar shape, firm, detached from the sides of the vessel, and floating, generally, in 
 transparent serum. 
 
 This is usually seen when the inflammation is violent ; when it occurs in strong 
 and vigorous constitutions; and more I believe when it has its seat in certain tissues, 
 in fibrous and serous parts especially. 
 
 In another form, the w'hole coagulum is large, like a cake, or of the figure of the 
 vessel containing it, not so much collected into a spherical shape ; and the buffy coat 
 is thin and flat, and easily broken. Here there is an imperfect separation of the 
 colouring matter from the fibrin, and no great aggregation of the particles of the 
 latter. This kind of buffy blood is apt to accompany slight or partial inflam- 
 mation. 
 
 In a third form, the buffy coat is thick and abundant, but it is flat and soft, loose 
 and flabby, like paste ; and the coagulum often adheres by its edges to the vessel in 
 which the blood has been received : there has been considerable separation, and but 
 slight aggregation. The serum is apt to contain a few red particles distinct from the 
 clot. Such blood is commonly said to be sizy. Dr. Alison states that when it is ob- 
 served, some other cause of general disorder of the system (continued fever, for 
 example) usually co-exists with the local inflammation. Probably the qualities of 
 the blood are altered, independently of the inflammation : the bufly coat taking place, 
 in consequence of the inflammation, upon blood which was previously in a diseased 
 or unnatural condition. 
 
 It is a curious fact that blood drawn by leeches never exhibits the buffy coat. It 
 seldom appears (yet I have seen it) upon blood that has been removed by means of 
 cupping glasses. 
 
 Ariirial blood is liable to the buffy coat. I have myself, twice at least, seen it 
 upon blood drawn from the temporal artery. One of the patients was violently 
 maniacal Avhea the blood was taken. The other was labouring under acute inflam- 
 mation of the membranes of the spinal cord, of which inflammation he died. 
 
 Blood is more likely to buff", cxieris paribus, when it is made to flow in a full 
 stream, and when it is received in a deep and narrow vessel. 
 
 On the other hand, the formation of the buffy coat appears to be hindered, when 
 the blood 'rickles from a small opening in the vein, and when it is caught in a large 
 flat vessel. It is said also, that the buffy coat may be prevented by adding to the 
 blood a solution of caustic potass ; by keeping it for some time in a state of agitation ; 
 by receiving it in a very cold vessel ; or by suffering it to fall from a height of three 
 or four feet, [n this last case M. Gendrin supposes that the prevention is owing 
 partly to the agitation which the descent of the stream produces in the blood already 
 in the vessel, and partly to the circumstance that the blood is cooled as it passes 
 through the air. 
 
 It is seldom, I believe, that the buffy coat appears on blood drawn at the very 
 outset of inflammation ; generally a day or two elapses before it shows itself. This 
 is just what we might expect if it be true, as it has been conjectured, that this un- 
 natural property of the blood is acquin^d only in the course of its transit through the 
 vessels of the inflamed part. 
 
 I have dwelt the longer upon this peculiar appearance of the blood, because it 
 really is of very great importance in determining the nature of various complaints, 
 and in directing our treatment of them. Speaking generally, when a given organ 
 is inflamed, the buffy coat is more marked in proportion to the intensity of the iii- 
 llammation : when the organ is not known, it is more likely to be of a fibrous or a 
 serous texture, in proportion as the blood is more decidedly buffed. The api)earance 
 hi the buffy coat is especially valuable as an indication of treatment in cases con- 
 ccrnmg wnich we are in doubt whether they are inflammatory or not. On the
 
 BUFFY COAT OF THE BLOOD. 105 
 
 Other hand, if we have good evidence, in other symptoms, of the existence of m- 
 flammation, we are not to be shaken in our opinion by the absence of the buffy 
 coat. Inflammation may certainly exist without it. I am not speakino; now of shVht 
 cases of inflammation, which do not disturb the general system. You would not 
 look for buffy blood in the inflammation that supervenes on a cut finger, or in a 
 small boil; but in serious inflammation, attended with pyrexia, the buffy coat may 
 be wanting. It is not unfrequently absent in inflammation of the mucous mem- 
 branes, especially in inflammation of the mucous hning of the bronchi. 
 
 I stated before — what is quite necessary to remember — that buffy blood is not con- 
 fined to cases of inflammation. The blood of persons affected with general plethora 
 is often found to present a buffy coat: and the same thing is true in respect to 
 pregnant women. 
 
 Buffy blood is no necessary measure of the danger of the disease. The blood 
 drawn in acute rheumatism is always very much buffed and cupped : yet so long 
 as the disease is confined to the joints, it is quite free from danger. 
 
 Neither is the appearance of buff" on the blood, taken by itself, a sufficient war- 
 rant for abstracting more blood : for the blood will sometimes, in common inflam- 
 mation, continue to be buffy, long after it has ceased to be useful, or safe, to bleed 
 the patient. 
 
 [In nearly all the strongly developed acute inflammations, there is an excess of fibrin and of 
 the colourless or lymph globules of the blood. From three parts in a thousand, which, accord- 
 ing to Andral, is the average proportion in health, the fibrin has been found to rise to six or 
 eight parts. In some cases, MM. Andral and Gavarret found it as high as ten parts in the 
 thousand ; namely, in pneumonia and acute articular rheumatism. The excess of fibrin was 
 noticed by Andral in cellular inflammation, or simple phlegmon, in acute inflammations of 
 the skin, as in burns and erysipelas, in mercurial stomatitis, in phlegmasice of the mucous 
 membrane of the respiratory and digestive organs, in acute cystitis, either simple or com- 
 bined with nephritis, in all of the phjegmasise of the serous membranes, in inflammation 
 of the lymphatic glands, and in softening of the brain. But it does not follow the pustules 
 of small jjox, the exantheme of measles or scarlatina, or the patches in dothinenteritis. 
 
 The increase of fibrin in the blood is manifested so soon as the inflammation begins. M. 
 Andral is inclined to believe, from what he has remarked in cases of burns, that the disease 
 commences in the solids before the change occurs in the blood. The sympathetic fever in 
 the phlegmasiae is, he thinks, due to the alteration in the blood from the excess of its fibrin. 
 With the increase of fibrin, the proportion of red particles remains unafiected. Even in 
 anemic cases, and in low fevers, in which there is a diminution in the proportion of fibrin, 
 tlie latter becomes abnormally increased whenever inflammation supervenes. 
 
 To this it may be objected, remarks Williams, that this fever frequently rises high before 
 the blood has begun to exhibit the buSy coat, often subsides when the buffy coat is most 
 abundant, and is sometimes wholly absent when the blood is both buffy and cupped, as in 
 sub-acute rheumatism. But he admits that it is very probable the excess of fibrin may con- 
 tribute to the excitement, and it certainly materially aflfects the duration and products of 
 inflammation. 
 
 It would appear very certain that the formation of the buffy coat in inflammatory diseases 
 is in a great degree dependent upon this excess of fibrin. It is found only in cases where 
 the proportion of fibrin is abnormally augmented. In ann?mia, the only disease excepting 
 inflammation, in which the bufl^y coat is observed, notwithstanding the quantity of fibrin 
 may be abnormally small, still it is very generally in excess in relation to the red globules. 
 The buffy coat forms, also, upon the blood drawn during the latter period of pregnancy: 
 when the blood also presents an excess of fibrin. In inflammation the buffy coat is fre- 
 quently not present in the blood drawn in the early period of the disease, the fibrin no; 
 being as yet sufficiently abundant, while it becomes less and less marked as the intensity of 
 the disease and the excess of fibrin diminish. 
 
 In cases of indirect prostration, incident upon great intensity of inflammation, the blood 
 first drawn may be without the buffy coat; it becoming api)arent only as the pulse and heat 
 of the surface rise, as they often do in such cases, under the use vi the lancet. 
 
 According to Andral, the newly-formed fibrin in inflammation coagulates more slowly 
 than the old. — See Andral, Patholog. HcBmatol. ; and Williams, Frincijiles of Medicine. — C] 
 
 Some pathologists enumerate several terminations of inflammation. Others quai- 
 rel with that word, as inappropriate ; alleging, with great truth, that the inflamma- 
 tion does not necessarily cease or terminate whenever these so-called " terminationjs" 
 happen. Some of them are in fact "co-existent states, or successive stages in the
 
 106 INFLAMMATION. 
 
 progress of the same inflammatory disease." It has been proposed to speak ratlier 
 of the local effects of inflammation : but even this phrase is not free from objection, 
 for sometimes (though rarel}^) there are no local effects produced, beyond the four 
 symptoms which characterize the inflammation itself. I think the events of iiijhtm- 
 mation is an expression not open to similar cavils. I have no ambition to introduce 
 new modes of speech, unless when those already in use are inexact or inapplicable. 
 It is enough if you clearly comprehend the meaning of the teraas I employ. Among 
 the events of inflammation I include only the local changes observed in its course. 
 To those which are constitutional I must afterwards revert. 
 
 You will recollect that I did allude, in the last lecture, though in a very briet 
 manner, to these local events of inflammation. Their frequency and importance 
 render it necessary that we should consider them somewhat more particularly. 
 
 One of these events is the simple subsidence or resolution of the inflammation : 
 this may strictly be called a termination also. The congestion of the blood-vessels 
 increases till the blood stagnates in some of the capillary canals towards the centre of 
 the affected part, which is then said to be inffatned; but the disease goes no further ; 
 there is no escape of the blood, nor of any part of the blood, nor of any of the con- 
 stituents of the blood, beyond its natural channels : or, at any rate, there is no sensible 
 evacuation into the inflamed tissue, or next to none. The inflammation begins to 
 recede ; the stagnant blood is again set in motion ; if there have been some slight 
 effusion, it is re-absorbed ; the rapidity of the circulation in the surrounding vessels 
 diminishes ; and the part returns, in all respects, to its former condition and integrity. 
 This may be considered the spontaneous cure of inflammation ; and to this event 
 there seems to be always a natural tendency. It may be promoted, sometimes, by 
 art. 
 
 When the process of resolution is unusually stidden and rapid, (as it occasion- 
 ally is, the well-marked phenomena of inflammation completelj'- disappearing in a 
 few hours,) it is called by our neighbours, the French, delitescence. And when the 
 symptoms of inflammation thus suddenly desert one part, and show themselves im- 
 mediately afterwards in another (as not unfrequently happens in respect to the joints 
 in acute rheumatism, and between the parotid gland and the testicle or mamma in 
 the mumps), metastasis is said to take place. 
 
 This transference, as it were, of morbid action from one part to another is a very 
 curious circumstance. It is one which we sometimes endeavour to imitate. We 
 excite inflammation upon the surface, where we know its effects will be of com- 
 paratively little consequence, in the hope of diverting it from some internal organ in 
 which it threatens to work serious or even fatal changes. We follow the same 
 principle perhaps when we apply purgative medicines to the mucous membrane of 
 the aUmentary canal. To denote the mode of cure, by stimulating distant parts, the 
 terms o[ counter-irritation, derivation, and revulsion are employed. 
 
 Most commonly, even under moderate inflammation, some amount of extravasation 
 takes place into the texture or from the surface of the part. 
 
 The first effect or event of that kind which we notice, is the pouring out or effusion 
 01 serous liquid. The liquid is so like the serum of the blood, that it is called serosity 
 or serous liquid ; and there can be no doubt, 1 conceive, that it consists of the serum 
 of the blood, slightly modified perhaps. You will recollect my stating that the 
 swellirtg which accompanies phlegmonous inflammation is not equally firm through- 
 out the wliole extent of the inflamed part ; that it is hard in the centre, softer towards 
 the circumference ; and that in the latter situation it sometimes retains for a few- 
 seconds the impression of one's finger; — pits. Now this results from the effusion 
 of serous fluid into the areolar tissue immediately surrounding the part inflamed : ii 
 is neither more nor less than (edema, — oedema (which may exist aiso quite inde- 
 pendently of inflammation) being a filling or infiltration of the areolar tissue with 
 serous fluid. Anasarca is an example of the same state, on a larger scale. Now 
 anasarca is very constantly produced by some impediment to the passage of the 
 blood along the veins ; the serous portion of the stagnating blood transudes through 
 the coats of the vessels : and I apprehend that the same explanation may be given
 
 COAGULABLE LYMPH. J 07 
 
 of the less extensive oedema which takes place around a phlegmon ; the blood 
 being stagnant in the neighbouring capillaries. 
 
 But whatever may be the intimate cause of serous effusion, it is one of the earHest 
 events of inflammation; and in some cases it is its most important event; producing, 
 mechanically, new symptoms, and giving rise to conditions of the most perilous kind. 
 The quantity of serous fluid poured out in a short time is often immense. One of 
 the pleura may be thus filled in a few hours, and the whole of one lung strongly 
 compressed, and the respiratory apparatus reduced to one half of its customary effi- 
 ciency. And if inflammation and effusion should take place on both sides of the 
 chest at once — if double pleurisy should occur, as it sometimes does — the patient 
 must presently perish by apnosa, unless his condition is recognized, and free vent is 
 given to the fluid. More than once or twice have I seen persons snatched from the 
 brink of suffocation by what is called tapping the chest. Fatal coma is no uncom- 
 mon result of the eflfusion of serosity, as an event of inflammation, into the ventricles 
 of the brain. 
 
 Even in the areolar tissue, where it is properly enough called oedema, a very 
 trifling amount of this serous effusion may be sufficient to destroy life : when, for 
 instance, it takes place into the submucous areolar tissue of the glottis, closing up 
 by its pressure that little chink, the rima gloltidis, and suffocating the patient after 
 another fashion. Here also art may come to the rescue : an urtijidal chink or hole 
 is made for the entrance and exit of air, below that part of the larynx in which the 
 disease is situated, and the patient is deUvered from imminent death. I have had 
 two cases under my own care, and have seen several others, in which life loas so 
 preserved. I allude to such cases now, merely to convince you of the importance 
 of attending to this event of inflammation, and of studying the indications of its 
 existence. 
 
 Sometimes some of the small vessels give way, and hemorrhage into the part 
 becomes an event of inflammation. Some slight degree of this occurs probably in 
 most cases ; and we frequently find that the colouring matter of the blood is mixed 
 with other effusions, giving to the serous liquid a deep tinge of red. 
 
 1 hinted before, that we must not infer inflammation from the presence of serous 
 effusion alone. Serum will exude, I believe, from loaded veins, even after death ; 
 but this never can be much in amount. It is certain that dropsical effusions may be, 
 and very often are, the result of congestion of a purely mechanical kind. 
 
 A third event of inflammation is the efilision of what is called coagulahle hpnph, 
 which, as I explained to you before, appears to be nothing else than the fibrin sepa- 
 rated from the other constituents of the blood, and concreted. It is poured forth, at 
 first, in a state of solution, or in a soft semi-fluid condition, and mixed with more or 
 less serosity ; but the fluider parts of the effusion are either soon reabsorbed, or soon 
 separate themselves from the fibrin, which becomes firmer, and at length solid. The 
 hard central portion of a phlegmon, in its earliest stages, owes its hardness to the 
 presence of coagulahle lymph in the natural interstices of the inflamed part ; and a 
 similar interstitial deposit of the same substance is common in various parts of the 
 body, as a result or concomitant of inflammation. What is called hepatization of 
 the lung is one instance : the spongy texture of the lung is blocked up and solidified 
 by this lymph. In certain cases of erysipelas, as well as in phlegmonous inflam- 
 mation, the subcutaneous areolar tissue is rendered dense and hard in the same way. 
 The white Opaque spots which are often seen upon the cornea are produced by 
 lymph interposed between the layers of that naturally transparent structure. But 
 the most striking examples of the effusion of coagulahle lymph are to be seen upon 
 the surfaces of inflamed membranes : it forms a web or layer which by decrees 
 assumes, itself, a membranous appearance : and is accordingly called by morbid 
 anatomists a false or an adventitious membrane. Sometimes several layers of this 
 kind are spread over each other, forming adventitious membranes of great thickness. 
 When coagulahle lymph is thus poured out between membranes that are habitually 
 in contact with each other, it often causes them to cohere : just as two leaves of a 
 book may be made to stick together by a layer of paste put between them. Thi.s 
 result is very common indeed with serous membranes, especiai'v the pleurce. the
 
 08 INFLAMMATION. 
 
 pericard'mr.i, and the peritoneum. Lymph is said also to be poured out, under 
 violent inflammation, from mucous surfaces. In croup, the interior of the trachea is 
 inflamed, and a substance exudes which assumes a membranous form, and adheres 
 more or less firmly to the sides of that tube, or is coughed up in ragged fragments 
 A similar effusion takes place occasionally from the mucous lining of the alimentary 
 canal, and is expelled, with the othe** contents of the bowels, in shreds, or in tubukr 
 portions, which are, in fact, casts of the interior of the gut. I say coagidabh lymph is 
 said to be thus poured out ; but it is more than doubtful whether the false membranes 
 in these cases are really composed of fibrin. Similar films form within the uterus, 
 and are moulded to the exact shape of its cavity, and marked with indentations that 
 correspond to its rugce ; and these membrane-like casts are at length separated and 
 extruded. These last are not very common ; but I show you one which came from 
 the uterus of a young woman who was a patient of mine in the Middlesex Hospital 
 not very long ago. You may see lymph deposited like beads, upon the anterior 
 surface of the iris under inflammation ; or gluing its posterior surface to the crystal- 
 hne lens behind it, and rendering the pupil irregular, and sometimes immovable. 
 The internal surface of the heart, and especially its valves, are often studded with 
 portions of lymph much resembling warts. When the opposite sides of an artery 
 are brought together by a ligature, they inflame, and become united by the same 
 medium. Coagulable lymph is effused, in the course of a few hours, upon the 
 edges of a cut wound ; and they adhere, under favourable circumstances, when 
 placed in mutual apposition. This surgeons call union by the fust intention; and 
 the inflammation which is accompanied by all kinds of exudation of lymph, or fibrin, 
 is called adhesive inflammation ; or the adhesive stage of inflammation. 
 
 It is seldom that coagulable lymph alone is thus poured out. Sometimes it is 
 tinged with the colouring matter of the blood. Oftener it is mingled with, or at first 
 dissolved in, a large quantity of serous fluid. When this happens in serous bags — 
 as in the pericardium or pleura — the thinner fluid may keep the opposite membranes 
 apart ; and for some time, or entirely, prevent their agglutination. Sometimes the 
 agglutination is partial, and the uniting portions of lymph are stretched out, by the 
 distending effect of the fluid effusion, or by the natural movements of the parts, into 
 strips or bridles of adhesion. 
 
 1 must call upon you to notice, in passing, that although this event of inflamma- 
 tion may sometimes perhaps have a detrimental or destructiv^e consequence, yet that 
 in a vast majority of instances it is distinctly a salutary and conservative event. 
 Vision may, no doubt, be destroyed by a plug of lymph which shuts up the pupil 
 of the eye. A portion of intestine may become strangulated by a band of adhesion. 
 Of this, which is a mere accident of the adhesion, I have seen some fatal examples. 
 The closure of the trachea by the membrane of croup is not, in my opinion, a fair 
 case in point. There are, at any rate, but few exceptions to the rule, that the effu- 
 sion of coagulable lymph proves beneficial by preventing some worse event of the 
 inflammation. It is better that inflammation of the areolar tissue should be limited 
 and hemmed in by a barrier of lymph, than that it should extensively diffuse itself. 
 It is better that the bag surrounding the heart, when it happens to be inflamed, 
 should become adherent to that organ, than that the inflammation should run on into 
 suppuration, and fill the pericardium, and oppress the heart, with pus. In the one 
 case life may continue for several years ; in the other it seldom lasts many days. It 
 is clearly more desirable, and more consistent with the safety and comfort of the 
 patient, that his lungs should be fastened to his ribs, than that they should be com- 
 pressed and flattened against his vertebral column. I shall have occasion so fre- 
 quently to speak of this protecting and reparative tendency of adhesive inflammation, 
 that I do not more than point it out to you at present. 
 
 When lymph has been effused upon an inflamed surface, it very readily becomes 
 vascular and organized. Red streaks begin to be visible in it. These are incipient 
 blood-ves.'^els, which may soon be seen to communicate freely, and to be continuous 
 with the blood-vessels of the inflamed part. The plastic lymph is fashioned into a 
 definite structure, and made a living constituent portion of the body. It is in truth 
 this remarkable plastic property belonging to the effused lymph, tliis aptitude for
 
 COAGULABLE LYMPH. 109 
 
 Deing organized, which invests the adhesive inflammation Avith its guardian and repa- 
 rative character. None of the other fluids poured out under inflammation are capable 
 of this change. It is in this way that the lips of recent wounds, and the surfaces of 
 inflamed membranes in contact with each other, are permanently stitched together 
 (if I may use so homely a metaphor!, by living vascular threads. By this needle- 
 work of nature parts recently severea from the body may sometimes be replaced ; 
 or even transferred and affixed to other situations, as in the Talicotian operation, 
 whereby a new nose is engrafted in the place of that which had been lost. It is 
 thus that ulcers fill up ; successive layers of lymph exude, and are in succession 
 attached to the ulcerated surface, and incorporated by tliis organizing process, until 
 the breach of texture is repaired. The lymph thus organized comes at last to resem- 
 ble, very exactly, areolar tissue, more or less condensed. 
 
 The length of time required for the pouring out of coagulable lymph in inflamma- 
 tion — and for its organization after it has been poured out — is variable under differ- 
 ent circumstances. It is often effused very early. Dr. John Thompson found a 
 distinct layer of it covering wounds he had made in an animal, in less than four 
 hours after they were inflicted ; and cases are related, in which vascular organiza- 
 tion of the effused lymph ha^ appeared to have been effected within the space of 
 twenty-four or thirty-six hours. Sometimes, on the other hand, many days seem to 
 elapse before any such organization is observable. 
 
 When serous fluid and coagulable lymph have been poured out in considerable 
 quantity, and simultaneously, the serous fluid is often rendered turbid by the admix- 
 ture of small portions of lymph, or of albumen, diffused through it ; and flakes of 
 lymph sometimes float in it, or settle, in virtue of their specific gravity, at the lowest 
 part of the cavity containing the effused matters. 
 
 Several conditions seem necessary to ensure this adliesive form, or adhesive stage 
 of inflammation. The inflammation must reach a certain degree of intensity, or no 
 lymph will be effused ; it must not go beyond a certain degree of intensity, or the 
 next event I have to mention, the formation of pus, will interfere with the adhesive 
 process. We learn also from what takes place in recent wounds, that seclusion 
 from the air, and the absence of all other causes of irritation, are necessary for adhe- 
 sion, or union by the first intention. 
 
 The formation oi pus — suppuration — is a fourth event of inflammation, to which 
 brief allusion has already been made. 
 
 Many opinions have been broached respecting the nature of pus, and the manner 
 in which it is formed. I shall not trouble you by discussing, nor even by narrating 
 them, but hmit myself to stating what are the notions held on these points by the 
 most able and the most recent observers. 
 
 Pus, then, as I told you before, is altered blood. It is an opaque, smooth, yellow 
 ish fluid, of the consistence of cream, and having no smell. I speak now of well- 
 formed, or what is called good, or healthy pus ; what the old writers spoke of as 
 pus laudabih. This has been thought an absurd epithet: but it serves as well as 
 any other to express what was meant, viz., that kind of pus which accompanies 
 benign forms of inflammation, and indicates that all is gomg on regularly, and pro- 
 mises a fortunate ending : pus, in short, the appearance of which was to he com- 
 mended. It is certainly not more absurd than the term healthy pus. This pus 
 laudabile was described as being album, Ixve, et xquale — light-coloured, smooth, 
 and homogeneous. This description of good pus has de^scended from the time of 
 
 Hippocrates, who says. To hi nvov, a^intov Xtvxov ti hui, xai uuaXov, xai Uiov, xai <o{ r^xn^fa 
 
 8v(jw63j. It consists of yellowish globules, difflised through a thinner fluid, which 
 resembles in some respects the serum of the blood. " If six or eight ounces of good 
 pus be suffered to stand in a phial, it will separate into two portions ; a yellowish 
 matter will sink to the bottom, and there will be a slightly yellow, clear, superna- 
 tant fluid, like oil in appearance, but not greasy to the touch." The sediment con- 
 sists of the globules ; which Gendrin supposed to be the red globules of the blood, 
 altered ; deprived of their coloured envelops, an.d swollen or enlarged. But, as I 
 stated before, the opinion now prevalent among pathologists is that these pus-globules 
 are transmitted " colourless corpuscles ;" moreover, that they are hollow cells. 
 
 K
 
 110 INFLAMMATION. 
 
 There are various modifications of pus ; and its qualities are liable to rapid altera- 
 tion by various circumstances. Sometimes the globules are few in proportion to the 
 more watery part ; and then the pus is said to be ichorous. It is sroiioiis when 
 some of the colouring matter of the blood is poured out with it. It is sometimes 
 viscid and slimy, from an admixture of mucus ; or flaky and curdled, which is com- 
 mon in scrofulous persons. Sometimes, also, instead of being inodorous, it is horribly 
 fetid. Ail abscesses that form in or about the alimentary canal are apt to contain 
 pus of an offensive odour; as those which occur in the tonsils and near the rectum. 
 A patient of mine, in the hospital, had a fluctuating tumour in the epigastrium, 
 which Mr. Arnott opened. There came out the collapsed bags of two or three 
 hydatids, and a quantity of stinking pus. The liver, no doubt, was the seat of the 
 suppuration in this case — and perhaps the stench might be owing to the death and 
 decomposition of the hydatids. 
 
 Great pains have been taken by many persons to discover some sure criterion 
 between pus and mucus. Healthy pus and healthy mucus are so totally unhke 
 each other, that they never can be confounded together. But sometimes we can 
 scarcely say whether Ave are looking at mucus so altered as to resemble pus, puri- 
 form mucus — or at genuine, though not perhaps praiseworthy, pus. I shall tell you 
 what has been made out upon this point hereafter, when I ti-eat of phthisis ; and I 
 shall show^ you at the same time that the distinction has not that great importance 
 which is sometimes assigned to it. 
 
 Pus may be poured out into one of the natural cavities of the body, and then it is 
 called purulent effusion. It may be contained in a closed cavity, which is not natu- 
 ral, but formed by lymph and condensed areolar tissue ; and then the collection of 
 pus is called an abscess. It may also proceed from a free surface of the bodjr — as 
 the skin, or a mucous membrane, or a superficial sore. 
 
 In the natural cavities of the body pus seems, sometimes, to mingle gradually 
 with the serous effusion, which grows turbid and whitish, and at length distinctly 
 assumes a puriform character. But in much the greater number of cases the forma- 
 tion of pus is preceded by the effusion of coagulable lymph, with or without the 
 effusion of serous fluid. The pus in these cases appears to be poured forth or 
 secreted by the coagulable lymph after it has become organized. Its formation 
 seems to characterize a more advanced stage of inflammation — to denote that the 
 inflammation has been pressed a httle beyond the adhesive stage. This was the 
 opinion of John Hunter, who was the first to teach us any thing w^orth knowing 
 about the process of inflammation. It is also the opinion of Gendrin, one of the 
 latest and most successful investigators of that process. Hunter thus expresses him 
 self on this subject : — " The new formed matter peculiar to suppuration is a remove 
 further from the nature of the blood than the matter formed by adhesive inflamma- 
 tion." And Gendrin says, " between the purulent fluid of inflamed tissues, and the 
 organizable coagulable fluid (i. e., between pus and coagulable lymph), there is but 
 0)2e degree of more.'''' 
 
 Even the preventing or the allowing the access of air to the surface of a recent 
 cut will make all the difference between adhesion and suppuration. And the same 
 influence of the air in promoting the suppurative process in preference to the adhe- 
 sive is remarkably seen in various other cases. In simple pleurisy — from exposure 
 to cold — we seldom have any liquids effused, except coagulable lymph and serous 
 fluid. But if the inflammation has been caused by a punctured wound from without, 
 or by laceration of the pulmonanj pleura by the sharp end of a fractured rib, or by 
 a perforation of the pulmonary pleura by the extension of a vomica in the lung — in 
 all which cases air finds its way into the cavity of the pleura — then true empyema 
 lesull.^ — pus is formed. S' jso in pneumonia: at first the inflamed lung is rendered 
 solid by the effusion o*" i< ;. -liable lymph into the air cells; but if the inflammation 
 persists, the next thing iha uappens is what is called by Laennec gray hepatization 
 — a puriform infiltration takes the place of the lymph, ^he same principle is exem- 
 plified in the case of the urethra ; inflammation of the free surface of its mucous 
 membrane leads rapidly to the formation of pus; inflammation of its attached surface 
 occasions the pouring out of lymph, which produces stricture. And in general I
 
 ULCERATION. Ill 
 
 think it may be said of surfaces that are open to the air, of teguraentary membranes, 
 that either pus is formed upon them, under inflammation, without any previous 
 effusion of plastic lymph, or the lymph is slight in amount, and transient in duration, 
 and presently superseded by a puriform discharge. We have every-day examples 
 of this, in inflammation of the conjunctiva, of the bronchi, and of the bladder. Per- 
 haps it is in this principle that we may find an explanation of the fact that whereas 
 in the inflammation of the areolar tissue, of glandular organs, and of the parenchyma 
 of the viscera generally, the pus which forms is collected into an abscess ; circum- 
 ecribed abscess in the substance of the lung, from common inflammation, such as we 
 are now considering, is very rare indeed. This is a point which wUl of course 
 come under our consideration again. 
 
 There is, however, manifestly a close connection in many cases between the effu- 
 sion of lymph and the effusion of pus ; although the progress and effects of adhesion 
 and suppuration are very different. When suppuration takes place, the pain belong- 
 ing to the inflammation usually abates, or ceases, except when the pus is imprisoned 
 so as to keep up the pre-existing tension. Certain remarkable constitutional pheno- 
 mena also declare themselves, which I shall notice again hereafter. 
 
 The effusion is longer continued in the case of suppuration ; and the quantity of 
 pus is more copious generally than of lymph, especially in the serous and tegu- 
 mentary membranes. When pus is diffused through the natural textures it tends to 
 soften and separate them — to break them down : whereas the direct effect of the 
 deposition of lymph in the same parts is to consolidate and harden. 
 
 The time required for the formation of pus is extremely variable. Suppuration 
 sometimes very quickly follows the commencement of the inflammation; within a 
 few hours, as in gonorrhcsa. Sometimes it is postponed to a very distant period, 
 even for weeks. 
 
 The duration of the suppurative process is also uncertain, and seems to have no 
 fixed relation to the intensity of the inflammation by which it has been preceded or 
 accompanied. 
 
 A fiflh event o[ inflammation is ulceration. You may remember my telling you 
 that ivaltenbrunner observed the progress of absorption in the inflamed tissues which 
 he examined by the help of the microscope : how the stellated spots gradually 
 vanished from the web of a frog's foot, and the fat from the mesentery of the rabbit. 
 
 Independently of these microscopical observations, it is quite evident that absorp- 
 tion goes on, often very actively, during the continuance of inflammation. The 
 effused fluids, or products of inflammation, the serum, the lymph, the pus, are partly 
 taken up again ; and not only are these products of inflammation liable to be so 
 removed, but the original textures of the body are carried off by absorption. We 
 cannot have a better proof of this than the progress that an abscess makes to the 
 nearest surface at which the pus it contains may be discharged ; the intervening 
 textures are gradually absorbed. Perhaps a great part of the principle concerned in 
 this progressive approach to the surface is pressure. The harder tissues of the 
 body, the bones themselves, yield and disappear before the increasing pressure of an 
 aneurismal tumour. In this case the absorption appears to be independent of 
 inflammation. 
 
 But taking the process as one of the events of inflammation, we may say with Dr. 
 Alison that, whenever the absorption of the effused lymph, and of the surrounding 
 textures, takes place in excess — in a greater degree, that is, and more irregularly 
 than seems to be required for any useful purpose — the result is ulceration. Th& 
 term is, however, commonly restricted to those cases in which the loss of ^substance 
 occurs upon some surface, internal or external. 
 
 Many circumstances influence the occurrence and progress of ulceration ; ami 
 great differences are observable between the different tissues, in respect to the facility 
 with which they severally ulcerate. Ulceration is most common in the tegumentacy 
 membranes. It is frequently met with, also, in the inner coats of the arteries, in 
 cartilages and in bones. But we are not always sure that it is in these cases an 
 event of inflammation. Ulceration is rare in fibrous tissues of all kinds, in serous 
 membranes, and in the outer coat of arteries. These differences have importam
 
 112 INFLAMMATION. 
 
 pathological bearings. But I may not slop to consider these at present : they will 
 be particularly noticed as the course proceeds. When I state that ulceratfon may 
 lead to perforations of the alimentary canal — of the air-tubes — of the gall and urinary 
 bladders — of the blood-vessels ; and to the fatal escape of the natural contents of 
 these organs ; I have said enough to convince you that ulceration, so frequently the 
 object of the surgeon's care, requires no less attention on the part of the physician. 
 
 There are certain forms of ulceration that are specific in their nature : with these 
 I do not at present meddle. The process of ulceration is very clearly explained in 
 Dr. Alison's admirable Ou/lines of PatJiology. 
 
 There are three things generally going on at the same time in an ulcerated sur- 
 face. First, there is an effusion of plastic lymph, by which what are called granu- 
 lations are formed. Granulations consist of coagulable lymph which has become 
 organized; furnished with numerous delicate blood-vessels. Secondly, there is 
 suppuration ; and, thirdly, there is absorption or the removal of parts. 
 
 Sometimes, apparently, there is no SKppuration ; we see no pus in ulcers of the 
 cornea, nor in certain cases of absorption of articular cartilages. 
 
 When the first of these three processes gets the better, if I may so speak, of the 
 others, the lymph overspreads the surface of the ulcer, fills up the cavity, and the 
 ulcer heals : cicatrization takes place. 
 
 When, on the other hand, the absorbing process predominates, the ulcer extends 
 itself — the excavation grows larger, or deeper — or both larger and deeper : and 
 when this excess of absorption is great, and the extension of the ulceration rapid, it 
 is called phagedenic ulceration. When a part of the textures perishes during the 
 process of the ulceration, and is separated in entire and sensible masses, the ulcer is 
 said to be a sloughing ulcer. " When the process is slow, the lymph effused at the 
 base and round the edge of the ulcer is hardened, and the granulations on its surface 
 are deficient, the ulcer is then said to be cullovs or indolent : and when the granu- 
 lations are larger and softer, and more flabby than usual, and require to be repressed 
 before the ulcer will heal: to this variety of ulcer the name oi fungous ulcer is 
 given :" and the coarse and too luxuriant granulations are called, by the vulgar, 
 proud flesh. These several terms, in the senses now assigned to them, you will 
 please to remember. 
 
 It is by regulating the three processes now described — so far as they are capable 
 of being regulated by art — that the surgeon and the physician endeavour to obviate 
 the threatened ill consequences of ulceration, and to promote the repair of the tex- 
 tures Avhich have been destroyed. 
 
 I explained to you, in a former lecture, that inflammation may lead to a wasting 
 of parts, although there is no suppuration or ulceration. The testis sometimes withers 
 as a consequence of inflammation : interstitial absorption takes place. Atrophy, in 
 short. 
 
 LECTURE XI. 
 
 Mortification, as an event of Inflammation. Inflammatory Fever. Hectic 
 Fever. Typhoid Fever. Modification of Inflammation by differences of 
 Tissue; Areolar Tissue; substance of Glands and Solid Viscera; Serous 
 Membranes ; Synovial Membranes : Tegumentary Membranes — Skin — Mu- 
 cous Membranes; Muscular Tissue; Arteries; Veins; substance of the 
 Brah^ 
 
 We were occupied, when last we met, with what may be properly called the 
 events of inflammation. We passed in review, 1st, resolution as an event of in- 
 flammation ; 2diy, serous effusion ; 3rdly, the pouring out of coagulable lymph, con- 
 stituting the adnesive form or stage of inflammation ; 4thly, the fonnation of pus, or 
 suppuration ; and 5thly, ulceration. The pathology of these several events, so far 
 ivi it is understood, and the change of symptoms to which they may respectively lead.
 
 MORTIFICATION. 113 
 
 were also treated of as fully as the limits of my course allow. At the close of the 
 lecture I was about to speak of the sixth and last event of inflammation that requires 
 to be noticed: vi2. gangrene, sphacelus, mortijication. 
 
 When mortification thus succeeds to inflammation, the part dies ; it becomes cold ; 
 all circulation through it is at an end ; all sensation in it is over. If it be an 
 external part, its colour changes ; from being red, it becomes mottled, purplish, green 
 or black ; decomposition takes place ; vesications appear, filled with dark-coloured 
 liquids ; air is extricated also. If there be a great accumulation of fluid in the 
 part there will still remain tension ; but usually the mortified part is flaccid and 
 boggy ; and it emits a cadaverous smell. 
 
 When internal parts mortify under inflammation, they do not always assume this 
 black appearance ; often they are yellowish ; or the soft tissue of the dead part 
 readily imbibes fluid, and takes the colour of the substances with which it has been 
 in contact. We see sloughs of the mucous membrane of the intestines presenting 
 the ochrey hue of the fa3cal matters which had rested upon them. 
 
 What 1 have described as mortification, occurring externally, and succeeding to 
 inflammation, is such as the surgeon witnesses. Sometimes it spreads, and loses and 
 confounds itself, insensibly, with the adjoining parts, which still retain life ; and 
 which may continue actively inflamed, and subsequently perish also. Under more 
 favourable circumstances, a distinct boundary line is formed between the dead and 
 living parts ; and nature proceeds to amputate the portion which has lost its vitality. 
 7^he process by which this is effected is extremely interesting. Adhesive inflam- 
 mation constructs a barrier of lymph against any further advance of the mortifi- 
 cation ; a furrow of ulceration marks out upon the surface the commencing 
 separation, and (supposing a part of one limb to have become gangrenous, the foot 
 for example) the furrow gradually deepens, until the dead part is completely cut off'. 
 This very fact shows that all the textures of the body, skin, muscle, nerve, blood- 
 vessel and bone, are capable of being removed by the ulcerative process. Mean- 
 while very interesting changes occur in the part that lives: the large vessels are 
 Jilugged up, to a certain distance, by the coagulation of the blood contained in them 
 the coagulation of the blood following its stagnation. They are further sealed up 
 and the smaller vessels also are closed, by coagulable lymph. Were it not for these 
 changes, fatal hemorrhage would follow the separation of the dead part. Now this 
 is just what a surgeon rudely imitates when he amputates a hmb ; he cuts through 
 the parts with knife and saw, and he ties the larger blood-vessels as he goes along. 
 He follows the path which the natural processes point out ; and, in truth, a great 
 part of both physic and surgery consists in learning what are the expedients of rejiair 
 and preservation for which provision has been made in the living body ; in exciting, 
 or repressing, or directing, or imitating those natural actions which generally tend, 
 and often suffice, to restore health and to save life. 
 
 Mortification is more common in some internal parts than in others. It is frequent 
 in the areolar tissue ; and in the mucous and submucous tissues of the alimentary 
 canal ; in the throat, for example, in cynanche maligna; and in the glandular parts 
 of the intestines in fever. 
 
 [The affection of the throat in cynanche mah'gna is not, strictly speaking, mortification. It 
 has been shown by Bretonneau and others, to be a true pellicular inflammation. The false 
 membranes, by which the fauces are covered, either in part or entirely, becoming tinged with 
 blood, assume a dark or almost black appearance, and exhale an intolerable fcetor — whicli 
 circumstances have caused them to be mistaken for sloughs — but when they become de- 
 tached the mucous membrane is found to be perfectly entire, and without any appearance 
 of softening; the peculiar odour of gangrene, also, is absent. — C] 
 
 Mortification seldom affects the other mucous systems — those which belong to the 
 air-passages and the urinary organs. It occurs sometimes — but not very often — 
 ill the substance of the lungs. It is seldom met with in serous and fibrous tissues 
 It is not at all uncommon in bone : producing exfoliation when it is slight and su- 
 perficial ; necrosis when the entire shaft of a long bone dies. In these cas^^s the 
 process is slow, and we can watch its repair ; and a beautiful process it is : but I 
 must not stop even to admire it. 
 
 8 K 2
 
 11 4 INFLAMMATION. 
 
 Novv mortification is no certain or constant event of inflammation. It depends, 
 more or less upon various causes and conditions. Sometimes, upon the mere in- 
 tensity of the inflammation, as sloughing inflammation of the genitals ; the progress 
 of the mortification being best checked by those measures which are calculated to 
 abate the violence of the inflammation. The sloughing of the cornea in gonorrhoea! 
 ophthalmia is another example to the same purpose. 
 
 1 Again whatever tends to weaken the circulation in the part affected — or in the 
 system at large — tends also to promote the perishing of the textures that are inflamed. 
 In persons who are debihtated by fever, the mere pressure of the body against the 
 bed is enough to produce sloughing of the integuments of the sacrum, hips, and 
 elbows. The same phenomena are apt to occur in parts that are palsied. In drop- 
 sical patients, with feeble and impeded circulation, we find that a blister on the 
 extremities, where the circulation is the most feeble, will sometimes cause mortifi- 
 cation ; while it might be apphed to the chest without any risk of that event. Pro- 
 bably, in each of these instances, the unhealthy condition of the blood conduces to 
 the sloughing process. Inflammation of the stomach and intestines is marked by 
 a strong disposition to run into gangrene — and this again is consistent w^ith what 
 I formerly mentioned, of the depressing influence of inflammation of these organs 
 upon the heart. 
 
 It is necessary to remember that mortification is capable of being produced by 
 other causes, as well as by inflammation. The death of frost-bitten parts is perhaps 
 scarcely an exception — the phenomena of mortification occur in them after the re- 
 application of a certain degree of heat — sufficient, probably, to give rise to more 
 action than the frozen parts can bear without perishing. But the mere cutting- off 
 the supply of arterial blood, independently of any inflammation, will cause mortifi- 
 cation. Ossification of the arterial trunks, and consequent stagnation and coagulation 
 of the blood in them, is the commonest cause of the dry gangrene of old persons — 
 gangrena senilis; which, by the way, is not always dry. In the majority, however, 
 of these cases, the gangrenous part, not being preternaturally loaded with fluid, docs 
 not so rapidly putrefy ; but remains dry and shrinks up again. Again, whatever 
 tends to prevent the return of the venous blood from a part (as a firm ligature placed 
 round a limb — or the constriction of the gut in strangulated hernia), is favourable, 
 also, to the production of mortification. Probably, here, too, the direct or indirect 
 pressure made upon the arteries is chiefly concerned in occasioning the death of the 
 part. We see limbs mortify sometimes after their principal artery has been tied for 
 the cure of aneurism, when the collateral arterial circulation fails sufficiently to 
 establish itself: we see the same thing when the passage of the blood through the 
 main artery is stopped by external injuries. 
 
 There is also a very curious form of chronic and dry gangrene, produced by the 
 continued u..e of diseased grain as food — and particularly of the spurred rye ; and 
 to this, as a distinct disease, I may perhaps have occasion to direct your attention 
 hereafter. 
 
 The different stages and events of inflammation that have now been described are 
 accompanied by corresponding disturbances of the system at large. These were 
 touched upon (barely mentioned, however) in that rough and general oulhne which 
 I attempted to sketch in the outset, of the various phenomena of inflammation ; and 
 to which I have since referred as a type. They require, for many reasons, to he 
 considered somewhat more minutely. 
 
 When, as surgeons, you have to deal with external inflammation, you have no 
 difficulty, in the first place, in ascertaining its actual existence : you see it ; and you 
 know, besides, merely by looking at the part, and perhaps handling it, whnt changes 
 it has undergone. You may perceive that the opposite lips of a wound have ad- 
 hered : or that a phlegmon, in which you can also detect fluctuation, has assumed a 
 pyramidal form, and begins to look white upon its summit ; or you observe that the 
 abscess has broken and left an ulcer behind it, which pours out pus, and which 
 shows a tendency to contract, or to enlarge itself: or you may remark the alteration 
 of colour and of temperature which denotes the approach of mortification, or the 
 uctual death of the part. The mere exercise of your external senses apprises you.
 
 INFLAMMATION. 115 
 
 not merely that there is inflammaiion, but also whether it is of the adhesive kind ; 
 or has reached the degree of suppitration; or has produced gangrene. At the 
 same time you do not fail to notice the nature of the constitutional disturbance that 
 may be present ; and the knowledge thus obtained of the local and of the general 
 symptoms determines your plan of treatment. 
 
 But when, as physicians, we have to do with inflammation of internal parts of 
 the body, and when the local changes attendant upon that process are concealed 
 from our view, the case is very different. We should often be unable to make out 
 the nature of the disease at all, if the presence of pyrexia did not instruct us. Some- 
 times the constitutional disturbance is all that is apparent until after death. And, 
 as the disease proceeds, we frequently are able to judge that this or that event of 
 inflammation has taken place, only by observing the indirect symptoms which de- 
 clare themselves through the medium of the system at large. Yet it is in many 
 cases of the greatest importance to mark the transition from one stage or event of 
 inflammation to another ; and to learn whether, and in what degree, the more urgent 
 of the symptoms depend upon the inflammation itself; or upon the effects which it 
 has produced. I do not mean to say that we have not, sometimes, as sure indica- 
 tions afforded us by direct symptoms, cognizable by the sense of hearing or of touch, 
 of the state of internal organs, as we could have if they were exposed to our view. 
 To these direct symptoms I am not now about to refer ; they must be spoken of in 
 connection with the diseases to which they belong. But the information which the 
 physician gains from what may be called constitutional symptoms is always highly 
 valuable : and it is sometimes the only information that offers any guidance to the 
 remedial measures he ought to adopt. 
 
 Inflammation sufficiently extensive or intense to disturb the general system at all, 
 is attended with pyrexia ; and the presence of pyrexia, when the part affected is 
 unseen, marks the nature of the disease. The most prominent of the symptoms 
 that denote the existence of inflammatory fever are debiHty and chilUness, followed 
 by, or alternating with, increased heat of skin, and increased frequency and force, 
 and often hardness of the pulse, with considerable derangement of most of the natural 
 functions of the body. Commonly there is headache and confusion of thought, lan- 
 guor, thirst, loss of appetite, a furred or white tongue. 
 
 Among these leading symptoms, the chilhness, often amounting to shivering, has 
 this particular importance attached to it, that it marks the date of the febrile disturb- 
 ance. And it is worth observing, that rigors more commonly attend the commence- 
 ment of spontaneous inflammation than of inflammation caused by external injury. 
 
 Now, without going more into detail — of this febrile condition belonging to the 
 early stage of inflammation, I make the following remarks : 
 
 1. That it generally succeeds the manifestation of the local symptoms of the inflam- 
 mation : and that we cannot, therefore, help considering the fever as the natural 
 effect of the inflammation. 
 
 Kaltenbrunner describes an experiment of this kind. He says, if a drop of alcohol 
 be applied to the web of a frog's foot, the blood presently flows towards the part irri- 
 tated, and the circulation in it is accelerated ; congestion takes place, and follows its 
 known march. 
 
 If the dose of alcohol be augmented, the phenomena of congestion increast con- 
 siderably, and extend over a larger space : at length points of stagnation appearing 
 in the focus of the affected part announce the establishment of inflammation. 
 
 If the dose of alcohol be still further increased, we observe that, on the one hant 
 the inflammatory points of stagnation become larger and more numerous ; and that, 
 on the other, the circumferential disturbances of the circulation extend themselves, 
 so as at length to implicate the whole of the circulating system : they give rise to a 
 fever which is added to the iriflammation. The circulation in the web of the oppo- 
 site foot is as much accelerated as in the vessels surrounding the inflamed part in the 
 first foot. If the word congestion had not a local meaning, we might call fever (he 
 says) a general congestion. 
 
 Perhaps the fever may be owing to the circulation of altered blood throughout the 
 body. We know that the blood is altered in these cases, inasmuch as it is found to
 
 116 INFLAMMATION. 
 
 contain an unusually large proportion of fibrin ; and it has acquired the unnatura 
 quality whereby, when withdrawn from the body, and allowed to coagulate, it exhi- 
 bits the buffy coat. 
 
 That the febrile state follows the local inflammation in point of time, is then the 
 rule ; but this rule has frequent exceptions. Erysipelas, and all the febrile exanthe- 
 mata, afford instances of exception ; the fever sets in before any manifestation at 
 least of the local symptoms. These are indeed diseases of a specific kind : but the 
 same is true sometimes of diseases that appear to be simply inflammatory ; such as 
 inflammatioB of the lungs, and cynanche tonsillaris. There are other cases in whicli 
 the local symptoms and the general febrile disturbance appear to burst forth simul- 
 taneously : this is seen in certain instances of pleurisy, and of peritonitis. 
 
 2. Again, it is a curious circumstance that the inflammatory fever is not always 
 proportioned, in its degree of violence, to either the size or the importance of the 
 part inflamed. The pyrexia is often very strongly marked in ihat common com- 
 plaint, the quinsy, inflammatory sore-throat, cynanche tonsillaris — which can scarcely 
 ever be said to imply much danger. 
 
 3. The situation, the extent, and the degree, of the local inflammation being the 
 same, the fever commouiy runs higher in young, and in plethoric persons, and in 
 those of sanguine temperament, than under the opposite conditions. 
 
 4. The inflammatory fever may be modified in the outset, or very early indeed, 
 by the nature of the part upon which the inflammation has seized. I have several 
 limes mentioned the peculiar depressing effect upon the action of the heart, pro- 
 duced by inflammation of the stomach and bowels, and of some other of the abdo- 
 minal organs ; and particularly by inflammation involving their peritoneal covering. 
 This lowering influence (which is analogous to that of certain mechanical injuries 
 to the abdomen) has been supposed to depend upon the subduing and sickening kind 
 of pain which is apt to accompany inflammation of these parts. Probably such 
 pain accompanies, rather than causes, the depression. However the latter may 
 arise, it gives a pecuhar character to the inflammatory fever : lessens the amount of 
 reaction, or abridges its duration ; affects especially the quality of the pulse ; and 
 carries with it a strong tendency towards death by asthenia. 
 
 5. There is no doubt either that the character of the inflammatory fever is liable 
 to be considerably modified, from the first, by the previous habits of the patient. In 
 persons who have been habitually intemperate — or who have been subject to long- 
 continued excitement of the nervous system of any kind — the fever which attends 
 inflammation approaches more or less to the typhoid form, from the very beginning. 
 The febrile reaction is less strongly pronounced. The functions of animal life are 
 sooner and more deeply involved in the train of morbid actions. Stupor and delirium 
 are apt to occur; with extreme debility and irregular movements of the voluntary 
 muscles. Still more conspicuous are these peculiarities in some cases of inflamed 
 veins ; and whenever inflammation is produced or accompanied by the introduction 
 of certain animal poisons into the system. 
 
 0. The relative duration of the inflammatory fever is subject to some variety. Ii 
 may persist for a little while, for a few days, even, after all the local signs of inflam- 
 mation have disappeared: this happens chiefly in persons of an irritable habit. W© 
 watch such cases narrowly, not without some apprehensions of a relapse. On the 
 other hand, a rapid abatement of the febrile symptoms sometimes takes place, while 
 the local changes continue, or even for a time increase in extent. Nevertheless, we 
 hail this change as a favourable augury of the ultimate result. 
 
 When inflammation, external or internal, has gone on to the formation of pus, ihat 
 event is frequently marked by the supervention of pecuhar symptoms ; and the 
 character of the fever undergoes, for the most pan. a striking alteration. 
 
 It IS very important to ascertain the time when this event of inflammation takes 
 place, or is at hand ; for the measures which might have been proper and necessary 
 while any prospect remained of the resolulion of the inflammation, may be useless, 
 and even hurtful, if continued after that prospect is at an end. 
 
 When the surgeon perceives any indication of the formation of pus in an external 
 part, he mostly despairs of being able to bring about resolution : ceases to abstract
 
 HECTIC FEVER. 117 
 
 blood from the part, or from the system ; and applies perhaps warmth and moisture, 
 by means of a hnseed poultice, to promote the suppuration. And a corresponding 
 change of plan is required in internal inflammations. 
 
 Now the commencement of suppuration is often marked by rigors ; and its con' 
 tiniiance by hectic fever. 
 
 If, after the symptoms of inflammation have lasted for a certain time, the patient 
 is attacked by cold shiverings, followed by some increase of heat, that circumstance 
 alone is enough to make us suspect that pus is formed, or is about to be formed : and 
 to teach us that the measures employed to effect a resolution of the inflammation 
 have not been successful. 
 
 Rigors are very striking symptoms ; but they are by no means necessarily con- 
 nected with suppuration. They usher in, as I presume you know, most forms of 
 fever, appearing at the very outset of the disease. They recur, at regular intervals, 
 in intermittent fevers. SHght causes will, sometimes, produce them. They often 
 follow the introduction of a bougie into the urethra. But when they occur after 
 symptoms of infernal inflammation have been for some time present, they denote, 
 in most cases, the production of pus in the part of the organ inflamed. Sometimes 
 one such shaking fit only is observed : sometimes several take place. When they 
 recur it is usually at irregular intervals ; but cases do happen in which the shiverings 
 indicative of internal suppuration are so strictly periodic, that unless all the circum- 
 stances be carefully taken into the account, they may be mistaken for signs of ague. 
 
 The leading symptoms of hectic fever (by which, I say, the continuance of sup- 
 puration is commonly marked) are an abiding frequency of pulse ; alternations of 
 chilliness with heat and flushing, followed by perspiration ; a gradual wasting of the 
 bod)'' ; and progressive debility. 
 
 I shall hereafter have to speak of a very difl'erent kind of disease, in which, how- 
 ever, there is a succession of symptoms resembling more or less closely the series 
 that characterizes hectic ; I mean remittent fever ; the succession of symptoms being 
 chilliness, heat, perspiration. But these two disorders are in most cases discriminated 
 from each other by the circumstances under which they occur. 
 
 The symptoms of hectic fever often creep on, at the outset, insidiously, and almost 
 imperceptibly. "A very slight degree of emaciation, a pulse a little quicker than 
 ordinary, with a small increase of heat, especially after meals, are often the first 
 symptoms which can lead us to suspect the formation of hectic." CuUen has de- 
 scribed hectic fever as consisting of two exacerbations in the twenty-four hours- 
 one about noon, the other towards evening ; but in many cases the latter alone is 
 distinctly marked. The patient feels shivery and cold towards night ; then the skin 
 becomes hot and dry, especially in the palms of the hands and the soles of the feet, 
 and the pulse more frequent ; and in the middle of the night or towards morning, he 
 wakes from short and uneasy sleep, in perspiration, which is often profuse. Some- 
 times, however, there are two or three fits in a day. The paroxysms are shorter, 
 and less regular, than those of intermittent or remittent fever. Each of the three 
 phenomena constituting the series may, in its turn, be wanting: and even if the 
 paroxysms are regular for two or three times together, they never continue to be so. 
 Many circumstances connected with the paroxysm itself are very distinctive. " The 
 hectic patient," says Dr. Heberden, who has left us a very good account of this 
 affection in his Commentaries, " is very little or not at all relieved by the breaking 
 out of the sweat ; but is often as restless and uneasy after he begins to perspire as 
 he was while he shivered or burned. All the signs of fever are sometimes found 
 the same after the perspiration is over: and during their height the chilliness will in 
 some patients return, which is an infallible character of this disorder. Almost all 
 other fevers begin with a sense of cold, but in them it is never known to return and 
 to last twenty minutes or half an hour, while the fever seems at its height, which in 
 hectic will sometimes happen." 
 
 Hectic fever is one of the fearful accompaniments, and sometimes the most strongly 
 marked symptom, of pulmonary consumption : and where the existence of thai 
 complaint is suspected, yet a matter of doubt, we look for indications of hectic fever 
 with the greatest anxieiy and dread.
 
 118 LNFLAMMATION. 
 
 With relation to hectic fever, considered as an indirect s3-mptom that suppuTTtion 
 has succeeded to inflammation, and is still going on, it will be worth your while to 
 notice the strong contrast it offers, in many particulars, with the injiammatory fever 
 that attends the earlier stages of inflammation. 
 
 The pulse loses much or all of its hardness and strength, but it remains perma- 
 nently more frequent than the pulse of health : the appetite returns in great measure ; 
 the thirst abates ; the tongue, instead of being covered with a white fur, becomes 
 clean and moist and towards the end is sometimes unnaturally red, or speckled with 
 aphthoE : there is no longer headache or confusion of thought. 
 
 A few more touches will suffice to fill up the picture of hectic fever. 
 
 The face is usually pale ; but during the exacerbations it is partially flushed, and 
 very often a characteristic circumscribed red spot appears upon either cheek. Besides 
 the evident emaciation, various minor changes mark the want of proper nourishment: 
 the skin, when not perspiring, is harsh and scurfy ; little branny scales may be 
 rubbed from the legs, merely by the friction produced in drawing off the stockings ; 
 the hairs become fine and fall off; the finger-nails are incurvated into an adunque 
 form; and the sclerotic coat of the eye, as seen through the conjunctiva, becomes of 
 a pearl}' white. As the disease advances osdematous swellings of the ankles are 
 very apt to come on. 
 
 The connection between hectic fever and the formation of pus in some part oi 
 other of the body is so frequent, that it has been deemed, by persons of great expe- 
 rience and sagacity, a universal fact. Dr. Cullen tells us, in his First Lines, that 
 he had never seen hectic in any case, when there was not evidenth^ or when he had 
 not ground to suppose there was, a permanent purulency or ulceration in some ex- 
 ternal or internal part. And Dr. J. Thomson, speaking of the opinion that hectic 
 might occur independently of suppuration, uses these words: "But till facts more 
 decisive, and cases more accurately described than any which have yet appeared 
 are produced in proof of that opinion, I shall think myself justified in adopting the 
 common opinion ; and in believing that hectic fever is in every instance connected, 
 if not with the absorption, at least with the formation of pus." 
 
 The notion alluded to in the latter part of this quotation was at one time very 
 commonly entertained, viz., that hectic fever resulted from the reabsorption of pus 
 into the blood ; but there are many facts decidedly opposed to this behef. Consider- 
 able collections of matter not unfrequently disappear, i. e., are taken up again into 
 the blood, without occasioning the slightest approach to hectic. Again, hectic will 
 accompany, and be kept up by, a scrofulous joint attended with an open sore, and it 
 will sometimes cease at once, and completely, upon the removal of the diseased limb 
 by amputation ; although a greater quantity of pus is secreted by the stump, than 
 had been secreted in the diseased part previously to the operation. Facts like these 
 prove, I think, that hectic is not simply a consequence of the absorption of pus into 
 the blood : and they seem to have suggested to Mr. Abernethy the notion (which 
 was held indeed by John Hunter also) that sympathetic hectic fever is a teased 
 action of the system, endeavouring to throw ofl' what annoys it ; the cause of irrita- 
 tion being removed, it ceases forthwith. | 
 
 And there is another conclusive circumstance to be mentioned. Notwithstanding 
 the opinions I have just now quoted from Cullen and Dr. Thomson, I believe few 
 persons who have attended to the subject, doubt, now, that there is such a thing as 
 idiopathic hectic ; hectic unconnected at least with suppuration anywhere. We 
 often see hectic, or a general state of the system not to be distinguished from hectic, 
 in mothers who have suckled their infants too long ; we see it, too, sometimes, if I 
 mistake not, in newly married husbands : and it may be noticed as occurring more 
 or less distinctly in those who labour under diabetes. What is common to all these 
 cases is, that there is an habitual drain upon the system beyond what the nutriment 
 taken into it can supply and counterbalance. It is certain, too, that hectic fever 
 sometimes happens in phthisis, not only before there has been any expectoration of 
 puriform matter, but prior even to the softening and suppuration of a single tubercle. 
 J call to mind one instance in particular of this. The hectic was distinctly marked, 
 znd continued long. The patient died, at last, comatose, after two attacks of convul-
 
 MORTIFICATION. 119 
 
 sion. Two or three large scrofulous tumours were found imbedded in the substance 
 of his brain. Various other organs were infested with tubercles ; but the tubercles 
 were all of them still hard and crude. 
 
 However, setting aside these rarer cases of exception, there can be no doubt that 
 hectic fever, considered as a constitutional symptom of mischief that may reveal 
 itself by scarcely any other token, and especially as a sign of suppuration, deserves 
 all the attention we can give it ; and for that reason have 1 spoken of it rather at 
 large. Whenever I mention hectic fever in the progress of these lectures, you will 
 know all that I wish to express by that term. 
 
 I have very little to say at present respecting that modification of the general 
 febrile disturbance, which sometimes attends niortijication as an event of inflamma- 
 tion. I stated before that the fever is apt in these cases to assume the typhoid form ; 
 and to be characterized by sinking of the pulse, shrunken features, coldness and 
 clamminess of the skin, a dry and black tongue, low muttering delirium or stupor, 
 tremors of the voluntary muscles, with spasmodic startings of their tendons, and 
 insensibility to the passage of fceces and of urine. I must, however, now inform you 
 that these typhoid symptoms are no constant or necessary concomitants of mortifica- 
 tion. The natural mode of death, under gangrene, is death by asthenia. But the 
 tyohoid state involves the nervous functions, and tends to death by coma. When- 
 ever, therefore, typhoid symptoms supervene upon inflammation which ends in 
 sphacelus, they may with much probability be attributed to some contamination of 
 the blood by an animal poison ; and such contamination may have taken place pre- 
 vioudy to the mortification, and have even helped to produce it, as when inflamma- 
 tion arises during the progress of the contagious febrile disorders; or it may occur 
 as a consequence of the mortification itself, by the direct absorption into the system 
 of some of the putrefying and poisonous elements, into which the dead part has been 
 resolved. 
 
 One circumstance, worth bearing in mind, as sometimes indicating the superven- 
 tion of internal mortification, is the sudden cessation of pain : giving hope to the 
 pati:3nt and his friends that the danger is over ; but not deceiving the experienced 
 physician. 
 
 So much, then, for the local and constitutional events of inflammation, considered 
 generally. 
 
 It remains for me to make some observations upon the modifications of inflamma 
 tion, according as it affects the different tissues of which the body is composed. 
 Many of these observations I have, indeed, already anticipated ; but it will be useful 
 to bring together, under one view, the most material facts ascertained on this matter 
 
 When inflammation affects the areolar tissue, all the events of inflammation 
 which I have taken some pains to describe are apt to occur ; and for that reason, 
 inflammation of this tissue, as it exists beneath the skin, was chosen by me as a 
 convenient type, or general representative of the inflammatory process. It is, there- 
 fore, the less needful that I should take up much of your time in speaking of the 
 characters of inflammation exhibited in areolar tissue. There is a strong tendency 
 to form circumscribed abscesses : the extension of the suppuration is prevented by a 
 wall of lymph built up around it. The adhesive inflammation sets bounds to the 
 suppurative. There is a good deal of pain when the areolar tissue is so situated 
 that tension is occasioned by its swelling. 
 
 But sometimes no such boundary wall is erected, and the inflammation spreads 
 and diffuses itself, and becomes a very terrible disease, destroying the areolar tissue 
 over a large and undefined space by a process compounded of sloughing and of bad 
 suppuration. When the skin also is implicated in the inflammation, the disease is 
 usually called erysipelas phlegmonoides : when the skin is not involved, it has been 
 called diffused injlammution of the cellular membrane. This difilised foim of in 
 jiammation frequently follows the introduction of animal poisons into the systenj , 
 and accompanies the inflammation of veins and of absorbent vessels. It is this 
 disease which is so often fatal to members of our profession, when it results from
 
 120 INFLAMMATION. 
 
 \vounds or punctures received in opening dead bodies. Dr. Craigie has recently put 
 forth the opinion that in these cases of spreading inflammation it is the adipose 
 tissue that is affected. 
 
 The substance of the larger glands, and of the solid viscera of the body, suffers 
 changes analogous to those observed in the areolar tissue : probably because areolar 
 tissue enters largely into their composition. Acute inflammation of the liver, when 
 ii does not terminate in resolution, leads to abscess in that organ. Abscess is rare in 
 the lungs, perhaps for the reasons mentioned in the last lecture. Gangrene is also 
 uncommon in the pulmonary substance : and quite unknown, I believe, in the hver, 
 and very rare in the kidney. Inflammation of the latter organ is not unfrequently 
 attended by purulent collections. Inflammation of the substance of the viscera is 
 not, in general, attended with much pain. 
 
 The areolar tissue is hable to be rendered permanently thick and hardy by chro- 
 nic inflammation, as well in the parenchyma of internal organs as where it is spread 
 out beneath the skin, or beneath serous or mucous membranes. Chronic induration 
 and thickening of the areolar tissue which composes Glisson's capsule is no unfre- 
 quent result of slow inflammation ; producing that particular change in the liver 
 which the French pathologists denominate cirrliose ; but of which the essence is 
 atrophy of its lobules from compression of its nutrient arteries. 
 
 The inflammation of serous membranes is characterized by sharp and severe pain ; 
 l)y hardness of the pulse ; and by bufly blood ; by its tendency to spread ; by the 
 efTusion of serous fluid, and of coagulable lymph ; and sometimes, when the inflam- 
 mation is very violent, or air gets admitted to the inflamed surface, by the effusion 
 of j)us. Speaking generally, however, it is adhesive inJJammation which we most 
 expect in this tissue. False membranes, consisting of organized lymph, belong to 
 it : and the agglutination of contiguous surfaces. Sometimes the l3-mph, instead of 
 being deposited in flakes or layers, appears in the form of numerous small granules : 
 this is a phenomenon frequently observable in inflammation of the arachnoid, and 
 of the peritoneum. Sometimes it has a villous or papillary or shaggy arrangement ; 
 or is cellular like a honeycomb. This is common in the ]iericardium. The surface 
 (to use the happy simile of Laennec) resembles that which may be produced by 
 separating two flat plates between which a layer of soft butter had been spread : and 
 it probably depends upon a similar cause ; since in health a perpetual sliding mo- 
 tion of the pericardium over the heart is going on. Ulceration of a serous membrane 
 is very uncommon. I mean ulceration coinmencing in that tissue ; for these mem- 
 branes are frequently perforated by ulcers which approach them on their attached 
 side, and which begin in other tissues, especially the mucous. Neither does morti- 
 fication occur in serous membranes, except sometimes by communication from other 
 parts. The effect of chronic inflammation of the serous surfaces is to thicken, harden, 
 and pucker them. We see this efl!ect in the omentum frequently ; in the peritoneal 
 cover of the liver ; in the serous membrane which forms so large a portion of the 
 valves of the heart. 
 
 The synovial membranes have a strong analogy with the serous. Gendrin includes 
 the two in the same category : yet their behaviour under inflammation offers, in 
 some respects, a marked distinction between them. They are less liable to inflam- 
 mation than the serous membranes: they rarely throw out coagulable lymph, and, 
 consequently, adhesion of their opposite surfaces is very uncommon. Joints do not 
 become immovable, or what is called anchylosed, in consequence of the agglutina- 
 tion of their synovial surfaces ; but, generally, by means of granulations arising upon 
 those surfaces after they have ulcerated. Very seldom, indeed, does pus form in 
 the synovial sacs, except (again) the inflammation has been caused by mechanical 
 injury, which has laid open the joint, and admitted air. When this is the case, very 
 serious constitutional disturbance is apt to take place, and the existence of the sufferer 
 is endangered. That this does not depend upon the mere violence of the exciting 
 cause is evident from the circumstance that the same acute inflammation, the same 
 general affection of the system, and equal danger, often result from the careful inci- 
 sion made into a joint by the surgeon, for the purpose of removing loose portions of 
 «:artilage. I have now at the hospital an out-patient who has, among other ills, a
 
 TEGUMENTARY MEMBRANES. 121 
 
 large cartilage floating about in fluid in one of his knee-joints : but I believe that Mr. 
 Aniott, whom I have consulted on the case, will be very slow to recommend its 
 removal, until the inconvenience produced by it is so great as to incapacitate the 
 patient from pursuing his employment, and until other methods of relief have failed. 
 Suppuration of the joints is also one of the occasional consequences of phlebitis. In- 
 flammation of the synovial membrane speedily leads to a serous elusion into the 
 joint, which often, especially in rheumatism, is as speedily taken up again. 
 
 Let us next inquire into the modifications which inflammation undergoes when it 
 atiects the tegunientary membranes. 
 
 Considering the skin as one membrane, and neglecting its subdivisions into epi- 
 dermis, rete mucosum, and cutis vera, we find that inflammation assumes a variety 
 of forms in this external covering of the body. Many of these belong to specific 
 diseases, and do not fall within my present purpose, which is that of noting how 
 common inflammation varies in the different tissues. 
 
 When the inflammation is superficial, it frequently is denoted by a diffused red 
 blush only, which may be banished for a moment by the pressure of the finger, and 
 which, after a certain time, disappears of its own accord — terminates by resolution ; 
 the only consequence of the inflammation being the separation of the cuticle in small 
 branny fragments ; in one word, desqtiamation. We call the superficial inflamma- 
 tion, in this case, erythema. If the inflammation has been a little more intense — as 
 in some cases of erysipelas, in scalds, and in that which we are every day exciting 
 by caatharides — a serous fluid is poured out, which elevates the cuticle in larger or 
 smaller patches of vesication. Remove the cuticle and admit air, and the serous 
 effusion becomes purulent effusion : and if the inflammation be pressed beyond a 
 certain point by any other stimulus besides that of air, we may have pus poured 
 out. Erysipelatous (which is also a specific) inflammation of the skin, is character- 
 ized by its remarkable tendency to spread ; and a most singular circumstance attends 
 several of the other specific inflammations of the skin, viz. : that having occurred 
 once, they never occur again ; this peculiarity belongs, however, to the great consti- 
 tutional diseases, of which the cutaneous affection forms merely a part. 
 
 Inflammations of the internal tegumentary membranes — of the three internal sur- 
 faces that communicate with the air, and are clothed with mucous membrane — are 
 very interesting to the physician : and the first thing which strikes our attention in 
 respect to them is the indisposition they manifest to adhesive inflammation : and we 
 are struck at the same time with the beauty of this provision. If the mucous mem- 
 branes were as ready to throw out coagulable lymph, and to adhere to each other as 
 the serous, almost every occurrence of inflammation in them would prove necessa- 
 rily fatal ; by closing up the inlets of the air passages ; or the outlets of the urinary 
 passages ; or any part of that long mucous canal which, passing through the body, 
 requires a free opening at both of its extremities. But the inflamed mucous mem- 
 brane pours out serous fluid, or viscid mucus, or pus, or blood. Inflammation of 
 these membranes is, however, sometimes [in children very frequently] attended 
 with the exudation of something which is very like coagulable lymph, and which 
 has been considered fbut in my opinion erroneously considered) to be such lymph. 
 The tracheal, bronchial, and pulmonary mucous membrane, the oesophageal, the 
 intestinal, and that which lines the uterus, are all more or less subject to the forma- 
 tion of adventitious membranes under inflammation. Casts of the smaller branches 
 of the air-tubes have, in rare instances, been repeatedly coughed up in large quan- 
 tity ; constituting what have been very inaptly called bronchial polypi. The mem- 
 branous exudation of croup is well known : a tubular substance is formed in the 
 trachea, and, sometimes, fortunately expelled : but too often it suffocates the patient. 
 Similar concrete exudations, broken into irregular shreds, are occasionally voided by 
 stool. It is said that a long membranous mass of the same kind, in size and shape 
 like an earth-worm, has been discharged from the urethra ; having formed there in 
 coiisequence of the injudicious use of stimulating substances, injected with the view 
 of checking the more innocent effusion of pus. The films, or membrane-like flakes 
 which are thus incidental to inflammation of the mucous surfaces, resemble, I say, 
 n their general appearance and disposition, the strata or layers of coagulable lymph
 
 122 INFLAMMATION. 
 
 which are the ordinary product of inflammation of the closed serous surfaces. Bat 
 they differ from these in some remarkable points. They are softer. They never 
 contract permanent or strong adhesions to the subjacent inflamed membrane ; but 
 are partially separated from it by the intervention of thinner matters, serous or puri- 
 form. Abov-e all, they never become organized. They appear to consist of inspis- 
 sated and altered mucus ; and are composed, in a great measure, of albumen. An 
 opinion has been entertained that the locmt of apposition of the opposite surfaces 
 has a great deal to do with their indisposition to cohere. The mucous «?> tubes are 
 kept open and apart by i\\e\Y structure : the stomach and intestines by their con- 
 tents, or by the frequent passage of solids and fluids through them : and therefore 
 (it has been supposed) they have no opporttrnify of adhering. But there can be no 
 doubt that these mucous membranes are but little disposed to throw out true lymph 
 at all : and when their opposite surfaces do grow together, I believe it will almost 
 always be found that some abrasion or ulceration of the mucous surface had previ- 
 ously happened. 
 
 Inflammation affecting the mucous membranes has sometimes a strong tendency 
 to spread and wander : sometimes, on the contrary, it is strictly confined to a small 
 and definite space. In the former case it commonly restricts itself for a long time, 
 or altogether, to the mucous tissue, leaving the neighbouring tissues untouched. In 
 the latter it is apt to penetrate to the subjacent parts, and to produce obvious and en- 
 during alterations of structure. The membrane becomes faster 3d to the parts which 
 it should, loosely clothe, and not unfrequently it ulcerates or sloughs. 
 
 The spreading form of inflammation is most often met Avilh in the air-passages. 
 Ulceration and sloughing, and circumscribed inflammation, are more common in the 
 ahmentary canal. 
 
 There is a remarkable contrast between the serous membranes and the mucous, 
 in respect to pain which attends t/heir inflammation. Very little pain is experienced 
 in many cases, when inflammation affects the mucous lining in any of the three 
 systems, except towards their openings, where the membranes are about to become 
 continuous with the external skin : in the mouth and throat, for example, the pha- 
 rynx, the rectum, the vagina, the extremity of the urethra. And as inflammation 
 of the mucous membranes is attended with less pain, so also it is accompanied by 
 less fever than when the serous membranes are attacked ; and the blood more seldom 
 exhibits the buffy coat. 
 
 The muscular tissue appears to take on the actions of inflammation ver)'^ reluc- 
 tantly : and its vessels seldom, if ever, pour forth any of the products of inflammation. 
 The chief effect of inflammation upon muscle, is the destruction of its contractile proper- 
 ties. Serum and lymph, and even pus, are sometimes found diffused through mus- 
 cular parts ; bi.it there is reason to believe that these eflusions are rather the 
 consequence of inflammation of the areolar tissue which enters into the composition 
 of the muscle, and ties together its fleshy fibres, than of inflammation of those fibres 
 themselves." 
 
 I have remarked already that inflammation of an artery presently leads to tho 
 effusion of lymph, and the coagulation of the blood, within the artery. But arteries 
 do not readily inflame, except under mechanical injury ; they do not often suppurate 
 either: and they possess a singular power of resisting mortification. Dr. J. Thomp- 
 son declares that he has seen cases of phlegmonous erysipelas, in which " several 
 inches of the femoral artery were laid completely bare by the gangrene, ulceration 
 and sphacelus of the parts covering it, without its giving way before death." 
 
 Inflammation of the veins is much more common than that of the arteries : and it is 
 a disease of fearful interest. In some cases it leads to a deposit of fibrin upon the inside 
 of the vessel, "furring it over," as Mr. Hunter says. The blood soon coagulates, 
 and blocks up the inflamed vein, or leaves, perhaps, a narrow passage in its centre. 
 From this mechanical obstruction to the current of the blood new symptoms arise 
 The part from which the venous trunk receives its tributary branches becomes osde- 
 niatous or dropsical. Inflammation of the femoral vein, obliterating its cavity, is the 
 essence of the complaint known to pathologists under the name of phlegmasia
 
 INFLAMMATION OF THE BRAIN. 123 
 
 dolens : a complaint which majr happen to persons of any age, and of either sex ; 
 but which is most common, in women soon after parturition. 
 
 This, which may be considered the adhesive form of phlebitis, is also its most • 
 innocent form. Too frequently the inflammation runs into suppuration : and then it 
 proves a most terrible and almost hopeless disorder. The vein remains pervious: 
 pus, of an unwholesome and poisonous qualitj^ — or some morbid product of the in- 
 flammation — is carried into the blood ; which thus scatters, in its course, the seeds of 
 inflammation, and determines the rapid formation of purulent collections, in various 
 and distant parts of the body, and especially in the lungs, the liver and the larger 
 joints. Great constitutional disturbance ensues, and fever of a typhoid type is often 
 established. To this, the destructive form of the disease, parturient Avomen are also 
 peculiarly liable. Phlebitis of ^ the uterine veins constitutes the source of the most 
 dangerous and deadly varieties of puerperal fever. It is the same disease which 
 gives to a vast majority of those surgical operations that are followed by death, their 
 fatal character. 
 
 We hear continually of inflammation of the bram ; but what is so called is, most 
 commonly, inflammation of the membranes which invest the brain. Inflammation of 
 the cerebral substance itself is, however, not very uncommon ; but it is more fre- 
 quently the result of injury than of spontaneous disease, and it is usually confined 
 to a limited portion of the brain. Softening and suppuration are its ordinary events. 
 Sometimes pus is met with, occupying a distinctly circumscribed space ; the pus is 
 collected into an abscess. Sometimes, on the other hand, it lies loose, as it were, 
 and surrounded by broken-down cerebral matter, or it is infiltrated into the cerebral 
 pulp. Around the softened portions the inflamed substance of the brain is more 
 dense and firm, sometimes, than is natural. Whether this be owing to the presence 
 of coagulable lymph, has not (so far as I know) been clearly ascertained. Mortifi- 
 cation must be very rare in the nervous substance. Dr. Bailhe has described it as 
 occurring after violent injury. Once or twice in my Hfe, portions of brain have been 
 shown to me, protruding through an aperture in the skull, dead, of a dark colour, 
 and having an offensive smell. Excepting in these cases of hernia cerebri, I have 
 never seen sphacelus of the brain from any cause. 
 
 Perhaps, however, I am incorrect in saying this. I formerly told you that portions 
 of the brain often become soft and diffluent, when there has been no inflammation : 
 but simply from atrophy, depending on a diseased state of the nutrient arteries of 
 the brain. Now some persons call this, mortification of the cerebral substance. 
 They consider it quite analogous to the gangrena senilis, which results from a similar 
 cause, although it happens in another part of the body. 
 
 The nature of the change, they say, is the same, although the physical cha- 
 racters of it differ. If this be so, I have seen gangrene of the brain some scores of 
 times ; but still I should be able to declare, that with, perhaps, the exception already 
 mentioned, I have never seen unequivocal mortification of the cerebral substance 
 as the result of injlammation : which is what we have now been considering. 
 
 This concludes, gentlemen, what I have to say concerning the phenomena of 
 common inflammation, as they are perpetually witnessed in the various textures of 
 the body. 1 have not, indeed, gone through aU the tissues ; I have said nothing of 
 the peculiar effects of inflammation in cartilages, for example, and in bones ; but 
 I have glanced at all those tissues in the inflammation of which the physician is 
 chiefly concerned. Upon such points as I have purposely omitted, you will be 
 amply instructed by mv colleaa-iie. the professor of surgery.
 
 124 INFLAMMATION. 
 
 LECTURE XII. 
 
 Varieties of Injlammation: Acute and Chronic; Latent; Specific. Scrofulous 
 Inflammation. Tubercles. Relative frequency of Scrofulous Disease in liifjer- 
 ent Organs. Signs of the Strumous Diathesis. 
 
 We have now, gentlemen, considered the phenomena of inflammation, local and 
 general ; its symptoms and its events ; and the intimation of those events which is 
 aflx)rded by the state of the system at large ; and we have surveyed the principal 
 tissues of the body, and observed the modifications and peculiarities to which the 
 process of inflammation is liable, according as it is situated in the one or the other 
 of those tissues. 
 
 There are still some varieties of inflammation ; and some epithets applied to 
 inflammation ; which require to be explained. 
 
 Acute, and chronic, inflammation : these are words perpetually in our mouths. I 
 have frequently employed them already. What do they mean ? Is acute inflam- 
 mation difffc>rent from chronic in kind? No: they differ only in degree. 
 
 When the disease runs its course rapidly, and is attended with much general as 
 well as local disturbance, it is said to be acute. When, on the other hand, the local 
 and constitutional symptoms are less violent, and the inflammation runs a longer 
 course, its phenomena following each other in slower succession, it is said to be chro- 
 nic. The process is the same, but its features are less strongly expressed. The dis- 
 ease passes through similar stages in both cases, but it travels at a different pace. 
 The characters, then, of acute inflammation are intensity of symptoms and rapidity 
 of progress : and the characters of chronic inflammation are mildness of symptoms 
 and slowness of progress. Inflammation can scarcely be very violent, and at the 
 same time of very long duration. When violent it has been likened (by Mr. Law- 
 rence, Avhose language I have here adopted) to a blazing fire, which soon burns itself 
 out. It may, however, be mild in its symptoms, and yet quickly over. The two 
 terms acute and chronic are not directly opposed to each other : acute has more rela- 
 tion to the intensity, chronic to the duration of the disease ; and some term is wanted 
 — althoueh it is hardly worth seeking for — to denote such a degree of inflammation 
 as exists in a pimple : which is neither severe nor long-continued. 
 
 Now, in respect to intensity of duration, there are innumerable shades of difl^er- 
 ence in difitrent cases of inflammation; and the same difficulty occurs here which 
 always occurs when general terms are employed to express mere differences of 
 degree. We feel no uncertainty or hesitation about those cases which occupy the 
 two extremes of the scale ; but with regard to those which lie in the middle we are 
 often at a loss. To meet this difficulty some pathologists have invented a third epi- 
 thet, viz., sub-acute, intending to designate thereby cases which hold an equivocal 
 rank ; which are neither decidedly acute nor plainly chronic ; in which the inflam- 
 mation may run a brief course, and be attended with a certain degree of fever; but 
 attains no great intensity, works no profound changes, and does not require very 
 tmergetic remedies to control it. 
 
 You must not suppose that, because chronic inflammation is attended with less 
 tumult and disturbance, it is necessarily on that account less dangerous or less de- 
 structive than acute. The latter is commonly more obedient to the influence of 
 remedies than the former: it is usually soon brought to an end: whereas chronic 
 inflammation is often obstinate and abiding, and leads to very serious changes in the 
 part upon which it fastens. Speaking, generally, it tends to thicken and indurate 
 when it is situated in the interior of organs, and to the effusion of pus when it affects 
 membranes, or surfaces. It is more common in weakly and debilitated persons than 
 .n others ; but you must not forget that such persons are also very liable to acute 
 <nflaminaticn. 
 
 Chronic inflammation is not unfrequently a sequel of acute inflammation. And 
 vnat the two differ me'-ely in degree, and not in kind, is evident from this : that acute
 
 VARIETIES OF INFLAMMATION. 125 
 
 inflammation may sink or subside into chronic ; and that, on the other hand, chronic 
 inflammation may readily be aggravated into acute. 
 
 There is another, but less inteUigible division of inflammation into active and 
 passive. I believe that they who use the term passive inflammation intend to signify 
 by it that languid and sluggish kind of inflammation which is apt to occur under the 
 same circumstances, and in the same conditions, with passive congestion. When 
 the granulations of an ulcer are in that state in which they may be made brighter, 
 smaller, and healthier, by the application of a stimulus; when the blood-vessels of 
 the eye are left, after acute inflammation, turgid and tortuous ; and that condition is 
 improved, instead of being worsened, by the use of a stimulating lotion : in such 
 cases as these, some persons would say there was passive inflammation. But I see 
 little difference between this and chronic inflammation ; nor do I know any differ- 
 ence between active and acute inflammation. 
 
 The term latent inflammation is one of modern introduction. It is applicable to 
 those cases in which internal inflammation runs its course silently, treacherously, 
 and unperceived ; without the usual warning tokens of its presence ; without its 
 more striking and prominent signs. Pneumonia, going on to disorganization of the 
 lung, may arise, proceed, and even prove fatal, without any of the symptoms which 
 ordinarily announce that disorder : without notable cough, or obvious dyspnoea, or 
 complaint of pain, or the expectoration proper to pneumonia. And the same is true 
 of other inflammations. We discover, with surprise and horror, the traces of their 
 operation, when we come to examine our patient's dead body. 
 
 This is a most important form of inflammation ; for though it does not declare 
 itself to ordinary observation, neither does it occur absolutely without symptoms ; 
 but it requires that the symptoms should be looked for. The auscultatory signs of 
 pneumonia, all those symptoms which are furnished by the physical condition of the 
 affected organ, are present, and speak as clearly as in the more flagrant cases. 
 
 Latent inflammation is apt to creep on during the progress of certain disorders, 
 whereby it is modified and masked. It belongs to those states of the system in which 
 the sensibility is dull, and the vital powers languid. In continued fever not only 
 have I known the lung pass into suppuration, when the existence of pneumonia had 
 been unsuspected : but I even have seen one case in which that usually torturing 
 accident, perforation of the bowel, took place, with the escape of its contents into the 
 cavity of the abdomen, and extensive peritonitis — yet the patient expressed no sense 
 of pain, and the inflammation was revealed, while he continued to live, by no intel- 
 ligible symptom. 
 
 Inflammation of this insidious and lurking character is most to be apprehended in 
 the aged, in those who are habitually intemperate, and in persons of sluggish tem- 
 perament. It sometimes occurs during convalescence from acute diseases. 
 
 Besides the varieties which have been mentioned in degree, there are also difl^er- 
 ences in hind among inflammations. What I have been speaking of during the 
 preceding lectures I have called common inflammation. It is the most common form 
 in which that process displays itself. All persons are liable to it ; and that again 
 and again. None are at any time privileged from its attacks. But there are several 
 forms of inflammation different from this, which are called specific. There are vari- 
 ous forms of specific inflammation affecting the skin, discriminated from each other 
 by the local appearances they exhibit, and by the constitutional disorder which 
 attends them. The rash and the fever of measles, are very unhke the rash and the 
 fever of scarlatina ; and both differ remarkably from those of small-pox, the eruption 
 of which consists of little phlegmons. In each of these diseases the application of a 
 specific poison is required for its production : and whereas common inflammatii;«L 
 has a tendency, when once it has happened, to happen in the same part again — tc 
 recur — these forms of specific inflammation never, or almost never, occur more than 
 once. 
 
 There is again the gouty inflammation — differing from common inflammation m 
 <ieveral signal respects ; in the production of chalk-stones ; in its attacking those 
 who are descended from ancestors who have had the disease, and scarcely an/ 
 others. Then there is rheumatic inflammation, cousin-german to the gouty, yet dis- 
 
 l2
 
 126 INFLAMMATION. 
 
 linguishable from it. And another variety of inflammation is that which arises from 
 •he introduction of the syphihtic poison into the system. 
 
 Of the specific forms of inflammation now adverted to I shall speak when I come 
 to consider gout and rheumatism, and the contagious exanthemata, as distinct diseases. 
 But there is one variety of inflammation — I mean the scrofulous — which meets us 
 on everj^ side ; and is apt to afiect so many parts of the body, and so great a number 
 of persons ; and has so fatal a tendency in most cases : that it cannot be left out of 
 the account that I have been desirous to give you of inflammation in general. 
 
 Scrofulous or strumous inflammation (for struma and scrofula are convertible 
 terms) is a slow process ; it falls therefore within the class of chronic inflammations. 
 It is not attended with much pain, or heat, nor for some time with much change of 
 colour; and the redness which does accompany it has often a livid or purplish 
 tinge. 
 
 These, however, are the negative properties of merel}* chronic inflammation. But 
 suppuration at length occurs, which also lasts long : and the pus formed is peculiar 
 and characteristic ; and by no means laudable. It is not homogeneous or smooth, but 
 consists partly of a thin serous whey-like fluid, and partly of fragments of a substance 
 resembling curd : and the ulceration that ensues is marked by corresponding pecu- 
 liarities. The ulcers are indolent ; show but little disposition to heal. Scrofulous 
 inflammation, compared with common, or what is called healthy inflammation, is in 
 general but little influenced by remedies. 
 
 Besides this scrofulous hiflammation, it is necessary that I should now direct 
 your attention to another form of disease, which is likewise properly denominated 
 scrofulous. It is marked by the appearance, in various parts of the body, of what 
 are called tubercles. These tubercles are masses of unorganized matter — also 
 resembhng curd or new cheese, more or less ; but of various shapes and sizes. They 
 suffer gradual changes ; soften or break down ; undergo a sort of suppuration ; and 
 the softer matter into which they thus (as it were) mek, has the characters that dis- 
 tinguish the pus of a scrofulous ulcer or abscess. 
 
 Now tubercles and scrofulous injiamnuition occur very continually in the same 
 individuals : and what is remarkable, although thej'' affect a very large portion of 
 the whole human race, and conduce more often and more surely than any one thing 
 else to shorten the natural period of human life, yet they belong, almost exclusiveh% 
 to certain classes of persons. We can tell, beforehand, that such and such persons 
 are likely to become affected with scrofulous inflammation, or with tubercles : and 
 we say of those persons that they hav ■; the scrofulous diathesis. I will not posi- 
 tively affirm that these forms of disease cannot be produced in any or in all persons ; 
 but thus much is certain — that some persons are particularly prone to them : fall 
 into them as it were spontaneously : or on the operation of very slight external 
 causes ; and even when all possible care is taken to prevent the operation of every 
 ascertained cause ; while other persons never show any tendency to scrofula, even 
 when continually exposed in the same manner ; or if they do become scrofulous at 
 all, it is only when the external circumstances most favourable to the production of 
 such disease have been extreme in degree, and protracted in their application. 
 
 The occurrence of scrofulous injlammation in various parts constitutes distinct 
 diseases ; and the occurrence of tubercles in various organs constitutes other 
 diseases. It will facilitate our future inquiries into these several diseases, if I take 
 this opportunity of staling to you what is known respecting the scrofulous diathesis 
 generally ; and of the modifications of inflammation which are determined by its 
 presence. 
 
 A good deal of discrepancy, obscuring the whole subject, and puzzling the 
 student, has existed — and I believe I may say still exists — among pathologists, as to 
 the nature, and origin, and precise seat of tubercles, and as to the changes which 
 they undergo. 
 
 In general they have been loosely described as being round masses of firm but 
 friable matter, deposited in various parts of the body. Laennec, who paid great 
 attention to tubercles, states that they are, at first, small, firm, grayish, semi-transpa 
 rent bodies, which gradually enlarge and become opaque. In that condition he calL*
 
 TUBERCLES. 127 
 
 them crude tubercles. At length, after an indefinite period, these crule tubercles 
 begin to grow soft in their centres, and are by degrees converted each into a liquid 
 mass, having the consistence of cream. There is much error in this description. 
 
 Andral, another great authority, says that tubercles are, m the outset, small, round, 
 opaque, yellowish bodies, unorganized, and of various degrees of consistence. He 
 ascribes their softening (not to any spontaneous changes in their central parts, but) 
 to the admixture of pus, poured out by the textures immediately surrounding the 
 tubercle ; which has irritated and inflamed those textures as any other foreign body 
 might. 
 
 In some respects this statement is nearer the truth than Laennec's. 
 
 But in the account which I am about to give you, I shall chiefly follow our coun- 
 tryman. Dr. Carswell, the first Professor of Pathological Anatomy in University 
 College ; who is one of the latest, and, as I think, most satisfactory writers on the 
 subject. His opinions were formed after a long and careful examination, for himself, 
 of the parts infested by these tubercles. He devoted several years to the study of 
 morbid anatomy, in Paris, where he made a very large collection of drawings, in 
 which various diseased appearances are beautifully, and doubtless faithfully deli- 
 neated. Some of these he has since published, 1 show you enlarged copies of 
 those which relate to tubercle. They bear out some novel opinions which are stated 
 in the letter-press which accompanies them. 
 
 After all, the points in question possess more of curious interest than of practical 
 importance. But as you cannot help forming some notions respecting them, I think 
 myself bound to lay before you those which most recommend themselves to my own 
 judgment. At the same time you are to understand that I do not vouch for their 
 absolute correctness. 
 
 Tubercles, then — or rather tubercular matter, is deposited from the blood. Whether 
 it is something totally new, something foreign to the natural materials of the body, 
 introduced into the blood from without — or whether, as seems more likely, it is the 
 result of some defect or error in the due elaboration of the blood itself — I cannot 
 satisfy you. If, as has been supposed, the deposit is at first fluid, it afterwards be- 
 comes firmer, through the absorption of its more watery particles ; and there then 
 remains a " pale yellow, or yellowish gray, opaque, unorganized substance." This 
 tubercular matter, so deposited, does not always assume a round form: far from it; 
 the shape in which it appears depends upon the nature of the part wherein it is 
 planted. It used to be held that the tubercular matter was always laid down in the 
 areolar tissue. But Dr. Carswell asserts that its most favourite seat (if one may so 
 speak) is the free surface of mucous membranes. In whatever organ it is met with, 
 if mucous tissue enters into the composition of that organ, that particular tissue is 
 either (he says) exclusively affected, or much more extensively affected than any of 
 the other component tissues. These remarks apply to the lungs, the alimentary 
 canal, the liver, the urinary organs, and the organs of generation ; but the presence 
 of the tubercular matter is much more easily detected in the mucous tissue of some 
 of these organs than in that of others. It is very conspicuous in the Fallopian tubes 
 and uterus. 
 
 But tubercular matter is often deposited on serous surfaces also; among which Dr. 
 Carswell includes the plates of the areolar tissue. It is even to be seen sometimes 
 in the blood itself: not indeed while it is retained in its proper vessels, but when it 
 is collected in the cells of the spleen. You know that the spongy texture of that 
 organ allows the blood to accumulate in it in considerable quantity : and the tuber- 
 cular matter may be seen forming in the blood at some distance from the walls of the 
 cells in which the blood is contained. In one cell, according to Dr. Carswell, you 
 may perceive simply the blood coagulated : in another, it will be coagulated and 
 deprived of its colouring matter; and in another, converted into a mass of sohd 
 fibrin, having in its centre a small module of tubercular matter. 
 
 Now when a speck or morsel of tubercular matter has been deposited anywhere, 
 il is liable to increase. It grows larger by continued accretion ; by additional deposits 
 upon its surface. This being the case, we see plainly enough how it happens that 
 tubercles assume different shapes, according as they occur in different parts. Thn
 
 128 INFLAMMATION. 
 
 round form which is so often observed is purely accidental. When a tubercle is 
 deposited in the substance of the brain — and becomes larger by the repeated acces- 
 sion of fresh tubercular matter upon and around it — it naturally takes a spherica. 
 form, because there is nothing to limit its enlargement, except the soft cerebral matter 
 Itself, nhich presses it with equal force on every side. For the same reason tuber- 
 cles deposited in the areolar tissue are globular. In like manner, if tubercular 
 matter be laid down in one of the pulmonary vesicles, so as to fill it up, it exhibits 
 the roundish form of the vesicle. When it fills the cavity of a mucous follicle, it 
 has a similar figure. But in the smaller bronchi it takes a more cylindrical arrange- 
 ment. When (as often happens) it occupies one of these tubes, and also all the air- 
 cells to which that tube leads, then we have twigs of tubercular matter, with cauli- 
 flower terminations. You see this depicted in the drawings before you. In the 
 cavity of the uterus, and the Fallopian tubes ; in the infundibula and pelvis of the 
 kidney, and in the ureters ; and in the lacteal and lymphatic vessels ; the tubercular 
 matter is moulded to the forms of these parts respectively. We are more in the 
 habit of examining tubercles in the lungs than anywhere ^Ise ; and you will observe 
 mat in making sections of these organs, and looking only at the surfaces of those 
 sections, we may easily overlook the branch-like disposition of the tubercular matter 
 in the smaller bronchial tubes. We see the transverse section only of the tubes, 
 which is necessarily more or less circular. On the surfaces of serous membranes, 
 whether natural or adventitious, the tubercular matter will assume a rounded, or a 
 lamellated form, according as the morbid secretion in which it originates has taken 
 place from separate points, or from a continuous surface. 
 
 From what has now been stated you will perceive that no alteration can be ex- 
 pected to take place in the tubercular matter after once it has been deposited, except 
 throucrh the agency of the parts around it and in contact with it. It is never org-an- 
 ized, or capable of organization ; md, consequently, no vital change in its consist- 
 ence can originate in the tubercle itself. If any spontaneous change arises, it must 
 be a chemical one : and of such we have no evidence at all. 
 
 It may therefore seem odd, that so accurate an observer as Laennec should have 
 persuaded himself that the softening of tubercles begins in their centre. 
 
 Now Dr. Carswell has given what appears to me a sufficient explanation of this 
 mistake. Take the lungs ; the morbid conditions of which were the most especial 
 object of Laennec's investigations. The tubercular matter is effused (principally) 
 upon the mucous surface ; upon the inner hning of the air-cells, and of the bronchial 
 tubes communicating with them. Yet it need not so accumulate as to Jill these 
 cavities ; and it often does not ; there is left a central vacuity, which contains mu- 
 cus, or other secreted fluids : and if the lung be cut across under these circumstances, 
 the divided air-vesicles will look like rings of tubercular matter grouped together; 
 and each divided bronchial tube will present also the appearance of a tubercle, with 
 a central depression, or soft central point. On the other hand, when the tubercular 
 matter has completely filled and blocked up these cavities, both vesicles and bron- 
 chial tubes will look, when divided, like sections of round solid tubercles. These 
 Laennec seems, in fact, to have regarded as crude tubercles: while he mistook the 
 former appearances for tubercles which were beginning to soften in their centres. 
 
 But you sometimes find large masses of tubercular matter in the lungs or else- 
 where : and in these masses you see that the process of softening is going on at 
 several points, within the mass, at the same time. How is this to be explained ? 
 Why these large masses are formed, in fact, by the aggregation of many smaller 
 masses, Avhich lying near each other, have coalesced as the deposit continued to 
 increase : and the areolar and other tissues originally intervening between these 
 coalescinor masses at length suppurate, by reason of the augmenting pressure ; and 
 by their suppuration, they soften, and gradually break down the tubercular matter 
 •"hich they enclose, and by which they are also enclosed. This is just the process 
 Dy which tubercles are frequently expelled from the body. They increase till the 
 surrounding parts take on inflammation, just as they might do if any foreign body 
 exercised the same degree of pressure upon them. The inflammation thus excited 
 '..s of the scrofulous kind ; the thin pus which is thrown out pervades and loosens
 
 TUBERCLES. 129 
 
 the tubercular matter ; a process of ulceration which goes on in the surrounding tex 
 tures ; and at length (supposing the lung to have been the seat of disease) the detritus 
 of the tubercle is brought up, gradually, by coughing. 
 
 Both Laennec and Louis, the latter also being a very close observer, describe the 
 nascent tubercle as a gray semitransparent corpuscle. I have frequently seen such ; 
 but the appearance is rare, in comparison with the more opaque form of tubercle. 
 Of this, too, Dr. Carswell offers what I think a very probable explanation. He says 
 that the mucous membrane of the air-tubes separates from the blood, not only the 
 matter of tubercle, but also its own proper secretion : and that, frequently, when the 
 two have been poured out together, a dull yellow opaque point of tubercular matter 
 becomes set, as it were, in a portion of gray, semitransparent, and, sometimes, in- 
 spissated mucus. The same deceptive appearance is common on serous membranes : 
 in tubercular peritonitis, coagulable lymph exudes, portions of which envelop little 
 globular masses of tubercular matter. 
 
 The account which I have now given you, and which I hope I have made intelli- 
 gible, is, I think, extremely interesting — and much credit is due to Dr. Carswell for 
 having so greatly simplified our views of a subject which had previously been 
 wrapped in profound obscurity. In no other writer, that I know of, is there to be 
 found so complete and credible an explanation of the origin of tubercles ; of the 
 forms they assume, of the phenomena attending their enlargement and subsequent 
 softening, and occasional expulsion. 
 
 [According to Barthez and Rilliet, who have given the most complete and accurate 
 description of tubercle, tlie various forms under which tubercle is found are the following: — 
 the miliary or gray tubercle, the yellow or crude tubercle, the gray and yellow forms of infil- 
 tration, the gelatinous infiltration, and tuberculous dust. There is no reason for ascribing 
 these forms of tuberculous matter solely to tubercle of the lung. As M. Valleix remarks, 
 incontestable proofs may be adduced to prove that the gray granulations of Laennec occur in 
 all the organs, and as the researches in pathological anatomy have been more carefully con- 
 ducted, these proofs have been multiplied. M. Papavoine, in his interesting memoir " On 
 Tubercle considered particularly in Children" expresses himself thus: — "We cannot admit the 
 seat of the gray granulations to be only in the pulmonary vesicles : forms of alteration 
 exactly similar, are to be met with in the lymphatic glands, in the liver, the spleen, and on 
 the serous membranes, especially in certain cases of general and acute tuberculization." 
 The statement of M. Nelaton leaves no doubt of the development of gray semitransparent 
 granulations in the osseous tissue. He has been able, repeatedly, to determine that the 
 Pubercles of the bones, like those of the lungs, recognize for points of departure, the gray 
 semitransparent granulatione described by Laennec, Louis, and others {Rccherches sur I'affcction 
 tuberculeuse des os, 1836). Dr. Glover has observed, in granular meningitis, the forms of 
 gray granulation, and yellow particles, answering very well to the yellow points which 
 appear in the gray granulations of the lungs. The miliary tubercle may exist in all the 
 organs, and it is in the form of gray infiltrated matter, granular to the microscope, more or 
 less dilfused through the aibstance of a gland that we detect the first occurrence of mesen- 
 teric tubercle ; afterwards we find a more crude or yellow appearance of the tubercle matter. 
 as in the bxngs. The appearance of infiltrated gray matter is especially marked in effusions 
 organized between the tunics of the intestinal canal. Some of the illustrations presented 
 by Dr. Glover (^Pathology and Treatment of Scrofula') show the tubercular effusion in a 
 mesenteric gland : — Istly, ia a diifused form throughout the hypertrophied tissue of the organ ; 
 2dly. forming strise and patches, varying in hue from gray to yellow; 3dly, in cysts filled 
 either with a tuberculous powder or with a curdy matter; 4thly, in masses of lardaceous 
 consistence, implicating either the whole gland, or more or less of its structure. We have 
 specimens, likewise, remarks the same author, of bronchial glands, and bronchi sprinkled 
 over, as it were, with a tuberculous powder, and studded with cretaceous particles. 
 
 "The gray granulation," as Barthez and Rilliet observe, "exists in all the organs, not only 
 in the intestines, peritoneum, and pleura, but in the spleen, the liver, the kidneys, th% 
 lymphatic glands and cerebral meninges." — (Maladies des Enfans^ In fact all the forms of 
 tubercle which occur in the ditferent organs are brought about chiefly by mechanical cause.-, 
 and differ very slightly in a physiological sense, never in their more minute anatomy. Thus, 
 for example, the liver is an organ, in which tumours generally are of large size, and of 
 various and irregular shapes ; in the lungs, the air-cells and the membranous charactei of 
 the tissue tend much, if the effusion be not rapid, to surround it, while progressing and 
 stiffening, with envelops of a membranous nature. The brain, from its structure, mus: 
 oppose pressure in every direction in which the progress of a deposit in its interior can takrt 
 place, and thus we find tubercles of the brain generally of small size and regularly circuni 
 9
 
 130 INFLAMMATION. 
 
 scribed. Between layers of membrane we find the deposit stretched out in flakes. In the 
 sub-cutaneous cellular tissue it forms irregular masses. On the free surfaces of mucous or 
 serous membranes its figure is irregular, or it occurs in superficial layers. In the bones, in 
 general, it is in little round granules, or in very circumscribed masses. — C] 
 
 These processes — of softening, produced by surrounding inflammation, and of 
 ultimate expulsion — may be regarded as a natural mode of cure. Such a cure is in 
 truth occasionally accomplished. A scrofulous abscess forms in the glands of the 
 neck; and pus and tubercular matter are discharged. At length the ulcer heals, 
 and no trace of the diseased process remains, beyond a scar. The same thing takes 
 place also in the lungs ; and, if there have been only one or two masses of tubercle 
 deposited, the patient may thus get quite well: but unfortunatelj'-, as the scrofulous 
 matter is extirpated from one part of the lung, it is apt to be multiplied in another, 
 till at length we have death by hectic, and all its melancholy accompaniments. 
 
 But I am desirous of pointing out to you another way in which tubercular disease 
 may be said to be cured by a natural process. And this also has been better described 
 by Dr. Carswell than by any other writer. One form of scrofulous disease, exceed- 
 ingly common too, especially among children, is what is called '• tabes mesentej-ica." 
 Tabes and phthisis, the one a Latin and the other a Greek word, signify, I need 
 scarcely tell you, the same thing: a wasting away, or a consuming: and phthisis is 
 applied to the same disease in the chest, to which tabes is applied in the belly. The 
 common English word is consumption ; and we might very well speak of thoracic 
 consumption, and of abdominal consumption ; but the technical name of the latter 
 complaint is tabes mesenterica. This is not only a very common but a very fatal 
 disease in children and young persons. The glands of the mesentery enlarge and 
 become charged with tubercular matter : but then they very rarely suppurate. Their 
 enlargement is commonly connected with scrofulous disease and ulceration of the 
 mucous follicles of the intestines; and the little patients die, because the lacteals are 
 no longer able to take up from the food a sufficient supply of nutriment : they die 
 starved. But some few do recover from tabes mesenterica. Dr. Carswell relates 
 an interesting case in which such recovery took place, and in which he had an op- 
 portunity of examining the glands at a subsequent period : it is the only case of the 
 kind perhaps on record. He says, " the patient who when a child had been affected 
 with tabes mesenterica, and also with swellings of the cervical glands, some of which 
 ulcerated, died at the age of 21, of inflammation of the uterus, seven days after 
 dehvery. Several of the mesenteric glands contained a dry cheesy matter, mixed 
 with a chalky-looking substance ; others were composed of a cretaceous substance ; 
 and a tumour, as large as a hen's egg, included within the folds of the peritoneum, 
 and which appeared to be the remains of a large agglomerated mass of glands, was 
 filled with a substance resembling a mixture of putty and dried mortar, moistened 
 with a small quantity of serosity. In the neck, and immediatelj^ beneath an old 
 cicatrix in the skin, there were two glands containing in several points of their sub- 
 stance (which was otherwise healthy), small masses of hard cretaceous matter." 
 
 Now what Dr. Carswell here saw in the mesentery and in the neck, is what 
 sometimes occurs in other parts of the body ; in the lungs ; and particularly in the 
 bronchial glands at their root, and about the bifurcation of the trachea. From these 
 situations, the hard chalky matter left by the absorption of all the more watery part 
 of the morbid deposit, and by the concretion of its earthy salts, is often coughed up. 
 But it may remain, when the tubercles are few, and there is no tendency to their 
 increase, for years, as an inert, and almost harmless miss. 
 
 I mentioned just now that the secretion or separation of the matter of tubercle 
 from the blood, takes place, by preference, upon the free surface of mucous mem- 
 branes, and very frequently also upon the surface of serous tissues, including the 
 areolar. 
 
 It may not be uninterestmg to inquire into the relative frequency of scrofulous 
 disease in different organs, or in different parts of the same organ. The facts 
 which we possess on this head afford us very valuable assistance sometimes in 
 respect of diagnosis. 
 
 During the periods of childhood and youth the lymphatic glands are excee Jingly
 
 TUBERCLES. 131 
 
 prone to scrofulous inflammation ; especially the mesenteric and the cervical glands. 
 But in adult age tubercles are, beyond all comparison, most frequent in the respira- 
 tory organs ; and they occupy the summit of the lung much more commonly and 
 thickly than any other part. The superior and posterior portion of the upper lobe 
 is the spot in which, if any tubercles at all exist in the lung, they are almost sure to 
 be found. It is here also that they first begin to suppurate or soften. This law has 
 long been well known : and so constant is it, that Dr. Carswell holds the formation 
 of tubercles in any other portions of the lung to be always of secondary occurrence. 
 He declares it to be the result of his experience (and few persons can have had 
 more opportunities of examining diseased lungs), that there is no deviation from this 
 rule, except when some other portion of the lung may have been the seat of an in- 
 flammatory attack, which has determined the priority of tubercular disease in that 
 portion. We shall see hereafter what a very important bearing a knowledge of 
 this law has, in settling the nature of a complaint which might, without it, be 
 doubtful. 
 
 Scrofulous ulceration of the larynx and trachea, when they occur, are usually 
 concomitants of tubercular deposits in the lungs. 
 
 Next, tubercular or strumous disease is exceedingly common in the digestive 
 organs : most of all in the mucous follicles of the small intestines ; both in those 
 follicles which are separate, and are called glandulse solitarice ; and in those which 
 are collected into roundish or oblong groups, the glandulse agminatas. It is second- 
 arily to these affections of the follicles, in many cases at least, that the glands of the 
 mesentery become implicated. Tubercular deposits are frequent also in the solitary 
 glands belonging to the CiECum. The ulceration which follows the evacuation of the 
 strumous matter from these parts gives the interior of the bowel an appearance 
 somewhat resembling that of a moth-eaten garment. Tubercular matter is seldom 
 deposited in any other parts of the intestines, great or small, than those which I have 
 mentioned. Dr. Carswell supposes that it may often be secreted upon the free sur- 
 face of the membrane, but that, not being entangled or confined in any mucous 
 crypt, it is removed as soon as it forms. It is not often that scrofulous tubercles are 
 found in the liver of adults : they are not very uncommon in that organ in children, 
 but even then they are few in number and small in size. It is a curious fact that 
 they are much more frequently seen in the spleen also in children, than in grown 
 up persons. The uterus, the testicle, the proscate gland, are all liable to them : they 
 are common enough upon the surface of the peritoneum. 
 
 In the nervous system, tubercles are by no means unfrequent : they are met with 
 oftener in the brain than in the spinal cord. That fearful disorder of childhood, 
 known by the name of hydrocephalus, occurs principally, if not altogether, in con- 
 nection with the scrofulous diathesis. 
 
 Strumous deposits are rare in the organs of circulation. Tubercles have been seen, 
 I believe, in the muscular substance of the heart : but this must be a very uncom- 
 mon thing. Scrofulous disease is not at all unfrequent in bone, ebpeciaily ''n tho 
 bodies of the vertebrjE, and in the spongy extremities of the long bones. 
 
 It is very seldom, indeed, that scrofulous tubercles occur in any one organ only. 
 Almost always they are met with in at kast two, and frequently in all the parts at 
 once which are liable to be infested by them. Sometimes the lungs alone are affected ; 
 but generally both the lungs and the intestines are occupied by the disease. It ha.s 
 been affirmed, by a ffreat hving pathologist, M. Louis, that if you find tubercles in 
 any other organ, you are sure to find them also, and in greater number, and further 
 advanced in the lungs. But this, though true as a general rule, is not without ex- 
 ceptions. I have seen the peritoneum crowded with myriads of these tubercles, 
 when the most careful examination could not detect a single one in the lungs. And 
 similar examples have fallen under Dr. Carswell's observation. 
 
 [The general diffusion of tubercular matter is much more common in children Aan in 
 adults. Thus, in 358 cases where tubercles existed in the lungs in adults, M. Louis notices 
 the existence of tubercular matter in the brain or its membranes only once ; in the bronchial 
 glands it was detected in about one-fifth of the cases ; in the mesenteric glands, in ont-fxflh ; \n 
 the liver, only twice ; in the kidneys, five times in one hundred and seventy cases ; on the otiaer
 
 132 INFLAMMATION. 
 
 hand ulceration of the larynx, existed in one-fourth ; ulceration of the hovels, in five-sixths of 
 the cases. In 180 cases in which tubercles of the lungs existed in children, Dr. Green found the 
 brain to be affected with tubercles in one-ni7ith of the cases ; the bronchial glands, in 100 out 
 of 112 ; the mesenteric glands were tuberculous, in one-half : the liver, in one-ninth ; the kidneys 
 in one eighteenth of the cases ; but ulceration of the larynx occurred only once, and ulceration 
 of the bowels, sixteen times in 112 cases. 
 
 M. Cless, of Stuttgard, his also published the results obtained from the examination of up- 
 wards of ISO bodies affected with tubercular disease. In 152 examinations of adults, M. 
 Cless found the hmgs free from tubercles six times. In 21 examinations of children, he only 
 found the lungs free from tubercles once. This was in a boy eleven years of age, who, besides 
 a considerable serous efiusion into the ventricles of the brain, had two large masses of tubercle 
 in the cerebellum, many small ones on the surace of the liver, and caries of the vertebrae. 
 
 In 146 adults allected with tubercles in the lungs, there were only thirty-five in whom tlve 
 disease was confined exclusively to the lungs. In children there were only three cases out 
 of twenty in which all the other organs were free. M. Cless never found the bronchial glands 
 in children affected with tubercular deposit without the existence of tubercles in the lungs 
 also. In thirteen adults and one child there were tubercles in the pleura. In sixty-one adults, 
 nnd four children, the tubercles were limited to the peritoneum eight times. The four chil 
 dren were between six months and ten years of age. In 152 adults affected with tubercles, 
 the small intestines were affected eighty-three tiixies, and the large intestines thirty-seven times, 
 and jji twenty-one children, the small intestines were affected seven times, the large ones only 
 once. Among 152 adults, thirty-two had tubercles of the mesenteric glands, while they occurred 
 in these glands in seven out of ^u-ejify-one children. In all the cases tubercles were found in the 
 other organs. Tubercles of the liver occurred once in an adult, twice in children, while other 
 organs were also affected. In four adults, and twelve children, the spleen was affected with 
 tubercles, these at the same time existing in other parts of the body. In children M. Cless 
 remarks, the parenchyma of the spleen is often completely invaded by tubercles. In the 
 kidneys, tubercles were met witli four times in adults, and three times in children; of five 
 children, aged from eight months to eleven years, in whom the membranes of the brain pre- 
 sented tubercles, four died of acute hydrocephalus. In all these there ■svere tubercles in the 
 lungs and other organs also. The tubercular granulations had always their seat on the ex- 
 ternal surface of the arachnoid, between this membrane and the pia mater, never within the 
 cavity of the arachnoid. In twenty-seven children who died from tubercles, /owr had tubercles 
 of the brain, as also in other organs ; M. Cless never found any in the brain of adults. Be- 
 sides their existence in the mesenteric and bronchial glands, M. Cless found tubercles in the 
 glands of the neck in five adults, and one child. See Condie on Diseases of Children, 2d 
 edition. — C] 
 
 The question has been much and eagerly discussed, whether the deposition of 
 tubercular matter be not, what I should call, an event of inflammation. Some persons 
 have strenuously argued that the curd-hke substance is nothing more than a parti- 
 cular kind of vitiated lymph, and that it is never poured out except as a consequence 
 of inflammation ; and they cite cases of persons who always had enjoyed good 
 health, until inflammation was accidentally excited in their lungs, immediately after 
 which the well-known signs of phthisis began to display themselves ; and, after 
 death, the lungs were found full of tubercles. But they forget to take into the 
 account another fact equally well established, viz. : that tubercles are found, in great 
 abundance, in the lungs of persons who were never known, in their lives, to have 
 any functional disturbance of those organs ; and whose lungs present, after death, no 
 other traces of having been inflamed. We even find tubercles in the lungs of unborn 
 children. Not that this is conclusive ; for inflammation does sometimes attack th«» 
 foetus in utero, aud leave permanent and unequivocal traces of its action. 
 
 Moreover, inflammation continually happens, in all the component textures of the 
 lung, in the forms of bronchitis, pneumonia, and pleurisy, without the subsequent 
 development of tubercles. I admit that this fact, to be of weight, should be proved 
 of persons who possess the scrofulous diathesis ; and I believe the proof might be 
 found ; but the search for it would require much carefulness and candour. 
 
 In my own opinion, there is not a shadow of evidence to show that the deposit ot 
 tubercular matter is always and necessarily preceded by inflammation. Yet 
 an undoubted and most important connection obtains between the occurrence of in- 
 flammation and the occurrence of tubercles. Tubercles will cause inflammation, and 
 inflammation will determine the development of tubercles. The enlarging tubercles 
 excite inflammation in the surrounding textures by the pressure they exert upon 
 ihem ; and probabl}" in other ways ; by mechanically interfering with the healthy
 
 TUBERCLES. 133 
 
 circulation of the blood, for example : and the inflammation lit up is usually of tho 
 scrofulous kind ; it is slow, and partial, and easily quicled by treatment, though 
 scarcely to be cured. On the other hand, there are numerous facts to prove thut, 
 in a person having the scrofulous diathesis, the occurrence of inflammation with the 
 chest may rouse that previously dormant tendency into action, and become the ex- 
 citing cause of the secretion or separation of tubercular matter from the blood. The 
 cases in which other parts of the lung than the apex are found exclusively occupied 
 with tubercles, are also cases in which, apparently, the same parts had been the seat 
 of inflammatory action :' of which we sometimes see other traces in adhesions of the 
 neighbouring pleura. 
 
 The connection between tubercles and inflammation is shown also by their occur- 
 rence in the substance of false membranes. And the same phenomenon marks the 
 fact that they are something distinct and different from coagulable lymph. 
 
 You must not suppose, from any thing I have said, that persons of the scrofulous 
 habit are not susceptible of common inflammation ; we know that they are, by the 
 readiness with which slight injuries often heal in such persons ; but there is always 
 much reason to apprehend that inflammation occurring in them will take on the 
 scrofulous form ; become chronic, if it was not so at first, suppurate tardily, and pro- 
 duce that unhealthy kind of puriform secretion which is characteristic of strumous 
 disease. 
 
 Another question relating to tubercular diseases is, whether they are contagious : 
 capable, i. e., of being communicated from one individual to another. The general 
 belief, in this country, is that they are not. Indeed their very dependence upon a 
 pecuHar diathesis would seem to disprove the supposition. Yet some practitioners, 
 even here, have, I know, misgivings on the subject : and in some parts of the con- 
 tinent, in Italy particularly, consumptive patients are shunned, from the persuasion 
 that their complaint is infectious. I shall revive this question when I speak of 
 phthisis hereafter. 
 
 I have stated that scrofulous disease appears, almost exclusively, in certain classes 
 of persons, of whom, therefore, we say, that they have the scrofulous diathesis. 
 
 It is both interesting and useful to be able to distinguish those in whom the scro- 
 fulous habit of body, or the predisposition to strumous disease, exists. 
 
 Now there are certain physical and moral characters which teach us to apprehend 
 the existence of a tendency to scrofulous disease, even when there has not, hitherto, 
 been any local manifestation of such disease. 
 
 Again, we infer the scrofulous diathesis, in many persons, from knowing that 
 scrofula has existed among their progenitors. 
 
 On these two points I have a few observations to make : and first, on what may 
 be considered the external tokens of a scrofulous constitntion. 
 
 The persons, in whom scrofulous disease is most apt to declare itself, are marked, 
 during childhood, by pale and pasty complexions, large heads, narrow chests, pro- 
 tuberant bellies, soft and flabby muscles, and a languid and feeble circulation. They 
 present many of the features belonging to that pattern of body which is denominated 
 the leucophlegmatic. But the strumous disposition very often, indeed, accompanies 
 a variety of the sanguine temperament also ; and is indicated by light or red hair, 
 gray or blue ej^es, with large and sluggish pupils, and long silky lashes, a fair trans- 
 parent brilliancy of skin, and rosy cheeks. This red colour, which is well defined 
 in general, is easily changed, however, by cold, to purple or livid ; the skin is thin 
 and readily irritated ; the sclerotic has often a peculiar pearly lustre ; and the extre- 
 mities are subject to chilblains. Such children are, many of them, extremely clever 
 and ready of apprehension, of eager tempers, and warm afltctions, lively, ardent, 
 imaginative, and susceptible. This precocity of mmd and intellect, while it delights 
 the fondness of the parent, awakens the fears of the more far-seeing physician. 
 
 But the disposition to scrofula is by no means confined to persons of the serous or 
 of the sanguine temperament. It is frequent, though less common, in what has been 
 called the melancholic or bilious temperament ; in persons of dark muddy com- 
 plexion, and harsh skin ; in whom the mental and bodily energies are rnore slujrgish 
 
 M
 
 134 INFLAMMATION. 
 
 and dull. And it is remarliod that in persons of this cast, scrofula, when it does 
 occur, is even more than usually obstinate and intractable. 
 
 Scrofula does often, indeed, appear in persons who exhibit none of those signs of a 
 strumous disposition which I have been enumerating; but is move likely to appear, 
 ceteris paribus, where those signs are observed. 
 
 There are several alleged marks of a scrofulous diathesis Avhich are, in fact, in- 
 stances of scrofulous disease. Such, for example, is that chronic lippitudo, which 
 so frequently disfigures strumous children, rendering them what is called blear-eyed ; 
 and chronic inflammation of the conjunctiva, lasting long, without much redness or 
 heat, and with extreme impatience of light, and a tendency to form little pusiules 
 near the edge of the cornea. The tumid and chapped upper lips, the redness and 
 swelling of "the columna nasi, and lower parts of the nostrils, so common in children, 
 especially during winter, are early fruits of the strumous taint. Certain maladies 
 of the joints, what are popularly called white swellings, are instances of scrofulous 
 disease. So may, perhaps, rickets be considered : at any rate, rickeiy children are 
 very often affected with scrofula also. Moist eruptions behind the ears ; chronic en- 
 largement of the glands of the neck ; that slow, eating ulceration of the nares, termed 
 lupus ; may all be included within the class of strumous disorders. 
 
 When any one of these scrofulous affections has once showm itself in any person, 
 we know, by that circumstance, that he possesses the strumous constitution ; 
 and we look for the recurrence of his complaint in the same part, or in other 
 parts. 
 
 In a former lecture I mentioned scrofula as one of those distempers the hereditary 
 tendency to which is indisputable. The scrofulous diathesis is hereditarj' : and 
 sometimes scrofulous disease is so too. I have seen lungs, taken from the body of a 
 foetus, stuffed with tubercles. There were some fine examples of this in Mr. Lang- 
 staff's museum in the city. We have, therefore, in respect to scrofula, the rare con- 
 junction of congenital disease, and hereditary disposition. I need not repeat here 
 the remarks I made before respecting hereditary diseases in general. No one, of 
 the least observation, can doubt that the disposition to consumption is very often 
 transmitted from parent to child. AVe see whole families swept away by its ravages. 
 Like other hereditary tendencies, it may skip over one or two generations, and re- 
 appear in the next, just as family-likenesses are known to do. There are other 
 families in which you can trace no such predisposition ; but such families are per- 
 haps few. A little leaven is sufficient, sometimes, effectually to taint a whole pedi- 
 gree. The tendency, however, exists in various degrees. It may be so strong that 
 no care, no favourable combination of circumstances, will prevent its local manifes- 
 tation ; and it may be so faint that it would never break out into actual mischief if 
 the exciting causes of scrofulous diseases could be warded off. it is important, 
 therefore, to know what these exciting causes are. 
 
 " They may all be ranked together (to use the language of Dr. Aiison) as causes 
 of debility, acting permanently, or habitually for a length of tin.e, although not so 
 powerfully as to produce sudden or violent effects." 
 
 The circumstances to which, acting separately, or in combiTiation, we most con- 
 fidently ascribe the power of developing scrofula, are insufficient nutriment, exposure 
 to wet and cold, impurity of the atmosphere, the want of natural exercise, and mental 
 disquietude. To estimate the separate effect of each of these causes may be diffi- 
 cult ; but their combined influence is unquestionable. 
 
 There can be no doubt that improper diet, or rather imperfect nourishment, is 
 one main exciting cause of scrofulous disease. Yet of this it is not an easy thing 
 to oDtam evidence, which shall be entirely free from fallacy. The disease occurs 
 very often among the poor; but then it very often occurs also in the famihes of the 
 rich. There is one fact which has always struck me as very instructive and con- 
 vincing on this point. Infants at the breast, having good milk and plenty of it, 
 seldom show any signs of scrofulous disorder : whereas, as soon as they are weaned, 
 uiey become subject to various complaints of a strumous kind. When an unweaned 
 'cnild is brought to us with ophthalmia, we expect almost always to discover inflam- 
 mation of the common and acute kind ; the purulent eye. In nine children out of
 
 SCROFULOUS DISEASE. ISi) 
 
 ten who come after weaning, we look for and find some form of scrofulous inflarn 
 mation, such as pustular ophthahnia. 
 
 [Mr. Phillips (^Scrofula, its nature and causes), lias succeeded in establishing very conclu- 
 sively the influence of bad and deficient food, and of an excess of vegetable food, in the 
 production of scrofula. — C] 
 
 The greater prevalence of scrofulous disease among the poor may be ascribed, in 
 great measure, to their frequent exposure to wet and cold. 
 
 [Barthez and Rilliet were only able to find two cases out of 314 tuberculous children, 
 where exposure to humidity appeared to be the sole cause of the tubercles. The researches 
 of Mr. Phillips would tend also to prove that the influence of humidity has been much over- 
 rated. — C] 
 
 Scrofula seldom breaks out in the mild and dry weather of summer. The influ- 
 ence of climate in fostering or repressing the disease is notorious. There is no cli- 
 mate in which it flourishes more than in our own. Consumption is called, in some 
 parts of the continent, the English disease. Persons w^ho migrate from this country 
 to warmer and more equable chmates, seldom become scrofulous ; nay, it very often 
 happens that the incipient indications of strumous disease are completely arrested or 
 quieted by the change. Phthisical patients, much troubled by symptoms here, are 
 sometimes so thoroughly freed from them soon after their arrival in Madeira, as to 
 be deceived into a belief that their case had been mistaken. They think themselves 
 well. A return to this country undeceives them. The native inhabitants of hot 
 regions are by no means, however, exempt from struma, in any of its forms. When 
 they come into these latitudes they are more subject to scrofula than we ourselves 
 are. And the same effect of climate is very distinctly visible in the lower animals. 
 The physicians in ordinary to the inmates of the Zoological Gardens will tell you 
 that the beasts and birds which are brought hither from warm latitudes perish in 
 great numbers from scrofulous diseases. John Hunter observed this long ago in 
 respect to monkeys. 
 
 Of the debilitating influence of impure air I spoke in a previous lecture. That it 
 promotes the evolution of scrofulous disorders we have proof, on a large scale, in 
 the great mortality produced by such disorders among the lower classes in large 
 cities as compared with agricultural districts. The per-centage of deaths from con- 
 sumption, hydrocephalus, and various other diseases which spring from a strumous 
 habit, is much greater in London than in the country. Even in individual cases this 
 mfluence is too manifest to be overlooked or mistaken. It is impossible to question 
 the beneficial efltct, upon children afflicted with scrofula, of a removal from London 
 to the sea-coast. 
 
 I said, when I first began to speak to you of inflammation, that it was the only 
 disease which we were able to excite at w'ill : that we could cause inflamma- 
 tion, in various ways, whenever we desired to do so ; but that to make a cancer or 
 a tubercle was beyond our power. Now in strictness of language, and in the prac- 
 tical meaning of these words, the assertion is quite true. But it is not so exact if 
 we extend it to all the predisposmg causes of disease. We are able to bring about 
 the formation of tubercles, in the lower animals at least, by so arranging external 
 influences as to concentrate their prejudicial effects. By shutting rabbits up in a 
 cold, damp, dark, and narrow place — and feeding them on food not natural or suited 
 to them — we can produce or evolve in them tubercular disease. Of course no ex- 
 periment of that kind can be purposely made upon a healthy man ; but accidental 
 opportunities arise of witnessing an approach to a similar trial of the human species. 
 Instances are recorded of persons, previously well (but having probably the slrumou?: 
 diathesis), becoming affected with scrofula after being confined in the dungeons of a 
 prison, and there scantily fed. 
 
 Something of this kind I have, very recently, had the opportunity of seeing 
 
 A number of male prisoners, chiefly young men, became affected with glandular 
 swellings of the neck, after incarceration for some length of time in the Penitentiary 
 at Milbank. The circumstances of their health led to a relaxation of their punish- 
 n>ent. Instead of being kept in solitary confinement in a coldish cell, and on th^■•
 
 136 INFLAMMATION. 
 
 prison diet, they were permitted to work, for several hours daily, in each others' 
 company in the garden of the establishment. Some porter was at the same time 
 given them, and their allowance of meat was increased. The improvement in their 
 condition was rapid and striking. Here we have the disorder germinating under 
 one state of external circumstances, and checked immediately under the opposite 
 state. 
 
 If you consider the way of life of the children of the poorer classes in this me- 
 tropolis, and in our large manufacturing towns, you will find that 'they are much 
 exposed (though in a less degree) to the same injurious influences, the combination 
 of which appears to generate tubercles in the rabbit. They live, for the most part, 
 in an atmosphere made stagnant by narrow streets ; and in small, crowded, ill-ven- 
 tilated and dark rooms in those narrow streets ; the stagnant atmosphere is contami- 
 nated in a thousand ways ; they are very insufficiently protected from transitions of 
 temperature, against cold and wet, by their clothing ; they are commonly ill-fed — 
 their diet being frequently scanty, and generally of a kind quite unsuited to their 
 growing years. We need not be surprised, therefore, at the ravages which scrofula, 
 in its manifold shapes, makes among the children of the poor in large and populous 
 towns. If ever scrofula be generated, in this country, independently of any heredi- 
 tary strumous taint in the constitution, it is in them. But in most cases I believe it 
 is the latent disposition that is called into action. Moderate exercise, in pure air, and 
 in the open daylight, with suitable nourishment, sufficient clothing, and attention 
 to the state of the bowels : these circumstances comprise nearly all that we can 
 attempt, in a given chmate, towards preventing the development of struma : and 
 from each, and all of them many of these poor children are habitually debarred. 
 
 LECTURE XIII. 
 
 Cancel ; its Specks or Varieties. Scirrhus; Encephaloid Cancer ; Colloid Cancer 
 
 Its mode of Groicth and Dissemination. Habitudes of the several Varieties. 
 Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting. 
 
 I HAVE more than once coupled cancer and tubercle in the same sentence. 
 Though very different in many respects, they are alike in their intractable cha- 
 racter and destructive tendencies. Of the two, cancer, while it is happily much the 
 more rare, is also much the more painful, loathsome, and hideous in its consequences. 
 It is to cancerous diseases that the epithet malignant especially belongs. Not re- 
 sulting from any change in the natural textures of the body, but constituting an 
 addition to them, and therefore assuming, usually, the shape of tumours, they are 
 commonly and correctly spoken of as cancerous grotvihs. But there are other 
 growths Avhich, by comparison, are innocent ; which do not imply any necessary 
 destruction of contiguous parts, nor any, inevitable danger to life, nor even any 
 marked deterioration of the general health. Such are certain fatty tumours, and 
 fibrous tumours, and osseous tumours. All these last, as their names denote, re- 
 semble in their sensible qualities some of the healthy and natural textures. They 
 have accordingly been styled analogous, or homologous growths; while cancer 
 and tubercle, which find no counterparts in the sound body, are said to be hetero- 
 logous. Some varieties of cancer are, however, very similar in outward appearance 
 to^he substance of the brain; and microscopic observers say that in their minute 
 and original structure there is no perceptible distinction between the most innocent 
 and the most malignant growths ; nay, that both agree in their primary corpuscular 
 elements with the healthy tissues of animals, and even of plants. 
 
 [This statement is not perfectly accurate. The microscope has not, it is true, thrown much 
 IS^ht upon the nature and causes of morbid growths; it has, however, shown that in many
 
 CANCER. 137 
 
 of the particulars of their intimate structure, they not only differ from the healthy tissues of 
 the body, but that they differ in this respect from each other. 
 
 That such is the case, is rendered evident by the result of all the more recent researches 
 into the intimate structure of cancerous formations. 
 
 By Miiller and other pathologists, cancerous formations have been arranged in two great 
 families or groups — the encepkaloid and the scirrhous. — Of the first there are three sub- 
 divisions. 
 
 1. Medullary Carcinoma; in which there is a predominance in the inedullary mass, of 
 round globules over loose fibrous tissue. The globules are of various sizes; but the smallest 
 are la.^er than pus-corpuscules. Each contains a granular substance or nucleus within. 
 They are very similar, in many respects, to those of common cancer, and of reticulated car- 
 cinoma or scirrhus. 
 
 2. Medullary Carcinoma, consisting of pale, elliptic, non-elongated corpuscles, and of a funda- 
 mental cerebrilorm mass. These corpuscles are usually twice or three times as large as the 
 globules of the blood. There is never any appearance of fibres proceeding from their sur- 
 face, and they rarely exhibit any traces of nuclei within them. 
 
 3. Medullary Carcinoma, •with Jjbrated or punform corpuscles. This species of encephaloid 
 structure has, at times, on laceration, a sort of fibrous aspect, when the puriform corpuscles 
 are arranged in a somewhat determinate direction; according to which the morbid mass 
 will present a radiated or a tufted appearance. In many cases their directions are so various 
 that the lacerated surface exhibits no traces of fibres anywhere. The puriform corpuscles 
 are sometimes nucleated, at others they contain granular points, but without distinct nuclei. 
 They are elongated, on one or two sides, into fibres of different lengths. They may be con- 
 sidered as cells that are arrested at the period of transition from the cellular to the fibrous 
 condition. 
 
 The three forms of disease now described, may, most probably, be regarded as so many 
 degrees or stages in the development of the same tissue; these successive stages being cha- 
 racterized, 1, by rounded nucleated globules ; 2, by elongated oviform globules, which are 
 eitner non-nucleated or indistinctly so ; and 3, by puriform globules. 
 
 These several kinds of globules may be regarded as so many successive epochs of evolu- 
 tion through which a cell must pass before it can become a. fibre. Thus we find, it is true, 
 tliat in an encephaloid mass there is the same transformation of the primitive elements, as 
 occurs in many normal tissues — with this difference only, that the process of evolution is 
 not complete — being arrested before the fibrin is perfectly formed. 
 
 The essential element of an encephaloid tumour is the presence of cells. In some cases 
 die entire mass is composed of them, placed one alongside of the other, but without hav- 
 ing any perceptible bond of union, while in others there is a network of fibrous or cellular 
 tissue interposed between the cells. When the fibrous tissue prevails, the encephaloid then 
 approaches in character to the scirrhous structure. In the latter the existence of the two 
 elements, cells and fibres, is always more distinctly marked than in the former. The fibres 
 are often quite perceptible to the naked eye. Sometimes they are lengthened, and run 
 parallel to each other ; at others, they form rounded capsules, within which the globules are 
 contained. As in the case of the newly formed fibres of the cellular tissue, so those of a 
 scirrhous formation are destroyed by acetic acid, leaving nuclei or nucleated fibres behind. 
 The fibres sometimes exhibit, at different points, a sort of varicose enlargement, within each 
 of which a nucleus is found. This appearance is often observed in fibrous tumours — no« 
 genuine scirrhus — of the uterus and other parts. 
 
 In the reticular carcinoma of Miiller, the white network which encloses the scirrhous glo- 
 bules in its meshes, is formed of round, opaque granulations, three or four times as large as 
 the blood globules ; they are, occasionally, agglomerated into roundetl masses. The genuine 
 scirrhous tissue, of a pale grayish colour, is composed of globules that, on the whole, resem 
 ble those of the first stage of an encephaloid formation. These globules are either round or 
 somewhat oval ; along with them, according to Vogel, we find free nuclei with their nucleoli. 
 
 From a variety of observations, it may be reasonably concluded that the cells of scirrhus 
 are formed around the nuclei of which M. Vogel speaks ; their contents are at first granular 
 and almost opaque. When the process of softening commences, the granulations disapjpear, 
 the globules become transparent, and within them are formed new cells, which at first are 
 few in number, and gradually multiply, until they entirely fill the parent cell. M. Valentin, 
 who, in part at least, admits this account of the progress of the cell, declares, that the parent 
 cells eventually burst and discharge their cellules ; we may thus account for the presenca 
 of young free cells in scirrhous formations that have become softened. 
 
 The inter-cellular substance seems to undergo certain modifications corresponding with 
 the evolution of the cells; the granulations or granular points which it often contains, 
 usually disappear, and it becomes limpid, while, at the same time, the space which it occu- 
 pies is diminished by the enhargement and multiplication of the cells. 
 
 The fibrous network does not appear to follow, in its alterations, the development of the 
 cells: it may remain firm and resisting while the cells are far advanced in their evoluUon 
 
 m3
 
 138 INFLAMMA nON. 
 
 Even when a scirrhous tumour has become completely softened, this tissue sometimes foims 
 shreds that retain their original character. 
 
 In alveolar cancer, the basis of the morbid tissue consists of white fibres and lamellcB, 
 which cross and intercrois with each other, containing, between the meshes thus formed, 
 limpid cells, either closed or communicating with each other, of various sizes, from that of 
 a grain of sand to that of a large pea, and filled with a transparent, gelatinous substance. 
 In this substance there are cells, wliich contain other cells more minute. The smallest of 
 tliese cells exhibit, at one point of their parietes, a distinct dark yellowish nucleus, and 
 sometimes, also, many free and unattached granules floating within them. . To this species 
 Miiller refers the gelatiniform and areolar cancers of Laennec and Cruveilhiir. The cells of 
 diis species of the disease appear to be only an advanced or more mature degree of the 
 cells of scirrhus. — C] 
 
 This very agreement, if it really be so complete, shows that in classifying morbid 
 growtk« we must reject the aid of the microscope, and attend to their grosser and 
 more palpable features. And, inasmuch as cancerous formations have, by some 
 pathologists, been ascribed (very erroneously, in my opinion) to injiammulion as 
 their cause, I shall scarcely be going out of my way if I state here some of the 
 broad facts which have been ascertained upon this very interesting subject. 
 
 Cancer, or carcinoma, considered as a genus of disease, comprehends two or three 
 species, which present among themselves very striking differences, and of which the 
 varieties have received a puzzling multiplicity of names ; scirrhus, stone cancer, 
 medullary sarcoma, encephaloid or cerebriform disease, soft cancer, fungus hcema- 
 todcs, colloid or gum cancer, and several more. The simplest division, founded 
 upon the consistence of the morbid growth, is into hard and soft cancer. But the 
 most modern and scientific system recognizes three species, viz., scirrhus ; encepha^ 
 loid, or brain-like cancer ; and colloid, or gum-like cancer. The physical characters 
 of these three species offer strong points, not merely of difference, but even of 
 contrast. 
 
 Scirrhus, as that word implies, is remarkable in its early stages, for its hardness. 
 It is as firm as cartilage, and creaks when divided by a sharp knife." The surfaces 
 exposed by its division present a glistening, satiny appearance, and a white, or gray, 
 or bluish-white colour. Athwart this grayish and semi-transparent substance run 
 opaque intersecting bands, having a fibrous aspect. By strong pressure a thin juice 
 may be made to ooze from a slice of the scirrhous tumour. 
 
 Encephaloid cancer is also well named. It is composed, in great measure, of a 
 soft, white, opaque pulpy substance, very closely resembling, both in colour and in 
 consistence, that of the healthy brain. This cerebriform pulp is traversed and cir- 
 cumscribed by fi-brous septa, w^iich are sometimes extremely thin and dehcate. In 
 both these species of cancerous growth, therefore, there is a contained and a containing 
 element. 
 
 The same feature is still more distinctly marked in the third species, the colloid 
 cancer, which exhibits the appearance of small portions of a greenish-yellow trans- 
 parent gum, or jelly, arranged in regular cells. Hence it is sometimes denominated 
 alveolar cancer. 
 
 You niay ask upon what principle structures so dissimilar in their physical ap- 
 pearance have been assigned to the same genus 1 Why, for these reasons. They 
 are all strictly destructive or mahgnant forms of disease. Although in any shape 
 they are of somewhat rare occurrence, yet when they do occur, two, or all three 
 of the species are often found to coexist in different organs of the same individual ; 
 nay, in contiguous parts of the same organ. ^Nlore than this : if a tumour consisting 
 of one species be amputated, and a fresh growth springs (as too often it does) from 
 the same spot, this secondary growth is frequently of another species. There can 
 be no doubt that all are connected by some very intimate bond of union; and the 
 facts I have 'ust stated suggest the question, whether instead of being different spe- 
 cies of the same genus, they ought not rather to be regarded as mere varieties of tht 
 same species. 
 
 Of all three it has been ascertained, by much and fatal experience, that occurnng 
 m any one part of the body they are prone to multiply in various other parts ; that 
 •hey are commonly attended, during some part at least of their progress, with very
 
 CANCER. 139 
 
 gew re pain ; that they are incontroUable by any known remedy ; and tend always, 
 sometimes slowly, sometimes with frightful rapidity, to augment in bulk; eating 
 away contiguous parts by their invasion and pressure ; breaking out, when near the 
 surface, into foul and repulsive ulceration; producing often the most ghastly disfi- 
 gurement ; and ultimately destroying life. Sometimes vital parts are slowly disor- 
 ganized by the corroding extension of these tumours; sometimes large blood-vessels 
 are laid open, and death is suddenly brought about by hemorrhage ; and sometimes 
 the powers of hfe sink gradually under the wearing influence of the disease, and 
 that degeneracy of the Wood which it causes or accompanies. 
 
 There is scarcely an organ or a texture of the body which is not liable to be 
 attacked by this terrible foe : the brain, the eye, the lip and face, the lungs, the 
 stomach, the intestines, the liver, the kidneys, the breast, the womb, the testicle, the 
 bones. But some parts are more often the seat of cancer than others. Among 
 these may be reckoned the female mamma, the uterus, the stomach, the liver, and 
 the testicle. 
 
 The mode in which cancer originates is uncertain ; the modes in which it spreads 
 and multiplies are better understood. An individual tumour may enlarge by ihe 
 progressive insinuation of the cancerous matter into the interstices of the neighbour- 
 ing tissues, which, thus fastening upon, it consolidates. The disease may be com- 
 municated, by imbibition, from one organ to another which is in mere contact^vith 
 it. But how does it come to occupy at the same time, or in quick succession, several 
 separate and distant organs ? This is a question of the greatest interest and im- 
 portance, and it admits of a distinct reply. 
 
 Cancer often makes its appearance in a single spot on the surface of the body ; in 
 the female breast, for instance. We see and feel it there while it is yet small, and 
 while the general health of the patient seems to be otherwise perfect. By degrees 
 the tumour increases, and at length it softens in some places ; the glands of the axilla 
 become swollen, hard, painful, and filled sometimes with cancerous matter ; the 
 tumour breaks perhaps through the skin, and presents the shocking spectacle of 
 "open cancer ;" the general health gives way, and the skin assumes a straw-coloured 
 tint. During this process, unless the patient dies prematurely, or the original disease 
 is removed by a surgical operation, cancerous tumours form in one or in several of 
 the internal organs, and give notice of their presence by appropriate symptoms. There 
 is an original morbid growth, and there are subsequent morbid growths ; a prin:iary 
 tumour, and secondary tumours ; and the latter are caused by the former. This is 
 a most important fact, if indeed it be true. 
 
 Now Miiller has discovered, by means of the microscope, and the discovery has 
 been confirmed by other observers, that the contained matter, in the several species 
 or varieties of cancer, consists of very minute cells, with nuclei attached to their 
 w^Us, and of granules still more minute, which are supposed to be the rudiments of 
 new cells. It is (apparently) by the amplification of these granules into cells, and 
 by the development of the nuclei into other cells, and by the growth and evolution 
 of young cells, which in some instances are included generation after generation 
 within parent cells, that the original tumours enlarge and extend themselves ; and it 
 IS by the transference of certain of these cells and granules from the original tumour 
 that a crop of secondary tumours is sown in remote parts of the body. The cells, 
 and probably the granules also, are endowed with the power of self-increase and 
 propagation, whenever they find a fitting nidus. Possessing, like the seeds of plants, 
 an inherent vitality of their own, they merely require, in order to germinate, to be 
 placed in contact with some living tissue, wherewith they may form vascular con- 
 nections, and wherefrom they may draw the materials of their nourishment. Co- 
 hering together, for the most part, with but httle force, they are easily detached from 
 the parent mass. It is matter of fact that the secondary tumours form most surely 
 and most rapidly when the primary tumour is of a soft kind ; and that when they 
 succeed to scirrhus, it is after the process of softening has commenced in that origin- 
 ally hard structure. These germs — which present, in their forms and mode of 
 generation, striking analogies to those of some of the lower animals, as well as to 
 tlio«e of plants — these, germs are probably carried sometimes through the lymphatic
 
 140 INFLAMMATION. 
 
 vessels to absorbent glands in the vicinity of the primary growth; hut tnere can 
 scarcely be a doubt that the blood is the main channel by which the seeds of this 
 dreadful malady are conveyed from its first to its subsequent sites, and thence per- 
 haps, if life continues long enough, to tertiary locations. The gross matter of cancer 
 is often to be found in the veins t^hat proceed from the primary tumour — nay, in large 
 venous trunks at a distance : so that some distinguished pathologists have too hastily 
 conjectured that it may originate in the veins. You are probably aware that foreign 
 substances, circulating with the blood, stop or are entangled more often in some 
 organs than in others. Minute globules of mercury, where that metal has been 
 introduced into the veins, are found strewed through the substance of the lungs, and 
 of the liver. Pus, received into the blood in phlebitis, is arrested, and forms scat- 
 tered points of inflammation and abscess, in the same organs ; and it is in the liver 
 and the lungs that separate tumours of secondary cancer are most commonly met 
 with. If this be the true theory of secondary cancerous formations, I need scarcely 
 point out to you the urgent importance of the rule which prescribes to the surgeon 
 the most complete extirpation of the primary tumour, at the earliest possible period 
 of its existence. 
 
 Of these primary formations the origin is involved in much obscurity. It seems, 
 however (and this, after what has just been stated, you might expect) that the germs 
 of the disease are capable of being transferred from one human being to another ; 
 and even to an animal of a different species. Langenbeck injected cancerous matter, 
 just taken from a living body, into the veins of a dog. After some weeks the dog 
 began to pine away, and was then killed, and cancerous growths were found in its 
 lungs. Several instances have occurred — I have myself known of two — of cancer 
 of the penis ,in men whose wives laboured under cancer of the uterus. Here it is 
 presumable that the cancerous germs, received upon a delicate and vascular surface, 
 and suffered perhaps to lodge there through neglect of cleanliness, might fasten upon 
 the part, take root there as it were, and grow. One very curious circumstance con 
 nected with this subject is, that the frequent contact of common soot seems to have 
 the power of producing cancer. There is a form of carcinoma, affecting chiefly the 
 sciotum, and familiar to surgeons as the chimney-sweeper's cancer. A case is 
 recorded of cancer of the same variety occurring in the right hand of a gardener, 
 who for years had been in the habit of sprinkling soot over his flower-beds with his 
 hands. 
 
 There are not wanting, then, plausible grounds for the hypothesis, that the seeds 
 of cancer may be introduced, in some way which eludes observation, from without 
 that cancerous growths are strictly parasitic, and independent of the body, excepting 
 so far as they derive their pabulum from its juices. The difficulties involved in 
 this supposition are not greater (as we shall see hereafter) than those which hang 
 over the source and origin of certain entozoa, whereby the body is liable to be 
 infested. But whether this hypothesis be true, or whether the cancer cells and germs 
 are merely morbid elements of the native tissues of the body, developed by some 
 perverted energy of the formative process, remains yet to be determined. 
 
 From the tables contained in the Reports of the Registrar-General, it would 
 appear that women are more subject to this fearful disorder than men, in the large 
 ratio of five to two. It fixes chiefly upon the female organs of reproduction ; the 
 mammce and the uterus. 
 
 The mortality from cancer, estimated with due reference to the whole number of 
 persons existing at different ages, increases steadily as hfe advances. 
 
 There are still some general habitudes of the different varieties of cancer, with 
 which I should wish you to be acquainted. 
 
 The secondary formations are most commonly of the encephaloid kind, whatever 
 the primary form may have been. 
 
 Encephaloid cancer, as compared with scirrhus, is abundantly furnished with 
 blood-vessels ; and upon this difference in their degree of vascularity,' other reniark- 
 able differences between the two varieties seem to depend. First, encephaloid 
 tumours generally augment w'ith much greater rapidity, and attain a much larger 
 size, than scirrhous tumours. Occasionally their magnitude comes to be enormous
 
 ENCEPHALOID CANCER. 141 
 
 Again, cerebriform growths seldom happen singly, but occupy several organs of the 
 body at once. Scirrhus, increasing slowly, occurs also in fewer sites ; it is some- 
 times even solitary. More tissues, too, appear to be obnoxious to the soft than to the 
 hard variety. 
 
 Now (as Dr. William Budd has well remarked) a large apparatus of blood-vessels, 
 bringing a proportionally plentiful supply of nourishment to the parasitic tumour, 
 accounts sufficiently for its rank and rapid growth ; and the same condition, espe- 
 cially when conjoined with softness of the parent mass, affords obvious facilities foi 
 the hberal dissemination of its germs through numerous returning channels. In 
 fact, the soft varieties alone have, as yet, been found in the veins. 
 
 The same multitude of its blood-vessels, and slender cohesion of its component 
 parts, serve to explain another peculiarity of the cerebriform species. Intermixed 
 with, or diffused through, the brain-hke substance, there is often to be seen a quan- 
 tity of extravasated blood ; and when the disease breaks out into ulceration, red, 
 ragged, and bleeding growths, of fungous aspect, sprout rapidly from the cpen sur- 
 face. To these accidents of cancer the term fungus haematodes is to be traced. We 
 do not find scirrhus to be the seat of similar interstitial hemorrhages. 
 
 Encephaloid cancer has less tendency to contract adhesions with contiguous partj 
 than scirrhus has. 
 
 Of the alveolar variety, which has been more lately discriminated, from the others, 
 and less studied, less is known. It occurs principally in the abdomen, affecting the 
 pyloric orifice of the stomach, and the omentum. It appears also occasionally in . 
 the bones, and the breast and testicle. Although sometimes combined with the two 
 other species in the same person, it is often alone, and hmited. to a single organ. I 
 believe it has not been met with except in adults. • 
 
 For more minute information upon this subject, so interesting and important both 
 in its pathological relations and in its practical bearings, I must refer you to a very 
 able and elaborate article on cancer, in the Cyclopxdia of Surgery, by Professor 
 Walshe, and to a shorter but admirable essay on the same topic, by Dr. Wilham 
 Budd, published in the Lancet. From these sources has been derived much of 
 what I have now been stating. [We may also refer the reader to the full and excel- 
 lent paper of Dr. Carswell, on Scirrhus, in the Cyclopaedia of Practical Medi^ 
 
 cine. — C.I 
 
 s 
 
 Returning to our current the^me, I proceed, in the next place, to speak, in a gene- 
 ral manner, of the measures to be adopted when we are called upon to administer to 
 the relief of a person labouring under inflammation : of what is sometimes called 
 the cure; but, more correctly, of the treatment of inflammation. 
 
 In describing the phenomena and progress of inflammation, I took external inflam- 
 mation as a type, and I shall keep that type principally in view in what 1 have to 
 say respecting its treatment : making, however, such reference to the inflammation 
 of internal parts as the subject will permit. You will bear in mind that my design 
 at present is merely to explain the principles of treatment, generally : I shall point 
 out, by and by, the application of those principles, and the modifications they may 
 require, in respect to particular cases. I speak also, now, of common inflammation, 
 occurring in a previously healthy person. There are many observations that con- 
 cern all inflammations alike, whether external or internal, and by despatching these 
 in the outset, I hope to avoid much repetition hereafter. 
 
 In all cases of inflammation, our first object is, if possible, to obtain resolution: 
 and if that be not possible, we next aim at securing that event of inflammation 
 which would be the most fortunate in the particular case before us. In external 
 inflammations good suppuration will generally, next to resolution, be the most 
 desirable event : in internal inflammations it will be sometimes suppuration, some- 
 times adhesion. 
 
 It is necessary to keep in view the distinction between the treatment proper for 
 the inflammation itself, and the treatment that may be required for the effects of 
 the inflammation. At present we are concerned only with the inflammation itself. 
 
 I stated to you in a former lecture, that a knowledge of the cause of a disease
 
 142 TREATMENT OF INFLAMMATION. 
 
 might help us in its treatment. Knowing the cause, our first care must be to 
 remove it, if we can. In the case formerly supposed, we should extract from the 
 inflamed arm the fragment of glass. If the inflammation has been excited by the 
 extremity of di fractured bone, of a broken rib, for example, we take measures for 
 bringing the separated bones into their proper places, and for keeping them there : 
 if the mere displacement of a part has occasioned the inflam.mation, as the disloca- 
 tion of a joint, the protrusion of the bowel in hernia, the first thing to be attended to 
 is the restoration of the part to its natural situation : if there be any chemical source 
 of irritation (in the stomach, for instance, threatening or producing inflammation 
 there,) we eject, neutralize, or dilute it. 
 
 I know of but one exception to this rule, and it belongs to surgery: to wif, when 
 a bullet or splinter is so lodged in the interior of the bod 3% that its extraction would 
 be more hurtful or hazardous than its remaining where it is. 
 
 A knowledge of the cause of an inflammator)^ disease may help us in another 
 way. We do not treat a joint that is inflamed in consequence of external violence 
 as we should treat the same joint when inflamed in rheumatism. 
 
 But it is very seldom, except when the inflammation is external, that we can 
 accomplish the removal of its cause. In most internal cases, either it cajinot be got 
 at, or it has already ceased to be applied; as when the inflammation has been excited 
 by exposure to cold. But it may be possible, and it is of the utmost importance 
 M'hen possible, to prevent any ?'e-application or repetition of the same cause, which 
 would be L'kelyto frustrate our endeavours to bring about resolution. 
 
 Next in importance to the removal and avoidance of the exciting cause, must be 
 placed in most instances, the observance of what is called the antiphlogistic regi- 
 men. This may seem an. old-fashioned, phrase, but it is a very convenient one ; 
 being a brief form of expressing the sum of several distinct provisions for the wel- 
 fare of the sick, and for the conduct of their attendants. The word antiphlogistic is 
 derived, indeed, from an obsolete theory ; but we retain it as a useful arbitrary term, 
 without reference to its etymology^ or to its original meaning. 
 
 The object of the antiphlogistic regimen is to put and keep the patient in that 
 state which is most favourable for the spontaneous subsidence of the disease, or for 
 the sanative influence of remedies. This regimen consists in the avoidance of every 
 stimulus that can be avoided, whether external or internal. Common sense will 
 suggest to you the details. It implies a total abstinence from animal food, and from 
 strong drink of all kinds. It prescribes the exclusion of all that might excite or 
 exercise the mind, or produce a strong impression upon the senses : noise ; bright 
 light ; great heat or cold. The patient should be kept in a temperature of about G2^, 
 and in a well-ventilated apartment. He must not be allowed to converse, nor to 
 attend to matters of business ; unless, indeed, his mind happens to be disturbed and 
 anxious about some point which one short interview with a friend may effectually 
 settle. All causes of strong emotion, and mental agitation, should be strictly guarded 
 against. Whatever tends to quicken the circulation is to be shunned ; and therefore 
 not only those influences which operate through the nervous system, but also all 
 needless bodily effort and exertion, must be prohibited. The patient (in the serious 
 cases I am now contemplating) must remain in bed : and in a position which facili- 
 tates, or at least does not impede, the free return of blood by the veins from the suf- 
 fering organ. If the inflammation is seated in or about the head, that part should 
 be elevated by pillows. If one of the lower extremities is affected, even when the 
 disease is not so intense as to require confinement to bed, the lijnb must be sustained 
 horizontally, or be even still more raised up. On the same principle it is that we 
 suspend an inflamed hand or fore-arm in a sling. In some cases of internal inflam- 
 mation — in pleurisy, for example — the patient will choose his own position. He is 
 admonished, by the pain and distress they occasion, that certain postures would be 
 hurtful or dangerous, and he carefully avoids them. We often derive much informa- 
 tion from this instinctive caution on the part of our patient. 
 
 The function of the organ inflamed should also be spared its exercise, whenever 
 and in as great a degree as that can be done. As you would not allow a patient to 
 Tiove an inflamed joint, so you must not permit him to use an inflamed eye ; to
 
 ANTIPHLOGISTIC REGIMEN. 143 
 
 sp^ak more than may be absolutely necessary with inflamed lungs ; to exert by 
 thinking, and by attention to external excitements, an inflamed brain. This last rule 
 IS essential, even when the brain is not the seat of the inflammation : it is to be 
 observed in all febrile disorders. 
 
 The adoption of this antiphlogistic regimen is not, indeed, necessary, nor even 
 proper, in all cases and stages of inflammation. The iaiflammation may be so slight 
 as not to require it ; particularly in external cases, of which the causes and the extent 
 are known ; as slight contusions, trifling wounds, and some kinds of eruption. But 
 this exception must always be applied with great caution to cases of internal inflam- 
 mation, about the causes and extent, and tendencies of which we may be less sure. 
 In chronic forms of inflammation again, as in scrofulous inflammation of the lympha- 
 tic glands, or of the eyes, attended with but little pain or heat, the antiphlogistic regi- 
 men would often fail to be beneficial : the state of the general system being such as 
 to require support and strengthening measures, more than the local symptoms call 
 for an opposite treatment. So also when suppuration or gangrene have supervened, 
 the antiphlogistic regimen must generally be modified, or abandoned. 
 
 But in the outset of all cases of serious inflammation, when the strength is entire, 
 and the inflammation intense enough to produce pyrexia, all the particulars of the 
 antiphlogistic regimen may require to be observed. 
 
 Of all the direct remedies of inflammation, the abstraction of blood, bleeding, or 
 hlooA-letting, as it is called, is by much the most effectual and important. We 
 should, I think, be prepared to expect this, prior to any experience of it. Blood 
 being the natural stimulus of the heart, we should deem it probable that the removal 
 of a portion of that fluid would diminish the force with which the heart contracts : 
 and as an inflamed part contains a preternatural quantity of blood, and as (with the 
 exception of resolution and mortification, which really are terminations of inflamma- 
 tion — as with these exceptions) all the events of inflammation depend upon the effu- 
 sion of certain parts of the blood from its containing blood-vessels, we should be 
 inclined, « priori, to believe that the amount of those effusions would be checked and 
 limited by lessening the supply of blood to the inflamed organ, as well as by abating 
 the force with Avhich the blood reaches it. And we find it in fact to be so. The 
 results of experience confirm, in this matter, the suggestions of our reason. Blood 
 forms the pabulum of the whole process. "If," (says Mr. Lawrence,) "we may be 
 allowed to use figurative language, the obvious increase of heat in the part is analo- 
 gous to that of fire ; and blood is the fuel by which the flame is kept up : in fact, 
 if we could completely take away its blood from the part, we should be able entirely 
 to control or arrest the increased action," 
 
 But it is not every case of inflammation that requires or warrants the abstraction 
 of blood : and when blood-letting is requisite, the mode of taking away the blood, 
 the proper quantity to be taken, and the propriety of repeating the bleeding, all vary 
 greatly in difl!erent cases. It is obviously of vast importance that you should learn 
 so to use this valuable remedy as not to abuse it. Its power is great for evil as well 
 as for good ; and in rash or inexperienced hands it too often becomes an instrument 
 of flital mischief. 
 
 There are, as you are all aware, several modes of abstracting blood : phlebotomy, 
 arteriotomy, scarification, cupping (which is merely a variety of scarification), the 
 application of leeches. Bleeding performed in'either of the first two of these me- 
 thods is called general bleeding. The rest are, in most instances, topical or local: 
 but they are not merely topical in all cases. The main object of general bleeding 
 is to diminish the whole quantity of blood in the system, and thus to lessen the force 
 of the heart's action. The object of local bleeding is, in most instances, that of emp 
 tying the gorged and loaded capillaries of the inflamed part. Sometimes the blood 
 is thus taken directly from the turgid vessels themselves ; more often, I fancy, topi- 
 cal blood-letting produces its efTect by diverting the flow of blood from the affected 
 part, and giving it a new direction, and so indirectly relieving the inflammatory con- 
 gestion. General bleeding has also incidentally a similar tendency to deplete the 
 vessels concerned in the diseased process : and, on the other hand, a dexterous cup- 
 per, under favourable circumstances, will take away blood from a part as copiously
 
 144 INFLAMMATION. 
 
 and rapidly as if it were made to flow from an opened vein : and then the eflee.. 
 upon the system will be alike in the one case and in the other. The same rnay 
 be said of leeches, when they are applied in the enormous numbers which our 
 neighbours, the French, are fond of using. In whatever way the blood is drawn, 
 Avhether from a vein or from an artery, or by the pressure of a cupping-glass around 
 a surface previously scarified, or by the suction of leeches, the general effect upon 
 the system will be in proportion to the quantity of blood abstracted in a given time. 
 The most convenient and effectual mode of general bleeding, upon the whole, is 
 certainly the common one, from the veins at the bend of the arm. But sometimes 
 those veins are small or deep, especially in fat people ; and we fail in our efforts to 
 get the blood to flow from them in a full stream : and then we may open some other 
 vein or an artery, or call in the cupper to our assistance, or cover the neighbouring 
 ■surface with leeches ; according to the situation of the part inflamed, and other cir- 
 cumstances. 
 
 Let us now briefly consider what the indications are by which we judge of the 
 "Expediency of taking away blood. We are guided very much by the degree of 
 pyrexia ; by the quality of the pulse ; by the importance of the organ affected ; by 
 the intensity of the inflammation, in what manner soever that may be measured ; by 
 the period or stage of the disease ; by the age, and sex, and general condition of the 
 patient; and frequently also by the ordinary character and course of the disease, 
 when inflammation happens to be, or to accompany, an epidemic disorder. It is not 
 one of these circumstances alone, but several of them, that we have to take into the 
 account, in most cases : and what I have now to say in reference to them must needs 
 be very general. 
 
 The presence of pyrexia, especially when the febrile disturbance is well marked, 
 admonishes us, indeed, to search after other indications of the propriety of blood- 
 letting, and confirms them if they are found ; but is not, of itself, a sufficient reason 
 for resorting to that remedy. There may be high febrile symptoms without any 
 inflammation at all ; as in the hot stage of an ague fit : and a smart attack of fever 
 may spnng out of local inflammation, and yet the known course of the disease, or 
 the nature of the part affected, may render the abstraction of blood unnecessary, and 
 therefore improper. 
 
 Our judgment is more often determined by the quality of the pulse, although we 
 are by no means to be wholly directed by this. The quality of the pulse which — 
 other things being the same — bespeak the necessity of blood-letting, is hardness. I 
 described this quality to you in a former lecture : it may coexist with a large or a 
 small, a slow or a frequent pulse. Most commonly (and "yet the exceptions are nu- 
 merous) in acute inflammations the pulse is full and frequent as well as hard. The 
 hardness is ascertained and measured by the resistance which the throb of the artery 
 makes to the pressure of your finger. The pulse is sometimes said to be incom- 
 pressible ; which means that, although you apply your finger with considerable firm- 
 ness, the blood still forces its way tlirough the vessel beneath it. 
 
 Now this hardness of the pulse is sometimes our best warrant for active depiction 
 by means of the lancet : yet I say we must not trust to this alone ; for a hard pulse 
 may habitually exist, where there is no inflammation. Certain chronic diseased 
 conditions of the heart may occasion it; and it probably results also sometimes 
 from some unnatural state, which is not inflammation, of the whole of the circulating 
 system. When you happen to know your patient, and have ascertained what kind 
 of pulse he has when he is well, and are previously aware that his pulse during 
 health is tiot a hard pulse, you learn from that circumstance that the new quality it 
 has now acquired denotes the presence of inflammation ; and usually of active inflam- 
 mation, likely to go on, if not controlled, to the destruction of the pan it has seized 
 upon 
 
 Many persons, and young practitioners in particular, are apt to look to the fre- 
 quency of the pulse, when they wish to ascertain the expediency of blood-letting: 
 but really its frequency is very subordinate in itnportance to its hardness or softness: 
 and this is very unlucky, because any body with his stop-watch in his hand can 
 tount a pulse : but it is not every one who can tell a hard pulse when he feels it.
 
 BLOOD-LETTING. 145 
 
 The finger requires a certain education for that purpose ; and there are some persons 
 who seem never to attain the tactus eruditus. I should advise you to attend par- 
 ticularly to this quality of the pulse, and to compare your perceptions to the hardness 
 or softness of the pulse in individual cases, with those of other medical men. 
 
 The frequency of an inflammatory pulse ranges for the most part between 90 and 
 120. When the hard pulse is much more frequent than this, it commonly occurs 
 either in young children, or in persons who are more than usually nervous and sus- 
 ceptible ; or in persons who were previously labouring under some chronic and 
 wasting complaint, in which the pulse was already frequent, though not hard : as, 
 for example, in phthisical patients, when acute pleurisy supervenes upon tubercular 
 disease of the lungs. 
 
 As the hardness of the pulse is, with certain exceptions at which I have just 
 glanced, our lawful warrant for general bleeding, so the disappearance of that hard- 
 ness is a token that the blood-letting has been carried far enough. 
 
 Again, the nature and importance of the organ affected will influence our judg- 
 ment in respect to the question of abstracting blood. If the organ inflamed be a vital 
 organ ; or if we are not sure about that, but have any reason to suspect that it may 
 be a vital organ ; I need scarcely say that we must act upon the worst supposition, 
 and bleed. But if the part be of less importance in the economy of the body; or if 
 uiflammation is known ordinarily to run its course in that part without producing 
 any abiding damage ; it may not be worth while, even though the fever be high and 
 the pulse hard, to have recourse to this potent remedy, for the sake of subduing 
 inflammation which is attended with so Httle danger. In this predicament may be 
 placed many instances of cynanche tonsillaris, and of acute rheumatism. The sub- 
 sequent debilitating effects of the loss of blood upon the system may be more certain 
 and more hurtful than the effect of the bleeding upon the local inflammation is likely 
 to be beneficial. 
 
 [Without pretending to advocate the employment of blood-letting in every case of cynanche 
 tonsillaris and of acute rheumatism, we must dissent from the correctness of Dr. Watson's 
 position, that " even though the fever be high and the pulse hard," it may not be worth 
 while to bleed " for the sake of subduing inflammation which, in these afTections, is attended 
 with so little danger." When acute rheumatism occurs in young, robust, and plethoric habits, 
 and is attended with considerable fever and a hard and accelerated pulse, we know of no 
 remedy from which such decided advantage is to be obtained as from a well-timed resort 
 to the lancet. The extent to which the bleeding is to be carried and the propriety of its 
 repetition, must be determined by the circumstances of each case, and the effects produced 
 by the first operation. We are no advocate, under any circumstances, for the profuse and 
 repeated bleedings recommended by M. Bouillaud as a means of cutting short an attack of 
 acute rheumatism ; we have had, however, ample experience of the very decided relief 
 obtained by a prudent and well-timed use of the lancet in this disease. 
 
 In many cases of cynanche tonsillaris, al.'^o. an early and full bleeding will have the effect 
 of arresting the inflainmation, and thus of saving the patient from much suffering, if not 
 danger. Even when the arrest of the disease is not affected by it, the inflammation is 
 reduced in violence and shortened in duration. — C] 
 
 The period or stage of the disease forms a most important element in the question 
 before us. It is of inflammation while yet in its early progress, that blootl-lettino- 
 may emphatically be pronounced the cure ; while the disease is still within the pos- 
 sibility of resolution ; before there is any great amount of effusion, or any serious 
 disorganization of structure. The sooner we bleed, the more surely will the inflam- 
 matory process be moderated and limited, even when it cannot be wholly quenched. 
 In no case within the range of medical practice is the maxim " principiis obsta" 
 more imperative. Those among you who happen to be attending the wards of the 
 Middlesex Hospital may wonder, indeed, after hearing my estimate of the power of 
 blood-letting over inflammation, that I so seldom prescribe venesection there. The 
 truth is, not that I undervalue the remedy, but that the time for its employment 
 has generally gone by. The poor are unwilling to relinquish the occupations bv 
 which they subsist : they struggle on as long as they can, and resort to hospital's 
 only when they are compelled to do so by the exigency of their malady. Many of 
 them labouring under inflammation, have been freely bled before admission. It \n 
 
 10 N
 
 146 INFLAMMATION. 
 
 commonly too late, when they present themselves, to expect that the course of the 
 disease can be so arrested. The first effect of blood-letting is to deplete and relieve 
 the labouring circulation. But when it is again and ag-ain repeated, it becomes (as 
 the French say) spolialive; it robs the vital fluid of its nutrient and plastic materials. 
 Pushed still further, it produces a peculiar state of the nervous sj'stem, marked by 
 great weakness and irritability. Now although blood-letting is the summum remedium 
 for inflammation at its commencement, there is a point beyond which it not only 
 does no good, but is positively injurious. And this point it is not always easy to 
 hit. On one side is the danger that the inflammatory action may continue and 
 extend : on the other the danger that the strength of the system may be so reduced 
 as to prove unequal to the process of restoration ; for, to remove the interstitial extra- 
 vasations, and to repair the damage that has accrued, a certain degree of vital power 
 is requisite, and a suflicient quantity of healthy blood. Bleeding will cure inflam- 
 mation, but it will not always cure the effects of inflammation ; nay, it may render 
 them lingering in their departure, or even determine their fatality. I cannot too 
 often, or too strongly inculcate the precept, that in order to check and extinguish 
 acute inflammation, you must, above all, bleed early. 
 
 We judge that the bleeding has been carried far enough when the inflammatory 
 fever subsides, or changes its character; when the pulse regams its softness, or 
 undergoes some marked alteration ; when any of the signs (already specified) of sup- 
 puration appear. Upon these points I hope to give you more explicit instruction 
 when we come to special instances of inflammation. 
 
 Whenever inflammation supervenes on other chronic disease : whenever it arises 
 in the progress of idiopathic fever, or whilst the constitution is contaminated by some 
 specific poison : whenever suppuration is inevitable, or even probable : in all these 
 cases general bloodletting may be necessary, but it must be employed with great 
 caution. 
 
 Nor can w^e, safely, neglect the age, and sex, and general condition, of the sick 
 person, when we are turning in our minds the propriety of bleeding. The very 
 young, the old and the feeble, do not bear well the loss of much blood. This con- 
 sideration is not to deter you from bleeding such persons when they are attacked by 
 dangerous inflammation ; but it especially enforces, with respect to them, the gene' 
 ral rule, that no more blood should be abstracted than is absolutely required to con- 
 trol the disease. 
 
 It is also very necessary to study the character and tendency of the reigning epi- 
 demic : whether that may depend upon some predisposition silently and gradually 
 produced in men's bodies by the agency of causes that are but little understood : or 
 whether it may result from some peculiarity in the exciting cause of a particular 
 epidemic disease. I have been long enough in practice in London to have learned, 
 in common with others, how much the character of continued fever may alter. Since 
 about the time when the virulent form of cholera made its first appearance among 
 us, continued fever has nehher required nor borne the abstraction of blood as it did 
 bear and require it for some years prior to that period. Perhaps some variation in 
 the intensity of the poison may partly explain the comparative malignity — the 
 greater tendency, I mean, to the typhoid type — v/hich marks certain epidemics of 
 scarlet fever, small-pox and measles. The influenza, or epidemic catarrh, which 
 was almost universal in this town and kingdom in the years 1833 and 1837, afforded 
 a striking illustration of the point I am endeavouring to set before you. The iuHnm- 
 matory symptoms — the bronchitis, and sometimes pneumonia — were in many crises 
 strongly marked, and it was necessary to abstract blood ; but persons suffering under 
 .iifluenza bore bleeding exceedingly ill, and where the use of the lancet could not be 
 avoided, it was never resorted to without reluctance and misgiving. 
 
 When we bleed in acute inflammation of an important organ, we endeavour, I 
 say, to effect our purpose as speedily as possible, and with as little expenditure of 
 the vital fluid as possible. It would be quite ridiculous to pretend to give any precise 
 direction as to the number of ounces of blood that should be taken. You must stay 
 by the patient, and bleed, in such cases as I am now contemplating, until you pro- 
 duce some distinct impression by the bleeding ; and one of the best guides in this
 
 BLOOD-LETTING. 147 
 
 matter is the state of the pulse. If you find, as you sometimes will do, that the most 
 pressing symptoms give way while the blood is still flowing — that the pain, for 
 instance, is mitigated — that the respiration (when the lungs are concerned) becomes 
 easier and deeper — that (in affections of the brain) the patient emerges from a state 
 of stupor or delirium — you may be sure that you are doing right in bleeding ; but 
 you must keep your finger upon your patient's wrist, and suffer the blood to flow, 
 until the hard pulse is sensibly softer, or until symptoms of impending syncope 
 appear ; and then you had better tie up the arm, and wait a few hours, and repeat the 
 bleeding if the symptoms which at first demanded it again become urgent. 
 
 As it is desirable to produce the necessary effect upon the system as quickly as 
 may be, the blood should be taken pleno rivo ; i. e., a sufficiently large orifice should 
 be made in the vein : and sometimes it may be right to open a vein in both arms : 
 and the patient should be bled in the upright position. Faintness and syncope 
 depend upon a defective supply of blood to the brain ; and therefore will be Ukely 
 to occur the sooner when the force of gravity facihtates the descent of the blood from 
 the head through the veins, and retards its ascent towards the head through the 
 arteries. And conversely, the first thing to be done towards remedying syncope 
 is to lay the person flat in a horizontal posture, or even with his head lower than 
 his trunk. 
 
 If you neglect these smaller matters, and make an insignificant slit in the vein, 
 and suffer your patient to lay down whilst you are bleeding him, you will be obliged 
 to take much more blood in the end ; or you may drain him of his blood and of 
 his strength by repeated bleedings of this sort, and make no impression after all 
 upon the disease. It is one of the numerous cases in which parsimony is not true 
 economy. 
 
 The quantity of blood requisite to be taken in order to produce the due effect is 
 exceedingly various. It is a remarkable circumstance, well worth attending to, and 
 much insisted upon of late years, especially by Dr. Marshall Hall, that a patient 
 under the influence of mere inflammation will bear to lose a far greater quantity of 
 blood without becoming faint, than he could bear in health : that the state of the 
 system produced by the presence of inflammation protects it from the ordinary con-« 
 sequences of loss of blood. The amount of the bleeding necessary to occasion syn- 
 cope will be in proportion to the exigency of the case. This fact — if it be really a 
 fact, as, indeed, I beheve it is — is evidently one of the highest value and importance, 
 for it furnishes, what is always so desirable, especially in an uncertain art like ours, 
 a simple rule of practice. Yet it is not a rule so firmly established as not to admit 
 of exceptions. If the mere state of syncope was the curative influence required, 
 Ave should have no difficulty. That the faintness does constitute a part of that influ- 
 ence I fully believe. Dr. M. Solon even relates a case in which it sufficed to the 
 cure of erysipelas of the head and face, attended with high fever. The patient 
 fainted from alarm, before the vein was opened. The inflammatory symptoms there- 
 upon ceased : but with returning animation they presently recurred. Again, prepa- 
 ration was made for venesection ; and again the young lady lapsed into syncope : 
 and this time the inflammation and fever disappeared, never to return. She is 
 described as having been quite well the next day. I cannot, however, entertain a 
 doubt that the withdrawal of a certain quantity of blood is, in almost every case, 
 essential to the permanent control of common acute inflammation, attended with 
 pyrexia : and it may be advisable to keep persons who, like M. Solon's patient, are 
 of a timid disposition, and liable to syncope from slight causes, in a recumbent 
 posture, in order that the requisite discharge of blood from the system may be 
 obtained. 
 
 In equivocal cases (and there are many such), where it is questionable whether 
 the symptoms proceed from inflammation or not, the diagnosis may often be settled 
 by observing the quantity of blood which, taken in the upright posture, suffices to 
 bring on incipient syncope. 
 
 Dr. Hall's book. On the Effects of Loss of Blood, is well worth your attentive 
 perusal. He suggests that a scale of diseases might be formed, representing the 
 protective influence of some maladies against the effects of blood-letting ; and the
 
 148 INFLAMMATION. 
 
 opposite influence of some others in producing preternatural susceptibility of those 
 effects. " It would begin (he says) with congestion of the head, or tendency to apo- 
 plexy ; inflammation of the serous membranes, and of the parenchymatous substance 
 of various organs, would follow ; then acute anasarca ; and lastly, inflammation of 
 the mucous membranes. This part of the scale would be divided from the next by 
 the condition of the system in health. Below this would be arranged fever ; the 
 effects of intestinal irritation ; some cases of dehrium ; reaction from loss of blood ; 
 and disorders of the same class with hysteria, dyspepsia, chlorosis, and cholera 
 morbus." 
 
 With respect to the propriety of repeating venesection, it is his remark, that if, at 
 the first blood-letting, much blood flowed before any tendency to syncope manifested 
 itself, an early repetition of that remedy ^^^ll probably be required — and at any rate 
 an early repetition of our visit to the patient will be proper. But this last precept 
 is of universal obhgation in all cases of serious inflammation. 
 
 I am ahnost afraid to tell you how much blood I have seen taken at one bleeding, 
 lest I should seem to encourage you to imitate such heroic practice. I once slood 
 by and saw, not without trembling — although I was quite free from responsibility 
 in the matter — a vein in the arm kept open until seventy-two ounces (four pints and 
 a half) of blood had issued from it : and then, and not till then, did the patient 
 become faint. The event of the case quite justified the bleeding in that instance, for 
 the man got perfectly well. It was a case of general dropsy, which had come on 
 suddenl}', in a young and robust man. It occurred in the clinical wards of the 
 Infirmary at Edinburgh ; the physician had desired the clinical clerk to bleed the 
 patient in the erect posture, until some sensible effect was produced upon his pulse : 
 and no such effect could be perceived until the enormous quantity I have mentioned 
 had been abstracted. It is very seldom that such large bleedings are required ; you 
 will generally find that five-and-twenty or thirty ounces, taken properly, will be suffi- 
 cient to accomplish the purpose of the measure. Sometimes one such bleeding will 
 extinguish, as it were, the inflammation ; sometimes two or three, or half-a-dozen 
 may be necessary : and we judge of the propriety of repeating the venesection by 
 the effect of the former bleeding ; by the character of the pulse ; by the appearance 
 of the blood already drawn. It would be impossible, in a general account like the 
 present, to lay down any minute directions on this head. 
 
 I have hitherto been speaking of bleeding as we perform it for the cure of active 
 inflammation, occurring in a person previously healthy, affecting an important organ, 
 and attended with febrile disturbance of the system. But the abstraction of blood 
 is scarcely less valuable as a remedial measure in chronic inflammation, when the 
 system at large scarcely sympathizes at all with the local disease. And here it is 
 that what is properly called local bleeding is so useful — by cupping glasses, or a 
 moderate number of leeches. The object is always the same, viz. : to unload and 
 relieve the turgid capillary vessels of the part : and this we could not do by general 
 bleeding without carrying it to an extent which would be dangerous to our patient's 
 existence. These local bleedings for chronic inflammation usually require to be often 
 repeated. Considered as a remedy, blood-letting resembles some other remedies in 
 this, that it must be proportioned and adjusted to the rate of progress, and the dura- 
 tion of the disease. The remedy must be used chronically when the malady is 
 chronic. A patient may lose, on the whole, much more blood for the cure of a 
 chronic inflammation, than for the cure of one that is violent and acute ; but then 
 the bleeding must be spread over a larger space of time. 
 
 With respect to the relative merits and advantages of cupping and of leeches, as 
 topical remedies for local inflammation ; it maj' be said in favour of cupping, that 
 the precise quantity of blood taken away is more accurately determined in that 
 manner, and the operation is sooner over, and is less fatiguing, than the suction of 
 leeches. But on the other hand, the leeches seldom bungle in the operation, while 
 the surgeon often does It requires a good deal of practice to become handy and 
 dexterous in the applicuuon of the glasses — to avoid torturing and burning the patient 
 — and therefore it is that in large towns, as in this metropolis, rupping is an art car-
 
 BLOOD-LETTING. 149 
 
 ried on bj^ a distinct class of persons. You may apply leeches also to parts where 
 the cupping-glasses could scarcely be used. 
 
 General bleeding, then, is best adapted to acute inflammation ; and topical bleed- 
 ing is most appropriate in that which is chronic and slow. But a combination of 
 the two is often highly proper and useful. You may lessen the force of the general 
 circulation by venesection : but the small vessels of the inflamed part may remain 
 unable to rid themselves of their excess of blood, and continue dilated and full. 
 Such, at least, we may reasonably suppose to be sometimes the case ; and certainly 
 we often act successfully upon that theory ; that is, we bleed from the arm, and at 
 the same time, or presently after, we empty the capillaries of the labouring organ, 
 or the neighbouring vessels, by the help of leeches, or by the scarificator and ex- 
 hausted cup. The good effect of local bleeding, after the general febrile disturbance 
 has abated under venesection, is often very marked in the relief of pain. 
 
 I have recommended blood-letting to you when, among other circumstances, the 
 pulse is full and hard ; and have stated that the blood should be suffered to flow 
 until some distinct impression is made upon the system. But I wish also to apprise 
 you, that you ought not to be deterred from bleeding merely because the pulse is 
 small. It is very apt to be so in dangerous inflammations within the abdomen ; and 
 it is a very curious thing that the pulse will often rise, and the artery develop or 
 expand itself, during the time the blood is flowing. Now you must look upon that 
 circumstance as a distinct impression made upon the system, although it is one of a 
 rather different kind from what I spoke of before. You had better, in my opinion, 
 pause when this effect is fairly obtained : for so great is the tendency to death by 
 syncope in abdominal inflammation that it would not be prudent to urge the influence 
 of the blood-letting further, at one time, than the change I have just mentioned. 
 Wait, therefore, and repeat the venesection if the circumstances should again render 
 it necessary. 
 
 LECTURE XIV. 
 
 Treatment of Inflammation, continued. Recapitulation. Bleeding. Purgatives. 
 
 Mercury. Jlntimony. Digitalis. Colchicum. Opium, 
 Local Remedies. External Cold. External warmth. Counter-Irritation. 
 
 After pointing out to you, yesterday, the necessity of guarding your patient, as 
 much as possible, from all stimulants or sources of irritation, both internal and ex- 
 ternal, the avoidance of which constitutes what is called the antiphlogistic regimen, 
 I began to speak of the remedies of inflammation. 
 
 Now the great remedy in acute and dangerous inflammation is blood-letting; and 
 when this remedy is used at afl, it should be used freely, and so as to produce a 
 decided impression : and its efficacy will always be the greater, in proportion as it 
 is applied in the earlier stages of the inflammation. The objects of the abstraction 
 of blood are two-fold : to lessen the force of the heart's action is one object ; to empty 
 the gorged capillaries of the part inflamed is the other. We effect the first of these 
 objects, or both of them at once it may be, by making an orifice with a lancet, m the 
 trunk of some convenient vein or artery, and allowing the blood to escape ; we ac- 
 complish the second by making little incisions with a scarifier through the skin as 
 near the inflamed part as we can, and forcing the blood through these little wounds 
 by the pressure of the atmosphere : i. e., we take off the pressure from the part sca- 
 rified, by placing over it a glass cup, from which the air has been in great measure 
 exhausted, and then the unbalanced weight of the atmosphere upon the surrounding 
 surface forces out the blood : or we suffer leeches to scarify the skin, and to suck 
 out the blood. These two modes of drawing blood, from the trunks of the blood- 
 vessels on the one hand, and from the capillaries on the other, we call, respi^ctively, 
 general bleeding, and topical bleeding. 
 
 I say the main point to be achieved in general bleeding is so to manage the opera- 
 
 n2
 
 150 INFLAMMATION. 
 
 lion as to make a decided impression, as quickly as possible, upon the pu.se or the 
 heart . and to do this we place our patient in an upright position, and make a free 
 orifice in the vein of one or both arms. 
 
 And when the force of the general circulation has been thus abated, it will in 
 many cases be proper and necessary to take away blood from the capillaries also, in 
 the neighbourhood of the suffering organ ; this is almost always safe and good prac- 
 tice : there can seldom be any reason for abstaining from it, except when the general 
 bleeding has brought the patient so low that the abstraction of a few more ounces in 
 any way might be hazardous. But the employment of local depletion presently 
 after general is then especially indicated, when the /oca/ symptoms remain unrelieved 
 when, although the indirect symptoms which manifest themselves through the 
 medium of the system at large have been moderated by the general blood-letting, 
 yet the direct symptoms belonging to the part, and disturbing its functions, the pain 
 for example, or the labouring breath, or the stupor, have not undergone a propor- 
 tional improvement. Under such circumstances, the unloading the oppressed capil- 
 laries by means of leeches or cupping-glasses will often be attended with the hap- 
 piest effects. 
 
 I mentioned that the most common way of performing general blood-letting in 
 this country is by venesection ; and that the veins chosen, as the most suitable for 
 that purpose, are the cephahc and basilic veins at the bend of the arm : but that 
 Avhen, from accidental circumstances, blood cannot be obtained easily and abundantly 
 from those veins, any other large and superficial blood-vessel may be opened. It 
 matters little which, in my opinion, so far as regards the effect of the abstraction of 
 blood upon the disease. Some persons are fond of opening the temporal artery when 
 the inflammatorj' disease is situated in or about the head : and certainly, when we 
 see this vessel starting from the surface hke a cord, and tortuous from its fullness, and 
 visibly throbbing, we feel tempted to give vent to the blood which is distending it. 
 But arteriotomy is not so easily managed as phlebotomy. It is sometimes difficult 
 to get the blood to flow properly ; and it is sometimes difficult to stop its egress when 
 we wish to do so ; and sometimes there are after-consequences which are far from 
 being pleasant : little aneurismal tumours are apt to arise. It is, besides, desirable 
 to avoid the necessity of bandaging the head, in order to restrain the further efflux 
 of blood from the artery. Other practitioners recommend opening the external 
 jugular vein in head cases, especially in children, whose veins in the arm are small. 
 This is a plan which I have very seldom adopted, and which, I am bound to tell 
 3'ou, I do not much like : first, because I think it is seldom necessary ; secondly, 
 because I think it is often unsafe. 
 
 It is seldom necessary : for in children we can always get as much blood by topi- 
 cal bleeding as will be equivalent to a general blood-letting. And it is unsafe in 
 two ways. In the first place, it is not always an easy matter to stop the bleeding 
 from the jugular vein, especially in a struggling and unmanageable child; and the 
 difference of a few ounces of blood may be a fatal difference. Here also any com- 
 pression of the neck, to stay the hemorrhage, might affect injuriously the cerebral 
 circulation. Again, there is a distinct and peculiar danger attending the incision of 
 this vein, that, namely, of admitting air into it. You perhaps are aware that if air 
 enters a large vein near the heart, and passes on to that organ, it kills outright. If 
 you open the jugular vein of a horse, and blow forcibly into it towards the heart, 
 the animal drops down dead. The celebrated Dupuytren was performing some ope- 
 ration about the neck, in the course of which he cut across one of the veins there 
 situate : some bubbles of air rushed in at its open mouth, with an audible clucking 
 noise, and, in an instant, his patient expired. The same frightful accident has 
 occurred in operations performed in this country, and in America, I was told very 
 lately that in one of our metropolitan hospitals it was thought right, for some reason 
 or other, to bleed an adult patient by opening his jugular vein : the opening was 
 made very near the clavicle, so that pressure between the orifice and the heart was 
 difficult to effect. Of course the blood soon leaves the portion of the vein nearest the 
 heart ; and whether by some suction power of the heart itself upon the veins, or how. 
 one scarcely knows, but air rushed in, and the patient was presently a dead man.
 
 BLEEDING. 151 
 
 Perhaps misadventures of this kind may be capable of being prevented by using 
 great caution in such cases ; but as it is the etiquette for physicians to direct but not 
 to perform these manual services towards the sick, and as, therefore, I should incur 
 all the responsibility, and at the same time be able to ensure none of the necessary 
 care, I confess that I am shy of recommending venesection to be made in that parti- 
 cular place. 
 
 Whether, all other things being the same, the abstraction of arterial blood may be 
 more or less effectual in restraining inflammation than the abstraction of venous, is 
 more than I can tell you. 
 
 When topical bleeding is employed with the view of disburdening the turgid 
 capillaries, either in chronic inflammation, or in acute inflammation as an auxiliary 
 to general bleeding, it would seem most expedient to get as near to the part affected 
 as we can. To apply, for example, our cupping-glasses or our leeches to the tem- 
 ples, or behind the ears, or just below the occiput in inflammatory affections of the 
 head ; to the chest or the precordia, when the lungs or heart are the seat of the dis- 
 ease ; to the surface of the abdomen, in inflammation of the liver, or stomach, or 
 intestines, and so on. And this is the plan which I have almost always adopted ; 
 and with such satisfactory results that I have felt Httle inclination to try any other. 
 But many persons do believe that local bleeding is more useful when it is performed 
 at some distance from the affected part : they would put leeches, for instance, on the 
 insteps, to reheve an inflamed throat ; and they attribute the benefit that ensues to 
 what is called revulsion : they suppose that the suction of the leeches solicits the 
 blood, as it were, to that quarter, and diverts it from the vessels of the part that is 
 inflamed. It seems to me that the revulsive influence of topical bleeding would be 
 greater in the neighbourhood of the inflamed part than far from it. I know, how- 
 ever, some very practical men who have been much struck with the results of thia 
 distant blood-letting, which they had seen practised in the Parisian hospitals. 
 Leeches are also sometimes applied at a distance from the seat of the inflammation, 
 on another principle — that of drawing the blood directly from the veins which com- 
 municate with the diseased part. In abdominal affections, in inflammation of the 
 liver or intestines, the French are in the habit of applying leeches in great numbers 
 to the verge of the anus : because, they say, the blood is then abstracted from the 
 very veins through which it is returning towards the already overloaded organs. It 
 is right that you should be aware of these opinions, and of this practice. I can say 
 but little of it from my own knowledge. I can well believe, however, that it is good 
 and useful practice : but in this country we should find it difficult to persuade many 
 of our patients to submit to have leeches planted round the anus ; and I have seldom 
 been disappointed of the benefit I expected from topical bleeding, when it has been 
 employed at the surface, as near the part inflamed as possible. 
 
 The evacuation next in importance to blood-letting, is purging. This is an expe- 
 dient which in cases of violent inflammation, or high general fever, should scarcely 
 ever be omitted. To keep the bowels what is called opoi, forms indeed a part of 
 the antiphlogistic reg-zmpn ; but in acute inflammatory diseases, active purging is 
 of very great service. These two points are gained by it. The stomach and intes- 
 tines are freed from accumulated faeces, or other matters which, by their bulk or 
 their acrimony, might prove irritating: and at the same time depletion is carried on 
 by means of the serous discharge which is produced from that large extent of mucous 
 merribrane. There are some cases of inflammation in which the operation of purga- 
 tive medicines is of especial benefit ; as in inflammatory affections of the head, eitner 
 external or internal, of which part these medicines assist or cause the depletion in a 
 very sensible manner. We have an illustration of this in the paleness of the face, 
 which often, during health, accompanies the action of a brisk cathartic. The use 
 fulness of repeated purgatives is less distinctly seen in inflammations situated be- 
 tween the thorax; although in these cases also they are often highly beneficial. 
 They are efficient remedies, too, in all inflammatoiy conditions of the liver. Bui 
 when inflammation has fastened upon the stomach or bowels themselves, although 
 it may be indispensable that they should be unloaded of their contents, which are 
 often composed of irritating, ill-digested food, and of morbid secretions no less feasinjj
 
 152 INFLAMMATION. 
 
 and hurtful, the propriety of going beyond this point is extremely questionable. I 
 believe that much harm is often done by pressing the inflamed alimentary canal 
 with active purgatives. But to all those points I shall have occasion to return. 
 
 Next to blood-letting, as a remedy, and of vastly superior value upon the whole, 
 to purgation, in serious inflammations of various kinds, is mercury. This mineral 
 is really a very powerful agent in controlling inflammation ; especially acute, 
 phlegmonous, adhesive inflammation ; such as glues parts together, and spoils the 
 texture of organs. It is of the greatest importance that you should accurately inform 
 yourselves concerning the various effects of mercury upon the system : the changes 
 it produces ; the changes it arrests or prevents ; the cases in which it does good ; 
 the cases in which it does harm ; that you should learn, in short, how to wield a 
 very potent, but a two-edged weapon. 
 
 If we inquire what mercury does when it is administered to a person in health, 
 we find three very marked effects following its internal use. They vary, indeed, in 
 different cases, and under different circumstances : but we know that the employ- 
 ment of mercury under any of its usual forms of exhibition is often followed by 
 increased watery evacuations from the intestines ; or by an increased discharge of 
 bile ; or by an increased flow of saliva ; that is to say, it determines (as the phrase 
 is) to certain secreting organs — the mucous membrane of the bowels, the liver, the 
 salivary glands ; it augments their natural secretion ; and in this augmentation of 
 s-ecretion is implied an increased afflux of blood to the secreting part. It is probable 
 that mercury has a similar influence on most or all the secreting surfaces of the body, 
 altering the "condition of the capillary circulation throughout. And an explanation 
 of its curative power in inflammation has been drawn from this fact : it has been 
 supposed that mercury thus tends to equalize the circulation ; that by causing the 
 blood to be distributed in larger quantity than common upon several surfaces at the 
 same time, it obviates, ^jro tanto, its excessive congestion or accumulation in any one 
 organ. Whether this hypothesis in respect to the modus operandi of mercury be 
 true or not, I will not pretend to say; but it certainly is not an unreasonable hypo- 
 thesis. 
 
 If you push this remedy in healthy persons, other effects ensue : inflammation is 
 actually ;;rorf»ce(/; the gums become tender, and red, and swollen, and at length 
 they ulcerate ; and in extreme cases, and in young children especially, the inflamed 
 parts ma)'- perish : the cheeks, for example, sometimes slough internally. Not only 
 the gums, but the throat and fauces, grow red, and sore and sloughy. 
 
 Now you will do well to observe what is the character of the inflammation thus 
 produced. It is superficial, spreading, erysipelatous : it leads to ulceration without 
 any distinct occurrence of suppuration ; the ulcers enlarge. Of the three processes 
 which I formerly pointed out as going on in different degrees, at the same time, in 
 an ulcerated surface, that of absorption is vastly predominant ; and you will find that 
 persons in whom this local aflfection, this condition of the parts within the mouth, 
 has been produced, get rapidly thin ; their fat disappears ; they become emaciated. 
 That is, the absorption of the old materials throughout the body exceeds the deposit 
 of new matter. Patients who are kept under the influence of mercury grow pale 
 as well as thin : and Dr. Farre, who has paid great attention to the effects, remedial 
 and injurious, of this drug, holds that it quickly destroys red blood : as efft-ctually 
 as u may be destroyed by venesection. As an example of this he was in the habit 
 of relating in his lectures the case of a lady who was attacked with hematemesis : 
 and whose gastric sj'stem and liver were gorged with blood, " Her complexion," 
 said the doctor, "was compounded of the rose and the violet. Under a course of 
 ■nercury she was blanched, in six weeks, as white as a lily." 
 
 There are still other, occasional, effects of the continued introduction of mercury 
 into the system: a peculiar eruptive disease; a peculiar condition of the nervous 
 system : but with these I do not now meddle ; they will come under our more parti- 
 cular consideraliou hereafter. At present I am desirous to place such facts before 
 you as may help you to determine in what cases mercury is a fit remedy for inflam 
 mation , In what oases it would be improper to give it. The facts T have already
 
 MERCURY. 153 
 
 mentioned show that it has a loosening effect upon certain textures ; that it works by 
 pulling down parts of the building. 
 
 But the great remedial property of mercury is that of stopping, controlling, or 
 altogether preventing the effusion of coagulable lymph ; of bridling adhesive injiam- 
 mation; and if we, in our turn, could always bridle and limit the influence of 
 mercury itself, it would be a still more valuable resource. 
 
 From the little I have now said you will readily understand in what description 
 of cases mercury is likely to be useful. In common adhesive inflammation, whether 
 of the serous or the areolar tissues ; whenever, in fact, you have reason to suppose 
 that coagulable lymph is effused, or about to be effused, and mischief is likely to 
 result from its presence, then you may expect much benefit from the proper admi- 
 nistration of mercury ; as an auxiliary, however, to blood-letting, not as a substitute 
 for it. 
 
 On the other hand, mercury is likely to be hurtful in those forms of disease 
 " where the morbid action approximates to its own action." In cases of erysipela- 
 tous inflammation having a disposition to gangrene ; in scrofulous diseases ; in 
 inflammatory complaints attended with general debility, and an irritable condition of 
 the nervous system, or a manifest tendency to take on a typhoid character. 
 
 When we have to contend with acute inflammation, and desire to prevent or arrest 
 the deposition of coagulable lymph, our object is, after such bleeding as may have 
 been proper, to bring the system as speedily as possible under the specific influence 
 of mercury. How may tliis best be done ? and how are we to know that it has beea 
 achieved ? 
 
 I will answer the last of these questions first. We know that the whole system 
 has been brought under the specific influence of mercury, as soon as its effects 
 become even slightly perceptible in the gums and breath of the patient ; and in 
 adults we cannot be sure of it before. The gums grow red and spongy ; the patient 
 complains that his gums are sore : and that he has a metaUic taste, a taste hke that 
 of copper, in his mouth ; and an unpleasant and very peculiar foetor, easily recog- 
 nized again when it has been once perceived, is smelt in his breath. These symp- 
 toms are enough : you need not in general look for any more decided affection of 
 the mouth, such as ulceration of the gums, swelling of the glands beneath the jaw, 
 and of the tongue, and a profuse flow of saliva. Formerly, when it was believed 
 that the material cause of the disease was carried out of the body with the saliva, 
 the mercurial treatment was continued with a view of producing the discharge of 
 many ounces, and even of a pint or two, in the twenty-four hours : but all that is 
 requisite is that the gums should become distinctly tender, and that the mercurial 
 foetor should be unequivocally manifest, and that these symptoms should be kept up 
 for a certain time. 
 
 Now this is best effected, usually, by giving some form of niercury in equal and 
 repeated doses, by the mouth. For urgent cases calomel is the best form in which 
 it can be administered : two or three grains, given every four or six hours, will 
 generally suffice to touch the gums in the course of thirty-six or forty-eight hours. 
 If it acts as a purgative its specific effect upon the whole system will be postponed 
 by that circumstance ; and it then becomes expedient to combine with it just so 
 much opium as will prevent its passing off' by the bowels. A quarter of a grain of 
 opium with two grains of calomel — or a third of a grain of opium with three or four 
 grains of calomel — will generally be sufficient to restrain the purgative operation of 
 the latter. When a speedier effect is desirable we give larger doses ; such as five 
 or ten grains every three, or even every two hours: or we combine mercurial 
 inunction with the exhibition of calomel by the mouth. It is impossible to lay down 
 any precise rule that will fit all cases. 
 
 Blue pill, or the hydrargyrum cum creta, may, in certain cases, be preferable to 
 calomel ; but they must be given in greater quantity. Some practitioners believe 
 •.hat a combination of blue pill and calomel acts sooner, and answers better, than a 
 proportional dose of either, given alone. 
 
 This mode of administering mercury, so as to affect the system at large, is emi- 
 nently useful in many instances of acute phlegmonous inflammation, after "ii'peding
 
 154 INFLAMMATION. 
 
 has been carried as far as the circumstances of the case may warrant. I repeat that 
 it must not be allowed to supersede blood-letting. Previous bleeding renders the 
 body more readily susceptible of the influence of mercury ; and the operation of 
 the mercury comes in aid of the salutary effect of the abstraction of blood. The 
 two remedies accomplish by their joint power what neither of them could accom- 
 plish singly. 
 
 It is important to know that different persons admit of, or resist, the specific agency 
 of mercury, in very different degrees ; so that in some patients the remedy becomes 
 unmanageable and hazardous ; while in others it is inert and useless. It is most 
 grievously disappointing to Avatch a patient labouring under inflammation which is 
 hkely to spoil some important organ, and to find, after bleeding has been pushed 
 as far as we dare push it, that no impression is made upon his gums by the 
 freest use of mercury. Such cases are not uncommon ; and unfortunately they 
 seem most apt to occur when the controlling agency of mercury is most urgently 
 required. On the other hand, there are persons in whom very small quantities of 
 mercury act as a violent poison ; a single dose producing the severest salivation and 
 bringing the patient's existence into jeopardy. This history was told to Dr. Farre 
 by a medical man, under whose notice it fell. A lady, whom he attended, said to 
 him, at his first professional visit to her, " Now, without asking why, or speculating 
 about it, never give me mercury, for it poisons me." Some time afterwards she met 
 with the late Mr. Chevalier, and spoke to him about her complaints ; and he pre- 
 scribed for her, as a purgative, once, two grains of calomel, with some cathartic 
 extract. She took the dose ; and the next morning showed the prescription to her 
 ordinary attendant. " Why (said he) you have done the very thing you were so 
 anxious to avoid ; you have taken mercury." She replied, " I thought as much, 
 from the sensations I have in my mouth." Furious salivation came on in a few 
 hours ; and she died, at the end of two years, worn out by the effects of the mercury, 
 and having lost portions of the jaw-bone by necrosis. 
 
 Another medical man informed me that he knew a person so susceptible of the 
 influence of mercury, that when his wife had rubbed a very small quantity of white 
 precipitate ointment upon her neck for some cutaneous affection, after sleeping with 
 her his gums were tender for three or four days, and slight salivation took place. 
 This did not happen once only, but three several times. On one occasion this same 
 man took two blue pills, as preliminary to a common purge, and he was salivated 
 profusely for six weeks. Cases similar to these occur now and then to most medical 
 men : we cannot tell beforehand in whom such effects are to be looked for ; but it is 
 never prudent to neglect any warning which the patient gives of his own previous 
 experience on this point. You will generally find that where the affection of the 
 gums and salivary organs goes on to a troublesome or distressing extent, it has super- 
 vened upon the employment of a very moderate quantity of mercury. 
 
 So distressing sometimes are these effects of mercury upon the mouth, that I may 
 pause a moment to tell you what I know about the means of remedying them. You 
 will constantly be called upon to do something for the relief of this disease (for so 
 we must call it), which you yourselves, or some of your brethren, have with the best 
 intentions inflicted. I have tried all sorts of expedients; and I have asked a great 
 number of my friends what is the best pfan to adopt in such cases : but I never 
 f ould get mucn satisfactory information from them. Some thought purging was the 
 best thing. Others recommended alum gargles ; or gargles made with the chloride 
 of soda ; and these last certainly have one good effect, that of correcting the foctor. 
 A dilute solution of chlorine in water, much used at the Middlesex Hospital, is better 
 still. Others believed that sulphur, which has long been prescribed in such emer- 
 gencies, was really of service ; and some advised that the patient should be as much 
 as possible in the open air: a few commended iodine. All admitted that they knevir 
 of no certain remedy. Neither do I. But there are two or three expedients which 
 I am confident are often of very great use in checking the violence of the salivation, 
 and in removing the most distressing of its accompaniments. If there be much 
 external swelling, treat the case as being, what it really is, a case of local injlamma- 
 iton : apply eight or ten leeches beneath the edge of the jaw bones, and wrap a soft
 
 MERCURY. 155 
 
 poultice round the neck, into which the orifices made by the leeches may bleed ; 
 and I can promise you that, in nine cases out of ten, you will receive the thanks ot 
 your patient for the great comfort this measure has afforded him. Pure tannin, 
 moistened and smeared upon the spongy gums, is remarkably efficacious in render- 
 ing them firmer and more comfortable. But this is not always to be procured : and 
 when the flow of saliva, and the soreness of the gums, formed the chief part of the 
 grievance, I have found nothing more generally useful than a gargle made of brandy 
 and water ; in the proportion of one part of brandy to four or five of water. This 
 last- piece of practice I learned from the present apothecary to the Middlesex Hos- 
 pital ; I have tried it over and over again ; and I tell it to you as a thing worth 
 remembering. These little points are by no means to be despised. A very fashion- 
 able and successful physician, now dead, used sometimes to say when he met others 
 of his brethren in consultation, " It is all very well to speculate about the exact situa- 
 tion, and the precise nature of the disorder, but the question with me is, ' what is 
 good for this, that, or t'other thing V " A wise phj'sician will seek to combine with an 
 accurate knowledge of disease, and settled principles of treatment, those practical 
 expedients and minor appliances which are picked up by casual experience ; which 
 could never have been reasoned out : and which sometimes constitute nearly all that 
 we can do for our patient's benefit. 
 
 But to return to mercury as a remedy against inflammation. Tt is of great service 
 m many cases of chronic inflammation ; and I may repeat here the observation I 
 formerly made when speaking of blood-letting — that the treatment must keep pace, 
 as it were, with the disease. When textures have been slowly altered by a gradual 
 deposition of coagulable lymph, we should gain but little by suddenly or speedily 
 salivating our patient. The lymph, if it can be dispersed at all, must be gradually 
 taken up again : and mercury, given with the view of promoting its absorption, 
 must be slowly and gradually introduced into the system ; and its specific influence, 
 when at length it is felt, must be sustained for a considerable length of time. 
 
 You must not expect any good, but the contrary, from the exhibition of mercury 
 in scrofulous inflammations ; and where the scrofulous diathesis is well marked, you 
 should be cautious in giving mercury at any time. But I am certain that many 
 men are too scrupulous in this respect ; and that, through over tenderness of your 
 patient's constitution, you may risk his life, by withholding mercury because he 
 shows tokens of scrofula. You may recollect my stating that scrofulous persons are 
 not exempt from attacks of common inflammation ; and in some such cases the pos- 
 sible aggravation of their general ill health, by mercury, is not to be put in competi- 
 tion with the immediate danger from the local inflammation. I have again and 
 again seen scrofulous patients benefited by moderate salivation ; which, if it proved 
 injurious at all to their general condition, Avas certainly less injurious than the 
 unchecked local complaint would have been. 
 
 ' There are some other remedies for acute inflammation which, in this general 
 account of its treatment, I must briefly notice. Antimoyiy is one of them ; and a 
 very valuable remedy it is in some forms of inflammatory, disease. Antimony, 
 properly administered, subdues the action of the heart and arteries, producing nausea, 
 paleness, and sinking of the pulse, and frequently great relief to the local symptoms. 
 You bring the circulation into that state into which it may be brought by free blood- 
 letting. But when the violence of the inflammatory symptoms recurs again and 
 again, you cannot again and again employ the lancet : or if you do so employ it as 
 at length to extinguish the inflammation, you reduce your patient to a state of pitiable, 
 and even perilous, debility. Now you may continue or repeat the depression of the 
 circulation by means of antimony, without any dread of such subsequent Aveakness. 
 Antimony, so far as m_y own observation goes, is admirably suited to cases of active 
 inflammation, in which mercury would either be not so useful, or could not be 
 brought to bear. It is in inflammation of the mucous membrane of the air passages 
 that antimony is so signally beneficial. You will see a patient labouring for breath, 
 unable perhaps to he down, with a turgid and livid countenance from imperfect 
 arterialization of the blood. He has been ill but a short time ; it is an acute aflTec- 
 tion ; and upon listening at his chest you hear that pecuhar wheezmg sound which
 
 156 INFLAMMATION. 
 
 we call sibilus, in every part of his lungs. I shall have to describe this sound, and 
 •jts causes, and its meaning, in a future part of the course. You give such a patient 
 repeated doses of antimony ; he becomes sick, vomits perhaps, but he feels nausea : 
 his pulse becomes less forcible, his face grows pale, and he can breathe again. The 
 nausea is not a pleasant sensation ; but the want of breath is a far more distressing 
 one ; and that is greatly mitigated. Perhaps free secretion takes place from the 
 congested membrane, and then the patient is easy and safe. Now you could not 
 effect this change so quickly and readily, or so conveniently, by mercury, and per- 
 haps not at all. Bronchitic affections are very common in children, in whom it is 
 usually difficult to induce the specific influence of mercury. 
 
 On the other hand, antimony does not appear to be nearly so valuable a r^edy 
 as mercury, when serous membranes are inflamed. 
 
 The French and Italian physicians place much rehance upon antimony for the 
 cure of inflammation ; and they seem to know Httle or nothing of the remarkable 
 agency of mercury upon that disease. For my own part I do not see how any 
 useful comparison can be made between these two substances in respect to inflam- 
 mation, considered generally, as we are now considering it. There are some par- 
 ticular forms of inflammation to which the one remedy is better suited, and there are 
 others in which the other is most effectual. I must content myself for the present 
 with having adverted to these distinctions. 
 
 As to the form in which the antimony should be exhibited, I apprehend that we 
 hall all come at last to freshly dissolved tartar emetic. The antimonial powder is 
 of ver}^ uncertain strength; and the antimonial wine contains too much spirit to allow 
 of its being given in large and frequently repeated doses. It is a curious circum- 
 stance, that akhough vomiting and purging are apt to be produced by the first two 
 or three doses, they usually cease when the same quantity is persevered with. 
 Tolerance of the remedy is established. But akhough these unpleasant primary 
 effects cease, the curative agency of the antimony appears to continue. When you 
 desire to obtain its full influence in a short time, you may dissolve a grain of the 
 tartar emetic in two ounces of hot water, and give a fourth part of the solution every 
 half hour. If the patient becomes pale and sick, you pause awhile and allow him 
 to recover himself; and if the inflammatory symptoms return, you repeat the medi- 
 cine. It sometimes acts violently upon the bowels, and then it is necessary to add a 
 few drops of laudanum to each dose. 
 
 [The remarks of Dr. Watson upon the remedial effects of tartar emetic in inflammatory 
 affections, are perfectly correct in reference to these diseases as they occur in the adult; in 
 the inflammatory diseases of infants and young children, however, the tartar emetic is not a 
 remedy that can be safely employed ; it produces in them always very considerable and 
 enduring disturbance of the stomach, and in many cases a state of extreme and, as remarked 
 by a late writer — Dr. Wilton, (Prov. Med. and Surg. Journ.) — even fatal depression of the 
 vital powers. — C] 
 
 Digilalis is another powerful medicine, from which, as a remedy for active inflam- 
 mation, much Avas at one time hoped ; but this hope has been in a great measure 
 disappointed. It is not a manageable remedy in such cases. Its singular property 
 of retarding the circulation, of bringing down the number of the heart's pulsations, 
 and abating its force, led to the expectation that it might render the use of the lancet 
 unnecessary ; that it might check the inflammatory process without permanently 
 reducing the strength of the patient. But if you give moderate doses of digitalis, 
 Its peculiar effect upon the pulse comes on at very uncertain periods, and may be 
 postponed until it is tO' late to be of any service. If, on the other hand, you give it 
 in such quantity as speedilj'' to affect the heart's action (which is what we want in 
 acute and serous inflammation), then you are never secure against what may b" 
 called its poisonous effects ; deadly faintness, frightful syncope, and even death itself. 
 Most practitioners can tell of cases in which patients, who were taking full doses of 
 digitalis, have suddenly expired ; and when the remedy has appeared to have had 
 more to do with the fatal event than the disease. There are practitioners, however, 
 and I know one of them, who affirm that digitalis may be given, after due depletion, 
 and in acute inflammation, in very large, and I should say starthng doses, with tho
 
 COLCHICUM, OPIUM. 157 
 
 very best «ffects — doses which range from half a drachm to half an ounce, and even 
 six drachms, of the officinal tincture. I confess to you that I should be very unwill- 
 ing to sanction this mode of using digitalis. I never attempt to employ it with the 
 view of knocking down acute inflammation — to which alone you will observe that 
 my present remarks apply. Digitalis is often of great service in other complaints ; 
 but I am not at present discussing the remedial virtues of digitalis, or of any other 
 drug, except so far as they relate to the cure of recent and active inflammation. 
 
 Colchicinn is a drug which is often prescribed in inflammation. It is a most valu- 
 able remedy in certain specific forms of inflammation. But for repressing common 
 phlegmonous inflammation we have much more certain and better remedies. For 
 this purpose colchicum is, I believe a very unimportant medicine. 
 
 I have formerly been asked, by students attending here — and therefore \ antici 
 pate the question now — respecting the utility of opium as a remedy in inflammation. 
 Certainly opium, like most of our powerful medicines, may do much good, as it may 
 do much harm, in different inflammatory diseases ; and it is not very easy to point 
 out clearly, in a general view of the treatment of inflammation, the rules for its 
 administration by which we must be guided in diflferent cases. Yet there are a few 
 general observations which I may make now on this subject. 
 
 The administration of a full dose of opium has been strongly recommended after 
 that free and effective bleeding which I have already described. It prevents the 
 rekindling of the inflammation which is apt to result from irritation of the nervous 
 system — a kind of irritation, you will remark, which the copious abstraction of 
 blood is calculated to produce ; or to augment, if it flnds it already existing. The 
 opium soothes this nervous irritability, and it must be given, when given at all, in 
 doses which will have that effect. It is best adapted to those cases in which a 
 natural irritability is inherent in the constitution of the patient — to those in which 
 .such irritability has been acquired by bad habits of life — and to those in which the 
 local disease is attended with much pain, which is in all constitutions a source of 
 irritation. 
 
 However, this is a remedy which requires to be used, in inflammation, with great 
 caution and discrimination. In cases of active inflammation within the cranium, its 
 propriety is very questionable. It is apt to confuse both the patient and his physi- 
 cian, who is unable to say, after a full dose of opium has been given, how much of 
 the stupor that follows is owing to the disease, and how much to the drug. It is a 
 very ticklish remedy in pectoral inflammations. I believe that by the free use of 
 opium I saved the life of a relation of my own, an old lady, who was in danger of 
 being worn out by the cough and bronchial affection which attended the influenza. 
 On the other hand I certainly have known more than one person, labouring under 
 extensive and severe bronchitis, so effectually quieted by a dose of the same medi- 
 cine, that they never woke again. As a general rule I should say that you must be 
 very careful how you venture upon opium in inflammatory diseases that tend to pro- 
 duce death by coma, or apnrea. If there be any unnatural duskiness of the face, if 
 ever so sHght a tinge of purple mingles itself with the red colour of the lips, this is 
 an appearance which (with certain exceptions, to be specified hereafter) should warn 
 you against opium. It shows that the blood is imperfectly arterialized : and imper- 
 fect arterialization of the blood, as I hope you all know, either results from, or con- 
 duces to, a state of coma. 
 
 On the other hand, it is, cseteris paribus, in cases where the tendency is towards 
 death by asthenia, that the use of opium, as a remedy for inflammation, is most 
 serviceable. It has a capital effect often, after free bleeding, in cases of peritonitis, 
 and of enteritis. It probably does good in various ways : by quieting the nerves — 
 by sustaining the faltering action of the heart — by keeping the inflamed parts at 
 rest. There are some frightful accidents in which we can expect little from blood- 
 letting, but in which the judicious employment of opium affords some glimmering 
 of hope. I allude to those cases of intense and general peritonitis which arise upon 
 the escape of irritating substances into the cavity of the belly ; the contents of the 
 intestines, from ulceration or from external injury ; urine from rupture of the blad- 
 der ; and so on. If there be any hope in such cases, it is to be found in the con 
 
 o
 
 158 INFLAMMATION. 
 
 tinucd exhibition of opium in considerable doses. But upon all these points I shall 
 go more into detail when we come to consider individual diseases. 
 
 A very few remarks, in respect to external remedies in cases of inflammation, 
 will terminate both this lecture and what I have to say, thus generally, of the 
 treatment of inflammatory complaints. 
 
 The application of external cold will aid us very powerfully, in certain serious 
 cases of inflammation; and especially in cases of inflammation within the cranium. 
 It is really wonderful what a sedative and soothincr efl^ect this expedient frequently 
 has in allaying delirium, the result of active inflammation of the brain and its 
 membranes. Thin folds of linen, kept constantly moist and cold by cold water, are 
 placed upon and around the shaven head. We often apply ice in the same way. 
 But I need not go at present into any detail on this subject ; I will only observe, 
 that we have a most excellent and simple guide as to the probable usefulness of cold 
 application to the head, in the sensations of our patients. It is very lucky that it 
 is so. As long as the cold cloths, or the bags of ice, are pleasant and grateful to the 
 patient, so long we sedulously continue to apply and renew them ; as soon as the 
 patient dislikes them, they had better be intermitted. 
 
 Cold apphcations to the chest, and to the belty, in active inflammation of parts 
 situated within those cavities, have been praised by some practitioners ; but I believe 
 are veiy seldom emploj^ed. I have no personal experience either of their utilitj'', 
 or of their hurtfulness. I confess that I should not like to use them. I should think 
 that the effect of the cold, in driving the blood from the cutaneous vessels, and accu- 
 mulating it in internal parts, would be hkely to be injurious. We shall see, by and 
 by, that the contents of the skull are somewhat differently circumstanced, in this 
 respect, from those of the thorax and abdomen. 
 
 The totally opposite measure, applying 7varmfh to the surface, is of very great 
 service in many cases of internal inflammation ; especially in inflammations of the 
 abdominal organs. We speak of cold lotions, and of hot fomentations. These 
 last are managed in various ways, into Avhich I do not at present enter. They seem 
 to do good by determining to the surface ; they promote perspiration ; they mitigate 
 pain, and persuade to sleep. 
 
 In cases of external inflammation, sometimes cold applications are found to be of 
 use, and sometimes warm. In this matter, also, the sensations of the patient afford 
 the best criterion. Both of them tend, in different circumstances, to promote reso- 
 lution. We have an illustration of the beneficial agency of cold applications for 
 this purpose in the treatment of recent burns and scalds, particularly Avhen the injury 
 is superficial, and the skin has not been destroyed. Probably there is scarcely any 
 one present who has not experienced the rehef given to the pain of a burned finger, 
 by dipping it in cold water; and the return of the pain upon taking the finger out 
 again. The cold may be so constantly applied that the pain will cease to recur 
 when the application is at length suspended. Dr. John Thomson relates a case in 
 which a burned arm was kept immersed in cold water for two days and two nights 
 incessantly ; and inflammation Avas thereby wholly prevented. I have known this 
 expedient fail, however. A nurse in the Middlesex Hospital fell as she was car- 
 rying a pail of hot water upstairs, and in her fall thrust one of her arms into the 
 scalding liquid. Without loss of time she plunged the same arm into cold nater; 
 but after a while was obliged to desist; the cold immersion bringing on severe 
 ngor?. 
 
 Tn ei3'sipelas I am persuaded that warm fomentations not only afford more 
 :omfort, but are more effectual and safer than cold lotions. 
 
 Independently of their occasional influence in promoting resolution, warm appli- 
 cations — warm soft poultices for instance — are often used with the view of forward- 
 mg suppuration. Hence this rule. Whenever resolution of the inflammation is 
 possible — but suppuration is likely to ensue — warm applications are the most proper: 
 because, under their use, we have an equal chance of obtaining resolution, with less 
 Ijfazard of retarding or rendering untoward the process of suppuration, in case 
 resolution does not take place. 
 
 Coxinter-irritation, by means of blisters, sinapisms, irritating ointments, setonB
 
 HEMORRHAGE. 159 
 
 issues, or moxas, is often very beneficial. It probably operates by attracting blood 
 into the neighbouring parts, and in the same degree diverting it from the inflamed 
 part. It is most serviceable in chronic inflammations, and towards the decline of 
 those which are acute. It is particularly adapted to scrofulous affections. There 
 is an objection to the use of counter-irritation during the height of the inflammatory 
 fever, on account of the increase of general irritation which it would then occasion. 
 Neither in local inflammation should counter-irritation be applied very near to the 
 inflamed part. Blisters upon the head or neck, are not proper, therefore, at least 
 in the early stages of the disease, in acute inflammation within the cranium ; but 
 they are sometimes applied in such cases, with advantage, to the lower extremities. 
 To the chest, however, in thoracic inflammation, and to the belly in abdominal, 
 bUsters are often not only perfectly safe, but of the greatest use, as will, I trust, be 
 apparent as we go on. 
 
 LECTURE XV. 
 
 Hemorrhage: — most commonly by Exhalation. Habitual Hemorrhages. Tlca- 
 rioKS Hemorrhages. Idiopathic Hemorrhages. Active and Passive. Symp- 
 tomatic Hemorrhages. Usual Situations of Hemorrhage. Symptoms and 
 Diagnosis. Principles of Treatment: 
 
 In the course of that somewhat cursory account which I have been endeavouring 
 to give you of the general facts and doctrines of pathology, as a preparation for the 
 better understanding of special forms of disease, we reached, some lectures back, 
 the subject of local plethora or congestion. From that point our road branched off" 
 in three several directions. We have pursued the first and main branch to its ter- 
 mination ; that which led to the discussion of inflammation. We must now go back 
 to the same point again, and follow first the one and then the other of the two 
 remaining branches, w^hich conduct respectively to the consideration of hemorrhage 
 and of dropsy. These branches are shorter than that along which we were last 
 travelling ; but they are not uninviting ; they will open to us, if I mistake not, some 
 interesting views of the country of which, we purpose, in the end, to make a more 
 particular survey. 
 
 You are to observe that I treat of hemorrhage only so far as it falls to the care of 
 the physician. The subject is exceedingly full of interest in its relation to surgery : 
 and it will receive at the hands of my colleague all the attention which its great 
 importance, as a surgical accident, demands. 
 
 But ive, also, as physicians, have much to do with hemorrhagie ; with what, for 
 distinction's sake, I may call medical hemorrhage ; which differs in kind, in cause, 
 in its consequences, and in the treatment it requires, from that which surgery con- 
 templates. 
 
 In surgical or traumatic bemorrhage the blood flows from some considerable 
 vessel, which has been cut or torn, or somehow ruptured. You would greatly 
 mistake, if you inferred from that circumstance (as you naturally might), that it is 
 Kstfally so — the only difference being in the situation of the vessel — in medical 
 hemorrhage also. 
 
 Yet that is the popular notion. When blood gushes out from internal parts, 
 through any of the natural apertures of the body, the person is said and supposed 
 to have broken a blood-vessel. But this is rarely, though it is sometimes, the case. 
 In nine cases out of ten, if there be any rupture at all, it is rupture of numerous 
 capillaries only : but even of this there is often no evidence. 
 
 Whence, then, and how, does the blood escape from its natural channels? Why, 
 it exudes from the unbroken surfaces of organs, without any appreciable lesion of 
 arteries, veins, or capillaries ; just in the same manner as sweat oozes from the 
 skin, macus from the inner surface of the bowels, and serum or synovia from th)i
 
 ICO HEMORRHAGE. 
 
 membranes that respectively furnish those fluids ; and probably by the very same 
 outlets. 
 
 This certainly is a very remarkable circumstance, if it be true ; and you will na- 
 turally ask what proof we have of its truth. 
 
 Tlie proof is simple, and, I think, conclusive. "VVe examine the surface from 
 which the blood must have proceeded, and we find it entire : we wash and even 
 macerate it: we employ the microscope to assist our powers of vision : yet we fail, 
 after this careful inspection, to discover the slightest breach of substance, or any 
 appearance of erosion. 
 
 When, for example, hemorrhage has occurred so profusely from the stomach oi 
 bowels, that the death which ensued could be sufficiently accoimted for by the mere 
 loss of blood, the whole tract of the alimentary canal has been diligently scrutinized, 
 and has exhibited no ruptured blood-vessel, no abrasion even of its surface, nor any 
 perceptible alteration of texture. Sometimes its mucous membrane appears, here 
 and there, of a red colour, and, as it were, charged Aviih blood. Sometimes it is pale 
 and transparent, while the vascular net-work visible immediately beneath it is gorged 
 and turgid. Sometimes the whole is colourless; the same net-work of vessels hav- 
 ing been completely emptied by the previous hemorrhage ; and sometimes, again 
 (and this is very illustrative of the mode by which the blood has issued), vast num- 
 bers of small dark-coloured masses, like grains of fine sand, can be made to start 
 from the surface of the membrane by slight pressure. There can be no doubt that 
 these are minute portions of blood which had remained and coagulated in the vessels 
 or apertures forming the ultimate channels of the hemorrhage. 
 
 We have absolute proof, therefore, that hemorrhage may transude through an 
 uninjured surface : nay, in some rare cases, the process has been actually witnessed. 
 There are well-authenticated instances on record of cutaneous hemorrhage ; where 
 a dew of blood has appeared upon some portion of the skin, has been wiped away, 
 and has reappeared ; and that, again and again, without any perceptible alteration of 
 the affected surface, beyond some occasional variation in its colour. So, again, the 
 menstrual discharge has been seen to issue guttuihn from the healthy surface of a 
 living but inverted uterus. I confess, however, that, although this analogical fact 
 helps our conception of the manner in which blood may be exhaled from an un- 
 broken membrane, I should not lay much stress upon it for any other purpose. It is 
 not exactly a case in point. The process of menstruation cannot be looked upon as 
 »i morbid process. During a certain portion of the life of an unpregnant female, it 
 IS not only consistent with perfect health, but even essential to it ; and the fluid poured 
 out is not strictly blood. 
 
 That the blood proceeds from the same vessels or apertures, Avhich, in health, pour 
 out the fluids natural to the part, is rendered the more probable by this fact : — that 
 certain hemorrhages are ushered in and succeeded by an increased efflux of the fluids 
 which belong to the surface concerned. In hemorrhages from the mucous mem- 
 branes the following succession of events is, in some persons, habitual. First, there 
 is an augmented flow of mucus alone ; then of mucus tinged with blood ; then of 
 pure blood : and the hemorrhage recedes by a similar but inverse gradation, towards 
 a mucous drain, which itself at length decreases or disappears. 
 
 When blood thus exudes, we say that the hemorrhage takes place by exhalation. 
 It is a convenient word, and will spare circumlocution. What the vessels or out- 
 lets to which we give the name of exhalants really are ; whether they be branches 
 from the capillaries not large enough in the natural state to admit the red particles, 
 or whether they be mere pores in the sides of the capillaries ; these are points con- 
 cerning which we have no positive knowledge. We know, indeed, that such chan- 
 nels must exist, though we cannot demonstrate or see them ; and we know that wbik 
 every part of the body is in a state of health and integrity, they do not aUow the 
 blood, as such, to pass through them. 
 
 I am aware that my learned colleague Dr. Todd objects to this doctrine of hemor- 
 rhage without rupture, even of capillary vessels : arguing that, if the red corpus- 
 cles of the blood, which measure from 4 ocu to 3 o'cu'-^ of ^"^ i"^^ i" diameter, could 
 pass through lateral pores in those vessels, such pores must be large enough to be-
 
 BY EXHALATION. 161 
 
 come visible under the microscope. But on the other hand, Mr. Wharton Jones, 
 who also is well versed in the use of that instrument, declares that the red corpuscles 
 "can readily accommodate themselves to vessels of a diameter less than their own." 
 However this may be, the distinction is broad enough between hemorrhage from a 
 palpable leak in a large vein or artery, and hemorrhage from innumerable capillaries 
 in which no rent can be demonstrated. Treating, then, this question of rupture 
 according to the old maxim, that de non apparentibus et de non existendibus eadem 
 est ratio, 1 shall venture to adhere to the term exhalation. 
 
 Now, although internal hemorrhage may happen in other ways ; as from the 
 bursting of an aneurism, or from an opening made in a large vessel by progressive 
 ulceration ; yet in by far the greater number of cases it takes place by exhala- 
 tion. Exhalation is the rule — other modes of hemorrhage furnish the occasional 
 
 o 
 
 exception. 
 
 I must exclude, however, from this general statement one very important hemor- 
 rhage. In the brain, the former exception becomes the rule. In almost all cases 
 cerebral hemorrhage results from the rupture of a blood-vessel. 
 
 There are various kinds of hemorrhage by exhalation. I will bring them before 
 you, in succession, as clearly and concisely as I can. 
 
 In the first place there are hemorrhages which, although they do not belong to the 
 state of health, if we take mankind in general, yet when they do occur, cannot pro- 
 perly be called diseases. There are some persons — I believe I may say there are 
 many persons — who are subject, during the greater part of their fives, to discharges 
 of blood ; which happen again and again, commonly at regular intervals, without 
 any perceptible detriment to the general health, independently of any obvious ex- 
 citing cause, and (as it would seem) from some inherent property or necessity of the 
 system. 
 
 Hemorrhages thus occurring, I will call habitual hemorrhages. They proceed 
 more commonly from the rectum, and from the nares, than from any other parts ; 
 although instances are recorded of their taking place from the bladder, and from the 
 bronchi. Appertaining to the original constitution of the body, this disposition to 
 periodic hemorrhage has been sometimes observed to be hereditary. 
 
 You will at once be struck with the analogy which obtains between these habitual 
 hemorrhages occurring in either sex, and the monthly discharge which is pecufiar to 
 the female. The analogy is even closer than it may at first sight appear: but it is 
 more distinctly marked in some individuals, liable to habitual hemorrhage, than in 
 others. It was one of the singular notions of the celebrated phrenologist M. Grail, 
 founded upon his analogy, that there is such a thing as male menstruation. The 
 points of resemblance between the two phenomena will be manifest in the following 
 summary of the characters belonging to habitual hemorrhage. 
 
 Like the catamenia, these hemorrhages do not ordinarily prevail throughout the 
 whole course of life. In most cases they do not commence before the period of 
 adolescence ; and they cease altogether, or recur at distant intervals only, in declin- 
 ing age. Their first eruption is sometimes preceded by a state of general indisposition, 
 more rarely by slight febrile disturbance, and even (according to some observers) by 
 a sort of chlorosis similar to tnat which affects young girls in whom the menstrual 
 evacuation is delayed or suspended. The hemorrhage sometimes recurs at precisely 
 regular intervals, and by monthly periods more commonly than any other : being 
 announced, on each occasion, by the same preludes, proceeding from the same part, 
 continuing for the same space of time, and furnishing always about the same quan- 
 tity of blood. Its accidental interruption is almost uniformly the cause or the conse 
 quence of some derangement of the health : and when it becomes excessive i: 
 becomes, like too profuse menstruation, a disease. 
 
 It forms a very curious part of the general history of hemorrhages that they aie 
 not unfrequently vicarious, or supplemental, sometimes of each other, but more often 
 of the monthly discharge from the uterus. Females are hable to perverted men 
 struation (so to call it) through other channels than the natural one : and here agam 
 the analogy between the catamenia and habitual hemorrhage comes into view. The 
 hemorrhages which belong to the constitution are apt to wander in their seal. As 
 11 o2
 
 IG2 HEMORRHAGE. 
 
 bleeding from the lungs, stomach, rectum, or skin, sometimes follows upon the sus 
 pension of the menses, so bleeding from the bladder, from the mouth, and from other 
 parts, has been occasionally observed to succeed the suppression of habitual hemor- 
 rhois. 
 
 These hemorrhagic deviations take place commonly by the same organ on each 
 occasion ; more seldom by different organs in succession. It is almost always in 
 this supplementary manner that the rarer forms of hemorrhage occur, and those of 
 the skin in particular. 
 
 This singular migration, this interchange of place between certain hemorrhages, 
 seems calculated to throw some light upon the obscure doctrine of revidsion : a 
 doctrine to which [ have already more than once referred, and which, though it is 
 very imperfectly understood, is of frequent avail in the practice of physic. 
 
 Vicarious hemorrhage always denotes a disordered slate of the general health : 
 and must be considered, in itself, as a malady. 
 
 Again, there are certain forms of hemorrhage, not habitual, which may be deno- 
 minated idiopathic : inasmuch as they are apt to arise without any perceptible con- 
 nection with antecedent local disease. 
 
 In other respects, however, they differ considerably, and require to be further 
 distinguished : and the terms active and passive, which are in common use, will 
 sufficiently express the two forms of idiopathic hemorrhage that I wish to bring 
 under your notice. 
 
 Active hemorrhage is preceded by active congestion, and therefore is akin to 
 inflammation ; and it often requires the treatment of inflammation. 
 
 Passive hemorrhage often occurs without any apparent previous congestion of any 
 kind. Hemorrhage of this passive character has been ascribed to some change — 
 different from that which we conceive to be produced by the distension of plethora — 
 in the vessels or apertures through which the healthy exhalations are transmitted. 
 The change is considered as being of the nature of morbid debility or relaxation. 
 That such a state may sometimes exist is not impossible, nor even unlikely : but as 
 we are altogether ignorant of the natural condition of these outlets, it is difficult to 
 reason about the alterations to which they may be subject in disease. This hypo- 
 thesis derives its chief support from the occasional efficacy of astringent substances 
 (either apphed locally, or taken into the system) in checking the effusion of blood, 
 when other remedies have failed. 
 
 A more probable hypothesis perhaps is that which supposes some alteration in the 
 consistence or composition of the blood itself; which thus becomes attenuated, and 
 capable of passing through channels or orifices that healthy blood, under ordinary 
 circumstances, cannot penetrate. In support of this supposition are adduced the 
 facts that hemorrhages are known to occur where the blood is more thin, pale, and 
 serous than common ; and still more remarkably where that fluid has undergone a 
 demonstrable change in its chemical nature, or is even visibly altered in its sensible 
 quahlies ; as, for example, in certain cases of purpura and sea-scurvy. And hemor- 
 rhages of this kind are often cured by measures calculated to repair the blood ; to 
 restore it to its natural condition by improvement in diet ; or by food of a pecuUar 
 kind, as the juice of lemons. 
 
 AVhatever may be the true explanation of the differences in question, there can 
 be no doubt that they exist, and are often strongly pronounced in case of hemorrhage, 
 wliich, inasmuch as they cannot be traced to any pre-existent local disease, we class 
 together as idiopathic. And it will be worth while to run over the distinctive cha- 
 racters of active and passive hemorrhage, as they are broadly and decidedly visible, 
 in well-marked cases. 
 
 JJctive hemorrhage (which is preceded, I repeat, by active congestion) occurs 
 principally in persons who are young and robust, who live fully, and lead indolent 
 lives, and are subject to the influence of those causes which tend to generate plethora. 
 Occasionally the hemorrhage can be traced to some exciting cause, such as exposure 
 to heai, strong mental emotion, violent exercise, or bodily efforts. More frequently, 
 perhaps, no exciting cause is apparent. It is sometimes ushered in by a set of 
 avmptoras expressive of what has been called the molimen hemorrhagicum. The
 
 IDIOPATHIC. 163 
 
 pafent experiences a general feeling of indisposition, with wandering and obscure 
 pains that gradually settle in the part from which the blood is about to be discharged. 
 A series of local symptoms, such as a sensation of weight, or of tension, or of heal 
 and tingling, sometimes a slight degree of turgescence and redness, and a visible 
 fullness of the larger veins, indicate the afflux o^ blood towards the labouring organ, 
 and the parts in its vicinity : while chilliness, paleness, and shrinking of distant 
 parts, and especially of the feet and hands, denote an opposite condition of the cir- 
 culation in them. And to this state of things there often succeeds a general increase 
 of heat, with a frequent pulse, — a pulse which is so characteristic sometimes, as to 
 have acquired a name ; you may often hear or read of a hemorrhagic pulse. The 
 blood, when at length it breaks forth, commonly escapes with rapidity ; is of a florid 
 colour ; proceeds from a single organ ; and readily coagulates, though it seldom 
 separates distinctly into serum and crassamentum. While it is flowing, the signs of 
 local congestion diminish and disappear; warmth returns to the extremities, and the 
 pulse regains its natural strength and frequency. The patient becomes conscious of 
 a sensible relief; and feels stronger and more lively than before. This kind of 
 hemorrhage is, in some sort, its own remedy ; it ceases in virtue of the discharge of 
 a certain quantity of blood, and it is followed by morbid consequences only when 
 that quantity has been excessive ; or when it inflicts some mechanical injury upon 
 the parts along which the blood passes. 
 
 I said that active hemorrhage is preceded by active congestion, and is consequently 
 akin to inflammation. Perhaps it may be more true that in some of these cases we 
 actually have the initial stage of mflammation, of which the hemorrhage proves the 
 natural cure : strangling it in its birth ; applying that remedy, in the very moment 
 when it is most efiective, which I told you, in the last lecture, was the most potent 
 of all the remedies of inflammation : namely, loss of blood. 
 
 Passive hemorrhage on the other hand is characterized by circumstances of an 
 exactly contrary nature. It occurs in those who are naturally feeble, or who have 
 been debilitated by disease, fatigue, insufficient nourishment, great evacuations, or 
 the depressing passions. It is not, in general, announced by any precursory symp- 
 toms, nor attended by any re-action. The effused blood is of a dark colour, serous, 
 and but little disposed to coagulate : and it often is poured forth from several parts 
 of the body at the same time. If the quantity lost be at all considerable, the natural 
 debihty of the patient is rapidly augmented : his face becomes pale, and his body 
 loses its heat. The hemorrhage leaves him in a worse condition than that in which 
 it found him. The flow of a certain quantity of blood is not, as in the cases of active 
 hemorrhage, suspensive of its further eff'usion ; frequently, indeed, passive hemor- 
 rhage resists the means opposed to it, the more, in proportion as it has continued 
 lono-er, or been more profuse. 
 
 Hemorrhages of the kind I have now been describing — that is to say, depending 
 upon no palpable disease of any organ, and, therefore, idiopathic — are of no uncom- 
 mon occurrence, whether we regard the active or the passive form in which they 
 appear : but by far the greater number of hemorrhages by exhalation are sympto 
 rnatic ; that is, they result from some previous disease, either in the organ from 
 which the blood proceeds, or in some other organ connected therewith by community 
 or dependence of function. 
 
 These secondary or symptomatic hemorrhages are preceded by congestion, but 
 for the most part the congestion is not of the active, but of the mechanical kind ; and 
 has more to do with the veins of the part than with the arteries. 
 
 Thus we have hemorrhage from the bronchial membrane, in consequence of crude 
 tubercular matter in the lungs, filling up a portion of the pulmonary tissue, and 
 obstructing the circulation of the blood through it. This is an example of symp- 
 tomatic hemorrhage by exhalation, depending upon previous disease in the organ 
 itself from which the blood proceeds. 
 
 In some of these cases the presence of pyrexia renders it probable that the hemoi 
 rhage is the consequence and the relief of active congestion, provoked by tho 
 irritation of tubercles ; rather than the result of a mechanical obstruction of tho 
 circulation.
 
 164 HEMORRHAGE. 
 
 Again, we have hemorrhage into and from the lungs, as a consequence of -tuch 
 disease of the heart as mechanically impedes the return of the blood from the lungs 
 to that organ : a narrowing of the mitral orifice, for instance. Here the blood is 
 barred up, as it were, in the lungs, till at length the capillaries, incapable of further 
 distention, either give way, or become so dilated as to allow of the exit of the blood 
 through their exhalant openings, or through inorganic pores in their sides. In pre- 
 cisely the same way blood is poured out by the mucous membrane of the stomach 
 and bowels, in consequence of disease in the liver, obstructing the portal circulation. 
 These are examples of symptomatic hemorrhage by exhalation, depending upon 
 previous disease, not of the organ itself from which the blood proceeds, but of ano- 
 ther organ intimately connected with the former. 
 
 When I say that hemorrhage into and from the lungs may result from such dis- 
 ease of the heart as impHes an impediment to the circulation, you must not suppose 
 that the lungs are the only channel through which the mechanical congestion can be 
 relieved. Disease of the central moving organ of the circulation leads often, at 
 length, to universal venous congestion : and the hemorrhage, which is apt to be the 
 consequence of such congestion, may burst forth from any part where th^ veins are 
 so overloaded. Hemorrhages from various portions of the mucous membranes are 
 in truth very common effects of cardiac disease. 
 
 The influence of mechanical congestion as a direct cause of hemorrhage is some- 
 times very distinctly seen in the bodies of persons who have been hanged. You 
 know that when suffocation has been produced by suddenly cutting off the access 
 of air to the lungs, the right side of the heart, the great veins, and indeed the venous 
 system generally, become loaded and distended with dark blood. Dr. Yelloly exa- 
 mined the stomachs of five men who had been executed by hanging: he found them 
 all exceedingly vascular ; and in two of the five cases, blood was actually extra va- 
 sated, and adhering to the surface of the membrane ; there had been, in short, une- 
 quivocal hemorrhage. 
 
 There are several things, worthy of notice, in respect to hemorrhage by exhala- 
 tion, of whatever kind. 
 
 In the first place, it occurs much more frequently and readily from some tissues 
 of the body than from others : and most especially of all, from mucous surfaces. 
 Thus we have hemorrhage from the mucous membrane lining the nasal cavities ; 
 from the pulmonary mucous membrane ; from the stomach and bowels ; from the 
 urinary organs ; and from the uterus ; constituting distinct forms of disease, which 
 we are, by and by, to investigate more particularly. Epistaxis, hfsmopfysis, hscma- 
 (emcsis, melxna, liscmorrhois, hacviaturia, mcnorrhagia, are names descriptive of 
 hemorrhage, as it is apt to occur from different parts of one or other of the three 
 tracts of mucous membrane met with in the body: and 3'ou will find that these 
 comprise very nearly all the complaints enumerated by nosological writers under the 
 head of hemorrhage. 
 
 Now this is a very remarkable fact : and very interesting questions arise out of 
 it. Has it any relation to the manner in which these membranes, and the tissues 
 subjacent to them, are supplied with a capillar}' circulation ? or may the fact be 
 explained by the laxity of their attachment, which facilitates and favours the accu- 
 mulation of blood in the vessels of the submucous tissue ? Or has the density or 
 consistence of their natural exhalations any thing to do with this disposition to 
 hemorrhage in the mucous membranes ? May we suppose that the vessels or orifices 
 appointed to exhale mucus, afford a more easy passage to the blood than those which 
 give egress to thinner fluids ; serum, for example, or the cutaneous perspiration ? 
 Whatever answers may be given to these questions, you will do well to recollect the 
 fact which has suggested them. 
 
 Hemorrhages by exhalation are not, however, exclusively confined to mucous sur 
 faces. They are fiable to occur, but much more rarely, from serous membranes. In 
 the majority of cases, however, in which blood is found effused into any of the serous 
 sars, it has either been an event of inflammation, or the blood has been poured out 
 from an accidental openmg in some considerable vessel. Cutaneous hemorrhage is 
 iLso \-ery rare; probably because the cuticle opposes a barrier to the exit of the
 
 USUAL SYMPTOMS. 165 
 
 blood : for the little red spots which characterize purpura are in fact hemorrhages, 
 although the blood has not penetrated the epidermis. There are cases, however, as 
 I mentioned before, in which blood has transpired, in a sort of dew, from the exter 
 nal surface of the body. 
 
 Another important general fact in respect to hemorrhages by exhalation is, that 
 they proceed more frequently from certain parts of the mucous membranes than 
 others, according to differences of age. Thus in children they are most common 
 from the membrane that lines the nasal cavities : in youth from the mucous mem- 
 brane of the lungs and bronchi ; in the middle years of hfe, and towards its decline, 
 from the rectum, uterus, and urinary organs. I should add here, from the blood- 
 vessels of the brain, in old age ; except that this, as I have already intimated, is not 
 (speaking generally) hemorrhage by exhalation. 
 
 Of course when I say that, in the instances specified, the blood is commonly poured 
 out by exhalation, you will understand that the hemorrhage sometimes occurs from 
 the laying open of a single vessel of some magnitude. Thus hemorrhage from the 
 fauces may be the result of ulceration there, which has penetrated the coats 
 of a vein or artery : hcemoptysis is occasionally produced by the laceration of a 
 blood-vessel during the softening and expulsion of tubercles. Haematemesis some- 
 times is the consequence of a breach made in a considerable blood-vessel during the 
 progress of cancer of the stomach, or by the extension of small corroding ulcers ; 
 hemorrhage from the bowels is no uncommon effect of ulceration, such as happens 
 in fever, of the mucous follicles of the small intestine ; calculous matter in the Idd- 
 neys will often lead to the rupture of some of the blood-vessels there, and to the 
 discharge of blood by the urethra. Aneurisms also may burst into almost any part 
 of the body. But events of this kind are unfrequent when compared with hemor* 
 rhage from the same parts in the way of exhalation. 
 
 In the head, however, the ratio is reversed. Blood does, sometimes, I believe, 
 exude from the membranes of the brain, but much more commonly cerebral hemor- 
 rhage is caused by the giving way of a diseased artery in the brain. 
 
 How, in ail these cases, to distinguish whether the blood has oozed out by many 
 orifices from a surface, or has escaped from a hole in the sides of a vein or artery, 
 will form matter for future inquiry. Sometimes we can make the distinction, arid 
 sometimes, it must be confessed, we cannot. 
 
 You will readily understand that hemorrhage must vary greatly in respect to its 
 importance, and to the danger which it impUes, according to the part from which it 
 proceeds, and the circumstances under which the blood is poured out. It sometimes 
 happens that death ensues from the mere loss of blood : either at once, by one pro- 
 fuse bleeding, or more slowly, by repeated bleedings which we are unable to restrain : 
 but this is comparatively rare, and when it does happen, the blood is generally found 
 to have proceeded from one considerable vessel, which has been ruptured or eroded. 
 The case approximates to traumatic hemorrhage, except that we cannot cut down 
 upon and tie the injured vessel. Much more commonly danger arises from the 
 presence and pressure of the extravasated blood in and upon internal parts ; upon 
 the brain, for example, in cerebral hemorrhage ; in the lungs, in pulmonary. 
 
 The symptoms, also, are hable to much variation in different cases. Even the 
 diagnosis of hemorrhage is not always equally easy or certain. When the part 
 into which the blood is directly poured communicates with the exterior of the body, 
 the expulsion of some of that fluid will, generally, sooner or later demonstrate tht 
 case to be one of hemorrhage. I say, generally, because cases have been known 
 to occur, in which patients, previously in a state of great weakness, have died out- 
 right, by syncope, from the mere extravasation of the blood, and before any of it 
 made its way out of the body. The stomach and bowels have been found full o*" 
 blood, when none had passed either by vomiting or by stool. And whun the blood 
 does make its appearance outwardly, it is sometimes not easy to determine whethei 
 it has come from a certain organ, or from the parts that lie between the same organ 
 and the natural outlet by which it ultimately escapes. For instance, it is sometimes 
 a matter of uncertainty whether the blood, in hematuria, proceeds from the kidneys, 
 or the bladder, or the urethra.
 
 ] G6 HEMORRHAGE. 
 
 The blood, itself, when it reaches the exterior, will generally be more fluid, and 
 brighter, in proportion as it is effused in greater quantity, and nearer the surface : 
 more in clots, and darker in colour, in proportion to the length of time that it has 
 remained within the body after its escape from its proper vessels ; and this length 
 of time may depend upon the smallness of the quantity of blood effused, and the 
 consequent tolerance of the organs through which it may have passed ; or upon the 
 actual space traversed. Respecting the colour, however, of the effused blood, 1 shall 
 have some curious explanations to offer you when I come to speak of hematemesis 
 as a disease. It would be superfluous to enter upon them now. 
 
 If the site of the hemorrhage does not communicate with the external air, we are 
 without that certainty which results from the actual spectacle of the blood. But 
 in such cases we are much assisted by local disturbances of function, springing from 
 the pressure upon, or the laceration or distension of, the suffering organ, or the parts 
 contiguous to it. And we may derive good information from observing the indirect 
 symptoms which declare themselves through the system at large ; many of which 
 indirect symptoms are the same whether the blood reach the exterior or not. They 
 principally vary according to the quantity of blood poured out, and to the rapidity 
 of its effusion : and some difference will occur according to the age and strength of 
 the patient. 
 
 Some of these indirect symptoms have not always been imputed to their true 
 cause. Paleness of the face, feebleness of the pulse, coldness of the extremities, and 
 a tendency to syncope — symptoms which are apt to be connected with hemorrhage 
 — have sometimes been ascribed to the alarm and sense of danger which the sight of 
 the blood is calculated to produce in the mind of the patient. This may, to a certain 
 exlent, be sometimes true ; but the explanation cannot apply to those cases in which 
 the hemorrhage is strictly confined to the interior of the body, yet in which the 
 symptoms just alluded to are often strongly marked. They //len depend — and 
 probably in all cases they chifjiy depend — upon the actual abstraction of the blood 
 from the circulation. 
 
 The management of individual cases of hemorrhage must be mainly regulated b}' 
 the particular circumstances under which they occur. The few observations that I 
 have at present to make respecting their treatment cannot be otherwise than very 
 general. 
 
 But a preliminary question, of some importance, presents itself. Is it in all cases 
 of hemorrhage proper, or safe, to attempt to stop the bleeding ? 
 
 Without going into detail, it may, I think, be laid down as a rule, that what 1 
 have called habitual hemorrhages ought not to be interfered with, so long as they 
 have no perceptible injurious influence upon the health, and so long as they proceed 
 (as they mostly do) from parts of which the structure is not likely to be spoiled, nor 
 the function impaired, by the repeated passages of the blood. The most common 
 seat of these habitual hemorrhages I have stated to be the rectum ; to which the 
 two conditions just mentioned are, fortunately, both of them applicable. Epista:xis 
 supplies a less frequent example of the same kind. When they deviate from their 
 usual channel, and are transferred (as it were) to some more important organ, it will 
 generally be right, among other remedial measures, to endeavour to recall the 
 original hemorrhage. It is very seldom that the metastasis takes place^br the better. 
 — i. e,, from a part where the bleeding is attended with danger, to one where it is 
 comparatively harmless. 
 
 However, when these habitual hemorrhages happen, as they often do, in plethoric 
 persons ; and when they are urged and kept up, as they frequently are, by intem- 
 perate and luxurious habits ; we ought not to content ourselves with merely looking 
 on. Hemorrhois often performs the office of a safety-valve in such persons ; and 
 there are many who have what are called bleeding piles, and Avho would rather 
 continue to have them, than to submit to any change in their mode of hfe, or to the 
 employment of other means of evacuation. Certainly these are cases in which 
 nothing should be done to stop the bleeding; yet such patients ought to be told that 
 the hemorrhoidal discharge is but a precarious, and often an inadequate relief of the 
 plethora : that while the plethora is suffered .0 exist there is danger of a cessation
 
 TREATx>IENT. 167 
 
 of the piles, and of the supervention of serious or fatal affections 6f other parts, and 
 especially of the head. Apoplexy, or cerebral hemorrhage, has frequently been 
 known to follow hard upon the suspension of constitutional hemorrhois. The 
 patient should be admonished also that the discharge of blood from the vessels of the 
 rectum may become excessive ; that if it be aggravated by exercise, or in any other 
 way, it may lead to inflammation about the anus, and to great inconvenience ; and 
 that there are safe and tolerably sure methods of getting rid of the plethora ; (which 
 IS what chiefly constitutes the danger of such cases), if they will submit to the ob- 
 servance of them. It is in the intervals between the hemorrhages that the danger 
 of which they are in some sort the token, may best be met. 
 
 Again, it will seldom be proper to employ direct expedients for staunching the 
 flow of blood, in the small class of active idiopathic hemorrhages; unless the 
 quantity lost is so great as to endanger the safety of the patient. Such hemor- 
 rhages have commonly a tendency to cure themselves, by relieving the general 
 plethora, or the local congestion, on which they depend. For these hemorrhages, 
 which bear so strong an analogy to inflammation, the treatment of inflammation 
 may often be requisite, as an indirect mode in which their amount may be mode- 
 rated, and their recurrence obviated. 
 
 With these exceptions, both direct and indirect measures are to be used, for 
 arresting the effusion of blood as speedily as may be. 
 
 To this end the patient is to be surrounded as much as possible with cool fresh 
 air, and kept in a state of absolute quiet. All motion of the body, and emotion of 
 the mind, all kinds of stimulating food and drink, every thing, in short, which has 
 a tendency to hurry the circulation, should be diligently avoided ; and that position 
 of the body should be chosen which is the least favourable to the afflux of blood 
 towards the part affected. The horizontal posture will be proper in hemorrhage 
 from the bowels, the uterus, or the urinary organs. In epistaxis, and in cerebral 
 hemorrhage, the head should be raised. 
 
 In two words, the antiphlogistic regimen should be strictly enjoined in all cases 
 of hemorrhage sufficiently severe to require medical assistance. 
 
 Of the actual remedies used for checking the further escape of the blood, one of 
 the most important has already been alluded to — I mean venesection. Herein we 
 are guilty of homoeopathy ; to prevent bleeding, we draw blood. After what was 
 stated respecting the use of blood-letting in inflammation, I need not dwell upon the 
 objects aimed at by this measure : they are, briefly, to abate the vigour and force of 
 the heart's contraction, to lessen general plethora when it exists, to remove local 
 congestion, and to divert the current of the blood from the suffering organ. The 
 method, and the amount, and the repetition of the blood-letting, must of course be 
 regulated by the circumstances of each particular case. And the same objects may 
 sometimes be efTected by other modes of general depletion, especially by the use of 
 purgative medicines. 
 
 Another important remedy for inward bleedings is mercury. Whatever may be 
 the modus operandi of that mineral, the fact is certain, that hemorrhage, which had 
 resisted other modes of treatment, has, in very numerous instances, ceased at once 
 upon the occurrence of a moderate degree of salivation. 
 
 Next to blood-letting and mercury, astringents constitute the great resource against 
 actually existing hemorrhage : and among these, cold is one of the chief. It may be 
 placed in direct contact with the bleeding surface: as when ice is swallowed to 
 restrain hematemesis ; or cold water injected into the rectum in excessive and 
 exhausting hemorrhois ; or into the vagina, in flooding from the uterus. Or it may 
 be applied to the surface of the body, as near as possible to the seat of the hemor- 
 rhage ; as to the nose and forehead in epistaxis ; to the chest in hemoptysis ; to the 
 epigastrium in hemorrhage from the stomach ; to the lower part of the abdomen or 
 to the perineum in hemorrhage from the intestines, uterus, or urinary organs. But 
 the influence of coid in eonstringing the smaller vessels is not confined to the part 
 with which it is m contact ; it wall stop hemorrhage by the sympathetic shrinking 
 which it produces in distant parts. Epistaxis, for example, has often been arresteti 
 by the sudden apposition of cold water to the neck, back, or genital organs. Tb«'
 
 168 DROPSV 
 
 nursery remedy consists in slipping a cold key down the back between the clothes 
 and the skin. 
 
 Of the mischievous power even of cold in this way we have continual illustration 
 in the suppression of the catamenia by cold and wet accidentally apphed to the feet. 
 
 There is a long catalogue of medicinal substances which are esteemed to possess 
 more or less of a specific virtue, when taken internally, in checking the flow of 
 blood. Most of these are of an astringent nature, and some of them are eminently 
 useful. The acetate of lead enjoys, in this country, a higher character, perhaps, 
 than any other of these substances. 
 
 Many vegetable matters, and some artificial compounds, frequently employed in 
 internal hemorrhage, seem to owe their astringent and styptic properties to the gaUic 
 acid which enters into their composition. Such are the rhatany root, uva ursi, bistort, 
 tormentil, the pomegranate, kino, catechu, the several preparations of gall nuts, and 
 the nostrum called RuspinVs styptic. 
 
 The power of arresting internal hemorrhage has also been confidently ascribed, 
 by different persons, to nitre given in large doses, to the mineral acids, to the muriated 
 tincture of iron, to alum, to the oil of turpentine, to the secale cornutum or spurred 
 rye, and to various other substances, a more particular account of the rules and indi- 
 cations for administering which, I may return to, when I have to speak of individual 
 hemorrhaofes. 
 
 LECTURE XVI. 
 
 Dropsy : its General Pathology. Passive Dropsy ; Cardiac and Renal. Active 
 Acute, or Febrile Dropsy. Prognosis ; and General Principles of Treattnent 
 in Dropsies. 
 
 There remains now only one subject, of the patholog}' of which it will be con- 
 venient and, I hope, instructive, to take a short general view, before we enter upon 
 the consideration of special diseases. I proceed to speak of dropsies : by which I 
 mean collections of serous liquid in one or more of the shut cavities of the body, or 
 in the areolar tissue, or in both, independent of inflammation. 
 
 We have already considered serous effusion as occurring as an effect or event of 
 inflammation. We are commonly able to say of this, that it has originated in inflam- 
 mation ; either from its being mixed with some of the less equivocal products of that 
 disease, such as coagulable lymph ; or from its having taken place while symptoms 
 of inflammation existed. But there are numerous examples of serous accumulation, 
 which cannot wiih any show of reason be regarded as events of inflammation. It is 
 to these that I would apply the simple term dropsy. 
 
 It has been said — and said with much truth — that dropsy is rather a symptom of 
 disease, than a disease in itself. And it has been affirmed that it Avould be more 
 philosoj)hical and scientific to treat of the original malady upon which the effusion 
 or accumulation depends ; to erase dropsy from the list of substantive diseases, and 
 to place it in the catalogue of mere symptoms. 
 
 But this, in my mind, is a very mistaken view of the matter. For, first, it is 
 oftentimes uncertain, while the patient is yet alive, what or where the primary dis- 
 ease may be ; and even after death we sometimes can discover no organic change 
 that would satisfactorily account for the effusion. Practically speaking, in such 
 cases the dropsy is the disease, and the sole object of our treatment. 
 
 And, secondly, dropsy is, in fact, to a medical eye, in all cases, something more 
 than an effect or symptom of disease. The imprisoned liquid is often a cause of 
 various other symptoms ; embarrassing, by its pressure, important functions, and 
 even extinguishing fife. The removal of the dropsy (although its original cause, of 
 which it was a symptom, may remain behind, untouched, to be again productive of 
 pffusion under circumstances favourable to its operation) — the removal of the dropsy
 
 DROPSY. l()d 
 
 will often restore a person to comparative comfort ; or even to what, so far as his 
 sensations, and powers, and belief are concerned, is, to him, for the time, a state of 
 health. 
 
 You see then, already, that in a dropsical person, whose dropsy depends upon 
 organic disease, there are two sets of symptoms to be distinguished : viz., those 
 which depend on the primary disease ; and those which depend on the collected 
 fluid. The latter, often the most grievous, are often to be got rid of: the former, 
 frequently permanent, are frequently also but httle complained of or felt by the 
 patient, except when effusion is the result. 
 
 Some persons, I fancy, have regarded dropsy as a less attractive subject of inves- 
 tigation than it might be if it were less frequently, in its nature, incurable. But as 
 far as the dropsy itself is concerned, the complaint often is curable ; and there are 
 some forms of dropsy that are curable in a more absolute sense ; that is, both the 
 effusion, and that condition which was the physical cause of the effusion, are some- 
 times remediable. 
 
 Besides, it is our business to cure when we can ; but whether we can cure or 
 not, to relieve and palliate human suffering ; and this, under Providence, we are able 
 to do, in many or most cases of dropsy, to a very considerable extent. 
 
 Wherever there is a shut sac, or wherever there is loose and permeable areolar 
 tissue, there we may have dropsy. 
 
 Thus there may be dropsy of the ventricles of the brain, or of the meshes of the 
 pia mater, leading to death by coma ; of the pleurse, of the areolar texture of the 
 lungs, or of the submucous areolar tissue of the glottis, any of which may cause death 
 by apnoea; of the pericardium, producing death by syncope. I mention these 
 instances in particular, to show that almost every mode of dying may result from 
 dropsical effusion ; and to win your attention to a disorder so full of peril. 
 
 When the cerebral ventricles are distended with water, we express the diseased 
 condition by the term hydrocephalus. When serous liquid collects in the pleurae, 
 or in the pericardium, we say that the patient has hydrofhorax, or hydropericar- 
 dium. If the cavity of the peritoneum be the seat of the effusion, we call the com- 
 plaint ascites. When the areolar tissue of a part becomes infiltered with serous 
 fluid, the part is said to be cedematous ; and anasarca is the name given to the 
 more or less general accumulation of serum into the areolar tissue throughout the 
 body, and especially to visible subcutaneous cedema of considerable extent. Finally, 
 the term general dropsy signifies the combination of anasarca with dropsy of one 
 or more of the large serous cavities. 
 
 Other local dropsies indeed there are, but, as they belong entirely to surgery, I 
 need not emunerate them. 
 
 Now what reasonable account can be given of these remarkable conditions ? How 
 is it that the hollows and interstices of the Hving body, or of parts of the body, 
 become thus water-logged ? 
 
 To solve this question, we must carry in our minds some physiological recol- 
 lections. 
 
 The closed cavities, or the interstitial tissues, within which the fluid of dropsy is 
 confined, are kept moist, during life and health, by a continual serous secretion from 
 their surfaces : and they are kept merely moist, for the fluid thus constantly secreted 
 is as constantly reabsorbed into the circulation. 
 
 When these tissues or cavities, without having undergone inflammation, become 
 filled and distended with the serous fluid which they habitually secrete, one of three 
 things must have happened. Either the quantity of fluid exhaled has been aug- 
 mented, the absorption remaining the same ; or the absorption has been diminished, 
 the exhalation continuing the same ; or else the exhalation has been increased, 
 while at the same time the absorption was either lessened or not proportionallv 
 increased. 
 
 The last is a mixed case ; and we need only consider the two others. 
 
 Now the balance between exhalation and absorption is often deranged, and dropsie<s 
 do actually arise, in each and all of these ways. 
 
 p
 
 170 DROPSY. 
 
 It will best suit my purpose to speak first of those dropsies which are occasioned 
 by defective absorption, and which are usually called chronic or passive dropsies. 
 
 The direct agency of the blood-vessels in the production, as well as in the removal 
 of dropsy, although indicated by many common and obvious facts, has not been 
 generally recognized till a comparatively recent period. Perhaps I should rather 
 say that more importance used to be assigned, in these respects, to the agency of the 
 .ymphatic absorbents, than they are really entitled to. You will find that patho- 
 logists, even in modern times, speak of a want of tone, of deficient energy, in the 
 absorbents, as a cause of dropsical accumulations ; the superfluous fluid of the part 
 is not adequately taken up (they say) by the enfeebled absorbents, meaning the ab- 
 sorbents strictly and anatomically so called. And this view of the matter, connecting 
 dropsy always with debility as its cause, has led to a corresponding plan of treat- 
 ment : the object aimed at being the stimulation of the absorbents to more energetic 
 action. 
 
 But to the doctrine that dropsy is a consequence of the deficient action of the ab- 
 sorbents, this obvious difficulty presents itself, — that absorption really goes on, and 
 goes on very actively, in dropsical patients : their adipose matter disappears, they 
 become wretchedly thin. There is no complaint in which wasting and emaciation 
 go to a greater extent than in dropsy. You will find also that persons labouring 
 under anasarca are readily enough affected by mercury ; which must of course be 
 absorbed before it can produce any of its specific effects. 
 
 It^ust be confessed that our knowledge respecting the mechanism of absorption 
 is neither complete nor certain ; but there is good reason for supposing that the 
 process is shared among the lacteals, the lymphatics, and the veins ; and it is pro- 
 bably distributed between these sets of vessels somewhat in this manner; — that the 
 lacteals absorb the chyle from the surface of the alimentary canal, and convey into 
 the blood the materials of its renovation ; that the office of the lymphatics is to take 
 up and carry into the blood those old and effete portions of the solid constituents of 
 the bod}% which require to be removed to make way for a fresh deposit ; while the 
 veins imbibe the serous fluid exhaled from the surfaces of serous membranes, and 
 into the meshes of the areolar tissue, as well as poisons and other substances that are 
 soluble and dissolved in that fluid. 
 
 If this be so, the difficulty just now mentioned vanishes. Of the two sets of ab- 
 sorbing vessels, the lymphatics and the veins, one set may continue to perform its 
 functions, while the other fails to do so. This theory is quite consistent with the 
 actual phenomena of dropsical disease ; and whether it be altogether true or not, a 
 part of it is certainly true ; that, namely, which assigns to the veins a large share in 
 the whole process of absorption. The experiments of Magendie and of others are 
 quite conclusive upon that point. 
 
 It has also been fully established, that fluids may and do pass into or out of the 
 veins, in the living body, not by any vital process, but by mere physical imbibition 
 and transudation, through the coats of those vessels ; that when the veins are dis- 
 tended to a certain degree with watery fluid, the entrance of more of the same fluid 
 through their sides, is impeded or prevented ; that, when the distension is still greater, 
 the aqueous part of the blood may even pass in the other direction out of the vessel; 
 and that, on the other hand, when the veins are comparatively empty, the surround- 
 ing serous fluid passes readily into them, or, in common language, is absorbed. 
 The venous absorption is explicable therefore upon the principles of endosmose and 
 exosmose, as laid down by Dutrochet ; or I woukl rather say, according to the more 
 general and more simple laws of heterogeneous attraction, as explained by Professor 
 Danicll. 
 
 Imbibition, being a form of that attraction, belongs in various degrees to all the 
 tissues of the body. Its rapidity — and even its direction in respect to the elastic 
 coats of a vessel surrounded by fluid, and also carrying fluid of a certain consistence 
 — will vary with the varying distension of the vessel. When the vessel is mode- 
 rately full, the exterior fluid passes uninterruptedly inwards, and is conveyed away 
 hy the internal current. When, on the other hand, the vessel is kept much dis- 
 iended by its contents, the contained fluid, or its thinner part, passes continually out-
 
 PASSIVE DROPSY. 171 
 
 wards ; and there is an intermediate degree of distension, at wnich the pressure is 
 just sufficient to prevent the transit of fluid in either direction, Magendie found, 
 accordingly, in a well-conducted and conclusive series of experiments, that by regu- 
 lating the conditions of comparative emptiness or fullness of the circulating system, 
 be could accelerate, or retard, or suspend altogether, the operation of a poison dis- 
 solved in the humours of the body. In other words, he could thus accelerate, retard, 
 or prevent, the process of absorption or imbibition through the blood-vessels. 
 
 Bearing these physiological truths in remembrance, we shall have no difficulty in 
 showing that the chronic forms of dropsy are attributable partly, and chiefly, and in 
 many instances entirely, to undue plenitude of the veins ; and that this venous re- 
 pletion is produced, almost always, by some impediment to the free return of the 
 blood towards the heart. 
 
 When the areolar tissue of a limited part of the body becomes filled and distended 
 by serous liquid, we call the swelling oedema ; but this is exactly the same, in its 
 nature, as anasarca. Now oedema is often the consequence of some mechanical ob- 
 struction to the venous circulation. We can produce it whenever w^e will. Our 
 countryman Dr. Lower, 170 years ago, tied the jugular vein of a hvingdog. When 
 a [ew hours had elapsed, he observed that all the parts beyond the ligature, reckoning 
 from the heart, were much swollen : and upon dissecting the animal after death he 
 found that the areolar tissues of the head and face were filled, not with red blood, as 
 he had expected it might be, but with clear and limpid serum. On another occasion 
 he placed a ligature upon the vena cava, just above the diaphragm : death soon 
 ensued, and a large quantity of water was discovered in the cavity of the peritoneum, 
 " non aliter quam si ascite diu (canis) laborasset." 
 
 These experiments were not instituted with any reference to the pathology of 
 dropsy; yet that Lower perceived their bearing upon that subject is plain from this 
 sentence : " Quantum hsec ad ascitis et anasarcfe causas investigandas conducant, 
 ahis judicandum relinquo." He even explains the extravasation of the thinner or 
 serous part of the blood as taking place by infiltration, " velt in filtro," through the 
 pores of the vessels. 
 
 Precisely similar phenomena succeed the compression or obliteration of a large 
 vein in various parts of the body. In operating for popliteal aneurism, Mr. Travers 
 was obliged to tie the femoral vein ; the areolar tissue of the hmb was speedily infil- 
 trated with serous fluid. Long-abiding oedema of one foot and ankle has been cured 
 at once by the reduction of a crural hernia, which had been pressing for the same 
 length of time upon the femoral vessels. You have heard, most probably, of the 
 disease called phlegmasia dolens ; a disease that is very common in women soou 
 after childbirth, although it is not pecuhar to them, nor to the female sex. The foot, 
 leg, and thigh, become enormously (Edematous. The essence of this disorder is 
 inflammation of the femoral vein ; blocking up that vessel near the groin, and retard- 
 ing or precluding the return of the venous blood from the limb. One arm often 
 swells in the same way, and from a similar cause, in women who are afflicted with 
 cancer of the breast. In pregnancy, the gravid uterus sometimes presses upon the 
 iliac veins, and obstructs the current of blood within them : the consequence is, ana- 
 sarca of the lower extremities, which disappears as soon as the pressure is removed 
 by the dehvery of the woman. The flow of blood through the vena portoe is fre- 
 quently hindered, by disease in the hver, or by other causes ; and serous liquid 
 accumulates in the peritoneum, constituting ascites. A French physician, M. Ton- 
 nelle, narrates several cases in which serosity was found in the cavity of the arach- 
 noid, in conjunction with obhteration of the venous sinuses of the dura mater. In 
 all these instances we have retardation of the venous current, undue plenitude of the 
 veins, and dropsy of the part from which they proceed. The natural exhalation 
 goes on, and the exhaled fluid collects and stagnates because the channel through 
 which it ought to be drained away is choked up. The larger the vein, and the 
 nearer we approach the heart, the more extensive is the dropsical accumulation : and 
 if we could plant an obstacle at the very termination of the venous stream, we should 
 dam up the blood in the whole system of veins, and produce a general dropsy 
 
 Such an obstacle is frequently placed there by disease. The returning Hood w
 
 172 DROPSY. 
 
 checked at its entrance into the heart ; at the confluence of all the veins of the body, 
 where they unite to empty themselves into the right chambers of that organ : and 
 then anasarca of the universal areolar tissue comes on, and water collects in all or 
 most of the great serous cavities. 
 
 It is no part of my present purpose to inquire how such disease of the heart as is 
 productive of dropsy, arises. Commonly we find the right auricle and ventricle 
 enlarged in capacity, the opening between them unnaturally wide, and the tricuspid 
 valve unequal to its office of plosing that aperture. Such a morbid state of the right 
 heart may be occasioned by any cause which impedes the flow of blood out of its 
 cavities. The diseased condition of those cavities may be primary ; but it is oftener, 
 perhaps, consecutive to other disease. It may be produced by disease of the lungs, 
 preventing the right ventricle from freely delivering its contents into the pulmonary 
 blood-vessels. Or the retarding cause may be still more distant, in the left side of 
 the heart, keeping the pulmonary blood-vessels unduly full, and thereby hindering 
 indirectly the escape of the blood from the right ventricle. The dropsy may ulti- 
 mately depend, therefore, upon some bar to the circulation, placed even at the mouth 
 of the aorta. Obstacles situated anywhere in the circuit fonned by the right heart, 
 the lungs, and the left heart, have the effect of producing secondary changes in the 
 parts behind them. But disease, thus propagated in a direction retrograde to the 
 course of the blood, is propagated gradually, and sometimes very slowly. These 
 are points of much interest, which we shall investigate together by and by. I allude 
 to them now, that you may not be perplexed by a knowledge of the fact, that dis- 
 eases of the heart often exist for a long while without inducing dropsy. It is with 
 disease of the right side of the heart, whether primary or secondary, that passive 
 dropsy is especially associated. 
 
 As if to furnish the experhnentwn crucis in respect to this doctrine, disease does 
 sometimes, with a curious precision, dam up one only of the two great venous trunks, 
 at the junction of which the right auricle is placed: and then the dropsy is as curi- 
 ously limited to that half of the body in which the tributary veins of the obstructed 
 trunk originate. The first example of this which I ever saw was a most remarkable 
 one. The patient was dropsical in his upper half only. His arms were so hugely 
 anasarcous that he could not bring his elbows near his sides ; his neck and face 
 were hideously bloated and exaggerated, and his eyes prominent and staring ; while 
 his lower limbs were of their natural size, and appeared preposterously small and 
 out of proportion. The poor man looked as if the upper part of his body had been 
 stuffed, for acting some ridiculous part upon the stage. The cause of this strange 
 and distressful state was found to be the obliteration of the vena cava superior, close 
 to the auricle. Its sides had been pressed together by a large aneurism of the aorta; 
 and a portion of the vein was fairly sealed up. I have seen two similar cases since. 
 
 Objections have, however, been taken to the accuracy of the conclusions drawn 
 from such cases as I have related ; and it is fit that you should be aware of them. 
 Thus it is stated that veins have been found obliterated, and yet there was no dropsy. 
 Now to this objection it may be answered, in the first. place, that it is not every vein, 
 the obliteration of which would cause manifest oedema. It must be the principal 
 venous trunk of the part concerned. When some of the secondary and smaller veins 
 alone become impervious, the blood may reach, and return by, the primary branches, 
 with sufficient readiness to relieve the turgid capillaries, and prevent any serous 
 accumulation. 
 
 But (it may be said) the principal vein itself has been found converted into a solid 
 cord, and still there was no dropsy. Granted: but it does not follow that there 
 never Iicid been dropsy. You know that when a large artery is tied, the circulation 
 is carried on in the corresponding limb, by means of collateral arterial branches : 
 imperfecdy, indeed, at first ; but, at length, as the supplemental channels become 
 more numerous and free, the supply of blood to the hmb is as copious as ever. It 
 is precisely the same, mutatis mutandis, with the veins ; only that the anastomosing 
 venous tubes are not (perhaps) so readily developed as the arterial. Now I am not 
 aw^ire of any instance in which it has been shown that the principal vein was oblite- 
 rated, and yet there neither was, nor had been, any oedema of the limb. The
 
 PASSIVE DROPSY. 173 
 
 recorded cases have been met with in dissecting-rooms, and the previous history of 
 thf subject has been unknown or unregistered, Mr. Kiernan has told me that he 
 once examined the body of a woman who had excited much curiosity among the 
 medical men by whom she had been seen during life, on account of a remarkable 
 and enormous dilatation of the superficial veins of the abdomen. She was not drop- 
 sical, and the cause of the huge varix was sought for with great interest after her 
 death. The inferior cava was obhterated. Here the compensating result was obvi- 
 ous to the sight ; the new channels had answered their purpose, and performed the 
 functions of the original channel. The history of this case was incomplete : it was 
 not ascertained whether the woman had always been free from dropsy. 
 
 I hold this objection therefore to be invahd, until some authentic instance shall be 
 brought forward of the obliteration of a large venous trunk, without a corresponding 
 accumulation of serous fluid, either at the time when the observation is made, or at 
 some previous time in the life of that individual. It is, besides, possible enough, 
 that the obstruction of a large vein may be effected gradually, by the slow encroach- 
 ment, for instance, of a growing tumour ; and the collateral circulation may begin 
 to be enlarged with the first impediment in the vein, and may keep pace with and 
 counterbalance that increasing impediment, till the closure of the vessel is complete ; 
 so that, from first to last, there may be no noticeable dropsy. 
 
 Again, it is affirmed, and truly affirmed, that anasarca often occurs, without any 
 obhteration of veins, and independent of any discoverable organic disease in the 
 heart or anywhere else. We see this every day, in weak chlorotic girls, with blood- 
 less cheeks, and pale hps. Some of you saw a case of this kind which was lately 
 under my care in the hospital ; besides the anasarca, the systolic sound of the heart 
 was accompanied by a loud, unmistakeable bellows sound. This girl got quite well, 
 and left the hospital without bellows sound, or any other trace of disease. There 
 could not then hav V?en an organic change : in fact there was not. Yet was there, 
 virtually, a retardation of the venous circulation ; not by any mechanical obstacle 
 opposed to its course, but in consequence of the debility of that hollow muscle, the 
 office of which is to propel onwards, with a certain degree of force, the blood that 
 reaches it. Girls of this description have weak and flabby voluntary muscles ; and 
 it is reasonable to presume that the involuntary muscle, the heart, partakes of the 
 general debility of the muscular system, and becomes incapable of sending the blood 
 forwards with the requisite energy. Nay, I believe that a heart thus feeble may 
 yield a little and dilate under the resisting pressure of the blood that enters its cham- 
 bers ; and that so an occasional but temporary bellows sound may arise, from the 
 altered relation between the cavities of the heart and their outlets. Certainly this 
 view of the matter is strengthened by the juvantia and Icedentia. If you are tempted, 
 by the pain complained of by your patient, or by the violence with which her heart 
 is throbbing, to take away blood, you find that she is ultimately made worse by the 
 depletion ; on the other hand, if you give her steel, feed her well, keep her bowels 
 free, and place her every morning under a cold shower-bath, you find that she reco- 
 vers her lost strength, that colour returns to her lips and cheeks, that her palpitations 
 cease, and her dropsy vanishes. In proportion as the muscular system in general 
 receives fresh tone and vigour, does that particular muscle, the heart, also regain the 
 degree of power necessary for the effectual discharge of its proper function, which is 
 very much that of a forcing-pump. Such is the way in which I should explain both 
 the cause of the dropsy, and the cause of its cessation. In such cases our patients 
 do not simply recoz)er ; they are cured. I should apply a similar explanation to 
 some other forms of dropsy. Andral describes a certain cachectic disposition of the 
 body as being a cause of dropsy ; persons may be bled into a dropsy, or starved or 
 weakeried into a dropsy. These are genuine instances of dropsy from debility, 
 which is what the ancients conceived all dropsies to proceed from. It may be that 
 the thin and watery quality of the blood induced by frequent bleedings, by insufR 
 cient nourishment, by certain poisons, or by other causes, may facilitate its passage 
 through the coats of the veins. But admitting this as a concurrent cause, I am dis- 
 posed to the belief that all passive dropsies occurring under the circumstances just 
 auverttid to, and without any apparent organic disease or change, are mamly to b«« 
 
 p2
 
 174 DROPSY. 
 
 ascribed to debility of the heart : and viewed in this way, they are all brought under 
 the same general principle ; viz., the retardation of the blood in the veins. 
 
 A large class then, of passive dropsies, depending upon mechanical congestion, 
 and defective absorption by the veins, are traceable, in their origin, to the heart ; ana 
 we call them, accordingly, cardiac dropsies. But another class, perhaps numerous, 
 are connected in a remarkable manner with certain diseased conditions of the kid- 
 ne}'s ; and these, for the sake of distinction, we style renal dropsies. I shall say a 
 few words respecting them, after I have briefly considered the other source of drop- 
 sical swellings, adverted to in the commencement of this lecture : namely, excessive 
 exhalation of serous liquid. Dropsy 60 caused comes on suddenly and tumultuously, 
 and is spoken of as being acute or active. It borders closely upon inflammation, 
 and sometimes can scarcely be discriminated from inflammation with serous effusion. 
 The condition of the capillary circulation is supposed to be intermediate between 
 that in which the ordinary amount of secretion is maintained, and that in which 
 inflammatory efflision takes place. The excessive increase of secretion is analogous 
 to what we observe in other parts and predicaments of the body ; to the abundant 
 perspirations, for example, that are occasioned by violent exercise ; to tlie plentiful 
 flow of tears caused by any irritation of the eye, or by the passion of grief; to the 
 augmented watery discharges from the mucous membrane of the bowels produced 
 by purgative medicines ; all of which may be independent of inflammation, but all 
 of which are attended with congestion that might readily be pushed into inflamma- 
 tion. In point of fact, if the secretions to which I have now referred were poured 
 into close cavities, instead of proceeding from the surfaces that are situated on the 
 exterior of the body, or that communicate readily with the exterior, they would con- 
 stitute dropsies. 
 
 The phenomena of active dropsy are of this kind : a labourer is engaged in some 
 employment, which, while it requires considerable bodily exertion, and causes copious 
 perspiration, necessarily exposes him also to the influence of external cold and mois- 
 ture : he has been digging (perhaps) in a wet ditch, in winter time, and he pauses 
 to take his meal ; or he has been unloading a waggon, and rides home, some miles 
 in a heavy rain that wets him to the skin ; or he has been mowing, in the heat of 
 summer, and lies down to sleep upon the damp grass. All these suppositions are 
 derived from actual occurrences. The perspiration is suddenly checked ; and in the 
 course of a few hours he becomes universally anasarcous. Again, a patient recover- 
 ing from scarlet fever ventures out into a cold atmosphere, while the process of des- 
 quamation is yet going on ; and he is attacked with dropsy of the areolar tissue ; 
 and, it may be, of some of the larger cavities also. The urine at the same time is 
 observed to be scanty, troubled, mixed with blood. 
 
 To comprehend this rapid change from a state of health to a state of dangerous 
 disease, we must again have recourse to the findings of physiology. 
 
 Besides the constant exhalation that takes place from the inner faces of the shut 
 serous cavities, a large amount of watery fluid is continually thrown out of the system, 
 by all those surfaces that communicate with the air — by the skin, the lungs, the 
 bowels, the kidneys. Now it is well ascertained that when the excretion of aqueous 
 fluid from one such surface is checked, the exhalation from some other surface becomes 
 more copious. It is probable that the aggregate quantity of water thus expelled 
 from the system in a given time, cannot vary much, in either direction, without de- 
 ranging the whole economy. But we are sure that the amount furnished by any 
 excreting surface may vary and oscillate within certain limits consistent with health, 
 provided that the defect or excess be compensated by an increase or diminution of 
 the ordinary expenditure of watery liquid through some other channel. Sound 
 health admits and requires this shifting and counterpoise of work between the organs 
 destined to remove aqueous fluid from the body. This supplemental or compensating 
 relation is more conspicuous in regard to some parts than to others. The reciprocal 
 but inverse accommodation of function that subsists between the skin and the kid- 
 neys aflbrds the strongest and the most familiar example. In the warm weather of 
 summer, when the perspiration is abundant, the urine is proportionally concentrated 
 and .scanty. On the other hand, during winter, when the cutaneous transpiration is
 
 ACTIVE DROPSY. 175 
 
 thecked by the agency of external cold, the flow of dilute water from the kidneys is 
 strikingly augmented. All this is well known to be compatible with the maintenance 
 of the most perfect health. But supposing the exhalation from one of these surfaces 
 to be much diminished, or to cease, without a corresponding increase of function in 
 the related organ, or in any excreting organ communicating with the exterior, then 
 dropsy, in some form or degree, is very apt to arise. The aqueous liquid thus de- 
 tained in the blood-vessels, seeks, and at length finds some unnatural and inward 
 vent, and is poured forth into the areolar tissue, or into the cavities bounded by the 
 serous membranes. 
 
 Dropsy of one part sometimes supervenes suddenly upon the rapid disappearance 
 of a watery collection from another part. It is no uncommon thing to see the swollen 
 unwieldy legs and thighs of an anasarcous patient qb>>kly unload themselves, and 
 resume their natural bulk and symmetry. His friends congratulate him, and each 
 other, that his disease is leaving him ; but as his legs are emptying, he becomes 
 drowsy, forgetful, comatose, apoplectic ; and after his death we find the ventricles of 
 the brain distended with serous fluid. 
 
 Or the dropsical accumulation may be transferred from its place through a safer 
 channel. The best instance of this that occurs to my recollection I heard related by 
 Dr. Farre. A gouty individual had hydrocele ; dropsy of the tunica vaginalis. After 
 the disease had lasted for some time he got very drunk one evening, with rack punch, 
 which greatly disordered his alimentary canal, and brought on a kind of cholera. 
 He had profuse vomiting and purging, which quite exhausted him : and at length he 
 fell asleep. When he awoke in the morning he found that his hydrocele, which 
 had been a large one, was gone : and it never returned. Such an accidental cure is 
 most instructive. 
 
 If Avater be injected, in some quantity, into the blood-vessels of a living animal, 
 the animal soon perishes; dying generally by coma, or by suffocation : and when 
 the carcass is examined, the lungs are found to be charged with serous Hquid, or 
 water is discovered in the areolar tissue of some other part, or in the shut serous 
 membranes. If, however, the animal be first bled, and then a quantity of water be 
 injected equal to the quantity of blood abstracted, the injection is followed by no seri- 
 ous consequences. 
 
 Facts like these throw, as it seems to me, a strong light upon a confessedly obscure 
 part of pathology. It appears that under various circumstances the blood-vessels 
 may receive a considerable and unwonted accession of watery fluid ; and that they 
 are very prone to get rid of the redundance. When they empty themselves through 
 some free surface, their preternatural distension is relieved by a flux. If, on the 
 other hand, the surface be that of a shut sac, in discharging their superfluity they 
 cause a dropsy. Why sometimes this organ, and sometimes that, is selected as the 
 channel by which the superabundant water shall be thrown out of the vessels, vve 
 can seldom tell. We often find it difficuk to determine which of the two facts in 
 question is to be considered the antecedent, and which the consequent. For not only 
 is it true that when the blood-vessels become overloaded with serous fluid, they rea- 
 dily deposit a part of it : but also that M^hen they are in the opposite condition of 
 comparative emptiness, when the}'^ contain less blood than is natural, they are equally 
 ready to replenish themselves by absorbing fluids from any source to which they car 
 find access. In the case of the man who was cured of his hydrocele upon the oc 
 currence of profuse watery discharges from the stomach and bowels, it seems cleai 
 that the expenditure of serous liquid from one part led to its absorption into the blood 
 from another. When anasarca suddenly leaves the extremities, and fatal coma fol- 
 lows, it appears probable that the absorption is the first of the changes, and the 
 efliision the second : and had this eflrision been determined to the mucous membrane 
 of the intestines, to the skin, or to the kidneys, it would have brought relief and 
 safety to the patient, instead of causing his death. 
 
 We have obtained, then, a glimpse of one or two most important principles in 
 respect to the pathology of dropsy. The blood-vessels, when preternaturally full of 
 aqueous fluid, have a strong tendency to empty themselves : when preternaturally 
 prapty, they readily drink up watery fluid wherever they come in contact with 't
 
 176 DROPSY. 
 
 From the discharge of their superfluity of water arises a dropsy or a flux. The 
 cause and the cure of many dropsies lie in these propositions. 
 
 The apphcation of these principles to the supposed case of active dropsy must be 
 obvious. No doubt, in some such cases, actual inflammation takes place ; but in 
 many of them there is merely the dropsical effusion, without any other trace or evi- 
 dence of inflammatory action. The two facts which it chiefly concerns us to remark 
 fire these — first, that the aqueous portion of the blood which in health is habitually 
 carried off to a very considerable amount by the skin, is suddenly diverted from that 
 tissue ; the perspiration, sensible and insensible, is suppressed : and secondly, that 
 the areolar tissue, or the large serous bags, or both, become filled with serosity. 
 
 It is not by any necessity, however, that the vicarious excretion is turned upon these 
 serous surfaces. In truth, the intercepted perspiration more often escapes, or labours 
 to escape, from some free surface ; and then we have, not a dropsy, but a flux. 
 Diarrhoea, for example, is more common, under the supposed circumstances, than 
 anasarca or ascites : apparently because there is a closer analogy of structure, and a 
 more direct consent or agreement in function, and a stronger reciprocal influence, be- 
 tween the skin and the mucous membrane of the alimentary canal, than between 
 the skin and the serous tissues. 
 
 Brief allusion has been made to a large class of chronic dropsies, connected with 
 and dependent upon a peculiar renal disease. This important species of dropsy will 
 require a detailed examination hereafter. It is more complex, and of more obscure 
 pathology, perhaps, than cardiac dropsy. It certainly has a more direct relation also 
 to what I have just been describing as active dropsy : of which it may almost be 
 regarded as the chronic form. Sometimes the kidney disease, of which the dropsy 
 is an incidental and not an essential symptom, springs up silently and without obvi- 
 ous cause. Sometimes it may distinctly be traced back to its origin in an attack of 
 acute dropsy : in which complaint the kidney always and manifestly labours, its 
 functions being violently deranged, and the urine being smaU in quantity, and mixed 
 with blood. 
 
 In this chronic and renal dropsy, the watery accumulation is accounted for by the 
 deficient excretion through the customary channels. The blood-vessels deposit that 
 excretion in a wrong place. The urine, in the outset of the dropsy at least, is 
 scanty. The skin is almost always dry, harsh, and unperspiring. The anasarca 
 usually increases or decreases, as the quantity of urine diminishes or augments 
 Remarkable alterations take place also in the qualities and composition of the urine 
 itself: it has a very low specific gravity, contains albumen, and is deficient in urea. 
 The blood degenerates too ; and other organs of the body, and especially the heart, 
 are apt to fall into disease. The suppression of perspiration, and the appearance 
 in the urine of blood or serum, unchanged by the secerning power of the kidney, 
 form striking links of connection between acute and renal dropsy. 
 
 In the sketch that I have been endeavouring to give you of the pathology of 
 dropsy, I have taken extreme cases to elucidate the two varieties of that disease 
 which have been respectively denominated active and passive. Let me once more 
 present to you, in a summary view, the points of resemblance, and the points of 
 distinction between them. 
 
 They resemble each other in the result ; namely, in the collection of serous liquid 
 m the circumscribed cavities and vacuities of the body. They differ in the rate at 
 which the collection augments. 
 
 In the well-marked acute dropsies the liquid is rapidly effused, in quantity much 
 beyond the natural amou-nt of exhalation. In the well-marked passive dropsies the 
 exhalation goes on as usual, but the fluid exhaled is not taken back again into the 
 circulating vessels with sufficient facility. In the one case the circulation is dis- 
 •.urbed and tumukuous ; in the other, it remains truhquil. It is probable that in tht 
 more acute forms, the serum transudes through the coats of the arteries, or of the 
 capillary vessels next adjacent to the arteries. In the completely chronic and cai- 
 diac forms, there is a defect of absorption by the veins. Active dropsies arc
 
 DROPSY. 177 
 
 sometimes spoken of as belonging to the left side of the heart ; passive dropsies lo 
 the right. 
 
 But there are intermediate degrees, in which the full veins are not only unable to 
 admit anj?- addition of aqueous Kquid, but also to retain that which they already hold ; 
 and serosity gradually exudes through their parietes. 
 
 What connects all these forms of dropsy is a preternatural fullness in some part, 
 or the whole of the hydraulic machine. And this seems to be the grand key to the 
 entire pathology, as well as to the remedial management of the disease. 
 
 I scarcely need point out to you the fact, that the water of dropsy is liable to 
 change its place, in obedience to the force of gravity. In general ansarca, when 
 the serous accumulation slowly augments, it first becomes visible about the feet and 
 ankles. There are two causes for this : the one occasional in its operation, the other 
 general. The veins of the lower extremities are apt, when the patient is erect, to 
 be more turgid than other veins ; for unless the action of their valves be quite per- 
 fect, those vessels sustain the weight of a large superincumbent column of blood, 
 which concurs with other causes to retard the upward current, and to keep the 
 depending capillaries unduly full. Under such circumstances the effusion, or the 
 arrest of absorption, may take place around the insteps earlier than in any other part. 
 But in general it is not so. In most cases, the truer and simpler reason of the ear- 
 lier manifestation of dropsical swelling about the ankles, is merely that the serous 
 liquid which fails to be removed from the areolar tissue in all parts of the body, 
 gravitates towards the lowest part ; and being thus collected into a comparatively 
 small space, is rendered more perceptible. During the night, when the horizontal 
 posture is maintained for several hours, the fcdema of the ankles disappears, but the 
 neck and face, perhaps, become bloated and puffy. And it is obvious why, in these 
 cases, the feet, towards evening, swell more than the hands. The hands receive the 
 serous fluid from the areolar tissue of the arms alone ; the feet, that which sinks 
 down, not only from the legs and thighs, but from the head and trunk also. The 
 limbs may be looked upon as bags, which fill up in proportion to the quantity of 
 liquid detained. And the lungs are similarly bags : and in these cases we com- 
 monly may hear the crepitation of pulmonary cedema in their lowermost portions. 
 
 I mentioned an instance in which one-half only of the body was anasarcous, and 
 that the upper half. The descent of the dropsical fluid was prevented by the dress 
 of the patient ; the waistband of his trowsers having compressed the areolar tissue 
 through which alone the gravitating hquid could seek a passage. So sometimes, it 
 is stopped at a lower point of its descent by tight garters, and the thighs swell ear- 
 lier than the insteps. It is not at all uncommon to see persons who, in the daytimef 
 at least, and in the erect posture, are anasarcous in the lower half only of the body. 
 We do not so often meet with anasarca of one moiety of the body, the division being 
 made by an imaginary plane drawn through its axis. Yet this does occasionally 
 happen. This curious phenomenon is usually the result of a mere accident, the 
 anasarcous patient being unable to leave his bed, or to lie at all, except on one side ; 
 and then the accumulating liquid gravitates to that side. I have, however, seen one 
 case to which this explanation would not apply. I believe that some local obstruc- 
 tion to a large vein in the neighbourhood of the shoulder caused oedema there, and 
 (he fluid sank down and filled the areolar tissue of that side alone. As the man 
 recovered, I had no means of verifying the truth of this conjecture. 
 
 Cfeferis paribus those parts of the body become the most loaded with serous fluid 
 and show the anasarca the plainest, of which the areolar tissue is plentiful and loose ; 
 as the eyelids, and the scrotum. But in extreme cases the liquid pervades the same 
 tissue, where it is much more dense and compact : as where, for example, it is sub- 
 jacent to mucous membranes. In the examination of a dropsical corpse, the mucous 
 coat of the intestines may sometimes be seen to be elevated by the water co-Uected 
 beneath it. It then looks hke jelly, and the valvulas conniventes, which are flat and 
 thin in their ordinary state, become round and convex. Dropsy of the submucou.s 
 'issue of the air-passages is frequently a cause of death. 
 
 Many persons seem disposed to ascribe these anasarcous swellings, espenallv 
 12
 
 178 DROPSY. 
 
 when they make their appearance suddenly, to inflammation ; and much is said 
 about the frequency of injjammalory dropsy. But the facts we have just been 
 cjusidfring sufficiently refute this theory. If the serous liquid be the product of 
 mflammation, what is the part inflamed ? It cannot be, as some appear to think, the 
 distended areolar tissue itself; for if so, the inflammation must shift its quarters under 
 the influence of gravity. The term inflammatory dropsy may not, perhaps, be inde- 
 fensible when applied to that class of dropsical affections that have been spoken of 
 under the head of active dropsy. I am far from denying- the frequent agency of 
 inflammation in producing changes which, in their turn, lead to dropsy, but we shall 
 do well not to confound those collections of serum mixed with blood or with coagu- 
 lable lymph, w'hich are distinctly events or products of inflammation, with other 
 collections of serum which resemble the former in that respect only, but differ 
 entirely from them in everj^ other particular. To the class denominated active, 
 which occur suddenly, from defect of some one or more of the usual channels of 
 aqueous excretion, and which are usually attended with much disturbance of the 
 whole system, the epithetyi'^nVe Avould not be inappropriate. There may be some 
 few cases in which it is impossible to determine whether the effusion be inflammatory 
 in its origin or not. If the serum be turbid, if we can discover in it the smallest ad- 
 mixture of pus, or of flakes of lymph, or if the disease has been marked by the ordi- 
 nary signs of internal inflammation, we need not hesitate in our opinion. One of the 
 latest systematic writers on dropsy in this country holds that all dropsies are more 
 or less inflammatory. We can see one reason for this mistake (for a mistake it 
 surely is) in the relief and amendment which often ensue upon the employment of 
 blood-letting in dropsy. 
 
 The oenexaX prognosis in this disease may be readily gathered from what I have 
 said of its causes and conditions. The anasarca which occurs in chlorotic young 
 women is the least perilous, and the most curable. Of the rest, febrile dropsies are 
 more obedient to treatment, and oftcner admit of complete recovery, than the passive 
 or chronic. Local dropsies are to be regarded w^ith hope, in proportion as the 
 obstruction on which they depend is capable of being removed, or compensated by 
 the development of fresh channels for the delayed blood. As far as the mere water 
 is concerned in the chronic forms of the disease, cardiac dropsies are more readily 
 dispersed for a time, but more likely also to return, than dropsies which are compli- 
 cated with renal disease. It is obvious also that the immediate danger of dropsical 
 accumulations will depend much upon the place the liquid may occupy. The dif- 
 ference in this respect is immense between the tunica vaginalis, and the peiicar- 
 dium; between the areolar tissue of a limb, and that which lies beneath the mucous 
 membrane of the glottis. 
 
 It remains that I should ofl^er a very few final remarks concerning the principles 
 upon which dropsies are to be treated. 
 
 The first object is to get rid of the preternatural accumulation of watery fluid : 
 the second is to prevent its collecting again ; in other words, to remedy the diseased 
 conditions which gave rise to the dropsy. Indeed, if we can accomplish this second 
 object without delay, the dropsy will generally disappear of its own accord. Now 
 venesection will often sensibly reduce the dropsical swelling. In what has been 
 called active or febrile anasarca, general blood-letting is advantageous in several 
 ways. It helps to relieve the congestion, akin to inflammation, upon w'hich the 
 effusion depends : it tends to abate the undue action of the heart : and by emptying 
 the blood-vessels, it facilitates the re-absorption of the effused liquid, and its ultimate 
 ejection from the system. 
 
 But although blood-letting is the most direct and certain way of unburdening the 
 loaded veins, and therefore, in many instances, the most efl^ectual remedy for the 
 dropsy, it is by no means adapted to all, nor even to many, forms of the malady. It 
 will always, indeed, remove a portion of the aqueous ingredient of the blood, but it 
 expends at the same time its fibrin and its red particles. It impoverishes the circu- 
 lating fluid, and thus enleebles the patient more than would the indirect measures, to 
 be mentioned pre-^f'ntly, for evacuating the collected liquid. Perhaps, by rendering 
 the blood more watery, venesection may indirectly favour the transuding of its serum
 
 TREATMENT. 179 
 
 outwards whenever the venous current happens to be retarded. It certainly weakens 
 the central organ of the circulation : and to muscular debility of the heart we have 
 already seen that certain forms of general dropsy may owe their origin ; and thus it 
 is that ill-timed or excessive bleeding may be the cause of dropsy. In these forms 
 of anasarca, instead of robbing the veins of their blood, we seek to repair the quality 
 and richness of that fluid, and so to restore the deficient tone and vigour of all the 
 muscles, and of the heart among the rest. 
 
 In many cases, then, it is inexpedient to let blood ; and we endeavour to empty 
 the vessels indirectly, and in such a manner as to withdraw from them the more 
 watery parts only of their contents. In other words, it becomes our object to aucr- 
 ment the discharge of watery fluid from one or more of the secreting surfaces of the 
 body : but it must not be the inner surface of a shut sac. 
 
 I noticed before the close analogy that obtains between dropsies and fluxes. Dropsy 
 is a flux into a closed cavity. Fluxes would be dropsies if the fluid poured forth did 
 not escape. And^you are to observe that we frequently try to cure a dropsy by pro- 
 ducing a flux. 
 
 By what surface or channel this artificial drain shall be attempted, is often a 
 matter of gteat nicety and importance. In some cases we strive to promote the 
 discharge of the superabundant water by the way of the kidneys ; in others, by the 
 mucous hning of the aUmentary canal : in others, by the external skin. The cir- 
 cumstances by which our choice must be determined will come under review here- 
 after. 
 
 Passive dropsies are much more difficult of cure than active, and will often baffle 
 our best directed efl!brts. You are not, however, to regard those passive dropsies 
 which depend upon the obliteration of a large vein as necessarily incurable ; for if a 
 collateral venous circulation be accomplished, the drops}?- will permanently disap- 
 pear. But we must give nature the credit of the cure in such cases. Time is the 
 best remedy ; and all that we can sometimes do is to alleviate in the meanwhile the 
 most distressing or threatening of the symptoms. 
 
 I mentioned, in the outset of the lecture, that the presence of the dropsical fluid 
 may constitute nearly all the sufl^ering of the patient, as well as much of his danger. 
 Now, when we cannot get rid of the water by bleeding, or by internal remedies 
 which excite serous discharges, we may often afford great present comfort to our 
 patient, and prolong his days, by letting the water out by a slight mechanical opera- 
 tion. Paracentesis is the scientific, and tapping the vulgar name, for this proceed- 
 ing. It has been performed successfully, by means of a small trocar, to evacuate 
 the water from the brain in chronic hydrocephalus ; it is often resorted to for the 
 purpose of emptying the peritoneal cavity, and the tunica vaginalis testis ; and it is 
 not seldom practised to let out the fluid of anasarca ; for acupuncture of the legs and 
 thighs and scrotum, is only another form of tapping. 
 
 In the local variety of dropsy that is called hydrocele, the re-accumulation of the 
 liquid is sometimes prevented by exciting just so much inflammation of the mem- 
 brane as may cause its opposite surfaces to cohere ; whereby the cavity itself being 
 abolished, any return of the disease is rendered impossible. 
 
 This is an expedient which we do not dare to employ in other species of dropsy ; 
 in ascites, for example : first, because the inflammation itself would place the 
 patient's existence in imminent peril ; and secondly, because if it could be safely 
 conducted, the adhesion and obliteration would seriously embarrass and impede the 
 functions of important organs. 
 
 The circumstances which require and justify this mechanical remedy ; the rule^j 
 and precautions to be observed in its performance ; and the measures to be adopted 
 for preventing the recurrence of the accumulation, by the removal of its efficient 
 cause, will all be considered in detail when we come to treat of the special forms of 
 dropsy.
 
 180 DISEASES OF THE EYE. 
 
 LECTURE XVII. 
 
 Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults. 
 
 Having brought my observations on general patholog}' to a close, I next proceed 
 to the consideration of individual diseases ; and I shall take them up, one by one, in 
 that anatomical order to which I adverted in the introductory lecture of this course. 
 That is to say, I shair go a capite ad calcem: interpolating those disorders which, 
 although they have a name, have as yet no ascertained local habitation, wherever it 
 may seem most convenient to introduce them. I mentioned before one advantage, as 
 it seems to me, of bringing together, in juxtaposition, all the diseased conditions to 
 which the same part, or the same neighbourhood, of the body is liable — namely, the 
 facility thus afforded of comparing the phenomena by which they are characterized, 
 and of discriminating one disorder from another. . In taking the parts in succession 
 from the head downwards, we adopt a sort of order, definite enough for the purpose 
 of aiding tlie memory, and yet free from the trammels which belong to all attempts 
 at arranging diseases according to their essential nature and affinities. 
 
 I propose then to speak, in the first place, of certain diseases of the organ of 
 vision. Diseases of the eye occupy a sort of neutral ground, upon which the sur- 
 geon and the physician may both lawfully enter. For some of them there are no 
 means of relief but in manual operations of the most delicate kind. On the other 
 hand, many of the internal parts of the eye require, when diseased, exactly the same 
 species of general treatment which the physician adopts in diseases of other internal 
 parts. We seek to change the condition of a small portion of the body, by remedies 
 which act upon and through the system at large. My real and only motive, however, 
 for beginning with a few of the numerous morbid states to which this little part is 
 liable, is this : — that we find, in the eye, more satisfactory and plain illustrations of 
 the general facts and doctrines of pathology, as I have been endeavouring to set 
 them before you, than in any other single organ of the body. " Here" (to use the 
 words of Dr. Latham, in his little volume on Clinical Medicine — a book which I 
 strongly recommend j-ou to study) " here you see almost all diseases in miniature : 
 and from the peculiar structure of the eye, you see them as through a glass ; and 
 you learn many of the little wonderful details in the nature of morbid processes, 
 which but for the observation of them in the eye would not have been known 
 at all." 
 
 "Within the small compass of the visual apparatus," says Mr, Lawrence, "we 
 meec with a greater variety of structures than in any other part of the body. Indeed 
 the eye, with its appendages, exhibits specimens of every one of the animal tissues. 
 We find in it bone, cellular and adipose substance, and blood-vessels; mucous, 
 fibrous, and serous membranes ; the conjunctiva exemplifying the first ; the sclero- 
 tica, the sheath of the optic nerve, and the lining of the orbit, the second ; the sur- 
 faces containing the aqueous humour, the third : muscular, nervous and glandular 
 parts ; common integument and hairs. Besides these, it contains several tissues of 
 peculiar nature, to which there is nothing strictly analogous in other parts." 
 
 The eye itself, taking it apart from its appendages, the spheroidal eyeball itself, is 
 scarcely an inch in its longest diameter. Yet it seldom happens that disease, of any 
 kind, occupies the whole, even of this small space, at once. Inflammation, for exam- 
 ple, is often confined to one of the tunics of the eye, external or internal ; and wher 
 it affects more, it is usually in consequence of the extension of the inflammatory pro- 
 cess, from some one texture in which it took its rise. You will not expect me tc 
 treat of the vast number of disorders to which the several parts of the eye are liable. 
 I shall bring, I repeat, a few of them only under your notice ; and I shall select 
 ihose concerning which the physician is most frequently consulted ; Avhich every 
 one, whatever brancn of the profession he may follow, ought to be competent tc 
 treat; and, more particularly, which are calculated to elucidate other diseases, and, 
 above all, other internal diseases, that are iipuedly assigned to the care of the phy
 
 CATARRHAL OPHTHALMIA. 164^ 
 
 sician. With the anatomy and physiology of the organ, I may take for granted that 
 you are already acquainted. 
 
 I will first briefly inquire into the inflammatory affections of what may be consi- 
 dered the mucous membrane of the eye. Like other mucous membranes, it forms 
 a surface communicating with the external air. Some of these affections are yery 
 trifling : some are very severe. 
 
 There is a mild form of inflammation of the conjunctiva, which constitutes the 
 most common disease of the eye to which adults are subject. It results, in most 
 cases, from vicissitudes of temperature ; or from certain conditions, or sudden varia- 
 tions, of the atmosphere. It is very apt to be excited by exposure to a stream or 
 draft of air, especially in the night, and during sleep. It has a strong analogy — 
 indeed it is the same disease, except in situation — with that moderate degree of 
 inflammation, produced by the action of the same causes, in the mucous membrane 
 of the nasal cavities, the throat, and the bronchi, which in common parlance we 
 style a cold in the head, or in the chest, as the case may be : and accordingly that 
 inflammation of the conjunctiva of which I speak is often called by the unlearned, a 
 cold in the eye: and the same analogy is expressed in its technical appellation : the 
 cold in the head or chest is termed by nosologists a catarrh; and the cold in the eye. 
 of the vulgar, is, with them, catarrhal ophthalmia. The suddenness (sometimes) of 
 its accession has procured for it also the denomination of a blight in the eye. 
 
 The term ophthalmia is at present used to denote inflammation of the eye gene- 
 rally ; it conveniently expresses in one word what would otherwise require more. 
 Formerly, when the diseases of the eye were not so well understood in this country 
 as they are at present, almost all the inflammatory conditions to which that organ is 
 subject, were lumped together under the common appellation of ophthalmia, or the 
 ophthalmia. That word now requires some epithet to distinguish the seat or the 
 kind of inflammation that is meant. 
 
 It can scarcely be otherwise than interesting to mark the phenomena which occur 
 in catarrhal ophthalmia, when we know that in its cause and nature, it is the same 
 with inflammation of a similar surface, in parts which we cannot so well inspect as 
 we can the conjunctiva. This membrane, as you know, hues the eyehds, and covers 
 about a third part of the globe of the eye anteriorly. The inflammation, in catarrhal 
 ophthalmia, is confined to the conjunctiva and the meibomian follicles. Its leading 
 symptoms are redness of the surface of the ej^e ; some pain and uneasiness there ; 
 an increased discharge from the affected membrane and the follicles : and a stick- 
 ing together of the eyelashes and lids. 
 
 The redness is worth notice, both in respect to its tint, and to the arrangement of 
 the vessels in which it appears. It is superficial, and of a bright scarlet colour; 
 and usually irregular, or diffliscd in patches, some fasciculi of vessels being more 
 distended than others. When, however, the inflammation is more intense, the 
 whole surface, except that of the cornea, becomes of a scarlet red. The vessels of 
 the conjunctiva, thus rendered visible by inflammation, anastomose continually with 
 each other, and form a network, which can be slipped and dragged about over the 
 subjacent surface by moving the eyelids with the finger. Frequently some of the 
 meshes of this network are filled up with little patches of extravasated blood ; the 
 eye is what is called blood-shot, or, to speak learnedly, there is ecchymosis ; and 
 sometimes all distinction of separate vessels is nearly lost. In the commencement 
 of the complaint the redness is confined to that part of the conjunctiva which lines 
 the lids ; and it afterwards advances gradually, from the angle where it is reflected 
 over the eyeball, towards the cornea. 
 
 Now all these particulars are of consequence, since they are diagnostic of the seat 
 of the disease ; and to show this I must mention, by anticipation, the appearance 
 and the arrangement of vessels that are observed when inflammation affects some of 
 the textures which lie deeper than the conjunctiva, and especially the sclerotica 
 The sclerotic redness is seen through the conjunctiva. It is of quite a different tint 
 from that of the conjunctiva. Instead of showing a blight scarlet colour, it is pink, 
 or sometimes of a slight violet hue. The vessels are much smaller and finer than 
 those belonging to the conjunctiva, like hairs. They are straight also, and arranger? 
 
 Q
 
 182 DISEASES OF THE EYE. 
 
 regularly, after the manner of radii in a circle. They lie in the sclerotic, round the 
 cornea, like what is called by painters a glor}% or like a halo, or zone surrounding 
 the central cornea; and they cannot be made to shift tlicir place by any dragging 
 of the lids. These are very important distinctions. They are such as are easily 
 recognized when two eyes are examined in which the two membranes in question 
 are separately inflamed and vascular; and they are still more palpable, perhaps, 
 ■when both membranes are simultaneously inflamed, as they often are, in the same 
 eye. Then, unless the conjunctiva is so universally red as to prevent our seeing the 
 sclerotica through it, the contrast between the larger, more tortuous, scarlet, and 
 reticular vessels of the conjunctiva, and the fine, straight, rose-coloured, radiating 
 vessels of the sclerotic, is exceedingly striking ; and those of the conjunctiva, which 
 lie naked on the loose mucous membrane, admit of being slipped about over the 
 fixed zone of vascularity which is presented by those of the fibrous tunic. 
 
 The pain which attends catarrhal ophthalmia is slight and trifling. At the outset 
 there is generally some uneasiness when the eye is exposed to the light ; but there 
 is no intolerance of light when the disease is fairly developed. The patient com- 
 plains rather of a sensation of stiffliess and dryness, and feels as though there were 
 some foreign substance in the eye, between the globe and the lids, especially when 
 the eye is moved ; a grain of sand, or gravel, or a little fly. So exact is the resem- 
 blance of this feehng, that you can with difficulty persuade the patient that there is 
 nothing of that sort in his eye. No doubt this sensation is produced by the ine- 
 quality and roughness of the surface, consequent upon the irregular distension of the 
 vessels of the inflamed membrane ; irritating the organ mechanically, just as a piece 
 of dust would irritate it. 
 
 Now in this respect, again, there is a m.arked difference between conjunctivitis 
 and sclerotitis. In the latter disease, the pain is much more severe, of a dull aching 
 character, with a sense of tightness : the part inflamed is denser, and less yielding 
 than the conjunctiva. The pain is attended also, frequently, by throbbing, and is 
 felt in the surrounding parts more severely perhaps than in the eye itself; in the 
 brow, temples, and head. It is a very remarkable circumstance, too, that the pain 
 is distinctly aggravated towards night ; increasing in violence from the evening till 
 after midnight, abating towards morninc:, and ceasingf in a great measure durincr the 
 day, to be again renewed in the evening. I am speaking now particularly of inflam- 
 mation of the sclerotica produced by the same causes as give rise to catarrhal oph- 
 thalmia ; of what is generally called rheumatic ophthalmia. 
 
 The increased discharge that takes place from the eye in catarrhal ophthalmia is 
 not a discharge of tears. In the beginning of the complaint there is sometimes a 
 slight degree of lachrymation. But this soon ceases, and the mucous secretion from 
 the surface of the membrane is augmented in quantity, and changed in quality. At 
 first it is somewhat thin, but it soon becomes thicker, and it is often puriform ; i. e., 
 opaque and yellow : sometimes it retains more exactly the characters of mucus, is 
 transparent and viscid ; so that the eye looks moist to a bystander, while to the 
 patient it feels gummy. The puriform secretion is not, in general, in any great 
 abundance. You may see it lying in the angle between the eye and the lower lid, 
 by pulling them apart ; or it makes itself visible at the corner of the eye, or between 
 the eye-lashes along the edges of the lids, Avhich it glues together at night. Some- 
 times, however, the discharge is more copious, so as to approximate to what is 
 observed in the less severe forms of another disease I shall presently mention ; viz., 
 purulent ophthalmia. 
 
 There is seldom much sweUing of the conjunctiva. If there be any, it results 
 from an cflusion of serous fluid into the meshes of the areolar tissue that connects 
 the membrane with the subjacent sclerotica : by which effusion the conjunctiva is 
 partially raised and separated. This kind of eff'usion often goes to a very great 
 extent in purulent ophthalmia, or in violent inflammation of the external membranes, 
 as I shall show you by and by. 
 
 So much, then, for the symptoms and causes of catarrhal ophthalmia. It is neces- 
 Kary that you should be familiarly acquainted with them ; not so much because the 
 complaint is very serious in its nature, but because it is rnmmon ; because you are
 
 CATARRHAL OPHTHALMIA. - 183 
 
 sure to be again and again consulted about it, and because it is of great importance 
 to distinguish it from other forms of oplithahnia, in order to adopt the proper treat- 
 ment. A mistake of diagnosis might lead to mischievous activity on the one hand : 
 or to still more pernicious inertness on the other. 
 
 When the inflammation does not extend beyond the mucous membrane, it will run 
 a certain course, and then, under favourable circumstances, subside. But if it be 
 improperly treated, or if the patient cannot guard himself against a repetition of its 
 exciting causes, it may continue for weeks, and harass him a good deal, and even 
 produce such a change in the inflamed lids as may prove a source of permanent 
 irritation, and of chronic disease, of the cornea over which they sweep. 
 
 Remedies of an active kind, such as influence the whole economy, are scarcely 
 ever necessary. The patient should observe the main particulars of the antiphlo- 
 gistic regimen, and avoid exposure to drafts or currents of air, and to cold and mois- 
 ture generally. When the external weather is inclement, he should remain in rooms 
 of a uniform temperature. It will be right to purge him in the outset with calomel - 
 and jalap, or witli calomel followed by a black dose finfusion of sennoe]. 
 
 If the system at large sympathize with the local disease, it may become necessary 
 to take blood from the arm, or to apply leeches ; but neither of these measures is 
 requisite, except the inflammation is unusually severe, or the disease has been ne- 
 glected or mismanaged. 
 
 After the bowels have been thoroughly cleared by an active purgative or two, 
 remedies which encourage moderate perspiration will be likely to forward the cure; 
 such as warm diluent drinks ; five grains of Dover's powder, and immersion of the 
 feet in warm water, at bed-time ; and saline draughts containing two or three drachms 
 of the liquor amrnonix acetatis, taken at intervals during the day. 
 
 But in this complaint local measures are of greater importance than those which 
 are addressed to the general system: stimulating or astringent applications to the 
 affected membrane itself. Almost all modern writers on diseases of the eye agree 
 in this. Dr. Mackenzie, of Glasgow, states it as the result of his observations on 
 Beer's practice in Vienna, and of his own subsequent experience, upon an extensive 
 scale, at the Glasgow Eye Infirmary, that " general remedies in this disease are in- 
 ferior to local ones ; that violent general remedies are worse than useless ; and that 
 a local stimulant treatment may almost entirely be rehed on." Mr. Melin, in a 
 report of ocular diseases at the General Hospital, Fort Pitt, states that he had treated 
 nearly 300 cases, some of them severe, upon the same principle, without either local 
 or general bleeding : and that he had satisfied himself of the efficacy of this plan 
 of management. And Mr. Lawrence, who for ten years was one of the surgeons 
 to the Ophthalmic Infirmary, in Moorfields, and who during that period had ample 
 opportunities of studying this disease of the eye as well as others, says that it is one 
 to which the use of powerful astringents is more particularly applicable. In dis- 
 orders which manifest a strong natural tendency to terminate in recovery, it is onlj- 
 by taking advantage of the conclusions derived from extensive observation that we 
 can be quite sure of our ground ; and when the same result is reached by different 
 and independent observers, we may safely place confidence in their concurrent 
 testimony. 
 
 Dr. Mackenzie and Mr. Melin both employ and recommend the same application, 
 viz., a solution of the nitrate of silver in distilled water, in the proportion of foijff 
 grains to the ounce. A large drop of this solution is to be applied to the membrane 
 once or twice, or three times, in the course of the day. If the patient recline his 
 head backwards, and the drop be placed in the hollow formed at the internal angle, 
 of the eye, it will be diffused over the globe upon the separation and subsequent 
 winking of the lids. After a minute or two this causes a pricking or smarting sen- 
 sation, which subsides in from ten to twenty minutes, and the eye then feels much 
 easier than it did before the drop was applied. Dr. Mackenzie says that the feeling 
 as if of sand in the eye, is uniformly relieved, and the inflammation abated, by the 
 use of this solution, which he speaks of as a remedy of sovereign utility in the puro- 
 mucous inflammations of the conjunctiva. The eye continues easy, after its appli- 
 cation, for five or six hours perhaps; and when the symptoms return, they are agaus
 
 184 DISEASES OF THE EYE. 
 
 to be met by the introduction of another drop. As the disease subsides the remedy 
 gives less and less pain, till at last it is scarcely felt. He tells us that " he has some- 
 times alarmed other practitioners by proposintr to drop upon the surface of an eye 
 highly vascular, affected with a feeling as if broken pieces of glass were roiling under 
 the eyelids, and evidently secreting puriform matter, a solution of lunar caustic ; and 
 that he has been not a httle pleased and amused at their surprise when, next day, 
 they have found all the symptoms much abated by the use of this application." He 
 declares, also, that the acetate of lead, and the sulphate of zinc, substances which 
 are much used in what are called colhjria or ei/e-ic ashes, are greatly inferior, as local 
 applications, to the nitrate of silver, in this disease. 
 
 There is another expedient that requires to be attended to in these cases. When 
 the eyelids are gummed together by the viscid discharge, much hurtful irritation is 
 often produced by the hasty attempts which the patient makes to separate them. 
 Now all this may be obviated hy smearing their tarsal edges at bed-time with any 
 mild ointment ; the spermaceti ointment, or a bit of lard. There is no necessity, 
 as I believe, in this form of disease, to use medicated or stimulating salves : the 
 object is to prevent the mutual adhesion of the lids ; and this is accompanied by 
 simple grease. 
 
 Purulent ophthalmia is another disease of the conjunctiva ; differing from catarrhal 
 ophthalmia in degree, in the severity (3f its symptoms, in the danger which it imphes 
 to the sense of vision, and in its exciting causes. It takes its name from the profuse 
 discharge of pus, or of altered mucus w'hich cannot be distinguished from pus, that 
 pours from the inflamed surface. There are three remarkable varieties of purulent 
 ophthalmia, called respectively — 1, purulent ophthalmia of adults, or Egyptian 
 ophthalmia, or contagious ophthalmia; 2, gonorrhceal ophthalmia; and 3, purulent 
 ophthalmia of ncAvly-born children. 
 
 The symptoms of the two first-mentioned varieties, especially in their severer 
 forms, are so much the same that it would involve us in mere repetition if I did not 
 take them together. In truth it appears to me much the simpler and better mode to 
 look upon purulent ophthalmia as one disease ; and then to specify, as we go on, the 
 differences by which its several forms are characterized : and not to split it into three 
 different diseases, and to give a separate description of each. 
 
 Although purulent ophthalmia is inflammation of the very same part that is in- 
 flamed in catarrhal ophthalmia, from which it differs chiefly in degree, it is a hideous 
 complaint, either to suffer or to treat : on account of the rapid progress it frequently 
 makes, and its destructive tendency. The inflammation is greatly more intense ; 
 the surface becomes, in the worst cases, highly vascular throughout. A copious 
 discharge of thick, yellow, puriform matter is speedily established ; this flov/s out 
 from between the swollen lids, and runs over the cheek which it often excoriates. 
 At the same time considerable effusion takes place into the areolar tissue that connects 
 the sclerotica and the conjunctiva. You are aware that the conjunctiva extends 
 over the whole anterior face of the globe ; adhering, however, so much more closely 
 to the cornea than to the sclerotica, that we might doubt at first whether it did not 
 stop at its margin. This close and firm adhesion over the cornea, and the looser 
 attachment to the sclerotica, give rise to a very sintrular phenomenon. The conjunc- 
 tiva is raised to some distance from the subjacent sclerotica by the effijsion that takes 
 place between them ; and it projects around the cornea in the shape of a large thick 
 ring, leaving the cornea buried, as it were, in a pit ; nay, sometimes, the swollen and 
 prominent membrane will lap over, so as nearly to exclude the cornea from our 
 sight. The same kind of effusion takes place, also, sometimes very rapidly, into 
 the areolar tissue connecting the conjunctiva with the palpebrre, producing great ex- 
 ternal tumefaction, and a livid red appearance of the eyelids, which project forwards 
 in large convex masses, and often prevent our seeing the globe of the eye at all ; 
 the upper lid especially becoming hard and stiff, and completely overhanging the 
 lower. This swelling from effusion into the subconjunctival tissue is of a pale red 
 fleshy colour, sometimes marked here and there with patches of extravasated blood. 
 The appearance is called chemosis : not ecchymosis, as the similarity of the sound
 
 PURULENT OPHTHALMIA. 185 
 
 has led some erroneously to suppose, but chemosis. ExxviArtoai?, from sxxn^, signifies 
 an effusion, and by common consent among medical writers, an effusion of blood. 
 Xriuaai;, the root of which is XW"-^ hiatus, means a gap or hollow. 
 
 Now this puriform or purulent inflammation, so long as it is confined to that part 
 of the membrane which lines the eyelid, is not of any serious importance ; but it is 
 prone to extend itself to the cornea, and the whole anterior surface of the eye, and 
 to produce ulceration or sloughing of the cornea, either in consequence of the actual 
 inflammation of that part, or in consequence of the pressure made upon and around 
 it by the swelling of chemosis. Frequently, when the cornea remains visible, a 
 furrow or trench of ulceration may be seen at its margin ; sometimes forming a 
 complete circle, sometimes portions of a circle, sometimes going quite through ; and 
 when this happens, or when the cornea bursts, from the effects of deeper-seated 
 inflarrmiation, the aqueous humour is evacuated, and the iris protrudes through the 
 aperture. Even when these horrible consequences do not take place, the eye is often 
 as effectually spoiled for the purposes of vision by an interstitial deposit between the 
 laminre of the cornea, rendering it opaque, and permanently precluding the passage 
 of light towards the retina. 
 
 And when neither of these lamentable effects of the inflammation is produced, it 
 is apt to leave behind it a chronic and very troublesome condition of the membrane. 
 The conjunctiva that lines the hds remains thickened, granular, hard, and rough, 
 instead of regaining its natural smoothness, softness, and polish. One consequence 
 of this is a perpetual irritation of the surface of the cornea, by the mechanical fric- 
 tion of the rough and hard lid in opening and closing the eye, and in the various 
 motions of the eyeball. The continuance of this irritation leads at length to hazi- 
 ness or opacity of the cornea, which becomes traversed also by visible red vessels. 
 Chronic inflammation of its investing membrane is produced, and kept up. 
 
 The most severe forms of this disease are attended, at length, with a good deal of 
 pain ; doubtless because the inflammation penetrates to the deeper-seated textures of 
 the organ. The pain then presents those characters which 1 mentioned before as 
 belonging to certain inflammations of the sclerotica : i. e., it is pulsative ; and some- 
 times sharp and lancinating, sometimes dull and aching ; and it is intermittent ; or 
 if constant, it is aggravated by paroxysms : the paroxysms coming on at night, and 
 abating towards morning: and it is not confined to the eye itself, but extends to the 
 parts around it. This circumorbilal pain is characteristic of inflammation of the 
 sclerotica and cornea, and of the internal tunics, the choroid and iris. When the 
 eye is not visible, from the swelling, we may conclude that the inflammation is as 
 yet confined to the conjunctiva, if the pain be only scalding or "sandy;" and that 
 it has extended to the sclerotica and cornea if the pain be severe, throbbing, and 
 paroxysmal. In the cases in which the latter kind of pain is felt, the cornea gene- 
 rally gives way. Sometimes this event brings relief to the pain, and sometimes the 
 pain continues to return after the bursting of the cornea. It is curious that with all 
 this, there is seldom much intolerance of light. 
 
 In the earlier stages of this malady, it is entirely local : the system at large is 
 scarcely disturbed at all. But the constitution^fbegins to sympathize and suffer when 
 the local symptoms increase in severity : the pulse becomes frequent, and the tongue 
 white, but there is seldom much thirst or fever; and when blood is drawn from a 
 vein, it does not, in general, exhibit the buffy coat. A good deal of variety in these 
 respects has been noticed, however, in diferent cases. Children manifest more 
 constitutional disturbance when labouring under purulent ophthalmia than adults. If 
 there be not much fever, there is always much uneasiness and irritation, and the 
 sleep is broken by the nocturnal accessions of pain. 
 
 Such being the general features and course of the disease, at least as it occurs in 
 adults, or in patients beyond the period of infancy, we may next inquire into the 
 circumstances under which it has been observed to arise. 
 
 Purulent ophthalmia has been ascertained to be a common disease in hot cUmates : 
 m India, Persia, and Egypt. It was brought into England, from the latter country, 
 by our troops in the beginning of the present century, after the well-known contest 
 which there took place between the French army and our own under Sir llal])b 
 
 a2
 
 186 DISEASES OF THE EYE. 
 
 Abercromby. In this way it got the name of the Egyptian ophthalmia. It naturally 
 excited very great attention at that tinie, and it does not appear to have been accu- 
 rately described before. 
 
 To give you some notion of its prevalence in certain places and at certain periods, 
 and of its serious nature, I may state that, according to returns made from the military 
 hospitals at Chelsea and Kilmainham, there were, on the 1st of December, 1810, no 
 fewer than 2317 soldiers a burden upon the public from blindness in consequence of 
 ophthalmia ; and in this number those soldiers who had lost the sight of one eye 
 only were not included. 
 
 Again, in the year 1804, within nine months, i. e., from April to December 
 nearly 400 cases of purulent ophthalmia occurred at the Royal Military Asylum; 
 and within six years from that time, without including relapses, upwards of 900 
 cases had taken place in the same establishment. 
 
 You Avill find these statements in a paper in the third volume of the Transactions 
 of a Society for the improvement of Medical and Chiriirgical Knowledge, by the 
 late Sir Patrick Macgregor. Many of our best regiments were for a time crippled 
 and rendered unfit for service by this disease ; which they carried from Egypt to 
 other foreign stations as well as to this country, especially to Sicily, Malta, and 
 Gibraltar. Nor were the French troops less extensively affected by it. Assalini, 
 who wrote an account of the ophthalmia of Egypt, states that two-thirds of the 
 French army were labouring under it at one time. It occurs also, but fortunately 
 not to such an extent, in civil life. It broke out, some years ago, in a large boys' 
 school in Yorkshire ; and Windness of one or both eyes, or serious injury to sight, 
 from opacity of the cornea, and other consequences, took place in nearly twenty 
 cases. 
 
 You perceive, therefore, that this formidable complaint has been ascertained, within 
 the last forty years, to have prevailed as an epidemic ; attacking great numbers of 
 persons living under the same circumstances, and having constant communication 
 with each other. And one of the first questions that naturally arises in one's mind 
 is, whether it is capable of beinj propagated from one person to another by conta- 
 gion. Much difference of opinion has existed on this subject. Fur my own part I 
 cannot imagine how any one can doubt its contagious properties. 
 
 I will give you a case or two, as related by Sir Patrick Macgregor, proving two 
 very im.}7i;rlant facts : first, that the disease is capable of being excited in the eye of 
 a person, previously healthy, by the direct application of the puriform discharge 
 from an eye affected with this ophthalmia; and secondly, the very rapid operation 
 of the poison so applied. 
 
 One of the nurses employed at the Mihtary Asylum, while syringing the eye of 
 a boy who had much purulent discharge, found that a considerable quantity of the 
 matter had s^^urted into her own right eye. This was at four o'clock in the after- 
 noon. She fek little or no smarting at the time ; but towards nine o'clock the same 
 evening her right eye became red and somewhat painful, and when she awoke the 
 next morning, the eyelids were swelled, there was purulent discharge, and she com- 
 plained of pain in the eyeball. The usual remedies were begun in the morning, 
 and she recovered in the space of three weeks or a month. The left eye, into which 
 none of the matter had gone, remained free from disease. 
 
 On another occasion a precisely similar mischance befell another of the nurses, 
 « xcept that the matter spurted into her Ifft eye, about nine in the morning. Sir. P. 
 Macgregor happened to be in the hospital at the time when the accident occurred. 
 He desired the nurse to bathe her eye immediately with lukewarm water, and she 
 did so for several minutes ; but notwithstanding this early precaution, about seven 
 o'clock in the evening the left eye began to itch to such a degree that she could not 
 refrain from rubbing it. When she awoke next morning the eye was considerably 
 inflamed, tlit; lids were swelled, and upon moving the eyeball she had a sensation as 
 if some sand were lodged beneath it. In the course of the same day, purulent 
 rtuid issued from the eye, and other symptoms followed, which were similar to those 
 of the children under her care. The disease subsided under the usual treatment, in 
 fourteen days. In this case also the other eye remained sound.
 
 PURULENT OPHTHALMIA. 187 
 
 A third nurse in the same institution did not come off so well. She wlis spong- 
 ing, with warm water, the eyes of a boy suffering severely from purulent ophthal- 
 mia: and she inadvertently applied the sponge she was using to her riglit eye. 
 This happened at eight o'clock in the morning. She mentioned the circumstance to 
 the other nurses, but she took no means to prevent infection. Between three and 
 four o'clock of the afternoon of the same day, itching of the right ^ye came on ; and 
 before she went to bed it was considerably inflamed. Next morning her eyelids 
 were swollen, she complained of pain in moving them, the whole anterior surface of 
 the eyeball was in a state of high inflammation, and a purulent discharge began to 
 trickle down the cheek from the inner canthus. The symptoms increased in severity 
 in spite of all the means employed to check them, and on the fourth day the eyeball 
 burst. The sight of the eye was irrecoverably lost, and the inflammation continued 
 for upwards of three months. The left eye did not suffer. 
 
 These were cases in which the poisonous matter was acddenially applied. But 
 a similar application has been made intentionallxj and by the way of experimenl, and 
 ivith the same results. Dr. Guillie, of Paris, introduced the puriforra secretion fur- 
 nished by some children affected with purulent ophthalmia, under the eyelids of 
 four other children belonging to a separate institution for the blind. These four 
 children were amaurotic, but the external surface of their eyes was healthy and 
 entire. In each instance a regular attack of purulent ophthalmia followed the intro- 
 duction of-the matter. 
 
 Facts of this kind prove, I say, beyond the possibility of question, that the disease 
 may be propagated from a diseased to a healthy eye by actual contact of the puri- 
 form matter. Here we have not one case (which might be considered as an acci- 
 dental coincidence), but several: the morbid secretion is applied to one eye only; 
 the symptoms of inflammation commence, and the regular form of the disease is 
 fully developed within a few hours after the first application of the pus; and that 
 eye only is affected. It is impossible to get over evidence of this kind. 
 
 The only questions, therefore, that can be raised respecting the sources of the 
 disease are these : — whether the malady can be communicated through the medium 
 of an atmosphere impregnated with the efliuvia that proceed from the diseased 
 part, without any actual contact of the pus in substance ? — whether the disorder 
 is ever produced in any other way than by contagion ? — and if so, how it is then 
 excited ? 
 
 I ought to observe, that independently of such isolated examples of the direct 
 communication of the complaint, by contact with the diseased matter, as I have just 
 laid before you, the history and progress of ophthalmia, since it has been noticed in 
 Europe, are very strongly indicative of its contagious nature. I have already stated 
 that it was not known in Europe till the commencement of the present century — till 
 after the Egyptian campaign in fact. It is not alluded to by any of the authors on 
 disorders of the eye who wrote previously to that period ; although some of the 
 Italian physicians and surgeons, and many of the Germans, had paid great attention 
 to ophthalmic diseases. It spread from Egypt both to France and to this country, 
 and to other places in which detachments of the Egyptian force were subsequently 
 stationed : in Sicily to wit, and in Gibraltar and Malta. Whenever it has prevailed 
 among our troops at home, this circumstance has been uniformly observed : that it 
 first broke out in soldiers who had come from Egypt, or had communicated with regi- 
 ments which had been in Egypt. In aU cases its origin could be traced to the intro- 
 duction of fresh troops into the regiment or the barracks. 
 
 Again, the manner in which it spreads is exceedingly instructive on this point. It 
 diffuses itself rapidly, when once introduced, in places where a considerable number 
 of persons are collected together ; especially under circumstances favourable to the 
 propagation of contagious maladies ; as among soldiers assembled in barracks, where 
 many of the men live in the same apartments, and use the same t9wels: while the 
 officers, who live in larger and better ventilated rooms, and apart from each other, 
 generally escape. And the good effect, in checking the further extension of the 
 disease, of separating the healthy from the sick, and of restricting every one to his 
 own washing utensils, and clothes, and towels and sponges, leads to the same cor»
 
 1S8 DISEASES OF THE EYE. 
 
 elusion. Rust, a German author, mentions this striking fact in corroboration of »^-hat 
 I have just been saying. The disease broke out in the town of Mayence. This 
 place was garrisoned by Prussian and Austrian troops. The ophthalmia began and 
 spread extensively among the Prussian soldiery ; while the Austrians, who were 
 stationed in separate barracks from the Prussians, in another quarter of the town, 
 remained quite free from it. 
 
 Those persons who deny, or who doubt, the contagious nature of purulent oph- 
 thalmia, rest their opinions upon some such considerations as these. They hold, in 
 the first place, that the peculiarities of the atmosphere, in Egypt, where the disease 
 has been found so common, are siffficient in themselves to account for it. That the 
 inhabitants of that country never dream of its being caused by contagion. Assalini, 
 who saw the complaint raging in the Frencii army, professes his behef that it did 
 not arise or spread by contagion. He remarks that the atmospheric conditions which 
 are known to occasion catarrhal affections, are very frequent and powerful in Egypt: 
 the days are very hot, the nights chilly, and attended with heavy dews ; and men's 
 eyes are perpetuall}' exposed in the day time, to a dazzling glare of light from the 
 white and arid surface, while the air is full of floating particles of hot sand, which 
 are raised from the ground by the sHghtest breeze. His opinion, therefore, and the 
 opinion of others who saw the disease as it prevailed in that country, was, that it 
 consisted simply of acute catarrhal inflammation of the conjunctiva ; and that it 
 affected those persons most who were most exposed to the exciting causes of 
 such inflammation : the common soldiers, therefore, more frequently than the 
 officers. 
 
 Other circumstances adduced by the disbelievers or sceptics, in respect to contagion, 
 are that many who have intercourse with the sick escape the disease ; and that when 
 bodies of men, among whom purulent ophthalmia has been prevailing to a great 
 extent, are broken up and dispersed, the complaint is not thereby disseminated, as 
 they say it ought to be, supposing it to be communicable from one person to another; 
 that, in fact, this dispersion, the disbanding of troops, for instance, and sending them 
 to their friends and families all over the country, is the surest way of stopping the 
 disorder. 
 
 Again, man)' inefTectual attempts have been made to inoculate the eyes of ani- 
 mals with the matter of purulent ophthalmia. Miiller, a German, with that pains- 
 taking industry, for which the Germans are so remarkable, collected on a camel's 
 hair pencil matter from the eyes of patients labouring under purulent ophthalmia, 
 early in the morning, before they had washed them, and inserted it under both the 
 lids of each eye, in a great number of animals, leaving the pencil there for a few 
 seconds, and then pressing it so as to squeeze the matter out. He also smeared 
 the pus copiously and repeatedly along the edges of the lids. He served in this 
 way five cats, ten dogs, two rabbits, two squirrels, two blackbirds, a starling, a 
 yellow-hammer, and a cock. And in none of them did the inoculation produce the 
 slightest effect. 
 
 It is a sufficient answer to these negative experiments, however, that other persons 
 were more successful in producing the disease in this manner. Vasani and Grafe 
 have both excited it repeatedly in dogs and cats, by the application to their eyes of 
 matter taken from human patients. And I have already informed you of many in- 
 ■lances in which the disease was generated in men by accidental, and even by 
 intentional inoculation. No amount of negative evidence can do away with positive 
 testimony so often repeated. 
 
 And with respect to the other objections, and especially the main objection, that 
 persons may associate and hold close intercourse with individuals labouring under 
 purulent ophthalmia without contracting the disease, I would have you remark that 
 this is no more than what continually happens in regard to diseases which are 
 ncknowledged on all hands to be contagious, and to have no other source at present, 
 iiowever they might have originated at first, hut contagion ; the small-pox, for 
 example. I think there is some reason for believing, from the facts which I have 
 been relating, that purulent ophthalmia, like the small-pox, is capable of being com 
 tnunioated from one person to another, not only by positive contact, but by trans-
 
 PURULENT OPHTHALMIA. 189 
 
 "nission of the specific poison somehow for a short distance through the air. Bui 
 many persons exposed to the contagion of smull-pox escape it altogether : and more 
 persons still, perhaps, fail to be affected, though fully exposed, at one time, and yet 
 readily accept the disease at another time, even when the exposure may seem much 
 more slight than on previous occasions. Now what is true of the small-pox may 
 be presumed to be likely, although, perhaps, in a different degree, of purulent 
 ophthalmia. 
 
 As to the circumstance that the disbanding of a regiment infected Avith the disease 
 prevents instead of favouring its dissemination, that circumstance is really no ar- 
 gument at all against our belief in its contagious nature. We shall see hereafter, 
 that when fever patients are collected in numbers in distinct wards, or in fever 
 hospitals, that disease is very apt to be communicated to the nurses and medical 
 attendants of the sick ; whereas, when such patients are distributed here and there 
 among others, in a general hospital, the disease is scarcely ever known to spread. 
 In the one case the poison is concentrated and effeciive, in the other it is diluted 
 and harmless. 
 
 Dr. Mackenzie, indeed, has come to the conclusion, from what he has himself 
 observed, that the discharge in catarrhal ophthalmia, especially when it is distinctly 
 puriform, if conveyed from the eyes of the patient to those of others by the fingers, 
 or by towels, and so forth, is capable of exciting inflammation of the conjunctiva, 
 still more severe, more distinctly puriform, and more dangerous, than was the original 
 ophthalmia. And with respect to the disease which 1 have been speaking of as 
 purulent ophthalmia, or Egyptian ophthalmia, the author calls it contagious oph- 
 thalmia; he holds that the mflammation of the conjunctiva, whether in the mild or 
 the more severe form, may and often does originate from common atmospheric in- 
 fluences ; but that, when so caused, it may be communicated from person to person, 
 especially when it is attended with a puriform discharge. 
 
 And this is an opinion which, I think, is fully warranted by the facts which we 
 are in possession of upon this subject. There is a strange reluctance, which I have 
 never been able to account for, in some medical men, to admit of the operation of 
 contagion, as a cause of disease. Undoubtedly there are some difficulties belonging 
 to the doctrine of contagion, and I hope in the progress of the course, and especially 
 when I come to speak of fever, to give that subject the careful attention which its 
 great importance demands ; and to enable you to make up your minds respecting it. 
 At present I will only remark, that there is nothing absurd, nor unlikely in the sup 
 position, that diseases may first arise from some other source, and then become 
 capable of spreading by contagion ; and that in all cases, even when the contagious 
 principle is most manifest, there seems to be something else required besides the 
 presence of contagious matter ; there must be a readiness to receive it, a suscep- 
 tibility of its influence, on the part of the person exposed to it : a predisposition which 
 is less common in regard to some diseases than to others ; but without which there 
 is scarcely any complaint that can be so propagated. 
 
 At any rate I would desire to impress upon you the expedience and propriety of 
 acting whatever your doubts or your belief may be, 'upon the safe side. We are 
 bound to proceed, in all questionable cases of this kind, upon the most unfavourable 
 supposition. Very great discredit and loss of reputation have fallen upon practi- 
 tioners who, having themselves no belief that a given complaint was contagious, 
 have neglected those precautions which, under a contrary impression, they would 
 have thought necessary. Perhaps they may have sometimes suffered utijustly ; but 
 you had better not commit yourselves, especially while you are young in years and 
 in experience, by strong assertions of the non-contagiousness of any disease, the 
 mode of propagation of which is at all questionable. And as for the disease ;/iat we 
 are now concerned with, you will do wefl to act as thougn it were certainly conta- 
 gious ; whether you meet with :t as a sporadic or as an epidemic complaint : whether 
 it be severe in its symptoms, or mild. You should forbid the use of your patient's 
 towels and washing vessels by other members of the family ; you should avoid em- 
 ploying the same instruments or sponges to any sound eye, which you have been 
 using for one that is affected with this complaint ; and you should take care to wash
 
 190 DISEASES OF THE EYE. 
 
 your own hands, after touching a diseased eye, before you apply your fingers to 
 another that is yet, in this respect, healthy. 
 
 LECTURE XVIII, 
 
 Purulent Ophthalmia, continued. Gonorrhceal Ophthalmia! Purulent Oplv- 
 thalmia of Infants. Strumous Ophthalmia. 
 
 When we last met, I spoke of catarrhal ophthalmia, i. e., a mild and common 
 form of inflammation of the conjunctiva, resulting from atmospheric influences. I 
 described its characteristic symptoms, and explained the treatment that has been 
 found most successful for its cure ; consisting chiefly in local stimulating or astrin- 
 gent applications. 
 
 I began also to speak of the severer forms of inflammation affecting the same part, 
 and included under the head of jmrulent ophthalmia. The symptoms and course 
 and consequences of the two varieties of this complaint, as it occurs in adults, are 
 so essentially the same, that one description of its phenomena is enough. There are 
 certain differences, however, that require to be noticed, in respect to its exciting 
 causes. I laid before you the reasons Avhich satisfy me, that what is called the 
 Egyptian ophthalmia is a contagious disease ; and which make it probable that the 
 complaint is capable of being propagated from person to person, through the medium 
 of the air, without the necessity for any substantial application of the morbid secre- 
 tion from a diseased to a sound eye. These reasons, briefly stated, are as follows : 
 that the disease was unknown in Europe till after the war in Egypt ; that, arising 
 among our own and the French troops in that country, it was conveyed by them 
 to various places, and extended itself to soldiers who had intercourse with those 
 troops ; that when once introduced it spreads rapidly wherever men are crowded 
 together within a small compass, pay insufficient attention to cleanhness, and use 
 the same towels and utensils ; that it has been propagated again and again by the 
 direct application of the morbid secretion ; and that its progress is checked by 
 measures that provide against such accidental apphcation, and by separating the 
 diseased from the healthy. 
 
 On the other hand, it has been contended that the disease is nothing more than 
 an extreme degree of catarrhal ophthalmia ; that the peculiar conditions of the 
 atmosphere in Egypt and other hot countries, where it is prevalent, are enough to 
 account for it ; and that when troops are disbanded, they do not give the disease to 
 their friends and families all over the country, but, on the contrary, the dispersion of 
 the sick in this way is the most efl^ectual mode of stopping the disease. 
 
 To these arguments the proper answer is, that the same difficulties meet us in. 
 respect to some other diseases which are confessed by all persons to be strictly con 
 tagious. 
 
 My own creed upon the matter is this — that the disease may, and often does arise, 
 independently of contagion, from the agency of ordinary causes of inflammation , 
 and that having so originated, it acquires contagious properties, which develop them- 
 selves only under circumstances that favour the propagation of most of the contagious 
 rompiaints. 
 
 I shall next advert to purulent ophthalmia as it is observed to occur, in the adult, 
 m connection with gonorrhoea. If we look to the mere phenomena presented by 
 the inflamed eye, we find nothing to distinguish the gonorrhceal from the Egyptian 
 ophthalmia. Taking the average of a large number of cases, the gonorrhceal is the 
 severer form of the two, and runs the more rapid course. It is said, also, that the 
 inflamniation usually commences on the lids in the Egyptian variety, while it attacks 
 the whole conjunctiva at once in the gonorrhceal. But comparing individual in- 
 stances, these mere differences, and slight differences, too, in degree and situation, 
 •rill not help our diagnosis
 
 GONORRHCEAL OPHTHALMIA. 191 
 
 But other circumstances may guide us. If a patient presents himself with 
 severe purulent ophthalmia, who has not been exposed to any of the known atmo- 
 spheric causes of that disease, and at a time when purulent ophthalmia is not pre- 
 vailinjT as an epidemic, and if this patient have a clap, we may conclude that we 
 have to deal with a case of gonorrlireol ophthalmia ; and this conclusion will be fur- 
 ther strengthened if the disease affects one eye only. For what, through the lack 
 of any better nomenclature, I am constrained to call Egyptian ophthalmia, seldom 
 restricts itself to a single eye. Dr. Vetch says, " there is but one case in a thousand 
 in which one eye only becomes affected." Walther observes that contagious oph- 
 thalmia almost always appears in both eyes together, but not in the same degree ; 
 and Eble (another German author) states that the contagious ophthalmia has not 
 confined itself to one eye in any instance. These round assertions require, how- 
 ever, some qualification ; the nurses, whose cases I quoted in the last lecture from Sir 
 Patrick Macgregor's paper, suffered each in one eye only. On the other hand, 
 gonorrhoea! ophthalmia mostly, but by no means always, is hmited to one eye. In 
 Mr. Lawrence's instructive book On the Venereal Diseases of the Eye, he mentions 
 fourteen cases of gonorrhoeal ophthalmia. In nine of these, one eye only was 
 inflamed. 
 
 It is always a matter of some interest to make out whether the disease h^is or has 
 not any connection with gonorrhcea ; even though we may gain nothing, in vespect 
 to the treatment, by the distinction. 
 
 Purulent ophthalmia has been said to be connected with gonorrhoea in three seve- 
 ral ways ; 1st, by direct contact of the gonorrhceal discharge from the urethra with 
 the conjunctiva ; 2d, by metastasis of the inflammation from the urethra to the eye, 
 without any such contact of matter; and 8d, independently of either of these ways; 
 i. e., purulent ophthalmia has been supposed to occur in connection with clap, just 
 as ulceration of the throat is apt to occur in venereal diseases. 
 
 Now the last two of these three modes of origin are more or less questionable ; 
 the first is certain. 
 
 Very odd speculative opinions are apt to possess themselves of the minds of medi- 
 cal as well as of other philosophers. Some who believe that the disease is commu- 
 nicable by direct contact of gonorrhoeal matter to the eye, yet hold that it must come 
 from the urethra of another person ; that the Hudibrastic aphorism is true, " No 
 man of himself doth catch." Dr. Vetch seems to have fallen into this opinion 
 through the very common mistake of drawing positive conclusions from negative 
 experiments. He had known a hospital assistant who, " with more faith than pru- 
 dence," conveyed the matter of gonorrhoea from his urethra to his eyes, with impu- 
 nity. He states also the converse experiment : a soldier in a very advanced stage 
 of Egyptian ophthalmia, attempted to divert the disease from his eyes by applying 
 some of the matter they were discharging to the orifice of his urethra : no effect 
 followed this trial. But in another case the matter take>. from the eye of one man, 
 labouring under purulent ophthalmia, was applied to the urethra of another man ; 
 and inflammation commenced there in thirty-six hours, and he had a very severe 
 attack of gonorrhoea. Some persons, judging from such cases as this, and from the 
 similarity of the discharge in the two diseases, " have gone the length of concluding 
 (according to Dr. Mackenzie) that gonorrhoea has been originally an inocula-tion oi 
 the urethra by the matter derived from the eye in the Egyptian ophthalmia ; whilst 
 others are of opinion that this last disease is nothing else than the effect of an inocu- 
 lation of the conjunctiva with matter from the urethra in gonorrhoea." 
 
 To satisfy you that a person may "catch" the complaint from himself, or from 
 others, it is right that I should bring before you one or two well-marked cases. 
 
 It is a common persuasion, among the lower classes, that to bathe the eyes in 
 human urine is good for the sight. This piece of practice has cost several persons 
 their vision. A gentleman belonging to the class mentioned to me the other day two 
 cases of purulent ophthalmia so produced, which he had seen among Mr. Guthrie's 
 patients at the Ophthalmic Hospital. In the one, a young woman, not so healthy as 
 she ought to have been, used her own water : in the other, an older woman, for 
 what reason it did not appear, preferred her husband's to her own. Mr. Lawrencu
 
 192 DISEASES OF THE EYE. 
 
 alludes to several similar cases. He details an instance also, in which partial slough- 
 ing of one cornea occurred; the disease having been caused by the patient's wiping 
 his e3'es with a towel soiled with the gonorrha:;al discharge from his own urethra. 
 But one of the neatest and most conclusive examples of the production of the dis- 
 ease in this way has been furnished by Dr. Mackenzie. A patient was brought to 
 him from the country with his left eye violently inflamed and chemosed, and dis- 
 charging a large quantity of purulent fluid ; the lower Hd everted, and the cornea 
 totally opaque. Thirteen days before, this man, who had then a profuse gonorrhoea, 
 but whose eyes were perfectly well, while stooping down and shaking away the dis- 
 charge from his penis, flung a drop of it fairly into his left eye. Violent inflamnia- 
 mation immediately set in, was confined to the eye that was thus inoculated, and 
 produced the rcsuks I have mentioned : the gonorrhoea going on just as before. 
 
 Numerous authentic cases have been recorded of gonorrhoeal ophthalmia produced 
 by the application to the eye of gonorrhoeal matter from another individual. Mr. 
 Wardrop met with the following example. An old lady went into the dressing-room 
 of her son, who had gonorrhoea, and washed her face with a towel which he had 
 recently heen making use of. Purulent ophthalmia quickly supervened, and de- 
 stroyed the eye in a few days. Delpech mentions the instance of a young and 
 healthy woman, who bathed her eyes with goulard water, by means of a sponge 
 which had been used by a young man who had a clap : violent inflammation soon 
 arose, and the sight of one eye was lost. Several cases of purulent ophthalmia 
 have been observed in laundresses, who had been employed in washing linen fouJ 
 with the discharge of gonorrhoea. 
 
 Mr. Lawrence seems to be of opinion that purulent ophthalmia is not a very fre- 
 quent consequence of the application of the urethral discharge to the eye of the 
 same person. " When we consider," he says, " how this matter is diffused over 
 the linen of patients, both male and female, how often the fingers must be smeared 
 Avith it, and how inattentive to cleanliness the lower classes are, we cannot help 
 concluding that the gonorrhoeal discharge must be often applied to the eyes of the 
 same individual; yet gonorrhoeal ophthalmia is comparatively rare." Dr. Macken- 
 zie, on the other hand, thinks that the application of the matter to the eye is seldom 
 made. "The instinctive closure of the eyelids," he observes, " when the finger 
 approaches the eye, making it actually difficult for a person to touch his own con- 
 junctiva, unless with one finger he draws down the lower lid, and intentionally 
 applies another finger to the eye, will serve in some measure to explain the rarity of 
 this kind of inoculation." 
 
 It has been noticed that women are much less frequently the subjects of gonor- 
 rheal ophthalmia than men. 
 
 Does gonorrhoeal ophthalmia ever occur by metastasis ? This question does not 
 admit of a positive answer. Practical men are divided in opinion on the subject. 
 In the majority of cases of gonorrhoeal ophthalmia, we are unable to trace any appli- 
 cation of the urethral discharge to the eye, either from the same or from another 
 individual. Yet it does not follow that no such application took place. The Ger- 
 man and Italian writers believe in metastasis. "In all the instances," says Beer. 
 " which I have seen, this ophthalmia has occurred in young, plethoric, robust, and 
 truly athletic men ; and it has always taken place in a very short time, generally in 
 a few hours, after the suppression of gonoirhceal discharge from the urethra." Mr. 
 Lawrence never knew the urethral discharge stop upon the coming on of the oph- 
 thalmia ; it has generally diminished, but in some instances has continued as copi- 
 ous as before. He seems to regard the occurrence of the ophthalmia as analogous 
 to those successive attacks of distant parts that are common in gout and rheumatism. 
 Dr. Mackenzie evidently doubts the occurrence of metastasis at all in this disease, 
 and IS inclined to refer all the cases in which it has been alleged, to inoculation, or 
 to an accidental occurrence of purulent ophthalmia and gonorrhoea in the same 
 person. 
 
 The supervention of purulent ophthalmia as a part of the gonorrhoeal malady, 
 independently of inoculation and of metastasis, seems to me extremely problematical. 
 The eye is well known to suffer, as well as other organs, in the secondary forms of
 
 GONORRHCEAL OPHTHALMIA. 193 
 
 syphilitic disease, but the conjunctiva is not the part that is attacked. I have never 
 seen nor heard of any satisfactory example of purulent ophthalmia alternating with 
 gonorrhoea, Avhere the possibility of inoculation was excluded. And, upon the 
 whole, my own opinion — (you will take it for whatever it may seem worth) — is 
 against the existence of this alleged form of purulent ophthalmia. Whether it exists 
 or not is of very little consequence in regard to the main question ; namely, w^iat is 
 the proper mode of treating the purulent ophthahnia of adults i^ 
 
 Now the two chief points to consider, so far as respects the treatment, are — first, 
 blood-letting; and secondly, the application of strong astringents to the inflamed 
 membrane. 
 
 Blood-letting has been carried to a very great extent in this disease, or in these 
 diseases, if you choose to consider the Egyptian purulent ophthalmia and the gonor- 
 rhoea! purulent ophthalmia as two different inflammations. Its effects have not been 
 very decisive or satisfactory ; indeed, we could hardly expect that they would. In 
 the first place the inflammation is so rapidly destructive, that, in many of the worst 
 cases, irreparable mischief is done before the patient applies for medical assistance. 
 In forty-eight hours, or a little more, Mr. Lawrence tells us, the affection may have 
 proceeded to such an extent as to be beyond our control. Of course this reason for 
 the want of success is equally applicable to every remedy that has been, or could 
 be, proposed. But independently of this, even when the disease is seen and sub- 
 mitted to treatment in its very beginning, we should have the less confidence in the 
 power of general blood-letting to control it, for these two reasons : that the pari 
 affected is a mucous membrane ; and that there is so little constitutional sympathy 
 with the local inflammation. Free venesection tells most upon inflammation, when 
 it is attended with fever and a hard pulse, i. e., with increased action of the heart : 
 which the abstraction of blood tends to abate. It is also a matter of experience, that 
 general bleeding has more influence over the inflammation of serous and fibrous 
 raembranes than over that of the mucous tissues. Accordingly, though bleeding 
 has been even lavishly employed in purulent ophthalmia, it has too often disap- 
 pointed the practitioner. There is one lesson, however, to be learned from copious 
 blood-letting in this disease, even when it fails of its object. It clearly demonstrates 
 what may be hoped for, by having recourse to that measure in internal inflamma- 
 tions. " You see a person," says Mr. Lawrence, who has both had, and used 
 freely, very numerous opportunities of putting this remedy to the test, " you see a 
 person with his eye bright red, and very painful ; he cannot face the light, and tears 
 gush out, with great suffering, if he attempts to do so. You bleed to fainting, and 
 immediately the capillaries are emptied, so that the organ resumes its natural pale- 
 ness ; the pain is gone, the eye is opened without difficulty, and the full influx of 
 hght can be borne without an uneasy sensation. For the time the part has passed 
 from violent inflammation to a nearly natural state. With the restoration of the 
 circulation the inflammation will recur after this temporary suspension ; but its vio 
 lence is diminished, and it often gradually abates." Mr. Lawrence is here speaking 
 of acute inflammation affecting the textures of the eye generally, and not of purulent 
 ophthalmia in particular; but I am desirous that, in passing, you should take notice 
 of this direct effect of bleeding to syncope, upon the capillaries of the eye, because' 
 it teaches us what the same expedient may do for the capillaries of any other inter- 
 nat part, which we cannot see-, when that part is attacked with inflammation. In 
 purulent ophthalmia, however, if you trusted to bleeding alone, you would often 
 reduce your patient to a very dangerous state of weakness, and after all fail of your 
 mark. Dr. Vetch bears strong testimony to the usefulness of blood-letting when 
 freely employed in the early stages of Egyptian ophthalmia; and certainly it ought 
 never to be neglected. In the very onset of the disease, it will aid the local expe- 
 dients which I shall presently mention ; and if the patient be not seen till the globe 
 of the eye is invisible for the swelling, the propriety of general bleeding will be still 
 further indicated by the occurrence of throbbing and circumorbital pain, returning 
 in nncturnul paroxysms ; for this symptom denotes that the inflammation has de- 
 scended deeper than the conjunctiva. The bleeding should be performed in the way 
 I formerly spoke of as being required in serous inflammation: the patient should b'" 
 
 V.\ R
 
 194 DISEASES OF THE EYE. 
 
 bled from the ami In an upright position, till fainting is about to ensue, or the pulse 
 begins to falter. You will do more towards obtaining safety for your patient's vision 
 in this way, and at less expense of his strength, than by bleeding him manj' times 
 to a smaller amount. The bleeding ad ddiqinum may require to be once or twice 
 repeated ; and when the patient begins to rally from his faintness, from twelve to 
 twenty-four leeches may often be applied with advantage; round i\\e eye and not 
 ripoii the tumid lids, where their bites are apt to add to the existing irritation, and to 
 fester. You had better bleed your patient from the arm, and not from the jugular 
 vein, or the temporal artery, for reasons which, as I have fully stated them already, 
 I need not now repeat. 
 
 But of late years, more reliance has been placed by many practitioners upon local 
 stimulants, for checking this horrible malady, than upon general or topical bleeding. 
 Dr. Vetch strongly recommended the insertion o'i imdihded liquor jdinnbi accfalis ; 
 and Mr. Briggs, in his translation of a work of Scarpa on the eye, advised the intro- 
 duction of a very minute quantity of the oil of turpentine between the eyelids. But 
 Mr. Guthrie has the merit of having applied, in its full extent, this principle of 
 curing conjunctival inflammation, even in its severes-t forms, by stimulant and astrin- 
 gent substances. I told you, when speaking of catarrhal ophthalmia, that Mr. Melin 
 and Dr. Mackenzie treat that complaint with a wash, made by dissolving four grains 
 of lunar caustic in an ounce of distilled water. I might have added other authorities 
 in favour of the same kind of practice. Now Mr. Guthrie treats purulent ophthal- 
 mia on the same principle, but with a much larger dose of the nitrate of silver. The 
 greater intensity of the disorder is met by increasing the strength of the remedy. He 
 considers it to be a local disease of a pecuhar character ; and, acting upon the aphor- 
 ism of John Hunter (an aphorism, however, which requires som.e quaUfication) that 
 two diseases or actions cannot go on in a part at the same time, he proposes to set 
 up in the inflamed conjunctiva a new action, which shall supersede the original dis- 
 ease, and create another that is more manageable. In this point of view Mr. Guth- 
 rie's ratio mcdendi agrees with that of Hahnemann, about which there has been so 
 absurd a noise made of late. I have never had the advantage of seeing Mr. Guth- 
 rie's plan tried, but, from all that I have heard of it, I beheve it to be a valuable dis- 
 covery. A priori, we should expect that the caustic application would add to the 
 existing mischief, and destroy all chance of saving the inflamed ej'e. But it is not 
 so. Even Mr. Lawrence, Avho v/as, I have reason to think, formerly very sceptical 
 on this point, appears to be so no longer. In his treatise On the J'enereal Diseases 
 of the Eye, he uses this cautious language : — " Destructive or injurious consequenres 
 have so frequently resulted under the usual management of this disease"— he i^ 
 speaking of gonorrhoea! ophthalmia — "chat I should certainly employ the local 
 astringent, if I met with a case favourable for the trial ; i. e., where the affection had 
 not extended beyond the conjunctiva. Blood-letting might be resorted to at the same 
 time ; in moc^ cases, however, our aid is not sought until the cornea has become 
 affected, and it is therefore too late for the astringent plan." But he subsequently 
 added a note, to the effect that after the statement I have just quoted was written, he 
 had employed the caustic solution in two cases of conjunctival inflammation with the 
 best result. 
 
 Mr. Guthrie's plan, therefore, you ought to be acquainted with. After many 
 trials, he has arrived at the conclusion that the best appliance, in this formidable 
 complaint is an ointment, made by mixing ten grains of the nitrate of silver, reducec 
 tu an impalpable powder, with a drachm of hog's lard. This is what he calls his 
 ten-grain ointment. 
 
 Before applying it to the diseased eye, the discharge must be well cleansed away 
 Dy a solution of alum ; then the ointment having been inserted beneath the lids, they 
 are to be moved freely up and down, so that the whole conjunctiva may get its due 
 share of the remedy ; and that it has done so is shown by its turning white. If the 
 surface does not turn white, the ointment has not been sufficiently applied, and will 
 iioi answer the purpose. If we wish to be quite sure, he says, we turn out the 
 eyelids, and rub the ointment on them. This application gives pain, which lasts 
 for half an hour or an hour, or more. " Warm narcotic fomentations may be em-
 
 PURULENT OPHTHALMIA. 195 
 
 ployed to relieve uneasiness, and opium given to allay pain, and to obtain sleep ; 
 while a solution of alum, in the proportion of a drachm to a pint should be injected 
 from time to time into the eye, to clear it ; but should the patient sleep, he must not 
 be disturbed. A mild ointment may be applied to the edges of the lids at night, to 
 prevent their stickin'^ to^Tether. The next morning the discharije is again to be re- 
 moved and the ointment to be reapphed ; for on no account should the action we are 
 desirous of exciting be allowed to cease." Of course Mr. Guthrie means it is not 
 to be suffered to cease prematurely. This, with free but not excessive venesection, 
 is the substance of his peculiar mode of treating purulent ophthalmia ; and it appears 
 to have been eminently prosperous in his hands. I have been informed, by one of 
 yourselves, that purulent ophthalmia has been successfully treated, on a large scale, 
 in Manchester, by applying the nitrate of silver, in substance, to the surface of the 
 conjunctiva; that this gives less pain than the ten-grain ointment, though perhaps it 
 may require to be oftener repeated. 
 
 I say I have never seen this method of Mr. Guthrie's carried into effect ; but after 
 what I have myself witnessed of the intractable and destructive nature of the dis- 
 ease, under the treatment ordinarily adopted before his ointment was devised, I will 
 say also that were I so unfortunate as to be attacked v/ith severe purulent ophthalmia, 
 I should desire to have the caustic applied as soon as possible, and to be freely bled 
 at the same time. 
 
 There are some minor points in the treatment that require a cursory notice 
 only. 
 
 Some persons, and Mr. Guthrie among the rest, recommend the exhibition of 
 mercury, so as to affect the gums. Now I beheve that mercury is quite useless in 
 this complaint; and if useless, mischievous. The disease is too rapid to be over- 
 taken by the mercury, and if you could obtain the specific influence of that mineral 
 in time, i. c, before any of the destructive effects of the inflammation were accom- 
 plished, you would do no good thereby. This is not the kind of inflammation over 
 which mercury exercises any useful control. Mr. Lawrence tells us that he hag 
 seen both the ordinary purulent, and gonorrhoea! ophthalmia, proceeding apparently 
 unchecked, under the full mercurial action. 
 
 Practical men are not agreed about the propriety of scarifying the conjunctiva 
 when it is swelled and elevated by chemosis. Mr. Lawrence objects to it, as likely 
 to increase the local iritation ; a disadvantage not compensated by the quantity of 
 blood discharged from the divided vessels. Dr. Mackenzie recommends it, stating 
 that the incisions will bleed copiously, and greatly allay the symptoms. Who shall 
 decide in this puzzhng discrepancy of opinion ? Mr. Guthrie's caustic ointment 
 would, I presume, supersede any other meddling with the inflamed surface. But 
 when the question happens to lie between scarification and no scarification, I should 
 give my vote for scarifying: not because I think any useful depletion of the blood- 
 vessels could be brought about by that measure, but because, if properly performed, 
 it would evacuate the serous effusion from the areolar tissue between the conjunc- 
 tiva and the sclerotic, which effusion constitutes the chemosis, and hastens, if it does 
 not cause, the sloughing of the cornea, by the mechanical pressure that it exerts 
 around it. 
 
 Are blisters of any use? Hear Dr. Mackenzie. "Counter-irritants are highly 
 serviceable in this disease, and ought always to be employed. There is generally a 
 marked change in the quantity and appearance of the discharge from the eye, as 
 soon as a counter-discharge is established by blisters on the temples, nape of the 
 neck, or behind the ears." But listen to Mr. Lawrence. "Experience does not 
 warrant us in ascribing much efficacy to blisters^ Now the truth is, I believe, thai 
 during the active stage of the disease, blisters are not of any use ; but that in the 
 more advanced and chronic periods, they are. Indeed, Mr. Lawrence admits thai 
 they may be regarded as auxiliary measures, and resorted to after antiphlogistic 
 means. 
 
 I agree with the same gentleman in thinking that no reliance is to be placea, m 
 gonorrhoea! ophthalmia, upon any attempts to reproduce the urethral discharge , ' 
 indeed, in most cases it is not suspended.
 
 196 DISEASES OF THE EYE. 
 
 Although I have not mentioned purgatives, you will conclude that they form a 
 very proper and necessary part of the treatment during the activity of the com- 
 plaint. 
 
 After what has already been said of purulent ophthalmia in the adult, and 
 of gonorrhceal ophthalmia, it will not be necessary for me to take up very much 
 of your time in speaking of purulent ophthalmia as it occurs in newly-born 
 children. 
 
 This is a very common disease : it is very serious when neglected : it is very 
 eanly managed when it is seen and treated in time. These are all reasons why 
 you should make yourselves familiar with the complaint, and with the mode of curing 
 it. You may perhaps never have occasion to treat a case of purulent ophthalmia in 
 the adult : you are sure to be consulted about the purulent eye of infants, the oph- 
 thcdmia neonatorum. 
 
 The importance of the disorder is apt to be overlooked by mothers and nurses ; 
 they say the baby has a cold in the eye, which will go off; and they wash it perhaps 
 with a little of the mother's milk, or some such insignificant fluid. Meanwhile the 
 eyelids swell, the mischief that is going on beneath them is concealed from sight, 
 and when at last a medical man is consulted, he too often finds that one of the eyes 
 has perished, or both : the cornea has sloughed or become opaque, or protrudes, and 
 constitutes what is called staphyloma ; prolapse of the iris has taken place ; or the 
 coats of the organ have shrunk up. 
 
 The inflammation usually comes on about three days after the child is born, 
 although it may commence later. It is confined, at first, to that part of the mem- 
 brane which fines the lids. Their edges are observed to stick together when the 
 infant wakes ; there is more intolerance of light, apparently, than is suffered in the 
 analogous disease of adults. The little patients cannot indeed tell us their sensa 
 tions by words, but they express them significantly enough by keeping their eyes 
 shut, by knitting their small brows, and by turning their heads away from the 
 light. At length the inflammation extends to the conjunctiva that covers the eyeball, 
 the eyelids swell, sometimes enormously : and an astonishingly copious discharge of 
 pus takes place. By the adhesion of the edges of the lids the puriform matter is 
 sometimes pent up, causing them to protrude ; and when they are separated it 
 escapes in a profuse hot gush. The eyelids are sometimes everted during the cries 
 and struggling of the little sufferer, and their mucous surface is then seen to be 
 villous and shaggy, and of as bright a scarlet as you ever saw the injected mucous 
 membrane of a foetal stomach. At last those destructive consequences to the eye 
 take place which I have already mentioned. The disease, however, may continue 
 for eight or ten days without any affection of the transparent parts ; and so long 
 as these remain uninjured, the eye is safe, provided that proper treatment be 
 adopted. 
 
 This disease is probably much the most fertile source of blindness with which we 
 are acquainted. It is believed to originate most commonly, if not always, in con- 
 tajrion. We might, perhaps, expect this from the analogy of the severe inflamma- 
 tion of the same parts in adults. And it is a matter of fact, that in a very large 
 number of cases the mother has been affected, at the time of her confinement, with 
 some kind of vaginal discharge — leucorrhoea, or gonorrhoj^a ; and the eyes of the 
 children are exposed to these morbid secretions, as they are brought into the world. 
 The circumstance of the disease commencing so regularly on the third day, is 
 greatly in favour of the supposition that it results from inoculation of the eyes by 
 the unhealthy fluids of the mother. The discharge from the infant's eyes has been 
 ascertained to be highly contagious. Dr. Mackenzie mentions a lamentable illustra- 
 tion of this fact, which fell under his observation at the Ej-e Infirmary, in Glasgow. 
 An infant and its grandfather became his patients there at the same time ; the latter 
 having been inoculated from the former. Both were so severely affected that the 
 infant had one eye left in a state of total, and the other of partial staphyloma : while 
 m each eye of the old man, the greater part of the cornea remained opaqae, and 
 ndherent to the iris. 
 
 However, the disease certainly occurs in the infants of mothers who seem to be
 
 PURULENT OPHTHALMIA. 197 
 
 nealthy, and who deny that they have any unnatural discharge. It may probably 
 be brought on, sometimes, by bad management on the part of the nurse : bj'' expo- 
 sure soon after birlii to draughts of cold air, or to the injurious influence of a hot and 
 jright fire ; or by the introduction of soap into the eye in the primary ablutions, or 
 vif gin, whereof the lower classes, in some absurd persuasion of its strengthening 
 virtues, are wont to bathe the unlucky infant's head. The disorder is observed to 
 ')e mosc common in damp and cold weather ; in low crowded places ; and among 
 Jfe chiluren of the poor. 
 
 [The reir.aiks of Dr. Watson on the causes of purulent ophthalmia in children, present a 
 brief sumniaij" of all that is positively known in relation to the subject — for further details, 
 '>earing more t8^>f!cially upon the question of the production of the disease in the infant by 
 H. morbid vaginal discharge existing in the mother at the period of its birth, and the circum- 
 stances generally, under which the affection most frequently presents itself, the reader is 
 leferred to the Ed-vor's Treatise on the Diseases of Children. We have not met with a single 
 lact, during a long aud somewhat extensive practice, in proof of the communication of the 
 i-urulent ophthalmia ciI infants by contagion. — C] 
 
 One striking difTere^TiCe between the disease as it exists in adults and in newly- 
 born children I have iilready adverted to; viz., its rapid and often uncontrollable 
 progress in the former; and the facihty with which it yields to suitable and timely 
 treatment in the latter. If a child is brought to you with purulent ophthalmia, and 
 you are able to separate ihe lids sufficiently to obtain a glimpse ^f the cornea, and 
 perceive that it is still brilliant and uninjured, you may confidently tell the anxious 
 mother thai, with due care on her part, her child's eye is safe. If the cornea has 
 lost its transparency, it is still within the reach of recovery, but the chances are 
 against it : if you cannot get a sight of the cornea at all, you will do wisely to give 
 a doubtful prognosis, or even an unfavourable prognosis ; for such is the ignorance 
 of the vulgar (and I include both rich and poor under this phrase) that if they are 
 not forewarned of the danger, they are very apt to attribute the blindness that ensues 
 to your stuff, as they call it. 
 
 In the severer forms and stages of the complaint, if the lids be very much swelled 
 and red externally, and especially if you are unable to obtain any satisfactory view 
 of the cornea without usinsr a deo-ree of violence that might be hurtful, it will be 
 right to apply a leech. In this case it may be placed upon the centre of the tumid 
 upper lid ; and you should, whenever that is possible, stay by the little patient until 
 the animal drops off, and the bleeding ceases ; for sometimes the bleeding is difficult 
 to stop, and must not be trusted to the care of the nurse ; and the loss of blood occa- 
 sioned by the bite of a single leech will often blanch the infant's skin, and make you 
 fear that the depletion, slight as it is in actual amount, has yet been too much. The 
 child's bowels should be emptied by a little castor oil; and a lotion, made by dis- 
 solving two grains of the acetate of lead in an ounce of water, may be applied to 
 the inflamed organ. 
 
 In less severe cases, and I believe in all cases in which you can see the uninjured 
 cornea gleaming through the pus that bathes it, it will be quite sufficient to keep 
 the infant's bowels open with magnesia; to apply a little lard along the edges of the 
 lids, that they may not stick together ; and to inject carefully into the eye, beneath 
 and between the lids, a solution of alum ; in the ratio of four grains to one ounce of 
 water. Such, Mr. Lawrence tells us, was the treatment in forty-nine cases out of 
 fifty at the London Ophthalmic Infirmary when he was surgeon to it: no other 
 means being used than magnesia internally, and the solution oi' alum locally : and 
 out of many hundred instances he scarcely recollected one that suffered in any 
 respect, if the cornea were clear when the infant was first seen. I had, for a con- 
 siderable period, the advantage of watching Mr. Lawrence's patients under that 
 treatment; and the result of it was so entirely and uniformly satisfactory, that I 
 should never think of employing any other. U the eye became at length insensible 
 to the stimulus of the alum, a solution of the nitrate of silver, (from one to four 
 grains in the ounce of water.) was substituted with advantage. Mr. Guthrie Uie.s 
 I fancy, his cau.stic ointment; but I am sure that the simple and less severe plan I 
 have been describing is quite sufficient. 
 
 r2
 
 198 DISEASES OF THE EYE. 
 
 [A very excellent application, in cases of the purulent ophthalmia of new-born infants, is 
 a strong infusion of ccmmon tea — when this cannot be introduced between the lids in any 
 other manner, it may be carefully injected by means of a syringe. — C] 
 
 There is just one more disease belonging to the conjunctiva, that I wish to brin-r 
 before you ; and then I have done with the morbid affections of this external mem- 
 brane of the eye. It has received several names ; sometimes it is called pustular 
 ophthalmia, from the appearance of little pustules upon the surface of the organ. 
 Dr. Mackenzie, who looks upon it as an eruptive disease, aftecting the conjunctiva 
 not so much as a juucous membrane, but rather as a continuation of the skin, names 
 it /7/?/i/r/o??//f/?- ophthalmia. It has also acquired the title oi .scrofulous or strumous 
 ophthalmia, from its continual occurrence in children of a scrofulous habit, and its 
 verv frequent association with scrofulous disease in other parts. It is a disorder of 
 childhood, and it is so common a form of disorder, that, of ten cases of inflammation 
 of the eves in young persons, nine will be of this kind. I shall call it strumous 
 ophthalmia. It is a form of ophthalmia that differs in many striking points from 
 those which we have been considering. 
 
 In the first place, it is intimately connected with the scrofulous constitution ; the 
 peculiarities of which I formerly explained. Akhough a disease of children, it is 
 not a disease of infants at the breast. It is most prevalent from the time of wean- 
 ing to about the age of eight. 1 mentioned to you, in a previous lecture, the remark- 
 able fact — showing the strong influence of unsuitable or insufficient nourishment in 
 developing scrofulous disease — that when asked to prescribe for children having^ bad 
 eyes, you will find, in nineteen cases out of twenty, that you have to deal with pu- 
 rulent ophthalmia if the child be still at the breast, and with strumous ophthalmia 
 if it have been weaned. 
 
 The leading symptoms of this disease are, slight redness; great intolerance of 
 light; the formation of little prominences or pustules on the surface of the conjunc- 
 tiva ; and specks which are the resuk of these. The complaint sometimes occurs 
 in one eye alone, oftener in both ; but then one eye is generally worse than the 
 other. Mere catarrhal ophthalmia is apt to degenerate into this affection in scrofulous 
 children. After seeing two or three cases of strumous ophthalmia, you cannot fail 
 to recognize it whenever you meet with it again. 
 
 The redness has this peculiarity, that it is slight and partial. Sometimes it is alto- 
 gether confined to that part of the membrane which lines the eyelids: generally a 
 few vessels, collected into little bundles, are seen proceeding from some point of the 
 circumference — more commonly from the angles of the eye than from any othei 
 point — towards the cornea : the vessels are evidently superficial, often prominent. 
 These scattered bundles of vessels (sometimes there is but one) stop when they reach 
 the cornea, or occasionally encroach a little upon it ; and where they stop, the small 
 elevations of the membrane may be observed, which are called pustules. This is 
 the most common situation of these elevated points, just at the line of junction be- 
 tween the sclerotica and the cornea, or near that line. Sometimes, however, vou 
 may see one or two near the centre of the cornea. They are smaller in size when 
 th' y appear on the cornea, than when they are situated near its edge. 
 
 These pimples may be absorbed, and leave behind them a temporary white spot; 
 morf frequently they break and form little ulcers. When these ulcers are beyond 
 the cornea they are of less consequence : when they are situated upon it, they be- 
 come sources of danger in two ways ; they may penetrate the cornea, and let out the 
 aqueous humour, and cause prolapsus iridis and various other mischief; or they may 
 leave, after healing, a permanent white opaque speck, (called leucoma,) which, 
 according to its size and its exact place, will interfere more or less with the patient's 
 vision. 
 
 The intolerance of light is a very prominent symptom of this disease, and some- 
 'imes it really is the only sy^mptom that manifests itself. It is curious that this 
 mabiiity to endure a bright light bears no regular or definite proportion to the inten 
 sity of the other symptoms. It is not that the eye is painful when protected from 
 tKe light ; but that the access of the ordinary light of day occasions extreme -.ufTer
 
 STRUMOUS OPHTHALMIA. l90 
 
 ing ; the eyelids being spasmodically closed and the orbicular muscle in such strong, 
 an^ appareruiy involuntary action, as effectually to resist all attempts at opening 
 them. Children that are affected with this disease, carry it legibly written in their 
 physiognomy. Although you cannot tell what is the actual condition of the eye 
 without examining it, you can tell, as soon as you look at the patient, what is the 
 nature of the inflammation under which he is suffering. The child's brow is knit 
 and contracted, while his alae nasi and his upper lip are drawn upwards; those 
 muscles of the face (they happen to be also muscles of expression) are instinctively 
 put in action, which tend to exclude the light without shutting out the perception of 
 external objects; producing a peculiar and distinctive grin. In the severer cases 
 the child will skulk all day in dark corners ; or if in bed, will lie upon his face, or 
 under the clothes ; and while the hght is thus kept off, he does not appear to suffer. 
 If brought towards a window, he holds his head down, and presses his hands or arms 
 over his eyes. When you attempt to open his eye to examine it, a profuse discharge 
 of scalding tears takes place : these pass partly into the nose, and excite fits of 
 sneezing, and partly over the skin, which they sometimes inflame and excoriate ; and 
 then, frequently, pustules arise, and produce a discharge that crusts over the cheek 
 and extends to the forehead and temples. This is called crusta lactea, and is very 
 characteristic of the scrofulous habit; it occasionally spreads over the whole body. 
 
 You might suppose, from this extreme intolerance of light, that the retina was 
 inflamed, or in danger. But it is not so. The affection of the retina is purely sym- 
 ])athetic, and need not of itself excite any fears about the vision. Towards dusk, 
 indeed, in the twilight, the child can generallj^ open his eyes, and then is quite as 
 able to see as if he were well. Dr. Mackenzie endeavours to explain the connection 
 of intolerance of light, spasmodic contraction of the lids, and lachrymation, even 
 when there is but little visible redness, by the distribution of the lachrymal nerve; 
 which, after supplying the lachrymal gland, goes to the conjunctiva, and to the orbi- 
 cularis palpebrarum. We have the same set of symptoms when a bit of dirt gets 
 into the eye, and fixes itself beneath the upper lid. When little or no redness exists, 
 this extreme intolerance of light has been called photophobia scrofulosa. 
 
 With this strumous affection of the eye there are usually present other evidences 
 also of scrofulous disease. Swelling and redness of the alee nasi and upper lip ; 
 enlargement of the absorbent glands about the neck ; eruptions upon the head ; sore 
 ears ; a large and hard belly ; disordered bowels ; offensive breath ; grinding of the 
 teeth ; and general debility. And the ophthalmia will alternate sometimes in seve- 
 rity with some of these other local scrofulous complaints ; getting better as they get 
 worse, and vice versa. 
 
 LECTURE XIX. 
 
 Strumozis Ophthalmia, continued. Recapittdation. Treatm.ent of Strumous Oph- 
 thalmia. General Remarks on Conjunctival hijlammations. Iritis: its Symp- 
 toms and Treatment. Causes of Iritis. 
 
 When we separated yesterday, I was about to describe the treatment which has 
 been found by experience to be the best for reheving strumous or phlyctenular oph- 
 thalmia. Before I take up the subject where it was then dropped, let me briefly 
 remind you of the character and principal symptoms of the disorder. It is a form 
 of inflammation of the conjunctiva, to which scrofulous children, from the time they 
 are weaned, to about the age of eight, are extremely liable. It may occur consider- 
 ably later. Sometimes it is the first and only token of the existence of the scrofulous 
 diathesis ; generally it is observed in children who bear other marks of the strumous 
 habit, and are afflicted with other forms of strumous disease. 
 
 Its symptoms are — first, slight vascularity ; the redness being partial, and proceed- 
 ing from one or more fasciculi of superficial vessels, which advance from the circum 
 ference of the visible part of the eye towards the cornea, where they usunllv ston ■
 
 200 DISEASES OF THE EYE. 
 
 sometimes, however, they pass a liltle beyond its edge. At the extremities of these 
 fasciculi, upon or near the line of separation between the cornea and the sclerotica, 
 small prominences appear, which are sometimes absorbed, sometimes break and form 
 ulcers. Less frequently the phlyctens are situate towards the central part of the 
 cornea. Secondly, with this partial vascularity and these pimples, and sometimes 
 even without them, there is extreme intolerance of light. The pain produced by 
 exposing the eye to the influence of light imparts a characteristic expression to the 
 countenance of the suffering child. Tears flow over the cheek, and inflame it often, 
 and give rise to the eruptive appearance termed crusta lactea: or, from its somethies 
 covering the cheek like a mask, porrigo larvalis. 
 
 I may add to this summary of what was stated in the last lecture, that sometimes 
 the vessels which pass along the conjunctiva and over the cornea, instead of leading 
 to pustules, extend laterally : so that several bundles of vessels unite by their mutual 
 ramifications ; and that part of the conjunctiva which covers the cornea becomes 
 ihick, as if it were darned; and more or less opaque. Indeed, the greater portion 
 of the whole of the corneal covering may thus be rendered patchy and vascular. 
 The appearance presented by the eye under these circumstances is called pannus. 
 
 You will readily believe, from what has been said of this complaint, that it is an 
 obstinate and troublesome one. Even when it has been cured it is very apt to 
 recur. The scrofulous habit on which it depends w-e cannot get rid of; and when 
 ever the exciting causes of scrofulous diseases come into action, this form of scrofula 
 is very prone to declare itself, at the period of hfe which I have already mentioned. 
 
 More good is to be done bj^ general treatment, applied to the system at large, in 
 this form of ophthalmia, than in those we were occupied with before ; and this is one 
 strong point of difference between them. 
 
 In the first place we must endeavour to correct that unnatural condition of the 
 whole system, and especially of the digestive organs, which is commonly so striking 
 a concomitant of the local disease. It will be proper to clear out the bowels in the 
 outset, and occasionally, by a mercurial purge ; and to regulate them at other times 
 by laxatives, such as rhubarb, or the confeclio sennse, or castor oil. The recovery 
 will be greatly promoted, also, by those measures which are found to benefit the 
 general health in such constitutions ; M-arm clothing, fi-equent ablution of the bodv, 
 nourishing though plain food, the respiration of a pure atmosphere, change of air, 
 and regular exercise. 
 
 In addition to these measures, tonic medicines should be administered ; the pre- 
 parations of iron, for example, or the dilute mineral acids : but the best remedy of 
 this kind is, undoubtedly, the sulphate of quina. This may be given to a child in 
 grain doses, three times a day, dissolved in water, with a drop of the dilute sulphuric 
 acid, and some syrup of orange-peel. Dr. Mackenzie, in particular, has put this 
 medicine fairly to the test, having employed it in a very large number of cases with 
 the happiest results. In most of his patients he declares tliat it acted like a charm, 
 '• abating, commonly, in a few days, the excessive intolerance of light and profuse 
 epiphora; promoting the absorption of phlyctenula?, and hastening the cicatrization 
 of ulcers of the cornea." And Mr. Lawrence adds his testimony to the same effect ; 
 and his experience in this disease, like Dr. Mackenzie's, has been large enough to 
 make it highly valuable, 
 
 A few words will suffice to explain the kind of local treatment that has been 
 found useful. You may feel tempted to apply leeches round the eye. This is sel- 
 dom requisite, except when there are more redness and pain than common, rxnd the 
 tongue becomes white, and the skin hot. Certainly you must not take the intole- 
 rance of light as a fit indication for the use of leeches. Abstraction of blood rather 
 uggravatoS that symptom ; apparently by increasing the irritability of the retina. 
 Warm fomentations are generally very comfortable to the patient's feehngs. 
 
 When the general disorder of the system has been somewhat rectified, local stimu- 
 .unts and astringents are of great service. The vinum opii and the solution oi lunar 
 caustic are the best. These are often tedious cases, and therefore it is necessary 
 nat you should be aware of one great objection to the long-continued em))loyment 
 • •' the nitrate of silver wash, wliich objection has been pointed out by Dr. Mac-
 
 STRUMOUS OPHTHALMIA. 201 
 
 kenzie. It is apt (but only when frequently repeated for a long time together) to 
 stain the conjunctiva of an indelible olive colour. For this reason the vinum opii is 
 to he preferred in slow cases, and in cases where frequent relapses happen. The 
 good effects of either of those preparations are very striking ; they diminish the 
 irritabihty of the eye, and promote the healing of the ulcers. The red precipitate 
 ointment, and the citrine ointment of the Pharmacopeia, diluted, are also found 
 beneficial. 
 
 [According to Dr. Glover (Pathol, and Treat, of Scrofula), there appears to be little doubt 
 of the success of an infusion or decoction of walnut leaves in scrofulous ophthalmia. — C] 
 
 Counter-irritation is another local measure, which is of undoubted utility in this 
 complaint. A great change for the better in the state of the organ often occurs, 
 almost suddenly, upon the rising of a blister placed behind the ear, or at the back 
 of the neck. And issues in the arms are not only serviceable in promoting the 
 cure, but have a marked effect in many children, in preventing relapses. Mr. Wel- 
 bank, in his notes to Frick's Treatise on Diseases of the Eye, states that he has 
 seen chronic strumous ophthalmia, of seven years' duration, quickly and effectually 
 relieved by an issue in the arm. " Having once (says he), in the case of a boy in 
 Christ's Hospital, directed the healing of an issue whicn had been made above 
 twelve months, I found the immediate consequence to be a relapse of strumous 
 inflammation and ulceration of the cornea, resisting every measure but the renewal 
 of the issue. 
 
 He suggests, also, (what parents are sometimes more willing to assent to,) the 
 advantage of making counter-irritation by piercing the lobe of the ear, and inserting 
 a ring or silk ; and " a very convenient form of vesication will be found in the 
 application of a strong thread, smeared with the emplastrum cantharidis, and firmly- 
 tied behind the ear at the angle of its reflection." 
 
 When ulceration is going on in the cornea, and threatening to penetrate it, the 
 progress of the ulcer may be checked by touching its surface once in two or three 
 days with a pencil of lunar caustic which has been scraped to a fine point. 
 
 When the more urgent symptoms have abated, and the discharge of hot and 
 irritating tears has ceased, the crusla lactea may very easily be got rid of. The 
 crusts are to be removed by a light poultice, or by warm water; and then the part 
 must be bathed from time to time with a lotion made by mixing the oxide of zinc 
 with water; a drachm to four ounces is the proportion I am in the habit of prescrib- 
 ing. If rose-water be used instead of common pump-water, the prescription will be 
 thought the more elegant. This lotion will speedily dry up the discharge, and in a 
 short time no vestige of the ugly-looking crust will remain. Parents are highly 
 delighted and very thankful when you thus accomplish the removal of a large dis- 
 figuring and disgusting scab, which they naturally enough felt apprehensive might 
 leave behind it a corresponding scar. But it is quite superficial. 
 
 I have now done with the exterior membrane of the fore part of the eye — with its 
 mucous membrane. In examining some of its diseases, we have had the oppor- 
 tunity of noticing several things which illustrate the pathology of the mucous tissues 
 generally, and which exemplify the influence of other circumstances also, as well as 
 of peculiarities of tissue, upon the morbid processes to which these membranes are 
 obnoxious. 
 
 We have seen that the mucous surface of the eye readily enough takes on inflam- 
 mation, under vicissitudes of external temperature, and from the agency of other 
 atmospheric conditions ; that the inflammation is apt to spread, often rapidly, over 
 the whole surface of the membrane ; and that, in some cases, it may be strictly 
 limited for a long time together, or entirely, to the mucous tissue in which it began; 
 but that when intense, or under special circumstances, it may dip through and 
 extend to the subjacent textures : that, on the other hand, the inflammation some- 
 times occupies separate specks only of the membrane, and then is more likely to 
 penetrate to the deeper seated tunics: that although the membrane is folded upon 
 itself, so that different portions of it are mutually in apposition and contact, these 
 opposing surfaces do not become adherent to each other under inflammation : on the
 
 202 DISEASES OF THE EYE. 
 
 contrary, that they readily pour forth pus. This tendency to the formation of pus I 
 formerly showed you to be commonly observable, whenever the air finds free access 
 to the inflamed part. The pus thus poured out possesses the remarkable property 
 of exciting the same kind of inflammation when placed in contact with any healthy 
 mucous membrane of the same or of another individual : whether it be the conjunc- 
 tiva of the eye, or the internal hning of the urethra. The pus, in short, acts locally, 
 upon certain parts at least, as a poison. And we perceive, in this fact, how a disor- 
 >der that originates in common and accidental causes may become capable of propa- 
 gating itself indefinitely — may become, in one word, contagious. We have seen 
 also that the most intense inflammation may occur in this membrane, without exciting 
 much or any constitutional disturbance ; an illustration of the fact that the inflamma- 
 tion of mucous membranes is not so prone to light up fever, is not in general attended 
 with so much pyrexia, as inflammation of some other tissues, and especially of the 
 serous and fibrous tissues: and in proportion as this constitutional sympathy with the 
 local disease is small or absent, so the influence of general bleeding upon the inflamed 
 part is slight or ineffectual. The effect of a new and strong local irritation, in alter- 
 ing or superseding- the original inflammation in some cases, has been illustrated in 
 the treatment of purulent ophthalmia as it occurs in the adult subject. The influence 
 of age in modifying the phenomena, and in qualifying the plan of treatment, has 
 been made perceptible in the differences noticed in these respects between purulent 
 ophthalmia in infants and in grown-up persons. We have witnessed, too, the 
 remarkable characters impressed upon inflammation of the very same part, by the 
 presence of the scrofulous diathesis. We shall hereafter meet with numerous 
 examples of chronic inflammation, and the deposition of tubercular matter, and the 
 formation of ulcers in consequence of the elimination of that matter, in other mucous 
 membranes. AVhether the phlyctena^, or pustules, which appear upon the surface 
 of the eye in strumous ophthalmia, result from a similar separation of tubercular 
 matter from the blood-vessels, near the extremities of which these prominences are 
 placed, has not been clearly ascertained. One other lesson we have learned from 
 this review of conjunctival inflammation, viz., that general bleeding, carried so far as 
 to produce syncope, will sometimes completely empty the capillaries of an inflamed 
 part of the red blood wherewith they were, just before, so turgid. 
 
 I shall next request your attention to a part of the organ which is strictly internal 
 — to the iris : that thin curtain, with a circular aperture nearly in its centre, which 
 hangs between the cornea and the crystalline lens, and is bathed on both sides by 
 the aqueous humour. This little part, the office of which is to regulate the quantity 
 of light admitted to the retina, is of exceeding interest in respect to its morbid as 
 well as its healthy conditions. It is frequently the seat of inflammation : and, small 
 as it is, the inflammation seems to be entirely confined to it, or to the surfaces im- 
 mediately before and behind it. No doubt, with inflammation of the iris, there is in 
 many cases inflammation of the choroid and retina also, and of the sclerotica. But 
 the inflammation seems to make the iris its point of departure, and there it works its 
 most striking changes. We cannot see so well Avhat is the actual condition of the 
 choroid and retina ; but we have this proof, either that thej'^ do not always partici- 
 pate in the disease, or that they often suffer less than the iris ; viz., that when the 
 natural pupil has been closed up by lymph, and a new or artificial one is formed, 
 vision is frequently restored. 
 
 The little cavity across which the iris is vertically stretched, is lined by a smooth 
 membrane, the source of the watery fluid always contained in the cavity. This 
 membrane is analogous in its smoothness, in its forming a shut sac, and in the nature 
 of its secretion, to the serous membranes met with in other parts of the body ; it is 
 analogous also to the serous membranes, in its behaviour under inflammation. It is, 
 in fact, the serous membrane of the eye. Now we have the means of inspecting a 
 portion at least of several of the mncoits surfaces of the body ; but this serous cavity, 
 constituting the anterior chambers of the eye, is the only serous cavity into vvhich 
 we have the privilege of looking, and of noting what is going on, when the mem- 
 hrane that forms its boundary is inflamed ; and this it is that makes iritis, to me, one
 
 IRITIS. 203 
 
 of the most interesting of all diseases. There is no aingie part of the body from 
 which vou can derive so much instruction concerning some of the minuter processes 
 of inflammation, and concerning ♦he power of certain medicines over those pro- 
 cesses, as you may by watching a few examples of inflammation of the iris. 
 
 All the changes which occur in iritis depend upon the circumstance that the 
 inflammation, like that of the serous membranes generally, is of the adhesive kind ; 
 i. e., is attended with the eflusion of coagulable lymph. By means of this lymph 
 the form and the colour of the part are changed; the size and figure of the pupil 
 undergo alterations, or that aperture is completely closed up ; the motions of the 
 iris are limited, or entirely put an end to. 
 
 The symptoms which characterize inflammation of the iris are very obvious. To 
 be perceived and understood, they require only to be looked at. Yet they long 
 escaped notice, and even now are not always so carefully studied as they deserve to 
 be. Not a great while ago I had to convince a surgeon of some pretensions, that he 
 did not know this disease when he saw it. And English surgeons and physicians 
 were all of them ignorant even of its existence as a distinct disease, until a most 
 excellent account of it was published by a German, Schmidt, in the first year of the 
 present century. 
 
 What are these plain and obvious symptoms that were so long overlooked, or that 
 were not understood when seen? They are the following. I will first enumerate 
 them, and then speak of each rather more particularly. Redness of the sclerotica ; 
 a change in the colour of the iris itself, and in its general appearance ; irregularity 
 of the pupil, produced by adhesion of the iris to the neighbouring parts; immobility 
 sometimes of the pupil from such adhesion ; a visible deposition of coagulable lymph. 
 All these changes are apparent and conspicuous. Scientific wn'iters term them ob- 
 jecfive symptoms. Then there are also the subjective symptoms, of which the 
 patient alone is conscious — impaired sight ; pain in the eye, and round it. 
 
 The redness is such as I formerly described as resulting from the vascularity of 
 the sclerotic. The cornea is surrounded by a zone of fine straight converging pink 
 lines, very different in appearance from the tortuous, anastomosing, scarlet blood- 
 vessels of the inflamed conjunctiva. These hair-like converging hues slop abruptly 
 at the edge, or just before they reach the edge of the cornea; they dip through the 
 sclerotic, in fact, to go to the iris. The vascular zone, therefore, is well defined in 
 front, while it becomes fainter from before backwards, and is gradually shaded ofl"; 
 the posterior portion of the sclerotic being generally pale. As the disease advances, 
 and in violent cases, the more superficial conjunctival vessels also sometimes enlarge, 
 and mingle their tint of redness with that of the sclerotic, and more or less confuse 
 or conceal it. Now this red zone or halo continues as long as the inflammation of 
 the iris continues, and disappears when that ceases. It is an important symptom 
 therefore. 
 
 The change in the colonr of the iris itself is also a remarkable circumstance. 
 You know that what is called the colour of the eye is simply the colour of the iris. 
 When the lymph begins to bo effused into the texture of this coloured part, it deep- 
 ens, and at the same time alters, its tint. A gray or blue eye is thus rendered yel- 
 lowish or greenish. A dark eye presents a reddish tinge. The change is such as 
 would be produced by a mixture of the colour of the lymph with that which is natu- 
 ral to the iris. But besides a variation of colour, the peculiar brilliancy of the sur- 
 face is spoiled. It becomes dull and tarnished, as it were, and the fibrous arrange- 
 ment, Avhich is usually so evident, is confused or gone. The change commences 
 at the inner or pupillary margin of the iris, and extends gradually towards the outer 
 or ciliary edge. This is a symptom which you can scarcely overlook. It is ren- 
 dered certain and unequivocal by comparing the sound eye with that which is 
 inflamed. 
 
 The change of colour which I have been describing is occasioned by the effusion 
 of lymph. But the same event of inflammation leads to various other changes not 
 less strikincr and more important, in so far as the functions of the organ are con- 
 cerned. The lymph becomes visible upon the surface of the iris. Its precise ap- 
 pearance varies considerably in different cases. Sometimes it presents htllc spou>
 
 204 DISEASES OF THE EYE. 
 
 bke freclcles, or specks of rust : or a thin stratum of the same colour is deposited. 
 Sometimes it exhibits the appeai-ance of drops, or (as the}^ have improperly been 
 called) tubercles, embossing the surface, and projecting from its pupillary edge. 
 These are commonly of a yellowish or reddish-brown colour, and they vary in mag- 
 nitude from the size of a small pin's head to that of a large shot. There are seldom 
 more than two or three of these masses. The lymph thus effused upon, or thrusting 
 forward the surface, is confined almost always to that part of the iris which is near- 
 est to the pupil, to the annulus minor; while its ciliary portion, or annulus major, 
 is dull and clouded. Sometimes, when the inflammation is very violent, or the dis- 
 ease has been neglected, actual suppuration takes place. A reddish-yellow promi- 
 nence arises from the surface of the iris, and at length breaks, and discharges matter 
 which sinks down to the bottom of the anterior chamber, and presents the appear- 
 ance that has been called hypopyon. All these changes, I say, become perceptible 
 near the margin of the iris ; its free edge which, in the natural state, is clear and 
 sharp, becomes rounded and blunt : and at the same time the pupil often begins to 
 lose its jet-black colour. 
 
 Another very common consequence of the effusion of lymph from and upon the 
 surface of the iris (from its hinder surface, that is, which is called the uvea, or from 
 its pupillary edge), is its adhesion to the capsule of the crystalhne lens, which lies, 
 you know, behind the iris and very near it. And the pupil itself is apt to become 
 blocked up by lymph. 
 
 The motions of the iris are seriously impeded by the mere effusion of lymph into 
 its texture. At first it moves sluggishly under variations of the hght ; gradually the 
 pupil contracts, and becomes fixed and motionless. The adhesion of the iris to the 
 capsule of the lens still more decidedly restrains the action of the part. When it 
 adheres at one or more points of the margin, and remains free elsewhere, the pupil 
 is deformed ; loses its circular shape; becomes angular ; and this deformity is the 
 most marked when the eye is examined either under a weak light, which allows the 
 pupil to dilate, except at the points where the iris is tied down to the lens ; or under 
 a very strong light, which forces the free portions of the margin, and those onl}'', to 
 approach the centre. Still more palpable does the alteration of figure become when 
 the pupil is artificially dilated. 
 
 Vision is always impaired in this complaint : partly because the posterior tunics 
 of the eye are liable to be implicated in the inflammatory process ; partly by the 
 detriment done to the proper function of the iris, which should duly measure the 
 quantity of light admitted to the retina; partly by the presence of more or less 
 lymph, filling up the pupil ; and partly by a change, not yet mentioned, which is 
 apt to take place, especially in severe cases, in the cornea, and perhaps in the aqueous 
 humour. The cornea becomes hazy and dull, and loses its bright polish. It looks 
 like a piece of glass that has just been breathed upon. It has been thought (on the 
 ground of analogy chiefly) that the aqueous humour grows turbid under the inflam- 
 mation of the membrane that secretes it ; just as serous effusion into the pleura is 
 often found to be troubled and thick. But there is no sure evidence that this is the 
 case. While the cornea remains transparent, the aqueous humour is seen to be 
 clear ; when the cornea is dim and semi-opaque, we cannot distinguish the stair of 
 the aqueous humour. 
 
 Acute iritis is attended with pain and intolerance of light. To the latter circum- 
 stance is probably owing the contraction of the pupil during the progress of the 
 inflammation : and then the lymph fixes the pupil in that slate of smallness and 
 contraction. There is pain in the eyeball itself, and in the parts about the eye, the 
 brow and temple, most severe at night. There is much variety, however, in regard 
 to the pain. Sometimes it is constant and severe, but still more agaravated in noc- 
 turnal ])aroxysms. Sometimes, even when the quantity of mischief that is visible 
 IS very great, scarcely any pain at all has been experienced. 
 
 The same remark applies to the constitutional symptoms. In some instances these 
 are but slightly pronounced ; but in most cases, particularly in acute cases (for iritis, 
 as I have hinted before, is sometimes a chronic disease) there is a good deal of fever 
 and headache, tne pulse is full and hard, and the tongue white, and the sleep is broken.
 
 IRITIS. 205 
 
 If the progress of the inflammation be not checked, it extends itself beyond its 
 origmal seat. It creeps from the pupillary margin to the cihary ; and thence it 
 passes on to the ciliary body, to the choroid coat, and to the retina ; and as this takes 
 place, the pain and the pyrexia increase, and blindness is usually the result. The 
 deUcate texture of the retina is spoiled for ever. 
 
 I have thus described the phenomena of iritis generally : and I will next consider, 
 in the same manner, the treatment which it requires. It will afterwards be neces- 
 sary for me to mention certain modifications of the disease, in respect to its rate of 
 progress, its causes, and the circumstances under which it occurs. I say it will be 
 necessary to mention these modifications, because they require a corresponding 
 adjustment of the plan of treatment. 
 
 When we have to deal \vith iritis alone — that is, when the inflammation and the 
 changes to which it may have led, are confined to the iris — the disease is always, I 
 believe, manageable ; and affords a beautiful instance of the power of well-directed 
 remedial measures. We cannot always tell whether the inflammation has been 
 restricted to the iris or not. 
 
 We have three powerful weapons wherewith to combat iritis; blood-letting; 
 mercury ; and a remedy that hitherto has not been mentioned in these lectures, 
 belladonna. 
 
 If I were restricted to the use of one of these means, I should choose mercury ; 
 if to two, mercury and belladonna ; but the combined employment of the three has 
 the most powerful effect in curing the disease ; and cases that have seemed almost 
 desperate, have been retrieved and rescued by these remedies. 
 
 With respect to blood-letting., I shall not run the risk of fatiguing you by dwelling 
 at any length upon the mode in which it should be employed, or the indications for 
 its adoption. I shall content myself with saying that the intensity of the local symp- 
 toms, especially of the pain, — and the degree in which the general symptoms, the 
 fever, and the hardness of pulse, are present, — offer the best measure, both of the 
 necessity for bleeding, and the amount to which it ought to be carried. Both will 
 depend somewhat also upon the strength and constitution of the patient. Bleeding 
 from the arm till some decided impression is made upon the circulation; cupping 
 from the temples ; or both these modes of taking blood, together or in succession, 
 will often be required. At the same time active purgatives should be exhibited; 
 and the whole of the antiphlogistic regimen strictly enforced. 
 
 But bleeding, assisted by purgatives and the antiphlogistic regimen, will not cure 
 the disease ; or it will not cure one case in a hundred. It will stop the inflamma- 
 tion probably, but not till the organ has been spoiled. Such a termination cannot 
 with any propriety be called a cure. We want not only to put an end to the inflam- 
 matory process, but to repair the mischief which may already have been done. 
 
 Yet bleeding is not to be despised or neglected because it is unequal to the cure 
 of iritis. It is productive of direct benefit by abating the force of the circulation, and 
 by checking the progress of the local inflammation : and it is productive of great 
 indirect benefit by preparing the system to submit itself more readily and rapidly 
 than it otherwise would, to the specific influence of mercury. Mercury is our sheet- 
 anchor in this disease. 
 
 After free blood-letting, then, or after such abstraction of blood from the system, 
 or from the part, as the circumstances of the case may dictate, you must administer 
 inercurij in the manner that I formerly recommended. The object is, in acute cases, 
 to affect the gums as speedily as possible ; the soreness of the gums, and the peculiar 
 fcEtorof the breath, being the tokens that the whole capillary system feels the specific 
 influence of the remedy. Calomel with opium is, in most cases, the best form in 
 which mercury can be introduced into the system ; the purpose of the opium being 
 to prevent the calomel from running off by the bowels. Two, three, or four grains 
 of calomel, with one-fourth, one-third, or one-half of a grain of opium, should be 
 given every four, or six, or eight hours. Equal doses at equal intervals. 
 
 Some persons prefer giving the calomel still more frequently ; one grain, for 
 instance, with one-tenth, or one-eighth of a grain of opium, every hour. If the 
 gums do not rise in the course of thirty-six or forty-eight hours, and a speedy eflTect
 
 206 DISEASES OF THE EYE. 
 
 is desirable, inunction of ihe mercurial ointment should be added. And in some 
 cases mercurial frictions alone may be sufficient, and tiie most expedient. Or tiie 
 hydnirgyruin cum creta, in five or ten grain doses. 
 
 You may liave bled your patient freely, and purged him well, and yet, on lookinor 
 into his eye, you perceiv^e the mischief to be still going on, and the deposition of 
 lymph increasing. But the instant that his gums and breath acknowledge the spe- 
 cific agency of mercury upon his system, a welcome change becomes visible; the 
 red zone surrounding the cornea begins to fade ; the drops of lymph to lessen ; the 
 iris to resume its proper tint; and the puckered and irregular pupil once more to 
 approach to the perfect circle ; till, at length, the eye is restored to its original in- 
 tegrit}', and beauty, and usefulness. 
 
 I speak now of favourable cases. The changes for the better that I have been 
 describing are sometimes rapidly accomphshed, sometimes slowly. If the disorder 
 has been long neglected, irreparable damage may have been done ; the elTused 
 lymph may have' become organized ; or firm adhesions may have been already 
 contracted between the iris and the lens. But even in cases of some standing, 
 when the inflammatory action has in a measure subsided, the use of mercury 
 will sometimes greatly improve, sometimes altogether restore, the impaired vision. 
 
 With the mercury, both before and while its specific influence is manifested, we 
 combine the use o{ beJludonna. 
 
 Doubtless you are all aware of the singular effect of this vegetable poison upon 
 the iris. It dilates the pupil. Now it is of great importance in iritis to prevent that 
 tendency to contraction which the pupil manifests. If we can artificially dilate the 
 pupil, we may prevent the iris from forming adhesions with the capsule of the crys- 
 wlline lens ; and if it has recently contracted such adhesions, we may, while the 
 .ymph is yet soft, stretch or break them. And this power of artificially dilating the 
 pupil we possess in the agency of belladonna, and of certain other narcotic vegetables. 
 This remarkable efTect of the belladonna was first discovered, accidentally, by our 
 countryman, the celebrated Ray. He tells us that a noble lady of his acquaintance 
 applied a leaf of the plant to a small ulcer, suspected to be cancerous, just below 
 one of her eyes. The pupil of that eye became greatly dilated, and the membrane 
 remained motionless under the strongest light. This effect gradually subsided when 
 the leaf was removed. But it took place on three several occasions, and was wit- 
 nessed by Ray himself. Other vegetables have the same property : henbane, for 
 exampk-", stramonium, and the cherry laurel. And there are others which have it 
 not, although we might have expected that they would possess it, from the analogy 
 they bear to the former in other respects. It has been ascertained that neither hem- 
 lock, nor aconite, nor foxglove, nor opium, has any such power. 
 
 Preparations of belladonna are chiefly, if not exclusively, employed in ophthal- 
 mic disorders in this country. It is used in two ways. The extract is rendered 
 soft and semifluid by admixture with distilled water, and then is smeared freely 
 arouad the eye, upon the lids, and brow, and forehead. It is washed ofT after 
 remaining an hour: generally it produces a marked effect upon the pupil. 
 
 A more efficacious and speedy mode of dilating the pupil, is to drop a solution 
 of the extract into the eye itself. The solution is to be made by rubbing down a 
 scruple of the extract in an ounce of distilled water, and filtering the fluid through 
 linen. Two or three drops of this solution are to be introduced between the 
 ej'elids. 
 
 Some very interesting experiments have been made in Germany by Dr. Rei- 
 singer upon this property of belladonna and hyoscyamus, of contracting the iris — 
 in other words, of dilating the pupil. The result of these experiments is given in 
 the 24th volume of the Edinburgh Medical and Surgical Journal. Dr. Reisinger 
 procured atropine and hijoscyamine, the active principles of the two plants, and 
 made comparative experiments with these principles, and with the coarser extracts ; 
 and he concludes that the former are much to be preferred to the latter. Thus, he 
 dissolved a grain of hyoscyamine in ten minims of water, and introduced a small 
 drop of the solution into the eyes of several dogs and cats. No irritation whatever 
 uf the eye was produced in any instance, but the pupil was so much widened by
 
 IRITIS. 207 
 
 the application, that in an hour's time onl\' a small ring of the iris could be seen 
 beyond the edge of the cornea; and after three hours, the pupil seemed as large as 
 the cornea itself. The dilatation did not begin to diminish till after three days ; and 
 the pupil did not recover its natural dimensions until the sixth day. Then he ap- 
 plied a solution of the extract of hyoscyamus, made by mixing five grains with ten 
 minims of water. This evidently caused irritation of the organ, which lasted from 
 five to eight minutes, and was evinced by a discharge of tears, by the animal's shut- 
 ting its eyes, and rubbing its eyebrows with its paws. Much less dilatation of the 
 pupil followed, and continued not more than six or eight hours in dogs, and about 
 twenty-four hours in cats. As soon as Dr. Reisinger had satisfied himself that the 
 hyoscyamine had no injurious influence either upon the conjunctiva, or upon the 
 deeper-seated textures of the organ, he applied it to the human eye. He dissolved 
 a grain of hyoscj'^amine in a drachm of distilled water, and inserted a drop of the 
 solution into the eye of an old lady of seventj^-one, who had cataract. So great was 
 the consequent dilatation of the pupil, that only a narrow ring of the iris remained 
 visible. No irritation whatever of any part of the eye was produced ; and the dila- 
 tation continued for seven days. 
 
 As chemistry is now furnishing us every day, in greater abundance, and with 
 more ease, the active principles of various of our medicinal vegetable substances, 
 we shall soon, in all probabilitj'', adopt hyoscyamine or atropine, for artificially 
 dilating the pupil, instead cf the preparations now in use. Till that time arrives, 
 you had better smear the surrounding skin with the moistened extract of bella- 
 donna whenever the eye is painful or much inflamed. But under other circum- 
 stances, the solution dropped into the eye is to be preferred for its readier action, 
 and its greater power. The use of this curious virtue possessed by certain plants is 
 not confined to the cure of iritis : it enables the surgeon to introduce instruments 
 through the pupil with greater facihty and safety; it affords us also the means of 
 examining the deeper-seated textures of the eye ; and it is of great service to many 
 persons who are partially blind ; to such, for example, as have central specks on 
 the cornea, or central opacities of the crystalline lens ; it enables such persons to 
 enlarge the window of the eye; to admit more light; and to have painted upon 
 the retina, and represented to the mind, the images of objects which, but for the 
 mysterious agency of these poisonous vegetables, they could never hope to see 
 at all. It is a very fortunate circumstance that the power of belladonna over the 
 iris does not diminish by repetition. Mr. Lawrence mentions two patients of his, 
 (Hie of whom had used it habitually for four or five years, and the other for four- 
 teen or fifteen ; and it dilated the pupil just as well at the end of these periods as 
 at the beginning. By carefully examining an eye in which lymph has recently 
 been effused, you may distinctly see the good effects of the artificial dilatation of 
 the pupil ; little strings of adhesion are often visible, connecting the edjie of the 
 iris with the surface of the lens ; and these are stretched, and not un frequently 
 broken under the influence of the belladonna : and minute black spots may some- 
 times be seen upon the capsule, marking the points where the uvea had stuck, and 
 where it left behind it, when it was detached by the belladonna, a portion of its 
 peculiar pigment. These black points are indelible. There is one case recorded 
 in which the pupil, after being dilated by belladonna, became fixed in that con- 
 dition ; probably by lymph subsequently efflised into its texture, and binding 
 together its fibres. Even this is better than that the pupil should be contracted and 
 fixed. 
 
 These three remedies, then — ^bleeding, mercury, and belladonna — are the means 
 by which we are to subdue inflammation of the iris, and repair the ravages it has 
 occasioned. With respect to the most important of the three, mercury, there are 
 some points that require to be further noticed. 
 
 You may ask to what extent the mercury should be pushed, and how long it 
 should be continued? 
 
 Why we have, in iritis, an illustration of what I have more than once mentioned 
 before, viz., that the rapidity of a disease will require a corresponding haste m tne 
 use of its remedy. In acute and violent cases, the mouth should be made decidedly
 
 208 DISEASES OF THE EYE. 
 
 sore, as quickly as possible ; and when that has been done, the further administration 
 of the mercury may be suspended. " Full sahvation," says Mr. Lawrence, " quickly 
 produced, cuts short recent disease, as if by a charm." In cases of longer stand in (t, 
 or of slower progress, we must be slower in the introduction of the remedy : it will 
 DC enough to obtain any, the smallest certain evidence of its action, in the gums and 
 breath ; and we must keep up that moderate influence for some time. For what 
 precise time it is impossible to say ; but till the redness has gone, and the natural 
 colour of the iris returns, and all the visible lymph has disappeared, and the sight is 
 perfectly restored ; and this may require a month or two. 
 
 ^Vhen you look from day to day into the aqueous chamber of an eye in which 
 iritis has recently produced its peculiar changes, and after the due effect of mercury 
 upon the gums has been achieved, you. will be surprised as well as delighted to see 
 large masses of lymph rapidly disappear, melt away, as it were, from the surface of 
 the iris, while that which had been deposited in its intimate texture, rendering it 
 confused and discoloured, as quickly clears ofT. And you will be inchned to beheve, 
 as many have done, that mercury has a vast influence in promoting and accelerating 
 absorption. It may have such a power : I am not disposed to deny it : but that it 
 really has so we cannot safely infer from such circumstances. It clearly has the 
 power of arresting the deposition of lymph ; of putting an end to the adhesive in- 
 flammation. Whether it does any thing more towards completing the cure, we have 
 these reasons for doubting. When blood happens to be effused into the anterior 
 chamber ; or pus ; or when, as frequently happens, pieces of a cataract that has 
 been broken up pass through the pupil, and show themselves between the iris and 
 cornea ; they (the blood, the pus, the fragments of the lens) disappear, i. e., are 
 absorbed, just as rapidly as the lymph in iritis, not a particle of mercury is taken 
 Mr. Lawrence even gives a case of syphilitic iritis, which got well without any 
 affection of the gums by mercury, and which had been marked by the deposition of 
 a large mass of Ij-mph on the iris ; and he says that the lymph was immediately 
 absorbed, as soon as the inflammation ceased ; and that he never saw it disappeai 
 more quickly under any circumstances. 
 
 There is one local use of mercury which I must not omit to mention, because 
 though it probably has no share in curing the complaint, it is productive of great 
 comfort and relief to the sufferings of the patient. It is adapted to those cases in 
 which severe pain is felt round and over the orbit of the eye at night. Ten grains 
 of the strong mercurial ointment, intimately mixed with two grains of finely powdered 
 opium, and well rubbed into the temple a little while before the nocturnal pain is 
 accustomed to recur, will in many cases completely prevent it. We owe this piece 
 of practice to the Germans. 
 
 Iritis is apt to occur from different causes, and in connection with different diseased 
 states of the system. It is no uncommon accident from surgical operations performed 
 upon the eye, the iris suffering mechanical injury. The inflammation thus excited 
 IS usually violent and acute, and requires that the whole plan of treatment that I have 
 been sketching out should be actively prosecuted. 
 
 But inflammation of the iris sometimes arises slowly and insidiously, without vas- 
 cularity enough to call attention to the eye, and without pain. This generally 
 happens when the eye has been strained by over-use ; in women who occupy them- 
 selves Avith fine needle-work ; in engravers, and such as are accustomed to look at 
 minute objects, or at bright objects. A more common effect of continued exertion 
 of the eyes in this way, is a diseased state of the retina; but (however the fact may 
 be explained) the iris is sometimes the part that suffers. In this form of the disease 
 mercury will often be found a successful remedy ; but its influence must be gra- 
 dually brought about; and it is not so certainly productive of benefit as when it is 
 employed in acute iritis : — probably because the chronic inflammation has involved 
 the posterior tunics also. 
 
 But most frequendy iritis is met with in combination with syphilitic, or with rheu- 
 matic disease, which manifests itself at the same time in other parts of the body. 
 Syphilitic iritis is more common than any other. It is one of the secondary symptoms 
 .-;t syphilis ; and accordingly it is commonly associated with other secondary symp-
 
 IRITIS. 209 
 
 toms ; with syphilitic eruptions, nodes, pains in the limbs, and ulceration of the 
 thioat. It IS also one of the earlier of these secondary affections, and therefore is 
 sometimes the only one to be seen; and occasionally it declares itself before the 
 primary disease is well. The pain that attends this species of iritis is chiefly felt 
 at night, but at that time it is apt to be very severe and distressing, so as entirely to 
 prevent sleep until it takes its departure in the morning. We cannot, I believe, dis- 
 cinguish syphihtic iritis with any certainty from other acute varieties of the same 
 complaint, by mere inspection of the eye. However, there are some points worth 
 remembering in respect of the local phenomena which it most commonly presents. 
 Syphilitic iritis is never attended (according to Mr. Lawrence) with abscess of 
 the iris, and hypopyon ; the lymph is usually deposited in distinct masses; and the 
 pupil becomes angular, and is not unfrequently displaced towards the root of the 
 nose, by the adhesions which the iris has contracted with the parts behind it. In 
 another variety of inflammation of the iris (which I shall mention to-morrow, arthri- 
 tic iritis) lymph is equally effused from the margin of the iris, but it is not usually 
 deposited in a distinct drop-like form. We ascertain the variety of iritis with which 
 we have to do by these peculiarities ; by the co-existence of other tokens of syphilis ; 
 by the periodical character of the nightly pain ; by taking into our account the a^e, 
 the constitutional habit, and the probable state of morals of our patient. Syphilis, 
 you know, is not uncommon in children ; it is sometimes even congenital : but it 
 very Sfldom afft-cts the iris at that early period of life. Among a large number of 
 syphilitic children brought to Mr. Lawrence, he never witnessed iritis but once. 
 
 It was in syphilitic iritis that the curative power of mercury over adhesive inflam- 
 mation was first distinctly recognized. But you must not fall into the error of sup- 
 posing that the success of the remedy depended upon the specific character of the 
 disorder ; upon its connection, I mean, with the venereal virus. Mercury is fully as 
 serviceable and as sure in common acute inflammation of the iris. Upon this point 
 ail men of experience are agreed. " Its influence (says Mr. Lawrence) is not con- 
 fined to the syphilitic form of the disease, but extends equally to the idiopathic." 
 And Dr. Farre bears testimony to the same effect. 
 
 LECTURE XX. 
 
 Iritis concluded. Rheumatic Ophthalmia. Amaurosis. 
 
 The principal theme of the last lecture was that most interesting disease, inflam- 
 mation of the iris. 
 
 The symptoms of iritis are these : a radiating zone of vascular redness situated in 
 the sclerotica, and surrounding the cornea ; a change in the colour of the iris, from 
 gray or blue to a yellow or greenish tint, from brown or hazel to a dusky reddish 
 hue ; a visible deposit of lymph upon the anterior and innermost portion of the iris ; 
 a thickening of its free edge ; contraction, irregularity, and immobility of the pupil ; 
 closure of the pupil by lymph ; adhesion of the uvea to the membrane of the chrys- 
 talline lens. All these we can see aqd ascertain for ourselves. We can ascertaiu 
 also the presence of fever, which attends the acute forms of the disease. And wj 
 learn from the testimony of our patient that his sight is impaired ; that the influx o. 
 hghl into the eye hurls him ; and that he experiences pain in and around the organ 
 especially at night. 
 
 The grand remedies in iritis are three. 
 
 1. Blood-letting : of which the objects are to abate the force of the heart's action, 
 to moderate the febrile disturbance ; and to facilitate the operation of the second 
 remedy : which is — 
 
 2. Mercury. This is to be given so as to produce soreness of the gums, and the 
 peculiar fostor of the breath : and these effects are to be sought for rapidly or gradu- 
 ally, according as the inflammation of t"".e iris is recent and acute, or moderaTe and 
 
 14 s3
 
 210 DISEASES OF THE EYE. 
 
 chronic. The object of this remedy is to arrest the efTusion of coagulable Ij^mph : 
 to put a stop to the adhesive inflammation. 
 
 S. The appHcation of the extract of belladonna to the conjunctiva, or to the skin 
 around the eye, so as to dilate the pupil. The objects of this measure are to pre- 
 vent the adhesion of the iris to the parts in its neighbourhood ; to detach it from ih^ 
 lens when it has already been glued thereto by soft lymph ; and to stretch and 
 elongate the bands of adhesion when they cannot be broken : and thus to obviat?; 
 any impairment of the free movements of the iris, and any deformity of the pupil, 
 after the inflammation shall have ceased. 
 
 I began to speak of the causes of iritis. 
 
 I say it may be occasioned by mechanical injury ; as during the operation for the 
 extraction of a cataract. A clean cut, however, is frequently followed by no bad 
 consequences ; a portion of the iris has been shaved oft' by the knife in making the 
 section of the cornea, without any injurious result. When iritis is excited by mecha- 
 nical violence, it is acute. 
 
 2dlv. A chronic form of iritis is sometimes brought on by excessive er./loyment 
 of the eye, in looki.ig at minute or bright objects. 
 
 '3dly. The most common species of iritis is that which arises in connection with 
 syphiltic disease. It is one of the early secondary symptoms of syphilis. l! is 
 marked by the co-existence of other secondary consequences of the introduction inio 
 the system of the syphilitic poison, and by the periodical character of the nightly 
 pain : it is never attended with abscess of the iris and hypopyon ; the lymph that 
 is effused is deposited in separate masses ; and the pupil is often displaced towards 
 the root of the nose, as well as rendered irregular, by the adhesion of the iris to the 
 capsule behind it. 
 
 4thly. It is curious enough that iritis has actually been ascribed to mercury, as a 
 cause. This notion can only have arisen from that loose kind of logic, and hasty 
 generalization, for which, I am sorry to say, medical reasoners are too often distin- 
 guished. Mercury is perpetually exhibited for the cure of syphiUs ; and people 
 who have been treated for syphilis are very hable to iritis. This seems to be the 
 only foundation for the opinion in question. When we come to appeal to i:;cts. we 
 find no ground for believing that this mineral is thus both bane and antidote. If it 
 were so, Benvolio's advice to the slighted Romeo might be very pertinently otTered 
 to the pal lent in such a case : 
 
 " Take thou some new infection to thiue eye, 
 And the rank poison of the old will die." 
 
 Mr. Lawrence has seen no instance of iritis, of whatever kind, in which there - 
 ha? appeared to him any reason for attributing the occurrence of the complaint to 
 this cause. I have never heard it alleged that persons who have taken large quan- 
 tities of mercury for other diseases, as for affections of the liver in India, are parti- 
 cularly subject to inflammation of the iris. On the other hand, iritis has come on, 
 in hundreds of cases, in connection with syphihs, though not a particle of mercury 
 had been sAvallowed by the patients. 
 
 Lastly, there is a pecuhar form or variety of iritis, called tne arthritic or rheii- 
 mafic. 
 
 This affection is characterized by the Vdowing general features. It occurs in 
 persons who are subject to gout or rheumatism, and often forms a part of the attack ' 
 of the one or the other of those diseases. Like them it is liable to return again and 
 again ; and this circumstance it is which makes arthritic iritis a serious disorder. It 
 is seldom that much or permanent damage to vision is effected by a single attack ; 
 bu* -^''hesions readily form under it, and lymph is effused : and in each successive 
 Attack fresh efliision takes place : the pupil becomes more and more contracted ; and 
 p may be filled up, at last, by an opaque plug of lymph. Some patients, howevjr, 
 >vill suffer ten or a dozen recurrences of the disease, and recover almost completely, 
 and enjoy perfect vision in the intervals, before the vision becomes much impaired. . 
 
 .Some of the local appearances are more or less characteristic of this variety of 
 iritis. It is seldomer attended than the syphihtic variety by a deposition of lymph
 
 RHEUMATIC OPHTHALMIA. 211 
 
 in distinct masses ; .the contracted pupil keeps its central position, and is not dis- 
 placed towards the root of the nose, as it is apt to be in syphihtic iritis. The adhe- 
 sions that bind the iris to the neighbouring parts are said to be whiter in this variety 
 of iritis than in others.. It is also a very remarkable circumstance that the zone of 
 red vessels encircling, the conjunctiva does net approach so close to the cornea as in 
 other species of iritis ; but a white ring is left between the cornea and the anterior 
 margin of the zone. Sometimes the circular white stripe is partial, being most 
 marked towards the angles of the eye ; sometimes, on the other hand, it is as perfect 
 as if it had been described with a pair of compasses. I believe, with Mr. Welbank, 
 that the appearance of this bluish ring depends upon the less intense degree of the 
 sclerotic inflammation. He says that he has noticed its coming on, when syphilitic 
 inflammation of the iris was beginning to yield to the action of mercury ; although 
 there had been no such interval during the height of the inflammation. Again, the 
 colour of the zone is not so bright as in other forms of iritis ; it is of a somewhat 
 livid, or slightly purplish tint : and the larger vessels at the back part of the eye, 
 belonging to the conjunctiva, are apt to become tortuous and varicose. 
 
 Rheumatic iritis is often met with in combination with what is called rheumatic 
 ophthalmia: a disease which. I have not before mentioned. But each may exist 
 alone. And as rheumatic iritis, though frequently an independent disease, does also 
 in many instances grow (as it were) out of rheumatic ophthalmia, I will take this 
 opportunity of shortly describing the latter complaint. 
 
 AVhat is called rheumatic ophthalmia, then, is' inflammation aff'ecting the fibrous 
 coat of the eye, the sclerotica. We. know that the fibrous tissues throughout the 
 body are frequently the seat of rheumatic inflammation. Some persons are more 
 liable to rheumatism than others — are more readily affected by its external exciting 
 causes, which are vicissitudes of temperature, and exposure to cold and wet. In 
 such persons there ^eems a tendency to take on inflammatory action in all the struc- 
 tures of the sams kind ; and most particularly in the fibrous membranes, and tei - 
 dons, lha.t help to form the various joints ; and as the sclerotica partakes of this 
 fibrous texture, so it is apt to suffer, in its turn, from rheumatic inflammation. The 
 connection of the movable eyeball with the head may be considered as a sort of 
 joint. The local symptoms are not in general of a violent kind ; and, as in other 
 parts, the rhematism seldom leadis to any permanent alteration of structure ; seldom, 
 at least, when che ophthalmia is confined, as it often is, to the sclerotica alone. Pcr- 
 naps the best way to put you in possession of the features that belong to rheumatic 
 ophthalmia will be to describe an actual instance of it. 1 will take a well-marked 
 example, related by Mr. Lawrence.. He was sent for to see a gentleman who was 
 suffering from whaf is commonly called rheumatic gout : swehing, some redness, 
 and severe pain of oni? foot and knee, and one hand; aching of the back; and 
 great constitutional excitement. He got Avell under the treatment adopted. After 
 a short interval, lipon Mr. Lawrence's calling to inquire how he was, he said there 
 was something the matter with his .eyes; and asked to have them examined. "I 
 looked, at them hastily," says Mr. Lawrence: "the room was dark, and the day 
 dull ; and I saw no appearance of disease. When I called again, after a few days, 
 as -the complaint was repeated, 1 examined more attentively. On bringing him 
 towards the window, he obviously felt the light troublesome; he drew down ihe 
 eyebrows, and half closed the hds, to avoid it. The conjunctiva was natural; but 
 the whole of the. sclerotica had a livid red, and mottled appearance, which might 
 have been called dull, or almost dirty, in comparison with the red colour of common 
 active iriflammation. The sclerotic vessels were partially distended ; the redness 
 terminated short of the cornea, so that there was a distinct white rim round the latter. 
 Vision was perfect; there was no pain so long as the eye remained at rest ; but 
 exertion of the organ, particularly under strong light, brought on uneasiness. The 
 nature of this gentleman's occupation, and of his tastes, which were literary, pre- 
 vented him from giving his eye the necessary repose ; and the condition of the scle- 
 rotica just descrih.ed lasted for three or four months;" so that Mr. Lawrence was 
 apprehensive that some serious mischief would ensue to the organ. The afTeotion 
 remained confined, however, to its original seat, evincing only that obstinate chafac
 
 212 DISEASES OF THE EYE. 
 
 tor which belongs to disorders of such structures ; and at last it disappeared com 
 pletely, leaving the eyes with their organization and powers unimpaired. 
 
 The treatment that appears to answer best in simple rheumatic ophthalmia of this 
 kind, consists in moderate topical bleedings, and counter-irritation : with such other 
 measures as conduce to improre the general health ; and among these, change of 
 air and scene have sometimes a decided effect. Those remedies also are to be given 
 which have been found by experience to be beneficial in rheumatic inflammation, 
 although we cannot always depend upon finding them useful : colchicum, I mean ; 
 bark ; sarsaparilla ; the iodide of potassium. In these abiding or frequently recur- 
 ring forms of disease, you will often be obliged to try the so-called specific remedies 
 one after the other. 
 
 Now when the rheumatic inflammation is not confined to the sclerotic, but creeps 
 inward, as by their vascular connections it easil}^ may, to the iris also, we name the 
 disease according to the most important part that it occupies — arthritic iritis. On 
 the other hand, when, Avith that affection of the sclerotic which I have been de- 
 scribing, there is combined a moderate degree of inflammation of the conjunctiva, 
 this complex disorder receives a compound denomination ; it is called catarrho* 
 rheumatic ophthcdmia. 
 
 Dr. iVlackenzie states it as the result of his experience, that arthritic iritis seldom 
 occurs in connection with the earlier appearance of gout, while the patients stil 
 retain strong powers of digestion, and have the means of indulging their appetites; 
 but rather with the asthenic and irregular forms of gout and rheumatism; when 
 repeated attacks have been followed by mental depression, indigestion, flatulence 
 and languor. He has generally met with the disease in subjects beyond the age 
 of fift)-, very frequently in tobacco-smokers, and whiskey-drinkers, who have often 
 suffered rheumatic affections, who are teased by headaches, acidity of stomach, bad 
 gums and teeth, and lowness of spirits :■ in persons, that is, whose health has heen 
 impaired and broken by intemperate habits. I believe you will find this to be a very 
 correct statement; although arthritic iritis may ■Q.ho take place in those who are 
 more robust. 
 
 After what has now been stated you will be prepared to believe that arthritic iritis 
 neither requires nor bears those free emissions of blood, and that liberal use of mer- 
 cury, which are necessary for the cure of other varieties of the complaint. Mercury, 
 pushed to salivation, is sometimes found to do more harm to the system than good 
 to the eye ; and in a disease which is so apt to recur, we must not be continually 
 salivating our patient. I can only say that the treatment must be conducted on the 
 principles already laid down, and adapted to circumstances. If there be an}^ fever, 
 and a hard pulse, and a white tongue, you should bleed and purge your patient, and 
 afterwards give him from twenty minims to half a drachm of the wine of colchicum 
 two or three times a day. When the symptoms are less active, you must be less 
 active too: strive to set the disordered dijjestive organs ri2"ht, and to correct the bad 
 habits of the patient: give small doses of mercurj' (such as five grains of Plummcr's 
 pill) three or four times a week ; excite counter-irritation bj' blisters, or by the tartar- 
 emetic ointment. After the use of bleeding or leeches, and the regulation of the 
 bowels, preparations of iron, the sulphate of quina — tonics, in short, — have been 
 found, in not a few cases, extremely beneficial. 
 
 I should have mentioned another remedy, which of late years has been recom- 
 mended in iritis, and especially in syphilitic iritis, by Mr. Carmichael, of Dublm : 
 not as being a better remedj' in itself than mercury, or so good, but as having con- 
 siderable, power over the disease, and as affording, therefore, a valuable resource 
 when from any cause the exhibitkin of mercury is forbidden. This remedy is the 
 oil of turpentine. He gives it in drachm doses, three times a day. He relates 
 cases of syphilitic iritis in which the pain, redness and other symptoms, were quickly 
 xemoved, and effiised lymph was absorbed, and vision restored, under the use of this 
 medicine. It is necessary to its beneficial action that the bowels should nqj be con- 
 nned. In other instances of the same disease, Mr. Carmichael was not so success- 
 ful. Mr. Guthrie, who has also tried this remedy, reports of it that " in some cases 
 t succeeded admirably, m others it has been of litde service, and in some unequal
 
 AMAUROSIS.. 213 
 
 to the cure of the complaint." I do not know that it has been fairly put to the test 
 in arthritic iritis. 
 
 I proceed next to quite a different kind of ophthalmic disease from any that we 
 have yet considered. I have spoken of inflammation of the exterior membrane of 
 the eye occurring separately; and of inflammation of certain internal parts, and par- 
 ticularly of the iris, occurring separately. Between these exterior and interior tunics, 
 the sclerotica forms a sort of natural barrier or shield, the chief point of connection 
 Detween them being near the edge of the cornea, where the sclerotic vessels dive 
 through to reach the iris. Inflammation of the sclerotica itself has also been de- 
 scribed. When vision is impaired or destroyed in consequence of any of the com- 
 plaints which have hitherto engaged our attention, that effect results from the partial 
 or total exclusion of light from the retina. The cornea is left opaque, or it bursts ; 
 the pupil, or aperture in the iris, is shut up by a web of lymph ; or the capsule of 
 the lens to which the iris adheres has undergone a change, and lost its transparency. 
 In each case the retina suffers an eclipse. 
 
 But light may be freely admitted, and yet no vision ensue. The transparent parts 
 of the eye, the several media, so skilfully and exquisitely adjusted for the due refrac- 
 tion and collection of the rays of light into an image of the object from which they 
 flow, may all be perfect and in order; but the beautiful apparatus is useless; the 
 patient cannot see Vv'ith it. The fault is: in the nervous matter that should receive 
 and transmit the impression, and render it an object of perception to the mind. 
 
 Now persons in this condition are said to have amaurosifi. The term is derived 
 from the Greek word a,uarpoj, which signifies obscure or dark. It expresses various 
 degrees of imperfect vision, from defective nervous function. The words gutta 
 serena are applied to that form of amaurosis in which vision is totally lost. It was 
 formerly supposed that this 'sort of blindness was caused by the effusion of some 
 humour or fluid behind the pupil: and this was held to be a clear fluid, because the 
 natural blackness of the pupil is sometimes not troubled in arnaurosis. Milton has 
 literally translated this term when, speaking of his own eyes, he says : 
 
 ■ " So thick a drop serene hath quenched their orbs." • 
 
 Amaurosis is a very obscure disease. It is capable of being caused by various 
 changes, the exact seat and nature of which we often have no means of determining 
 during life; and which frequently leave no traces behind them in -the dead body. 
 It would take a much larger space than I can possibly devote to it in these lectures, 
 thoroughly to discuss this difficult but interesting subject. I shall endeavour to give 
 you such a sketch of it as you may fill up and complete by future observation and 
 reading for yourselves. Ii will be something to learn the direction and objects of 
 our inquiries into what is yet unknown in the pathology of this affection. 
 
 There is one division of the disorder which immediately suggests itself. The 
 cause of defect may exist in the brain, at or beyond the origin of the optic nerve; 
 or it may be situated in any part of the course of that nerve, from its commencement 
 at the base of the brain to its termination in theretina; or it may be confined to the 
 retina itself. 
 
 There is reason to believe that the functions of the retina may be impaired or sus- 
 pended, by deviations from the natural quantity of blood sent to it; by disturbances 
 of its circulation. Various degrees of amaurosis aje common among persons who 
 employ the sense of vision overmuch, and strain the eye. This over-use is likely 
 to produce congestion, or chronic inflammation,' in the vessels of the retina ; and very 
 slight changes of that kind may seriously affect the function of a part so delicate and 
 tender. I say we frequently meet with amaurosis among those whose occupations 
 oblige them to look attentively at small or bright objects during many hours of the 
 day; or what is still more pernicious, during many hours of lamp or candle lighi ; 
 so as habitually to fatigue the eye. Engravers, printers, watchmakers, tailors and 
 milliners, mathematical in.^trument makers, persons who gain their oread by writing, 
 miniature painters, cooks who are exposed to the heat and glare of large fires, men 
 who have the charge of forges or furnaces, and so on. Here a continual stimulua
 
 £14 DISEASES OF THE EYE. 
 
 Jcads to a chronic disorder, which, increasing in intensitj', may terminate in total 
 blindness. We call these cases of amuuroais, but they may be justly-considered to 
 be instances o^ chronic wjlammution of the retina; we cannot see the suffering part 
 indeed. during life ; and the complaint is not a fatal one, and, therefore, we have few 
 opportunities, or none, of examining after death the condition of the retina while the 
 amaurosis is yet recent. But judging from the nature of the causes that precede 
 the defect of vision, and' from the nature of the remedies that are often found to re- 
 move it, we are ^yarranted in regarding the essence of the disease to-be retinitis^ 
 The same condition, apparently, may be suddenly produced b}' the transient opera- 
 tion of some more powerful cause of congestion: such as intense light. 1 will 
 illustrate this form of amaurosis — amaurosis, that is, dependent upon congestionj 
 which, perhaps, amounts to inflamniation, sometimes slowly established, and some- 
 times very suddenly — by the narration- of a few cases. I may as well premise, 
 however, that the treatment which' promises niost, or I should rather say, which has 
 performed most, in this form and kind of amaurosis, is very nearly the same (except- 
 ing the use of belladonna) that I have already recommended for chronic and acute 
 iritis. Blood-letting, general or topical, according as there are more or less pain and 
 fever, and fullness of the system, and according as the amaurosis is more or less 
 recent ; and above all mercury, so administered as to affect the gums, and rapidly 
 introduced into the system in the acuter cases: more slowly in proportion as the 
 disease has crept on more gradually and lasted longer. This treatment is very often 
 quite successful : the mercury is the most important part of it ; and we have in 
 this facta strong corroboration of the inference drawn from the nature of the exciting 
 causes, viz., that the complaint is essentially inflammatory. And again, supposing 
 it inflammatory, we need not be surprised that a remedy, the curative effect of which 
 we can see in inflammation of the iris, should be equally serviceable when the same 
 diseased process is set up in the retina, which we cannot see. Purgatives, counter- 
 irritation, and perfect repose of the eye, are necessary parts of the treatment in both 
 forms of disease. 
 
 Mr. Allan gives the following account of the master of a printing-office, who be- 
 came blind. He had corrected the press, and Avas otherwise engaged in reading, for 
 eighteen hours daily out of the twenty-four. He continued this practice for twelve 
 months, notwithstanding an evident failure of his sight.. At the end of that time the 
 amaurosis was so complete that he could not distinguish one object from anothu-r, 
 but was merely capable of just perceiving the light, so as to grope his way along 
 the streets. He continued in this state for several years, but ultimately recovered 
 his vision. 
 
 The next instance that I shall cite is recorded, in these words, by Mr. Lawrence. 
 "A young woman, of florid complexion and full habit, came to the London Ophthal- 
 mic Infirmary, complaining that she had lost the sight of one eye. She was a cook, 
 in a family, and occupied for several hours daily before large fires, supporting he' 
 strength by free living. The pupil was slightly dilated ; the iris motionless. A 
 faint and scarcely perceptible pink tint was observed in the sclerotica near the cornea. 
 Vision was dim, and had been so for three days. There were headache, flushed 
 countenance, heat of skin, whitish tongue, and thirst. 1 considered the case to be 
 pure retinitis ; and to afford a favourable opportunity for slwwing whether the affec- 
 tion could be arrested by antiphlogistic treatment. At that time (now many years 
 ago) I did not possess the knowledge of the power of mercury in inflammation of 
 the retina, which subsequent experience has given me. I directed a fuU bleeding 
 from the arm, free purging, low difet, repose of the organ, and general rest. At the 
 end of two days the sight was worse : cupping and a bhster were now ordered ; but 
 there was no improvement at the end of two daj's.more. I now determined on try- 
 mg mercury, and ordered two grains of calomel every four hours. Before the 
 remedy had affected the system, vision was quite lost, or at least reduced to the mere 
 power of distinguishing light from darkness. FuU salivation, which took place in 
 about a week from the first application of this patient at the infirmary, suspended 
 all the symptoms ; the sight immediately improved, and was soon completely 
 restored."
 
 AMAUROSIS. 215 
 
 A soldier, unacquainted with the proper method of observing an ecHpse of the 
 sun, employed fur that purpose a piece of opaque glass, with a transparent point in 
 its centre. Notwithstanding the vivid and painful impression he experienced from 
 the rays that passed through the lucid part of the glass, he continued to look at the 
 sun till the eclipse was over, using his right eye. He vi^as soon after seized with 
 vertigo, and pain in the right side of the head, and found himself almost entirely 
 deprived of the sight of the right eye. Some weeks afterwards, the pain in the 
 head continuing, he came under the care of Baron Larrey, who observed that the 
 vessels of the eye were injected, the pupil somewhat smaller than that of the other 
 eye, retaining, however, its natural freedom of motion ; the vision very obscure or 
 almost gone. This man recovered his sight completely after two bleedings, one 
 from the temporal artery, the other from the jugular vein ; blisters to the temple and 
 nape of the neck ; ice to the head, and moxas. — [Mackenzie from the Mtmoires 
 de Chirurgie.) 
 
 In the year 1833, a young man standing in a door-way, by a lamp-iron, in a 
 thunder-storm, was struck by the lightning, fell backwards, and was convulsed. He 
 t^aid afterwards that the lightning appeared to enter his eye with a scorchino- sensa- 
 tion. During the night, vision was quite lost. The next morning there was no red- 
 ness, nor any unusual appearance of the eye. The iris was motionless, however, 
 and the patient could not see even the sun. He was treated with calomel, and his 
 sight returned ; but the retina remained extremely irritable, and unable to bear the 
 light. A month afterwards, when this account was written, he could see distinctly 
 t-nough, but he could not use his eyes without the protection of blue glasses. — 
 {Lawrence.) 
 
 In these cases the nervous apparatus that ministers to vision is not, I believe, in 
 general, the only part of the nervous system that is injured. In August, 1839, 
 Phoebe Judge, a delicate-looking girl, eleven years old, became my patient in the 
 Middlesex Hospital. She had lost, in a great degree, the power of using her legs : 
 when she attempted to stand they separated, and she sank down. She had not per- 
 fect control over her bladder. The desire to make water was frequent, and if not 
 immediately attended to, the urine escaped in spite of her efforts to retain it. The 
 same urgency, and inability to wait, occurred whenever her bowels were about to act. 
 Sensibihty in the legs and thighs Avas impaired, but not extinct. 
 
 Her parents informed me that some time previously, while stooping to raise up a 
 sister in a room at Hampstead, she had been struck by lightning, fell backwards, 
 became blind, and remained so for ten days. She did not lose her consciousness, 
 but complained immediately that the lightning had hurt her eyes. They presented 
 no visible irijury or defect, but the upper lids fell, and she was unable to raise them. 
 It was soon found, however, that when pressure was made on the right eyelid she 
 could open the other eye. The palsy of her limbs commenced, by degrees, two 
 or three days afterwards. The power of vision returned suddenly, and at the same 
 moment the power of moving her limbs was restored ; but it gradually went again. 
 When she lay down, her limbs were still; but they began to femble, and to be 
 agitated as soon as she sat up. Even when lying in bed, she had occasionally a 
 sensation and dread, as if she were falling down. She had been in this state nearly 
 three weeks. 
 
 She was put upon steel, and a tonic plan of treatment, and in ten days she could 
 walk, dragging her left leg a little afier her. In ten days more she was dismissed 
 quite well, and able to run from one end of a long ward to the other. 
 
 The greater number of the cases of amaurosis depending upon a morbid condition 
 of the retina itself, belong to the class that I have now been mentioning: there 
 is congestion of the vessels of the retina ; or inflammation, chronic or acute. In a 
 few instances a totally opposite condition of the blood-vessels is presumed to exisi. 
 I say presumed to exist, because our judgment of this matter is founded, as before, 
 upon the nature of the circumstances that have caused the affection, and upon the 
 nature of the treatment that removes it. On these grounds some cases of amaurosis 
 (few in number, speaking comparatively) may fairly be ascribed to a deficient supply 
 of blood to the vessels of the retina. We know that a temporary defect of sight may
 
 216 DISEASES OF THE EYE. 
 
 be produced by a diminished circulation through the retina, as in approaching syn- 
 cope under hemorrhage ; and we can therefore the more readily believe that more 
 permanent amaurosis may be occasioned by causes that gradually lessen the quantity 
 of blood circulating in the body, and debilitate the whole system. " It is well known 
 (writes the late Dr. Gooch) that large losses of blood enfeeble vision. I saw a 
 striking instance of this in a lady who was flooded to death. When I entered the 
 chamber she had no pulse, and she was tossing about in that restless state which is 
 so fatal a sign in these terrific cases. She could still speak ; asked whether I was 
 come ? (she knew I had been sent for), and said, ' Am I in any danger ? — How dark 
 the room is ! I can't see.' The shutters were open, the blind up, and the light 
 from the window facing the bed fell strong on her face. I had the curiosity to lift 
 the hd, and to observe the state of the eye. The pupil was completely dilated, and 
 perfectly motionless, though the light fell full upon it. Who can doubt that here 
 the insensibility of the retina depended on the deficiency of its circulation?" 
 
 One might ask, also, who can doubt that the retina may become insensible from a 
 similar state of the circulation in it, brought on by some long-continued drain upon 
 the system ? Amaurosis of this kind, proceeding from too profuse and protracted a 
 secretion (which may be considered a sort of hemorrhage), is sometimes noticed in 
 nurses. Mr. Lawrence describes the case of a 3'oung mother of slender make, who 
 suckled her first child, which was strong, and look the breast very often ; her milk 
 was abundant. After two or three months she began to feel very weak, could not 
 lift a weight, and cried frequently, without having any moral reason for grief. She 
 became totally blind, and was led to his house by a friend. He found her pallid, 
 with a small feeble pulse. The pupils were of middle size, and the irides moved 
 slightly. The retina Avas completely insensible. She could not discern the situation 
 of the window, nor see a lighted candle held close to her. After weaning the child, 
 and using generous diet, she got perfectly well. Some counter-irritation was em- 
 ployed in this instance, but I question whether it had any thing to do with the 
 recovery. Such cases are not unconmion, and their well-known occurrence has 
 probably tended to encourage the notion — too prevalent among both patients and 
 practitioners — that amaurosis is always essentially a disease of debility, and requires 
 tonic and stimulant remedies ; bark, and high feeding, and strychnia, and electricity. 
 "Our eyes are iveak,^'' say they, "and we require strengthening medicines." You 
 must perceive from what has already been said, how necessary it is to discriminate 
 in such cases : to look closely into all the circumstances under which the disease has 
 occurred. 
 
 W'hen amaurosis is the resuU of pressure or of disease, in the course of the optic 
 nerve, or in the sensorium, the complaint is generally less within the power of reme- 
 dial measures. We cannot say, indeed, in many instances, where the cause of defect 
 lies : and in obscure cases, I should always advise a trial of the mercurial plan. I 
 have again and again seen slight palsy of some of the voluntary muscles, evidently 
 depending upon some morbid condition of the brain, clear away rapidly upon the 
 affection of the gums by mercury ; and the lost power of the retina will sometimes 
 return under similar treatment. 
 
 There is something very peculiar in the expression of countenance, and in the 
 gait, of an amaurotic person, by attending to which alone, you may almost recognize 
 his disease. He comes into a room with an air of uncertainty in his movements ; 
 the eyes are not directed towards the surrounding objects ; the eyelids are wide 
 open ; to use a strange but common and intelligible phrase, the patient seems gazing 
 upon vacancy — has an unmeaning stare ; and there is a want of that harmony of 
 •noveuu'iit and ex[)ression which results in a great measure from the information 
 Obtained by the exercise of vision. This seeming stare at nothing at all, is not 
 observed in patients who are blind in consequence of opacity of the crystalline lens 
 or its capsule, i. c, in consequence of cataract. They, on the contrary, while they 
 :^nnot see, still seem to look about them, as if they were conscious that the power 
 of sight remained to the retina, although light was shut out from it. 
 
 When the amaurosis is incomplete, the motions of the iris are sluggish, and the 
 [>upil is largfer than ordinary. When the bhndness is total, the commonest condition
 
 AMAUROSIS. 217 
 
 of the eye is that of great dilatation of the pupil, with complete immobility of the 
 iris. A mere ring of iris is all that is visible, and no change takes place in the 
 diameter of the pupil, under the greatest variation of the Hght that falls upon it. 
 
 Sometimes, on the other hand, though the amaurosis be total, the iris is as active 
 as ever; and this is a very interesting circumstance, and may help us, in some 
 degree, to conjecture the actual seat of the malady. When the amaurosis is con- 
 fined to one eye, this may happen. You examine the diseased eye, and you find 
 that the pupil enlarges, or contracts, as you diminish or increase the hght. But the 
 other eye is open. Shut the sound eye, and try the amaurotic eye again, and you 
 find the pupil fixed, although you vary the light. The motion you formerly noticed 
 was sympathetic of the motion of the iris in the healthy eye. We express this 
 otherwise by saying that the associated movements of the iris were natural and 
 iiveljr, but its independent movements were- lost. But sometimes the independent 
 movement is unaffected : nay, the motions of both irides may be perfect, although 
 both eyes are completely amaurotic. I may state, by the way, that cseteris paribus, 
 when both eyes are affected, that is a ground for supposing the cause of the disease 
 to be situate within the cranium. And I should come to the same conclusion if, in 
 the case where one eye alone was amaurotic, I found the independent motion of the 
 iris of that eye unimpaired. AVe know that in the healthy condition of the parts, 
 the brightness of the light admitted to the retina determines the size of the pupil ; 
 but the motions of the iris do not depend solely or directly upon the retina. It has 
 been ascertained, by experiments made upon animals, that the pupil may be made to 
 contract either by mechanical irritation of the optic nerve within the cranium, or by 
 irritation of the third nerve ; a motor nerve which sends filaments to the ophthalmic 
 ganglion, whence the ciliary nerves, passing to the iris, are derived. Now the optic 
 and the third nerves have some link of connection within the brain; and if the 
 morbid condition upon which the amaurosis depends is situate deeper than the point 
 of connection, we may understand, I think, how disease so placed may destroy the 
 power of vision, and yet leave the connection between the retina and the third pair 
 unafl^ected : and then the influence of light falling on the retina, though it fails to 
 create a perception in the mind, will be reflected back upon the third pair of nerves, 
 and so continue to govern the motions of the pupil. In conformity with these views, 
 jM. Andral relates cases in which amaurosis connected with disease in the cerebellum 
 was attended with brisk movements of the iris. 
 
 There are other causes of amaurosis besides those that I have already adverted to. 
 It is sometimes produced by the presence of worms in the alimentary canal. 
 
 [That amaurosis is frequently dependent upon irritations seated within the stomach and 
 bowels, and upon derangements of the digestive organs generally, there can be little doubt. 
 We liave met with many cases of this kind, and they are repeatedly referred to, more espe- 
 cially by the German writers on the disease. Children confined in ill-ventilated and ill 
 lighted apartments, and supplied with coarse and indigestible food, are often affected with a 
 certain degree of amaurotic blindness, which is readily removed by a proper hygienic treat- 
 ment, and such remedies as are adapted to restore the regular functions of the stomach and 
 alimentary canal. We have observed the disease, also, in children who have been at too 
 early an age, confined in crowded school rooms for many hours of the day, while their minds 
 were compelled to the performance of tasks beyond their powers. Complete blindness, we 
 have known suddenly to occur in consequence of the jiresence of indigestible food in the 
 stomach, and to be as quickly, removed upon its expulsion. For further information on this 
 subject, the reader is referred to the chapter on amaurosis by Ur. Taylor, in the 2d volume 
 of Tweedie's Library, Philadelphia edition, page 515, and to the very able paper of Dr. Jaoob 
 on the same subject in' the Cyclopa;dia of Practical Medicine, Philadelphia edition, vol. i. 
 page 78.— C] 
 
 It has some obscure connection with teething, probably through irritation of the 
 facial branches of the fifth pair. A physician of my acquaintance, residing in Lon- 
 don, has a young son, who on two or three occasions has caused him great uneasi- 
 ness, by becoming blind in one eye without any obvious cause, and with no visible 
 change in the organ; but the blindness on each occasion has gone off again, appa- 
 rently in consequence of the extraction of some teeth which had grown irregularly. 
 I am assured by Dr. Ashburner that such cases are common. Mr. Lawrence relarie* 
 
 T
 
 £18 DISEASES OF THE EYE. 
 
 a very singular instance of denfal irritation giving rise to amaunsis. A, man, thirty 
 years old, was suddenly attacked with violent pain in the left temple near the eye, 
 and in that side of the face generally. The pain continued to recur from time to 
 time, and at length he discovered that he was blind in the left eye. By and by the 
 cheek swelled, and some spoonfuls of bloody matter were discharged by a spontaneous 
 opening in the lower eyelid, and then the pain subsided ; but after some months it 
 returned with great severity. The patient then went to Wilna, with the intention 
 of having his eye extirpated, and consulted Professor Galenzowski, who found the 
 left eye totally insensible to light, with the pupil dilated, and no other visible altera- 
 tion. He ascertained, however, that the first molar tooth on that side was carious: 
 it had never caused the patient much uneasiness ; and the toothache which he had 
 occasionally suffered had not been coincident, in point of time, with the pains in the 
 head and eye. , Dr. Galenzowski thought fit to extract this tooth, and was greatly 
 surprised at seeing a small substance protruding from the extremity of its fang. This 
 proved to be a little splinter of wood about three lines in length, which had perforated 
 the Centre of the tooth, and had probably been introduced in using a wooden tooth- 
 pick. A probe passed from the socket into the antrum, from which a few drops of 
 a thin purulent fluid escaped. The pain ceased almost entirely, and on the same 
 evening the eye began to be sensible to light. The vision gradually improved, and 
 on the ninth day from that time, after thirteen months' blindness in that eye, he was 
 able to see with it as perfectly as with the other. M. Galenzowski has since been 
 in England, and he showed Mr. Lawrence the tooth, and the splinter of wood. 
 Doubtless he felt some pride in exhibiting these trophies of his exploit. 
 
 Amaurosis is said also to occur as an hysterical affection : and t am certain that I 
 have seen this myself. An unmarried lady, of a very nervous and susceptible habit, 
 came to town in great apprehension about her eyes, the sight of one of them being 
 quite gone. I could perceive no defect in the eye itself. I saw her in consultation 
 with Mr. Tra vers, who took an unfavourable view of the case, and thought the 
 chance of recovery was very slender. I had one reason for hoping a better result, 
 in the knowledge of some facts which Mr, Travers was not aware of till I mentioned 
 them to him. I had been acquainted with this lady for some years, and during that 
 period she had several times almost entirely lost, and again recovered, the use of her 
 lower extremities. On two occasions she had been affected with aphonia, and unablfe 
 to speak, except in a whisper, for months together ; and then, on a sudden, without 
 any apparent cause, her voice returned. I trusted, therefore, that this suspension of 
 the power of vision in one eye might be a similar freak ; and so it turned out. After 
 a {e\v weeks the sight returned, she knew not how; and she has since lost it a 
 second time, and a second time regained it. 
 
 Certain ])oisons will produce temporary amaurosis; and the suppression of certain 
 natural evacuations, as of the perspiration, of the rhenstrual fluid, and of the bleeding 
 from piles, and the repulsion of certain eruptions, have been charged, by authors, 
 with- producing tlie same complaint. 
 
 In those cases in which amaurosis creeps on slowly and insidiously, as it is apt to 
 do fi-on> various causes : and more particularly when it depends upon a low and. 
 chronic inflammation, engrafted upon habitual congestion of the vessels of the inter- 
 nal tunics of the eye;, its approach is marked by sundry curious affections of the 
 vision. The rye feels full or stiff, and sometimes there is pain of the head in its 
 neighbouihood; the patient complains that he sees things through a fog or mist, or 
 as if a thick piece of gauze were interposed between his eye and the object he is 
 looking at. In the daylight, the gauze or fog seems dulf and murky, but in the 
 dark it often appears shining, reddish and fiery : the flame of a candle is seen ^ur• 
 founded with a halo of prismatic colours. That amaurosis of this kind is often really 
 dependent upon local congestion we are taught by the hcdenlio, by the circumstances 
 that aggravate it: thus slrainins; of any kind, M'liich augments for the time the fiill- 
 ness of the vessels about the head, will make the mist appear more dense : the same 
 effect may be produced by tj'eingthe neckcloth tight; or even by stooping. Boerhaave 
 lelates the case of a man who, whenever he was intoxicated, laboured under com- 
 plete amaurosis : it came on by degrees, increasing according to the quantity of
 
 AMAUROSIS. 219 
 
 vi'ine he drank; and after the drunkenness went off, his vision returned. Surely 
 the^e phenomena are very illustrative of the way in which nervous disorders may 
 arise, or be made worse, from mere local plethora, in almost any part of the body. 
 
 Sometimes the perfect amaurosis is preceded by a remarkable diminution of the 
 apparent size of the objects looked at. A patient told Dr. Farre that a carriage, 
 which happened to pass the window, seemed to him as small as a wheelbarrow, and 
 the horses no bigger than dogs. More commonly ocular spectra become visible : 
 that. is, parts of the rej.ina lose their power, or perhaps are eclipsed by turgid vessels : 
 the patient sees flies in the air, muscse volltantes, particles of soot, blacks, as we, 
 who live in London, call them, which always float before his eyes, and seeiii to fol-' 
 low their. motions ; and which are especially plain and troublesome when he is look- 
 ing upon a white surface. They multiply in number till the whole becomes dark. 
 
 Do not, however, suppose that the appearance of these muscoe volitantes, even 
 Vvhen they are permanent, necessarily implies "(he approach of amaurosis. I should 
 oe sorry if it were so, for I see two of them every morning, when' my eyes are 
 directed towards a white basin, while I arti washing my'face. I can find them at 
 other times if I look for them ; else I am not sensible of their presence. They bode 
 no further evil, if they are associated with no other defect, in function or in appear- 
 ance, of the instrument of vision. 
 
 It is obvious that no particular rules, no rules, that is, which will fit all cases, can 
 be laid down for the treatment of so multiform a complaint as amaurosis. When it 
 manifestly results from disease of the brain, as when it accompanies hydrocephalus, 
 or remains after a stroke of apoplexy, our attention must be directed to the disease 
 from which it has sprung. When there is any reason to suppose that congestion or 
 chronic inflammation of the internal tunics of the eye itself is concerned in the pro- 
 duction of the amaurosis, we must adopt the measures that I have already described, 
 as the most likely to remove the congestion; and especially the mercurial plan. 
 When there is ground for suspecting that the blindness takes its rise in vascular 
 exhaustion, or nervous debility, we must have recourse to tonics ; bark, preparation? 
 of iron, nourishing diet, the cold' bath. 
 
 After all, you will find too many cases which will baffle your best-directed attempts, 
 and in which you will be required and warranted to try other expedients. When 
 what I may call rational measures have been expended in vain, you may have 
 recourse to such as are empirical and tentative. There are various stimulants which 
 have occasionally been found serviceable ; but most of them, I believe, fail much 
 oftener than they succeed. Electricity is one of these : it is applied by taking small 
 sparks from the eyelids, and from the integuments, round the orbit. The object of 
 this is to rouse the dormant energies of the impassive nerve : and it appears some- 
 tiniesHo do this for the retina, as well as for the nerves supplying voluntary mus- 
 cles. Mr. Ware tells us that electricity is most beneficial in those cases in which 
 amaurosis has succeeded a stroke of lightning. You must take great care .not to 
 employ this remedy when there is any inflammatory action at the bottom of the 
 complaint : it should seldom be tried therefore when the affection is recent. 
 
 S'lrycluiia has, of late years, been used for the cure of amaurosis. I shall here- 
 after take an opportunity of telling you the ordinary effects of that substance upon 
 the body, when given in a certain dose — what is its poisonous operation, and what 
 may sometimes be hoped from it as a remedy. In amaurosis it does good, when it 
 is useful at all, by stimiilating the exhausted or atonic nerve into action. With 
 respect to this remedy also I may say — first endeavour to ascertain that it is not 
 Jik( ly to do harm ; as it will be if the blindness depend upon any condition akin to 
 inflammation. Mr. Middlemore, of Birmingham, has probably given this remedy 
 an ampler trial than any other person, and he speaks very favourably of its effects 
 in certain cases : in others he found it to produce so much pain, and spasm, and dis- 
 tre.ss, that he was obliged to discontinue its use. It is not given, in these cases, by 
 the mouth, but applied locally ; and Mr. Middlemore considers that it is most efficient 
 when placed over the supra-orbitary nerve. He puts a narrow blister above the 
 eyebrow.; when it has risen he cuts off the cuticle, and applies a piece of linen, for 
 half an hour, to absorb the serum that continues to ooze forth ; then he spnnkles fJJB
 
 220 DISEASES OF THE BRAIN 
 
 Strychnia, finely powdered, upon the raw part, and covers it with linen smeared with 
 the iinguentum cefacei. He repeats this every twenty-four hours, cautiously increas- 
 ing the dose till the vision improves, or some sensible evidence of ihe agency of the 
 strychnia becomes apparent. He commences with the sixth part of a grain. 
 
 I must here leave the subject of diseases of the eye. 
 
 In addition to the lessons which I pointed out before as capable of being learned 
 by attending to the disorders of this small organ, I may now mention a few "others, 
 of no little moment, since we shall meet with their application again and again, as 
 ^ye proceed to investigate the morbid conditions of other parts. We have seen 
 enough to convince us that mercury, properly administered, has the invaluable 
 power of stopping adhesive inflammation ; of arresting the effusion of coagulable 
 lymph from the blood-vessels : that inflammation of a given part may be sensibly 
 modified by the simuUaneous agency of some specific poison upon the system, as 
 that of syphilis ; or by the presence of constitutional tendencies to disease, such as 
 •ire observable in gouty and rheumatic people. And we have seen that the func- 
 tions of a nerve may be perverted; suspended, or abolished, in various ways : by 
 pressure made upon it; by a plethoric state of its blood-vessels, or by an empty 
 state of them; by injiammation of its texture, chronic or acute : and even, in some 
 mysterious, or hitherto unexplained manner, by mere irritation of a distant part; by 
 Avorms, for example, in the alimentary canal ; by poisorious substances introduced 
 into the stomach: and by what, in oiir ignorance,. we denominate the freaks and 
 caprices of hysterical disorder. All these lessons we shall find repeated, as the 
 course advances. 
 
 LECTURE XXI. 
 
 Diseases of the Brain and Nervous System. Difficulties of the subject. Short 
 Revieiv of some points in the Physiology of the Brain and Nerves. Peculiarity 
 of the Cerebral Circulation. Pressure. 
 
 Having considered some of the most important disorders of the ej-e, because they 
 afforded me the means of illustrating many of the doctrines and principles, which I 
 had previously endeavoured to lay before you, o^ general pathology, I go next to the 
 diseases of that portion of the body, which, though it includes many distinct parts, 
 is called, collectively, the head. I pass over the maladies to which the integuments 
 of the head are liable, because they will fall more naturally and conveniently into 
 the class of cutaneous disorders ; and I come at once upon one of the most interest- 
 ing, and at the same time most difficult and obscure subjects of special pathology — ■ 
 that which embraces the 'diseases of the brain and nerves. Though it will be a 
 slight departure from the plan I have proposed of taking diseases as they affect dif- 
 ferent parts of the body from the head downwards in succession, I shall speak of 
 diseases of the spinal cord, and of the nervous system generally, in connection with 
 'Jiose of the brain. To disunite them would neither be easy nor useful. 
 
 The study of the maladies and disordered conditions of the brain and nervous sys- 
 tem, h surrounded with peculiar difficukies : and, accordingly, our knowledge of 
 these diseases is less- precise than of the diseases of most other parts of the body. 
 
 1. One source of difficulty lies in the circumstance, that the structure of the ner- 
 vous system has no perceptible or understood subservience to its functions. We do 
 not discover in the mechanism of this system that adaptation of means to an end 
 which is so conspicuous in many other parts of the body : and consequently, though 
 such adaptation doubtless exists, we are not able to trace the reason or the manner 
 tjf its interruption. We find in the lungs an apparatus of tubes and cells fitted fo) 
 che reception of air, upon the expansion of the chest by the contraction of certain 
 muscles ; of which muscles also we can see and understand the action. If we meet, 
 vilh any obstruction of these tubes, or any obvious impediment to the play of thosi
 
 AND NERVOUS SYSTEM. 221 
 
 muscles, we perceivt at once how and why the function of respiration is deranged. 
 But no alterations that becgnoe visible, after death, in the brain or spinal marrow, 
 afford us any explanation of the interruption of their proper functions; which are, 
 in^hree words, sensation, thought, and motion. An apoplectic cell has no relation, 
 direct or inverse, that we are capable of appreciating, with a sentiment ; nor a dis- 
 tended lateral ventricle with the exercise of the will. The morbid anatomy does not 
 in any degree elucidate the disorder, simply because the natural structure throws no 
 light upon the healthy office of the parts concerned. 
 
 2. It is a further source of difficulty, that physiologists have not yet been able to 
 determine, with any thing like precision or certainty, what share the several parts 
 of the brain and spinal cord have in regulating, respectively, the functions which all 
 physiologists acknowledge to belong to the nervous system in the aggregate.. There 
 are many and convincing reasons, for believing that the brain is a complex organ ; 
 but we. can seldom put our finger upon this or that portion of the nervous m.atter 
 which composes it, and say, here resides the influence that governs this or that par- 
 ticular function. 
 
 3. Again, the brain and cranio-spinal axis are so encased by their bony coverings, 
 that, in the living body, we are unable to ascertain their physical conditions by 
 jneans of any of our senses. Of many parts of the frame we ascertain the state by 
 the sense of sight ; and of many parts that we cannot see, we still may recognize the 
 changes by the faculty of touch, or by the ear. The brain and spinal cord we can 
 neither see, nor hear, nor handle. 
 
 4. Besides these obstacles to the acquisition of information by. the exercise of our 
 Own senses, concerning the organs affected, the very disturbance of the functions of 
 the brain cuts us off, in many cases, from that kind of information which we might 
 otherwise derive from the statements of the patient himself. 
 
 5. There is a still greater cause of perplexity, with which we have to contend. 
 The very same symptoms accompany alterations of the brain apparently of a very 
 different, nay of the most opposite kind ; and on the other hand, changes of struc- 
 ture, which, as far as we can perceive, are absolutely identical in their nature, are 
 associated, in different cases, with totally different symptoms; and more frequently 
 than not, nervous diseases are attended with no alterations of structure, appreciable 
 by our senses, 
 
 6. And lastly, we are perpetually asking ourselves, when we find the proper func- 
 tions of the nervous system disordered, — is this disorder the result of disease in the 
 nervous matter itself? or is it merely sympathetic of disease in other parts? for there 
 are few diseases of any kind which do not, in some degree, modify or disturb the 
 due exercise of the offices of the brain and nerves: and it is very difficult often, 
 and. sometimes it is impossible, to determine whether, and how far, the disturbance 
 is primary or' secondary. 
 
 With all its difficulties, however, the pathology of the brain and nerves is always 
 full of interest. How can it be otherwise, when we reflect that the nervous system 
 is the medium through which we hold comnmnion with the world around us; the 
 stage upon which all the phenomena of animal life are transacted : the instrument 
 of the mind ? 
 
 And '.vith all its difficulties, there is also a good deal in the pathology of tJie brani 
 and n<'rves that is fairly made out and well understood ; and we are at present in the 
 right way for advancing our knowledge of this intricate and mysterious subject, by 
 that careful collection of facts, and rigid induction of particulars, that will lead, at 
 length, to a safe and useful generalization. 
 
 I shall endeavour to point out to you what is known of the morbid conditions of 
 the nervous system ; I shall also state the conjectures and probabilities by which our 
 judgment and practice must be guided,' when absolute certainty is unattainable. 
 With mere speculative questions, that have no practical beanng, I sna.l meddle aa 
 little as I can. 
 
 Our knowledge, I say, of the exact functions of the different parts of the nervous 
 apparatus, is scanty and imperfect. Some certainties, however, we possess ; an 'I 
 
 t2
 
 222 DISEASES OF THE BRAIN 
 
 some strong probabilities which almost amount to certainties. Without first ex- 
 pounding mj' creed upon these matters, it Avould be inipossible for me to explain, as 
 it would be for 3'ou to understand, the notions I entertain respecting /many of the 
 diseases of the brain and nerves. 
 
 Omitting the sympathetic nerve and its ramifications (for we know but little of 
 its office, and still less of its disorders), the nervous system is made up of certain 
 rnasses of nervous matter, called the nervous centres; and of ?je?T'e^ therewith con- 
 nected. 
 
 The nervous centres consist of the cerebrum and cerebellum, the medulla ob 
 longata and the medulla spinalis. I shall include the cerebral hemispheres, and the 
 lobes of the cerebellum, under the common term, the brain. So I shall speak of 
 the oblong and of the spinal-marrow, in the single phrase, the spinal cord, or. the 
 craniospinal axis ; their endowments appearing to differ more in relation and de- 
 gree, than in kind. 
 
 I adopt the belief that the gray (which are much the more vascular portions of 
 these nervous centres, form the part in which their peculiar powers reside, or are 
 generated ; and that their white or fibrous portions are, like the white and fibrous 
 nerves, mere conductors of the nervous influence. 
 
 I incline, also, to the opinion (recollect, if you please, that I do not press these 
 opinions of mine upon you as being necessarily correct) that the influence which 
 originates in the gray matter, and is transmitted by the white, will at last be found 
 to consist in, or to be closely connected with, some modification of electricity; We 
 know that some of the effects of this influence may be very exactly imitated, in ani- 
 mals recently dead, by galvanism. 
 
 The functions of the brain and nerves are sensation, thought, volition, and the 
 power of originating motion. Other functions indeed there are ; but these four are 
 all that we need, at present, concern ourselves with. 
 
 Now, it is a part of my creed, that the faculties of sensation, of thought, and of 
 the will, belong to the brain : in all probability to the cerebrum alone. The precise 
 office of the cerebellum is involved in much obscurity and dispute. Some of the 
 opinions that have been formed respecting it, I shall notice hereafter. , 
 
 The chief grounds for beheving that the brain proper is, exclusively, the- instru- 
 ment of the mind, are these : — 
 
 1. Because this portion of the nervous centres is superadded to the cranio-spinal 
 axis, in the greatest bulk and most comphcated form, in man : and after him, in those 
 of . the inferior animals which show the largest share of reason. r 
 
 . ■2. Because, in inferior animals which evince a certain amount of mental endow- 
 ment, all manifestation of intellect ceases upon the gentle and gradual removal of 
 the cerebrum and cerebellum : the animals continuing to live, for a long time, not* 
 withstanding this mutilation. 
 
 , Again, it forms part of my creed on these subjects that the motive power resides 
 m the spinal cord. 
 
 The muscles furnish the instruments of motion. 
 
 Now there is a certain class of muscles which contract without our willing theii 
 contraction : and generally without our being conscious that they are contracting, 
 Such are the heart, the njuscular fibres of the alimentary canal, and of the bladder. 
 These are, therefore, called involuntary muscles. 
 
 There is another large class of muscles which obey the bidding of the will, and 
 .serve the purposes of prehension, locomotion, and bodily effort. These are consi- 
 dered and called voluntary muscles. 
 
 There is still another distinct set of muscles, of which the habitual action is invo- 
 luntary, yet which submit also to the interposing control of the will. You will 
 'all to mind at once the muscles of respiration, which act while we are asleep, or 
 otherwise unconscious ; and the sphincters, which regulate the entrances and outlets 
 of th') body. Here, I say, the habit is involuntary, but the occasional action is 
 prompted and governed by volition. But sometimes the involuntary action rebels 
 njjainst thp willed action, and overcomes it. The muscle contracts in spite of tho 
 ATii:
 
 AND NERVOUS SYSTEM. 223 
 
 Nay, those muscles which, ordinarily, move only in obedience to voliiion, do 
 sometimes, under the influence of strong emotion, or of disease, contract independ- 
 ently of any effort of the will, and even in opposition to, and defiance of, the volun- 
 tary power. 
 
 Under certain circumstances the limbs move with much briskness and force in 
 decapitated animals, in Avhich sensation and volition are extinct. Some physiologists 
 hold, indeed, that sensation and volition are properties of the spinal cord ; and they 
 would object to these cases, that no one is warranted in afiirming the movements in 
 question to be independent of the will. The animal has no means of informing us 
 whether it feels or not, any more than the human head that has been severed by the 
 axe or the guillotine. 
 
 This point, however, has been settled by certain phenomena which are observed 
 to occur, in the human body, under disease. Limbs completely palsied as to volun- 
 tary motion, and quite dead as to sensation, do yet, under certain conditions, contract 
 and move when the integuments are pinched ; the rational patient not feehng the 
 pinch, and not being conscious of the movement. 
 
 Whence does the impulse that leads to motion in these cases proceed — how is the 
 motive power awrkened ? 
 
 The answer to this physiological question has a most important bearing upon the 
 pathology of the nervous system. 
 
 It is no part of my purpose to enter into any history of the steps by which this 
 curious problem has been worked out. Its solution is an achievement of our own 
 time ; and I may add, of our own country. I profess no more than to sketch, in 
 mere outline, the leading facts that have been ascertained ; yet I must, in passing, 
 pay the tribute due to one indefatigable labourer in this department of science, 
 whose sagacity has enabled him to seize the clue, and in a greiat measure to unfold 
 the mazes of the labyrinth in which this part of the physiology of the nervous system 
 was so long entangled. Dim and uncertain glimmerings of the truth appear in the 
 writings of bygone authors, but it was never clearly discerned, and plainly stated, 
 and successfully applied to the elucidation of a large class of disorders, until the 
 publication, in 183*^ or 1833, of Dr. Marshall Hall's ingenious and most interesting 
 researches into " the functions of the medulla oblongata and spinal cord." Similar 
 views appear to have suggested themselves, about the same time, to Professor MuUer 
 of Berlin. I must recommend you to study the works of these authors; and Imay 
 also point out, as fit writings for your perusal (since the doctrines I am now speaking 
 of are comparatively new), Dr. Grainger's Observations on the Structure and 
 Functions of the Spinal cord; Dr. Carpenter's two works. Principles of General 
 and Comparative Physiology, and Principles of Human Physiology : and a very 
 able paper on the Pathology of l^he Spinal Cord, by Dr. William Budd, in the 22(1 
 volume of the Medico-Chirur gical Transactions. 
 
 If, on the other hand, you wish to see how nearly the idea, which has been so 
 happily simphfied into an intelligible principle by Dr. Hall, was reached by earher 
 observers, you may consult the writings of Dr. Whytt, upon nervous diseases. 
 
 What, then, respecting this intricate subject, are the main facts and doctrines 
 which modern research has made clearer ? 
 
 It seems ascertained, that the movements of those muscles which acknowledge the 
 empire of the will, depend essentially upon some momentary change in the condi- 
 tion of the spinal cord. This change (whatever may be its nature) is capable of 
 being effected in three several ways. 
 
 First, volition, or emotion, originating in the brain, may send down an influence 
 which travels with electrical rapidity to the spinal cord : whence, the renuisite change 
 having been instantly produced, the motive influence passes, with proportional speed, 
 along the nerves which connect the cord with the muscles to be moved. 
 
 Secondly, the change productive of motion may be wrought in the cord, whethei 
 the brain be attached to it or not, by mechanical, chemical, or electrical agencies, 
 operating directly upon the cord itself. 
 
 Thirdly, the change productive of motion may be wrought in the cord, bv an
 
 2'M DISEASES OF THE BRAIN 
 
 influrncc carried to the cord, not from the brain, but from the extremiiies of nerves 
 distributed upon the internal and external surfaces of the body, 
 
 The action of this nervous circle, whereby, I say, an influence is first carried from 
 the surfaces of the body, along nerves to the spinal cord — whence again an influence 
 is transmitted, or reflected, as it were, to certain muscles along certain other nerves— ^ 
 has been called by Dr. Hall the reflex function of the spinal cord. The apparatus 
 subservient to this function is named by him the excito-motory system; the nerves 
 which carry the impression to the cord are incident or cxcitor nerves; those which 
 convey the motive imj)ulse froin the cord, reflex or motor nerves. Dr. Carpenter's 
 terms (which I like better, except for their similarity in sound) are querent and 
 efferent nerves. 
 
 Mr. C4rainger believes that physiology indicates, and anatomy can exhibit, four 
 sets of fibres belonging to the nerves and the nervous centres. Sensiferous, S-wA 
 volition nerves, connected with the gray substance of the cerebrum and subordinate 
 to the exercise of feeling and of the will ; awA incident and reflex nerves, connected 
 with the gray matter of the cord, and belonging to the excito-motory system. 
 
 Whether this be the true state of the case, or whether the efiexent fibres be the 
 game, while the afll;rent fibres are difl^erent ; the latter coming to the spinal marrow 
 both from the brain and from the various surfaces, just as two trains may arrive at 
 Euston Square ultimately by the same rail, although tlie one starts at. Derby and the 
 other at Birmingham; or (which- is perhaps the better illustration) just as, in some 
 houses, the same bell is made to ring in the servants' hall by pulling, indifferently, 
 the dining-room or the drawing-room rope : — which of these two hypotheses is the 
 more correct, I am not competent to determine. 
 
 This reflex action, independent of the will, and although attended often by con- 
 sciousness and sensation, yet often also exercised when there is neither, governs the 
 orifice by which air and food are introduced, and excrements are voided. The 
 infant breathes and sucks by it; the adult uses his will for bringing nutriment into 
 his mouth ; in both, the act of deglutition, after the food has reached a certain point, 
 is involuntary. The expulsion of the feces, the urine, the semen, and the foetus, is 
 regulated by the same function. Nevertheless, most of these, muscular acts are 
 capable of being moderated and directed by volition. The reflex power, on the 
 other hand, extends, both in health and in disease, to the entire system of the strictly 
 voluntary muscles ; during health it is manifested only in the maintenance of what 
 is called their tone, their natural tension and firmness : in disease, as we shall here- 
 after see, it sometimes acts upon them with terrific energy. 
 
 Some of the difficulties which I enumerated in the beginning of the lecture, as 
 impeding our researches into the diseases of the nervous centres, are insurmount- 
 able. One or two of them, however, appear to call for a more attentive consideration. 
 
 I say we often fail to discover any deviation from the natural condition of these 
 nervous centres, or of their appendages; even when the disorder of their functions 
 has been broadly displayed. ' 
 
 We tire not to infer, from this, that no change has taken place in these parts. 
 The only legitimate conclusion is, that the nervous functions are liable to be deranged, 
 impaired, or suspended, by altered conditions, not traceable by our senses, or at least 
 not yet discovered by us, of the organs which minister to those functions. 
 
 There may be only one such undiscovered disturbing cause, variable in degree in 
 difll'rent cases ; or (what is more probable) there may be several such conditions 
 differing in kind. A blow or fall, which jctrs the brain ; a sudden mental emotion ; 
 an electric shock ; a teaspoonful of prussic acid ; any one of these causes may de- 
 stroy life, yet leave no vestige of its action in the nervous substance upon which it 
 operates. It is probable that the fatal condition is not, in each case, the same. 
 
 We may even form a reasonable conjecture of the manner in which the invisible 
 changes are sometimes brought about. We can conceive, for example, that undue 
 pressure upon the nervous pulp on one hand, or insufficient pressure on the other, 
 may constitute conditions of the kind we are in search of; and I shall be able, I 
 think, to convince you that such is sometimes the case. Again, we can conceive
 
 AND NERVOUS SYSTEM. 225 
 
 that such conditions may be furnished by the varying state of the cerebral circulation. 
 In point of fact, we kno7V of some changes m the circulation through the brain 
 which have the effect, invariably, first of modifying, and at length, if they are con- 
 tinued, of arresting, the cerebral" functions. If no blood be sent through the arteries 
 of the brain, death°in the way of syncope ensues ; if venous blood circulates in those 
 vessels, it leads to death by coma. 
 
 But whatever may be the nature of the unknown, and perhaps fugitive, physical 
 conditions of the nervous centres, thus capable of disturbing or abolishing their func- 
 tions, it is useful to keep in our minds a distinct and clear conception of the fact that 
 there must be some such physical conditions. By steadily retaining this idea of 
 their real existence, we may hope, at length, to get some insight into their nature ; 
 which we are the less likely to obtain, if we dwell only on the obvious and visible 
 injuries effected in the nervous substance ; associated, as they are apt to be, with so 
 perplexing a diversity of symptoms. Indeed, by the help of this distinct conception, 
 we are at once enabled to reconcile some of the seeming anomalies and inconsisten- 
 cies to Avhich I before adverted. The same symptoms, I repeat, have been found to 
 accompany phj'sical lesions of die nervous centres, apparently different in kind, 
 place, and degree: and, on the contrary, physical lesions, apparently identical in 
 their nature, extent, and situation, are attended by different and contradictory symp- 
 toms. We must not attribute the symptoms, in such cases, to the visible physical 
 lesions, but to some unperceived condition of the nervous centres, concomitant with 
 those lesions. The proximate cause of the symptoms escapes our notice. The 
 obvious physical changes may be remoter causes of the symptoms — causes of this 
 proximate cause : but they may also be merely cotemporaneous effects of some other 
 remote agency. 
 
 I have adverted to deviations from the natural and healthy circulation of the blood 
 through the brain, as being capable of modifying the nervous functions. Of such 
 deviation, one mode which is conceivable, and which has been assigned as a pre- 
 sumed cause of morbid phenomena, is a variation in the relative quantity of blood 
 contained respectively in the arteries and veins that He within the cranium. And it 
 seems probable enough that a healthy condition of the cerebral circulation may imply 
 and require a certain balancing and adjustment of the amount of blood carried in 
 hese two sets of vessels. But with this theory — that disturbance of the functions 
 of the brain may result from an altered ratio of the arterial and venous blood therein 
 — has been associated another; namely, that although the blood may, at different 
 times, be variously distributed between the cerebral veins and arteries, yet that the 
 absolute quantity of blood circulating within the cranium is always and necessarily 
 the same, or nearly so. 
 
 This notion, broached by the second Monro of Edinburgh, and upheld (as it then 
 seemed) by experiments performed upon animals by Dr. Kellie, received at a later 
 period the sanction and approval of Dr. Abercrombie. And, resting upon such 
 authority, I have been in the habit of delivering the same theory, not, however, with- 
 out some misgiving as to its soundness, in these lectures. It has been completely 
 overthrown, of late, by Dr. George Burrows. 
 
 The doctrine was this. The brain is closely shut up in an unyielding case o\ 
 bone. Its surfiice must therefore be exempt from the influence of atmospheric 
 pressure. Hence, supposing its substance to be unaltered and incompressible, it 
 would seem impossible to empty the blood-vessels of the brain. The cavity being 
 completely full, the blood which circulates in those vessels can neither be materially 
 increased, unless something is displaced or compressed to make room for tho addi- 
 tion ; nor materially diminished, without the entrance of something to supply the 
 place of the blood substracted. 
 
 Dr. Kellie noticed that while, in animals bled to death, the other ^Jrganb of the 
 body were emptied of their blood, and blanched — the brain presented its ordinary 
 appearance, and even seemed to contain more blood in its superficial vessels than 
 usual. Having satisfied himself upon this point, he varied his experiment. He first 
 made a small opening in the skull, by means of the trephining instrument, takmy 
 15
 
 226 DISEASES OF THE BRAIN 
 
 away a little circular piece of bone, and then he bled the animals until they died : 
 and in these cases he found that the brain was as completely drained of red blood as 
 the rest of the body. He did that with respect to the cranium which housekeepers 
 do when they tap a barrel of beer. You know that if the barrel be quite full, you 
 may introduce a fawcet at its lower orifice, but no beer will run out through it. The 
 pressure of the atmosphere operates upon that portion only of the fluid which is now 
 exposed to the air, and its effect is to keep the beer in. But if j'ou bore a small hole 
 with a gimlet through the top of the cask, and so admit air to the upper surface of 
 the beer, it will then flow readily through the lower outlet. Dr. Kellie imitated this 
 process of making a vent-hole, when he trepanned the skulls of sheep, and admitted 
 air to the yielding membranes of the brain. 
 
 He availed himself, also, in these researches, of what he considered the converse 
 experiment. He desired to ascertain whether, under circumstances calculated to 
 gorge the vessels of the head, those of the brain were or were not made really more 
 full than usual. With this object he examined the brains of two men who had 
 been hanged. When the scalp in these cases was divided, a great quantity of blood 
 escaped ; marking plainly enough the congestioniBf the vessels exterior to the era- 
 niinn, but there was no such congestion observable tvifhin. " The sinuses contained 
 blood, but in no extraordinary quantity ; the larger vessels on the surface and be- 
 tween the convolutions were but moderately filled ; and the pia mater was, upon the 
 whole, paler, and less vascular than we often find it in ordinary cases." Similar 
 appearances have been noticed by myself. I paid particular attention to the condi- 
 tion of the head during the examination, below-stairs, of the body of Bishop, the 
 murderer of the Italian boy. When the corpse was brought hither after the execu- 
 tion, the eyes were blood-shotten, and the lips and countenance turgid and hvid. The 
 inner surface of the scalp, when it was turned back, and the exposed surface of the 
 skull, were very red and bloody ; and in one part, on the right side of the head, 
 there was some blood exfravasated. But when the bone had been sawn through, 
 and the skull-cap removed, the large veins of the brain did 7iot appear unnaturally 
 full. 
 
 In the year 1826 I was present in St. Bartholomew's Hospital, at the opening of 
 the head of a woman who had been hanged the day before, for murder. I find the 
 following statement in a note which I made at the time. " The scalp was bloody, 
 but the brain w^as of very natural texture and appearance, and not more than com- 
 monly full of blood." 
 
 Among the propositions deduced by Dr. Kellie from his observations and experi- 
 ments were the following : — 
 
 1. That in the brains of animals that hr.ve died of hemorrhage, there is no lack 
 of blood, but, on the contrary, very often a state of venous congestion. 
 
 2. That congestion of the cerebral vessels is not met with in those cases in which 
 we should most expect to find it ; in persons, for example, who die strangled. 
 
 8. That the quantity of blood in the cerebral vessels is not afl"ected by gravitation: 
 in other words, that it remains the same, whatever may be the posture of the body, 
 and the position of the head. 
 
 Dr. Burrows, distrusting the whole theory, and unsatisfied with the experiments 
 by which it was fortified, determined to repeat them, taking care as much as was 
 possible, to exclude every conceivable source of fallacy : and he has shown, most 
 convincingly, that Dr. Kellie's conclusions were erroneous. 
 
 First, he demonstrated that hemorrhage has a most decided effect in depleting the 
 cerebral blood-vessels, and in reducmg the quantity of blood within, as well as upon 
 the outside of the cranium. Two well-grown rabbits were killed : the one (A) by 
 opening the jugular vein and carotid artery on one side of the throat ; the other (B) 
 by strangulation. Round the throat of the first, as soon as it was dead, a ligature 
 was tightly drawn, to prevent any further escape of blood from the -essels of the 
 head. 
 
 " The contrast between the two brains in point of vascularity, both on the surface 
 and m the interior, was most striking. In the one, scarcely the trace of a blood- 
 vessel could be seen ; in the other, every vessel was turgid with blood."
 
 AND NERVOUS SYSTEM. 227 
 
 He next investigated the effect of posture upon the condition of the intercranial 
 ressels. 
 
 •'Two full-grown rabbits were killed by prussic acid; and while their hearts 
 were still pulsating, the one (C) was suspended by the ears, the other (D) hy the 
 hind legs. They were left suspended for twenty-four hours ; and before they were 
 taken down for examination, a hght hgature was placed round the throat of each 
 rabbit, to prevent, as effectually as was possible, any further flow of blood to or from 
 the head, after they were removed from their respective positions. 
 
 " In the rabbit (C) the whole of the external parts of the head, the ears, the eye- 
 balls, &c., were pallid and flaccid ; the muscles of the scalp and bones of the cra- 
 nium were also remarkably exsanguine. Upon opening the cranium, the membranes 
 and substance of the brain were pallid, the sinuses and other vessels were exsanguine 
 — ancemic beyond my expectation. 
 
 " In the rabbit (D), the external parts of the head, the ears, eyeballs, &c., were 
 turgid, livid, and congested. The muscles and bones of the cranium were of a dark 
 hue, and gorged with blood, which at some parts appeared extravasated. Upon 
 opening the cranium, the membranes and vessels were dark, and turgid with liquid 
 blood ; the superficial veins were proininent, the longitudinal and lateral sinuses 
 were gorged with dark blood, and there was straining of the tissues, if not extrava- 
 sation of blood into the membranes. The substance of the brain was uniformly 
 dark, and congested to a remarkable extent." 
 
 From these experiments. Dr. Burrows draws the logical inference, that " the 
 principle of the subsidence of fluids after death operates on the parts contained 
 Within the cranium, as well as upon those situated in the thorax or abdomen." 
 
 And of that absence of vascularity sometimes observed within the skulls of 
 persons who have died of strangulation, he offers a very satisfactory explanation. 
 
 In the first place, the cerebral vessels are, in some instances, highly congested. 
 Something will depend upon the position of the rope; which may press unequally 
 upon the jugular veins on the opposite sides of the neck, leaving one of them more 
 or less pervious. 
 
 " But there is another still more efficient cause of the occasional absence of con- 
 gestion of the cerebral vessels after death by hanging. It is the subsidence of the 
 Jlidd blood after death, while the body is yet suspended, through the cervical 
 vessels which are not completely obliterated by the pressure of the cord. And, it 
 should be recollected, there are some channels which are scarcely, if at all, affected 
 by the compression of the rope. These other channels are the vertebral sinuses, 
 and special plexus of veins, so ably dehneated by M. Breschet." 
 
 Moreover, the manner in which the corpse is generally examined, proves an ad- 
 ditional source of fallacy. All the great vessels of the neck are usually cut across, 
 and the viscera of the thorax removed from the body, before the skull is opened. 
 Then, while the head is elevated, during the operation of taking off the calvarium, 
 and examining the brain, the blood, still fluid (as it almost always remains, after 
 sudden death of any kind,) "gravitates from the cranium, and pours from the 
 divided cervical vessels into the chest." 
 
 By this refutation of a prevalent error, not unlikely to warp or mislead our 
 practice in some cerebral disorders. Dr. Burrows has done the science of medicine 
 an essential service. 
 
 The theory which he has demolished involved probably more than one erroneoiu 
 assumption. Dr. Burrows thinks that the anatomical structure of the human cra- 
 nium does not warrant the opinion that its contents are withdrawn from the pressure 
 of the atmosphere. " The numerous fissures, and foramina, for the transmission of 
 vessels and nerves through the bones of the cranium, appear to me (he says) to do 
 away with the idea of the cranium being a perfect sphere, like a glass globe, to 
 which it has been compared by some writers. If there were not always an equi 
 hbrium of pressure on the parts within and without the cranium, very serious 
 consequences would arise at the various foramina of the skuU." 
 
 We fall back, therefore, upon another principle, whereby some of the difficulty 
 and obscureness which attend certain affections of the brain and nerves may \^
 
 228 DISEASES OF THE BRAIN. 
 
 explained. 1 mean the principle of varying jrressure upon the nervous substance 
 Physiologists say that the cerebral matter is incompressible. This is another of the 
 questionable assumptions implied in the foregoing theory. Upon what grounds the 
 opinion may rest, I am ignorant : but whether the brain be compressible or not, 
 whether, that is, it be or be not reducible by pressure into a smaller compass, it is 
 clearly capable of having different degrees of pressure applied to it, and of being 
 pressed out of its ordinary form. We shall see, hereafter, that by pressure exercised 
 from within, by the distension of what are called the ventricles of the brain, the 
 convolutions on its surface are sometimes flattened, and the natural furrows between 
 them nearly effaced. Pressure there certainly is in what I shall have to describe 
 to you as hypertrophy of the brain. There must be considerable pressure on the 
 nervous pulp when blood is poured out within it from a ruptured artery in cerebral 
 hemorrhage. But the phenomena noticeable when a portion of the skull has been 
 removed by the trephine, show very clearly that the encephalon sustains pressure 
 from the varying states of the circulation during perfect health. The surface of the 
 brain, seen through the circular opening in the bone, is observed to pulsate ; and to 
 pulsate with a twofold motion. With every systole of the heart, the surface pro- 
 trudes a little ; and it again subsides with the succeeding diastole. This shows 
 that the tension of the arteries, produced by every contraction of the ventricles of the 
 heart, exerts a degree of pressure upon the contents of the cranium. But the brain 
 has an alternate movement also, corresponding with the movements of the the rax in 
 breathing ; rising with every act of expiration, and sinking with every act of inspi- 
 ration. Now, during expiration, the blood escapes less freely from the head through 
 the veins ; and thus again vascular fulness is found connected with evidence of pres- 
 sure on the parts within the head. In further proof of this, if any were needed, I 
 may again refer to Dr. Kellie's experiments. He removed a portion of the cranium 
 of a dog by the trephine. The brain was observed to rise and fall alternately, but so 
 as always to fill the cranium; the rise being marked by a sort of protrusion through 
 the hole that had been made. One of the carotid arteries was now opened, and in a 
 minute or two afterwards there was an evident gradual sinking and receding of the 
 brain from the margin of the bone. So, likewise, when the blood was flowing from 
 the rabbit (A) in Dr. Burrows' experiment, "the conjunctiva was observed to 
 become pallid, and the eyeballs to shrink within the sockets.^^ 
 
 It is certain then that, whether the cerebral pulp yields to it or not, there is a 
 constant alternation of a greater and a less compressing force, exerted upon it, during 
 life. It is not improbable that this continual variation of the compressing force may 
 be essential to the performance of the cerebral functions. May not the brain 
 be thus incessantly charged, if indeed it be (as has been suggested by no less a 
 philosopher than Sir John Herschel) "an electric pile, constantly in action," dis- 
 charging itself by the nerves, at brief intervals, " when the tension of the electricity 
 developed reaches a certain point?" However this may be, it is equally certain that 
 the compressing force may transgress its natural limits, in either direction ; may be 
 too great or too little. The functions of the nervous centres may be perverted, or 
 lost, when the pressure becomes excessive : or, on the other hand, when the pressure 
 is insufficient. 
 
 It IS plain that excess of pressure may cause fatal coma, or defect of pressure fatal 
 syncope, and yet no evidence of the operation of these causes be left in the dead 
 brain. And we may explain, by the help of this same theory of pressure, a very 
 singular phenomenon observed in certain forms of cerebral disease ; I mean the 
 occasional recurrence only of the symptoms, although the organic disease itself be 
 permanent. For example, we see continually persons who are epileptic: that is, 
 they have fits of convulsion and stupor noio and then, and appear perfectly well in 
 the intervals. After the death of such patients we sometimes find organic disease of 
 the brain ; a piece of bone perhaps projecting from the cranium, or a tumour, or a 
 cyst : and this we are apt to consider as a sufficient explanation of the preceding 
 disease; but we are always pressed with this difficulty; if the tumour or piece of 
 bone was the cause of the paroxysms, why had the paroxysms any cessation ? 
 
 It seems probable, or not improbable, that in such cases as these, and in manj
 
 SYMPTOMS OF CEREBRAL DISEASES. 229 
 
 Others, the permanent morbid condition is a predisposing cause only of the occa 
 sional symptoms ; rendering the diseased organ more sensible to variations in the 
 circulation; to accidental circumstances which determine an undue amount of conf- 
 pressing force, or a deficient amount ; and I think Dr. Abercrombie has gone too 
 far when he says "we may safely assert that the brain is not compressible by any 
 such force as can be conveyed to it from the heart through the carotid and vertebral 
 arteries." 
 
 Dr. Kellie narrates the following curious circumstance : — "Mr. G., with a nume- 
 rous train of distressing symptoms, which too well marked the existence of enlarge- 
 ment of the heart, and the violent propulsive energy of that viscus, had only one 
 characteristic of any disturbance within the head. On looking upwards to the 
 whitened ceiling of a room, he saw a darkened spectrum, which vanished ari reap- 
 peared with great regularity. It was soon discovered that the appearance of this 
 umbra was synchronous with the systole of the heart, so that he used often, in my 
 presence, to count his pulse with the utmost precision, by keeping his eye fixed on 
 the ceiling, and numbering every appearance of the spectrum." In this case it is- 
 presumable that b)'" each contraction of the left ventricle of the heart, plethora of the 
 cerebral blood-vessels was produced, and therefore an excess of pressure upon the 
 cerebral substance. In that which I am about to quote it seems, on the other hand, 
 probable that comparative emptiness of the vessels of the brain, and a consequent 
 defect of the requisite degree of pressure, occasioned the morbid phenomenon. 
 
 A gentleman, thirty years old, was reduced to a state of extreme weakness and 
 emaciation by some complaint of his stomach. As the debihty advanced he became 
 very deaf; and this symptom varied in the following instructive manner. He was 
 very deaf while sitting erect, or standing; but when he lay horizontally, with his 
 head quite low, he could hear very well. If, when standing, he stooped forwards, 
 so as to produce flushing of the face, his hearing was perfect ; and upon raising 
 himself again into the erect posture, he continued to hear distinctly as long as the 
 flushing continued : as this went off the deafness returned. — (Abercrombie.) An 
 old clergj'man, who is sometimes my patient, is troubled by two grievances : deaf- 
 ness and an intermitting pulse. They are both always benefited by quina. 
 
 Objections, I should tell you, have been raised against this theory of pressure 
 affecting the functions of the nervous centres ; but I think the objections are sus- 
 ceptible of a satisfactory answer. I must content myself, however, for the present, 
 with having pointed out the main grounds upon which the theory rests. The diffi- 
 culties that attend it, and the considerations which diminish the force of those diffi- 
 culties, \vill come necessarily before us on a future occasion. 
 
 LECTURE XXII. 
 
 Symptoms of Cerebral Diseases. — Inflammation of the Dura Mater and Arach- 
 noid, from external injury ; from Disease of the Bones of the Ear, and of the 
 Nose. — Inflammation of the Pia Mater. 
 
 The functions of the brain, summarily expressed, being sensation, thought, and 
 voluntary motion, we naturally look for disturbances of those functions whenever 
 the organ suffers disorder or disease. And experience has made us familiar witn 
 various forms of disturbance to which these same cerebral functions are liable. Let 
 us pass them shortly in review. 
 
 1. The faculty of sensation may be morbidly keen, or morbidly ooiuse ; or it may 
 be perverted : in other words, it may deviate in degree, or in kind, from the healthy 
 standard. 
 
 The sensations referred to the several surfaces and structures of the body, and to 
 the organs of sense, may (without any fault in those parts and organs) be preternatu- 
 ra.ly acute. Tenderness ascribed to different parts, their ratural sensations being 
 
 u
 
 230 DISEASES OF THE BRAIN. 
 
 heightened into pain ; a general state of irritability ; intolerance of Hght, and of 
 noise ; are so many instances of this over-sensitiveness of the percipient organ. 
 •Under the head of diminished or defective sensation may be ranked, numbness in 
 all its degrees, up to total loss of sensibility or ansesthesia ; dullness of hearing, deaf- 
 ness ; dimness of sight, blindness ; failure, or absolute extinction of the senses ot 
 taste and of smell. 
 
 Perverted sensations, sensations unnatural in kind, are very numerous. To men- 
 tion a iew : giddiness ; nausea ; ringing in the ears ; ocular spectra ; ill smells in 
 the nostrils ; false tastes on the palate ; itching ; and sundry uneasy feehngs, many 
 of which are indescribable. Various kinds of pain belong to this class ; spirits vio- 
 lently high ; causeless depression, anxiety, and dread. 
 
 2. Innumerable degrees and varieties of disturbance of the faculty of tJwvght are 
 met with. Dehrium in all its shades ; dullness and confusion of intellect ; sundry 
 defects of memory ; incapacity of judgment ; and every degree of stupor up to com- 
 plete coma. 
 
 3. Of the function of voluntary motion there are also various kinds and grada- 
 tions of derangement : twitchings of the muscles ; tremors of the limbs ; rigidity 
 from spasm ; irregular and involuntary jactitation ; convulsions ; muscular debihty ; 
 palsy. 
 
 Now, as I stated before, there is, and there can be, no ph3'^sical exploration of the 
 living brain. We are limited, therefore, in studying its diseases, to the rational 
 symptoms. It becomes our task to interpret the import of the multiform disturbances 
 of function just enumerated, in every case in which more or fewer of them appear; 
 and when you are told that these sj^mptoms are apt to present themselves in almost 
 every conceivable order and combination, and, moreover, that many of them may be 
 S3'mpathetic of diseases of other parts than the brain, you will scarcely need to be 
 further informed, that the language thej^ speak is often very hard to construe ; that 
 we frequently fail to reach and discover, by these outAvard signals, the inward things 
 they denote. 
 
 I am about to consider, in the first place, some of the inflammatory affections of 
 the brain, and some which may easily be mistaken for inflammatory affections ; and 
 I warn you beforehand, that, in respect to exactness of diagnosis, we are sadly bar- 
 ren of certainties in these matters. Hints, sketches, approxinnations, are nearly all 
 that I can promise concerning not a few of the many diseased conditions to which 
 the brain and its appendages are obnoxious. 
 
 In the brain, as in other composite organs, inflammation may be general or par- 
 tial. It may attack certain tissues only : it may be seated in the substance of the 
 cerebral mass ; or in the membranes that envelop it. 
 
 I need not tell any of you that the membranes which invest the brain are three in 
 number; the fibrous dura mater, the serous arachnoid, and the pia mater, which ie 
 composed of blood-vessels held together by a web or areolar tissue. 
 
 Speaking generally, inflammation of the cerebral substance alone, is perhaps more 
 common than inflammation of the investing membranes alone. The central parts of 
 the nervous mass may and do suffer inflammation, while the membranes escape. 
 But it seems to me scarcely possible that inflammation of the pia mater should take 
 place without imphcating also the surface of the convolutions with which it has so 
 close a relation, and so intimate a vascular connection. 
 
 Agam, with respect to the membranes themselves, the dura mater my be inflamed 
 while the pia mater remains unaffected. I befieve also that the arachnoid may suflTer 
 inflammation, and leave the subjacent pia mater untouched. Whether the arachnoid 
 ever escapes participating in the inflammation of the dura mater on the one side, or 
 of the pia mater on the other, is to be doubted. 
 
 Cin we separate and distinguish these several inflammations by assigning to each 
 Its proper external phenomena 1 Seldom ; scarcely ever. Doubtless each has its 
 peculiar symptoms ; and if inflammation were often strictly limited to the one mem- 
 brane or the other, and if the course and events of the inflammation did not modify 
 the condition of the brain itself, by pressure, or by affecting the circulation of blood 
 mrough it, then we might expect greater uniformity, and might hope by careful ami
 
 DURA MATER AND ARACHNOID. 231 
 
 repeated observation to seize upon the desired distinctions. But this simplicity is 
 not exhibited by the inflammatory affections of the parts v/ithin the cranium. Inflam- 
 mation commencing in one membrane is apt to spread readily and rapidly to the 
 rest, and to the cerebral substance; and the compHcation of diseased conditions 
 coexisting within the skull at the same time, throws confusion over the whole sub- 
 ject. This unceriainty of exact diagnosis is however of the less consequence, inas- 
 much as when we have learned that inflammation is going on in any part of the 
 encephalon, we have learned enough to direct us as to the geileral plan of treatment 
 to be adopted. 
 
 After all, certain symptoms do present themselves more frequently when one part 
 is inflamed, and certain other symptoms more frequently when another part is 
 inflamed ; and it will be proper and convenient to contemplate certain forms of 
 meningeal inflammation separately. 
 
 Let us, first, then, consider inflammation as it is confined, occasionally, to the dura 
 mater — or to the dura mater and arachnoid. 
 
 This very rarely happens as an idiopathic or spontaneous disease ; but it is not at 
 all uncommon as a result of external injury. And we may advantageously trace its 
 ordinary phenomena and consequences, by attending to these instances of traumatic 
 inflammation of the dura mater. They were excellently well described many years 
 ago, by Mr. Pott. A man receives a blow on the head ; the blow stuns him per- 
 haps at the time, but he presently recovers himself, and remains, for a certain period, 
 apparently in perfect health. But after some days he begins to complain ; he has 
 pain of the head, is restless, cannot sleep, has a frequent and hard pulse, a hot and 
 dry skin, his countenance becomes flushed, his eyes are red and ferrety ; rigours, 
 nausea, and vomiting supervene ; and, towards the end, deHrium, convulsions, or 
 coma. Meanwhile the part which was struck becomes puffy, tumid, and somewhat 
 lender ; and if this tumid portion of the scalp be cut through, the pericranium beneath 
 it is found to be separated from the bone ; moreover, the bone itself is observed to be 
 altered in colour, whiter and drier than the healthy bone ; and if a piece of this bone 
 be reiuuved, it is also seen that the dura mater on the other side of it is detached 
 from the cranium, and sometimes smeared with lymph or puriform matter. This is 
 a form of disease very often met with by the surgeon. I have watched, with much 
 interest, several such cases under the care of my hospital colleagues. One or two 
 of them I will briefly describe. 
 
 In the year 1833, during Christmas time, the coachman of a lady living in my 
 neighbourhood fell, being intoxicated, into a cellar or area, struck in his fall one side 
 of his head, and tore up the scalp over a considerable space. He was carried to the 
 hospital, where the loose flap of integuments was cleansed and replaced. After 
 some days erysipelas came on, and then a much larger portion of the scalp sloughed 
 away, so that the bone was laid bare to a frightful extent, and looked, at a little dis- 
 tance, as he sat up in bed, like the tonsure of a monk. Nevertheless the man seemed 
 wonderfully free from suffering or distress : his pulse, indeed, v.-as frequent, but it 
 was said to be so during health. His intellect was clear, and he had no head symp- 
 toms ; or rather, no brain symptoms. 
 
 In the early part of February, 1834, he had a shivering fit, which was followed 
 by convulsions of the right side of the body, and subsequently by paralysis of the 
 right arm and leg, and by stupor, from which he could easily be roused. He would 
 put out his tongue when desired to do so; but to every question he answered "yes." 
 A portion of the left parietal bone was evidently dead : here the trephine was 
 applied; and a piece of bone being removed, the dura mater was exposed. It 
 looked as if it had lost its vitality. Some pus lay upon it. No relief followed the 
 operation. 
 
 On the lOtli of February fluctuation was detected beneath the dura mater which 
 was then slit open. About three drachms of puriform fluid escaped. The patient 
 died soon afterwards, having had no active delirium throughout. 
 
 The surface of the dura mater was found to be nearly of its natural appearance, 
 except where the trepanning had been performed. At that spot it was dry and
 
 232 DISEASES OF THE BRAIN. 
 
 sloughy. Over the whole of the anterior and lateral surface of the left hemisphere 
 there lay, upon the arachnoid, a thick coating of coagulable lymph, smeared with 
 pus : this extended down the posterior part of the hemisphere also, nearly to its 
 base. There was no other morbid appearance ; no fluid in the pia mater, nor in the 
 ventricles. The substance of the brain was everywhere perfectly sound and healthy : 
 it was divided in all directions in search of an abscess, but nothing unnatural could 
 be delected. 
 
 Another man came to the hospital to have a small incised wound of the scalp 
 looked at. The injury appeared to be trivial ; the cut was dressed, and the man 
 made an out-patient. A few days afterwards he came again, incompletely paralytic 
 on one side of his body. I saw this man's skull trepanned ; he was perfectly calm 
 and collected : that part of the dura mater which corresponded to the wound was 
 found to be inflamed ; and there was pus diffiised over the arachnoid covering the 
 cerebral convolutions on the same side. He sank quietly into a state of coma, and 
 so died. Not the slightest incoherence or dehrium had been manifested: there 
 had been no convulsions, nor was there any other morbid appearance within the 
 cranium. 
 
 I mention these cases to show you the grounds of my own opinion, that inflam- 
 mation, beginning in the fibrous membrane, may affect the arachnoid, without neces- 
 sarily extending to the pia mater; just as inflammation ??ift^ overspread the pleura, 
 or the pericardium, without touching the lung or heart which those serous mem- 
 branes respectively clothe. Here no sensible traces of inflammation were discovered 
 deeper than the free surface of the arachnoid ; and there had been no disturbance, 
 t]*ll towards the end, of the proper functions of the brain. I conclude that the disease 
 did not pass beyond the serous membrane ; for I can scarcely conceive inflammation 
 of the pia mater to exist without involving, in some degree, the surface of the brain; 
 nor inflammation of the surface of the brain to exist without some manifest derange- 
 ment of the cerebral functions. In the instances that I have been relating, the final 
 stupor and palsy may reasonably be ascribed to pressure resulting from the events 
 of the inflammation of the arachnoid : from the effused pus and lymph. 
 
 Inflammation of the dura mater is very rare as a simple and idiopathic affection. 
 Dr. Abercrombie relates one instance of it, as the only one he had seen ; and even 
 that was not a pure case of inflammation of the dura mater. There was pus upon 
 that membrane, which adhered to the cranium over a space as big as a crown-piece, 
 and at that spot was ulcerated. But there was also found an adventitious membrane 
 beneath the arachnoid where it covers the brain. 
 
 Speaking generally, this complaint is marked by pain of the head, by fever, and 
 by rigors which intermit ; and so regular sometimes are the intermissions, that the 
 practitioner may be tempted to beHeve that he has got an aguish patient, and to 
 administer bark. The intellectual faculties, especially at the outset of the disease, 
 are but little affected ; which is just what we might expect. The dura mater and 
 the arachnoid lying apart from the sensorium, their inflammation can have no other 
 than an indirect influence upon its functions. 
 
 Although inflammation of the dura mater is very uncommon as an idiopathic or 
 primary disorder, we very frequently meet with it as a secondary afll'Ction ; and 
 then there are few diseases more surely fatal or less within the reach of remedies. 
 It is as a consequence of what is called otitis, that physicians are chiefly accustomed 
 to encounter inflammation of the dura mater. It results from disease of the internal 
 ear, and of the petrous portion of the temporal bone. Sometimes acute inflammation 
 arises within the tympanum, when there has been no previous disease : the patient 
 has severe headache ; at length a gush of matter comes from the external meatus, 
 but the pain does not, as it usually does in such cases, cease ; it continues, or even 
 increases in intensity : the patient begins to shiver; he becomes dull and drowsy ; 
 slight dehrium, perhaps, occurs ; and by degrees he sinks into stupor. In some 
 instances no pus issues externally. More commonl)* symptoms of the same kind 
 •supervene upon a chronic discharge of purulent matter from the ear. It is scarcely 
 possible to sketch an accurate general picture of this insidious but most dangerous 
 r-innplamt. Next to seeing and watching actual cases of it, the best way of becoming
 
 DURA MATER AND ARACHNOID. 233 
 
 acquainted with its phenomena is by attending to recorded instances. I will bring 
 before you, therefore, some examples of inflammation of the dura mater, occurring 
 in connection with disease of the interior of the organ of hearing. 
 
 A youth, sixteen years old, applied to the late Dr. Powell (who has related the 
 case in the fifth volume of the Transactions of the College of Physicians) on account 
 of an eruption, with an acrid discharge behind the right ear. He had become deaf 
 five years before, after scarlet fever, but no discharge took place at that time from 
 the ear. In the following year, however, he had the measles, and then an absces.<5 
 formed in the right ear ; and after giving him much pain, it burst. He had again 
 suffered, three days before Dr. Powell first saw him, a sudden attack of very severe 
 pain in the same ear. The pain quite deprived him of rest ; but he had no fever, 
 nor delirium, nor soma. He slept, indeed, a great deal, but that was the effect of 
 opiates, which he took to relieve the pain. This symptom was quieted by the opium ; 
 but it always returned with severity if the medicine was suspended. A foetid dis- 
 charge came from the ear. On the tenth day of this attack, after a most violent 
 paroxysm of pain, his strength rapidly declined, and he died. 
 
 "When the head was examined, *the structure of the dura mater was healthy and 
 natural, but beneath this membrane the whole superior surface of the right hemi- 
 sphere was covered with a layer of coagulable lymph and pus. The vessels of the 
 substance of the brain were not more numerous or loaded than usual, and the brain 
 itself was healthy in every part. In the base of the skull the dura mater adhered 
 to the bone, except at one part, of about half an inch diameter, just over the petrous 
 portion of the temporal bone, where it was black and sloughy. The subjacent 
 portion of the bone itself was carious, black, and crumbling ; and contained foetid 
 pus." 
 
 In this case, you will observe, there was no symptom to mark the extensive mis- 
 chief within the head, except the pain : the pulse never exceeded 72 ; the skin 
 was warm and moist ; there was neither fever, nor delirium, nor convulsion, nor 
 coma. 
 
 A girl, aged nine, (I take this case from Dr. Abercrombie, whose volume on the 
 diseases of the brain is full of practically instructive examples,) had been liable to 
 attacks of suppuration of the ear, which were usually preceded by severe pain, and 
 some fever. She suffered one of these attacks in the left ear, in July, 1810. Upon 
 the discharge of matter from the ear she did not obtain ease, as she had done on 
 former occasions ; but continued to be affected with pain, which extended over the 
 forehead. When Dr. Abercrombie saw her, he found that, besides the pain, she 
 had some vomiting, and impatience of light. Her look was oppressed ; the pulse 
 84. Blood-letting, purging, blistering, and mercury, were employed without relief. 
 Two days afterwards there was slight and transient delirium, a degree of stupor, and 
 slight convulsions. She lay constantly with both her hands pressed upon her fore- 
 head, and moaning from pain, of which there had not been the least alleviation. On 
 the fifth day from the commencement of the discharge, she continued sensible, and 
 died suddenly in the afternoon, without either squinting, blindness, or C0K\a, the pulse 
 having been always under 90. A. considerable quantity of colourless fluid Avas 
 found in the ventricles of the brain, which, in other respects, was healthy. In the 
 left lobe of the cerebellum there was an abscess of considerable extent, containing 
 purulent matter of intolerable foetor. The dura mater, where it covered this part of 
 the cerebellum, was thickened and spongy, and the bone corresponding to this portion 
 was soft, and slightly carious on its inner surface ; but there was no communication 
 with the cavity of the ear. 
 
 Here again the pain was the most prominent symptom, and probably resulted from 
 the partial inflammation of the dura mater. It is interesting to mark these two 
 points : — that the disease in the bone imparted disease to the dura mater, although 
 no passage was opened from the tympanum ; and that this inflammatory state of 
 the external membrane of the brain led (apparently^ to deep-seated sujfpuration 
 in the cerebellum; the parts lying between the aoscess and the dura matei 
 escaping. 
 
 This last, and somewhat singular circumstance, might have been owing, (so at 
 
 u2
 
 234 DISEASES OF THE BRAIN. 
 
 least I conjecture), to the extension of the inflammation from the suppuratinir ear to 
 some of the veins of the skull ; and the consequent formation in the cerebellum of 
 one of those secondary abscesses so commonly noticed in uncircumscribed phlebitis. 
 Two very remarkable instances of diffused inflammation of veins, and of its terrible 
 effects, occurring in connection with purulent otorrhosa, have fallen under my own 
 observation ; one of them in private practice, the other in the hospital. As I am not 
 aware that such consequences as supervened in these cases upon otitis, have received 
 much attention, I will briefly describe them. 
 
 The first of these two patients was a boy, eleven years old, whom I attended with 
 Dr. Maclntyre and Mr. Arnott. He had had a discharge of offensive purulent 
 matter from his ear since the time when, four years before, he had gone through 
 scarlet fever. In August, 1833, he went, for a walk, into Kensington Gardens, and 
 there lay down, and slept upon the damp grass. The next day he was attacked 
 with headache, shivering, and fever. Strong rigors, followed by heat and perspi- 
 ration, occurred very regularly for two or three days in succession ; suggesting the 
 suspicion that his complaint might be ague : but then pain and swelling of some of 
 the joints came on, and were, at first, considered'rheumatic. However, the true and 
 alarming nature of the case soon became apparent. Abscesses formed in and about 
 the affected joints ; and one of these fluctuating swellings was opened, and a consi- 
 derable quantity of foul, grumous, dark-coloured matter let out. After about a fort- 
 night the child sunk under the continued irritation of the disease. The hip-joint 
 presented a frightful specimen of disorganization ; it was full of unhealthy sanious 
 pus, the ligamentum teres was destroyed, the articular cartilages were gone, and 
 matter had burrowed extensively among the surrounding muscles. The knee and 
 ankle joints of the same limb were in a similar state. It is curious that the destruc- 
 tive disease of the joints was limited to those of the right lower extremity, while the 
 primary suppuration was in the left ear. Unfortunately the head was not examined ; 
 but that the fatal disorder had penetrated from the ear to the dura mater, I entertain 
 no doubt : in all probabihty the inflammation had involved the veins or sinuses of 
 the head. 
 
 The second case had many points of similarity with this. 
 
 William Marriott, aged 19, was admitted under my care into the Middlesex Hos- 
 pital, on the 18th of October, 1834, having pain and tumefaction of the right shoulder, 
 wrist, and foot, with redness of the latter. He complained also of headache, vertigo, 
 drowsiness, and of an occasional feeling of stupor. His skin was hot and dry, his 
 face flushed, his tongue furred, his pulse frequent (112), and his bowels were re- 
 laxed. A puriform discharge came from his right ear. 
 
 He had been suddenly seized, a week before, with sharp pain in that ear, which 
 lasted twenty-four hours, when the discharge commenced, and the pain was relieved. 
 He then began also to have headache, which had never left him, and to be sometimes 
 dizzy. Three days previously to his admission the rheumatism (as he supposed it 
 to be) commenced in the foot. When this part was examined, the redness was 
 found to be circumscribed, somewhat livid, and limited to the great toe. It had much 
 the appearance of gout. 
 
 He soon began to be troubled with shivering fits, which recurred regularly every 
 morning about the same hour, and were followed by burning heat of the skin, but 
 no sweating. An abscess formed near the toe, and was opened by Mr. Mayo, and 
 some healthy-looking pus evacuated. Next a large fluctuating tumour near the 
 bhoulder was punctured, and three ounces of pus, mixed with blood, came out. 
 After this incision the rigors ceased ; but the abscesses continued open, and the dis- 
 charge had an offensive smell. On the 14th of November it was discovered that 
 matter had collected in the left hip : this also was emptied by puncture. On the 1st 
 of December, a very large quantity, not less than three pints, of unhealthy and 
 grumous pus, was let out from a vast abscess which had formed in the loins : and 
 pus was 'noticed in his stools. The discharge from the shoulder came at last to 
 resemble the lees of port wine. 
 
 During all this while the patient remained feverish, with a dry parched tongue, 
 ajid a rapid and feeble pulse. The diarrhoea continued, more or less, throughour
 
 DURA MATER AND ARACHNOID. 23S 
 
 I For some titno oefore his death, which happened about the middle of the month of 
 I December, the left leg and thigh had been much enlarged by osdema. 
 
 I was not able to be present at the inspection of the body ; and I have to regret 
 that in the report which I received of it, the condition of the brain, of its membranes, 
 and of its veins, was not noted. 
 
 The right shoulder-joint was extensively diseased ; the cartilages Avere destroyed 
 by ulceration over a considerable space. Those of the left hip were entire, but the 
 synovial cavity was full of foul matter. The joint of the great toe was implicated 
 also in the abscess wliich had formed there. The femoral vein, on the left side, was 
 plugged up, throughout its whole extent, by a coagulum, which was firm and of a 
 reddish brown colour at the upper part of the vessel, loose and darker towards the 
 ham. The saphena was pervious : the iliac was free from disease. 
 
 The lungs had undergone partial disorganization. Several distinct portions of the 
 pulmonary tissue were nearly solid, while the tissue immediately around them was 
 crepitant and healthy. From these small solidified portions, puiulent riiatter could 
 be made to ooze by gentle pressure. 
 
 The mastoid cells of the right temporal bone were filled with pus, and there was 
 a sht-like opening in the membrana tympani. The small bones of the ear were 
 sound. 
 
 I much lament that in these instances, the direct link of connection between the 
 disease of the ear and the dis'organization of the joints was not demonstrated : for 
 seeing (they say) is believing. Yet the pain of the ear, the discharge of pus from 
 the external meatus, the subsequent pain of the head, coming on with fevers and 
 rigors, and followed after a short interval by destructive suppuration in several dis- 
 tant parts, and, in the last case, the actual femoral phlebitis: these circumstances 
 form a chain of presumptive evidence, amounting, in my judgment, to moral cer- 
 tainty, that the fatal mischief, in each case, found entrance through " the porches or 
 the ear;'' and that the dura mater underwent inflammation. The same evidence is 
 scarcely less affirmative of the complication of cerebral phlebitis. Perhaps the veins 
 of the diploe, which in the cranial bones are of considerable magnitude, were 
 involved in the inflammatory mischief ; perhaps the large sinuses of the brain. The 
 close vicinity of the lateral sinus to the diseased bone, and its formation by a dupli- 
 cature of the dura mater, would seem to render such a complication highly probable. 
 
 These views, which were brought forward in my first course of lectures here, in 
 183G, have been confirmed by the publication, very recently (1841) in the Medical 
 Gazette, by Dr. Bruce of Liverpool, of two cases witnessed by himself, of "Phle- 
 bitis of the cerebral sinuses as a result of purulent otorrhcea." He refers to several 
 other instances of the same kind recorded by diflerent authors. This combination 
 of disease is doubtless more common than had been heretofore supposed : and the 
 important pathological considerations connected with it will probably receive further 
 illustration, now that the attention of the profession has been called to the subject by 
 Dr. Bruce's paper. 
 
 Dr. Griffin has pubhshed, in the DuhUn Journal of Science, two examples of 
 otitis attended with symptoms exactly resembling those of intermittent fever. One 
 of them is as follows : — A young man, previously healthy, was attacked with fits of 
 shivering, accompanied by pain in the left side of the head. At first the paroxysms 
 were rather irregular, but they soon assumed the form of tertian ague ^ coming on 
 every other day, at about the same hour; the cold fit commencing at noon, and 
 lasting about half an hour, followed by a hot stage of somewhat longer duration, 
 and then a profuse sweat. In the intermissions the pain in the head was triflino-: 
 there was no thirst nor heat of skin, but he did not sleep. A tumour formed over 
 the mastoid process of the left side, and was opened, and a quantity of extremely 
 ofll'nsive brownish pus sprang out with great force. This gave much relief. The 
 bone was carious over a space as big as a shilling. After about ten days, the pam 
 in the head and in the mastoid process became very severe ; the patient had violent 
 shivering fits many times in the day, great thirst, heat of skin, vomiting, and dei.- 
 riuin : his face was flushed, and his pulse hard ; and he died within a few hours 
 after the acci?ssion of these last symptoms.
 
 236 DISEASES OF THE BRAIN. 
 
 The most remarkable features in this case were the similarity of the fits of shiver 
 ing to the paroxysms of ague, their regular recurrence at periods of forty-eight hours, 
 and the circumstance that they seemed to be checked, for some time, by the treat- 
 ment proper in ague ; namely, the exhibition of bark. The occurrence of quotidian 
 paroxysms of the same kind has been noticed in relating some of the previous cases. 
 
 I have related them to show you what different symptoms may result from inflam- 
 mation of the dura mater ; and to put you upon your guard against overlooking the 
 cause from which such inflammation does frequently originate. The suppuration of 
 the tympanum, and consequent disease of the bone, are more common in scrofulous 
 persons than in others ; and they are more apt to occur as a sequel of scarlet fever 
 than in any other way. I conceive that the inflammation of the throat, belonging to 
 that disorder, and often constituting all its danger, creeps along the Eustachian tube 
 into the interior of the ear. In strumous subjects the fire thus hghted smoulders on, 
 or if it ever goes out, is readily rekindled : that part of the temporal bone, in which 
 the organ of hearing is principally lodged, becomes carious : the membrana tympani 
 is perforated : the little bones of the ear come away : more or less deafness ensues ; 
 and from time to time, or habitually it may be, there is a discharge of pus from the 
 external orifice. At length the inner surface of the bone participates in the disease ; 
 and then the inflammation is apt to be propagated to the dura mater, in the manner 
 of which I have given you some instances. It is in the first onset of the inflamma- 
 tion in the ear that remedies are most likely to be efficient in preventing this catas- 
 trophe. Leeches applied early and repeatedly to the mastoid process, especially 
 when that part becomes tender, as it often does in such cases, and counter-irritation 
 afterwards, are the best means in our possession. 
 
 [The frequency with which inflammation of the dura mater supervenes upon otitis, espe- 
 cially in children, should be kept constantly in mind ; for it is only by a prompt, active, and 
 judicious treatment, whilst the disease is confined to the internal ear, that we can have any 
 hopes of saving the patient — when inflammation has extended to the dura mater, the termi- 
 nation is very generally fatal. — C] 
 
 If symptoms of acute inflammation within the head supervene, the complaint 
 requires more vigorous treatment, which I shall describe when I have spoken of in- 
 flammation of the other membranes of the brain. After what has been said, it is 
 unnecessary to point out to you that the prognosis in these cases is very unfavour- 
 able. But we are not to abandon them in despair. That inflammation of the dura 
 mater may be recovered from, we know, by what happens in certain injuries of the 
 head : and the following would seem to be an instance of recovery when the source 
 of the mischief was situated in the ear. A young lady, after the usual symptoms 
 in the head, lay for three or four days in a state of perfect coma, and her condition 
 was thought utterly hopeless. Her medical attendants continued to visit her as a 
 matter of form ; and one day they were agreeably surprised to find her sitting up, 
 and free from complaint : a copious discharge of matter had taken place from the 
 ear, with immediate relief: and she continued in good health. — (Abercrombie.) 
 We cannot be sure in such a case that the matter came from the brain ; but the 
 symptom made that supposition exceedingly probable. The case shows clearly one 
 of two things ; either that pus may thus escape from the skull, and the patient get 
 well; or that pus shut up in the cavity of the tympanum may produce the urgent 
 symptoms that are known to result from cerebral pres-sure. 
 
 Cases are recorded of analogous disease communicated from the carious cethmoid 
 bone to the dura mater; the patients having had pain in the forehead and purulent 
 discharge from the nose, and becoming at last forgetful and delirious, and dying in 
 a state of coma. I have never met with an instance of this kind ; nor of inflamma- 
 tion spreading inwards from the socket of the eye ; but I make no doubt that each 
 may occasionally happen. 
 
 These three, then — j(/jo/jo//a'c inflammation of the dura mater — very rare ; in- 
 flammation of the dura mater by extension of disease from the sethmoid bone, or 
 from the orbit — also infrequent; and inflammation of the dura mater by extension 
 of disease from the petrous portion of the temporal bone — very common : constitute 
 those forms of inflammation of the outermost tunic of the brain, which the physician
 
 PIA MATER. 237 
 
 may be called upon to treat. The inflammation is not always — nay, perhaps it is 
 Iseldom, if ever — restricted to that tunic ; but it begins there ; and the essence of the 
 Idisease is inflammation of the dura mater. 
 
 Acute aracJmitis — by which I mean active and uncombined inflammation of the 
 arachnoid membrane — is, I apprehend, a very uncommon disorder ; although that 
 term is of frequent occurrence in medical writings. I have shown you already that 
 inflammation may pass from the fibrous dura mater to the serous membrane reflected 
 over it ; and thence (by what is sometimes called contiguous sympathy) to the oppo- 
 site portion of the same membrane spread over the surface of the brain. So, hke- 
 wise, inflammation may extend from the pia mater to the arachnoid. If simple 
 arachnitis, of an acute kind, ever . happens, it has not been my fortune to see or to 
 recognize it ; and I can tell you nothing about it. In truth, the authors who use the 
 word arachnitis do not intend thereby to express unmixed inflammation of the arach- 
 noid ; but include under that term inflammation of the pia mater also. Some apply 
 the name meningitis to that compound affection ; and the only objection to this 
 nomenclature is, that the dura mater is as much one of the meninges of the brain as 
 either of the two others. 
 
 In the few remarks which I have to make upon inflammation of the pia mater 
 (or, if you will, of the pia mater and arachnoid at once), I shall chiefly follow Dr. 
 Abercrombie : because his observations are comparatively recent, and carefully 
 made ; because his veracity, and sobriety of judgment, and philosophical turn of 
 mind, are well known ; and because his cases (as regards this particular affection) 
 are quite to the point, and his descriptions clear and concise. 
 
 But I must premise a word or two respecting the anatomical characters of the 
 disease. 
 
 When the upper part of the skull, and the dura mater, have been removed, you 
 may frequently see, on the surface of the exposed brain, what seems to be a thin 
 layer of a clear gelatinous substance : but this appearance is fallacious. Puncture 
 here and there the transparent arachnoid, and a limpid fluid, like water, trickles out ; 
 and the jelly-hke investment of the convolutions is gone. Now this thin serous 
 liquid, thus collected in the meshes of the pia mater, may be the event of inflamma- 
 tion of that membrane : but it may also be produced, and it very often indeed is 
 produced, by simple congestion and remora in the cerebral veins. Nay, a certain 
 amount of serosity, in this situation, belongs to the condition of health. We cannot, 
 therefore, with any certainty, infer, merely from seeing this serous effusion, that 
 there has been inflammation : we judge of its import, by noting the co-existence, or 
 the absence, of other traces of inflammation ; and by the character of the symptoms 
 that preceded death. 
 
 On the other hand, we may be sure that there has been inflammation of one or 
 both of these tunics of the brain when we find false membranes between them ; 
 layers, i. e,, of coagulable lymph. In the effusion of this substance I conclude that 
 the vessels of the pia mater play the main part ; both because it is always, in such 
 cases, excessively vascular, while the arachnoid is seldom found to be so in any 
 remarkable degree, if at all: and also, because the false membrane commonly, though 
 not always, sends down layers between those duplicatures of the pia mater which 
 descend into the sulci formed by the convolutions ; where, as you know, the arach- 
 noid does not go. In fact, considering the arachnoid as the serous membrane of the 
 brain, we should expect that, when inflamed, it would present the events or products 
 of inflammation on its free surface ; and we sometimes find them there ; but this is 
 very rare ; and for my own part, I look upon those effusions which he beneath the 
 arachnoid, between it and the pia mater, as being furnished exclusively by the ves- 
 sels of which the latter membrane is mainly composed. 
 
 Now the inflammation of these membranes (taking them together) commences, 
 and declares itself, by no fixed or uniform symptoms. The most common and 
 striking phenomena is a sudden and long-continued paroxysm of general convul- 
 sions. Sometimes this is the first thinsj noticed. Sometimes it comes on after a 
 few day» of discomfort, shght headache, and vomiting. The convulsions recur, and
 
 'SS8 DISEASES OF THE BRAIN. 
 
 at length end in coma. Sometimes, again, the first attack of convulsions is preceded 
 by violent pain in the head, setting in quite suddenly, and attended with screaming 
 Considering, on the one hand, the intimate connection between the pia mater and 
 the gray matter of the convolutions, and, on the other, the presumed functions of 
 that gray matter, we might expect that inflammation of the pia mater would soon be 
 attended with some manifest derangement of the mental faculties. Accordingly, 
 delirium, often violent and continued, is stated by most authors to accompany and 
 denote inflammation of the membranes ; and especially of the membranes where 
 the}^ invest the upper surface of the cerebral hemispheres. Yet I do not find that 
 symptom mentioned in any of the various examples of meningitis recorded by Dr. 
 Abercrombie. He does give cases, indeed, in which there was much delirium; 
 but they were not cases of meningitis of any kind. He relates them as instances 
 " of a very dangerous modification of the disease, which shows only increased vas- 
 cularity." I venture with great hurftility to question or criticise any opinion of Dr. 
 Abercrombie's ; but I entertain no doubt about the nature of the cases which he so 
 describes ; and I hope to convince you by-and-by that they are not examples of 
 inflammation at all : they neither show the anatomical characters of inflammation, 
 nor yield to the remedies of inflammation. Excluding these cases, I do not find 
 dchrium specified as a symptom of uncombined meningitis. I shall abridge one or 
 two of the well-marked examples of the disease. 
 
 A girl, aged nine, woke suddenly in the middle of the night, screaming from vio- 
 lent headache, and exclaiming that some person had given her a blow on the head. 
 For the next two days she complained of some, but not much pain in her forehead, 
 and did not even remain constantly in bed : no alarm was felt about her. On the 
 third day she was seized with violent and long-continued convulsions, and imme- 
 diately after the convulsions she fell into a state of deep coma ; she remained in this 
 state, with a natural pulse, till she died, on the sixth day of the disease. 
 
 When the dura mater had been removed, the other membranes appeared highly 
 vascular, except where this appearance was concealed by a layer of yellow adven- 
 titious membrane, spread out betwixt the arachnoid and the pia mater. This was 
 distributed in irregular patches over various parts of the surface of the brain, but 
 was most abundant on the upper part of the right hemisphere. It was as thick as 
 a wafer, and in some places dipped down between the convolutions. A considera- 
 ble quantity of it extended over the surface of the cerebellum also. 
 
 A child two years old was suddenly attacked one morning with severe and long- 
 continued convulsions. The convulsions recurred many times ; in the intervals she 
 ■was dull and torpid, in a state of partial coma, with occasional starting, and a frequent 
 and feeble pulse. On the fourth day she sank. 
 
 The surface of the brain, when the dura mater was removed, was covered in many 
 places, betwixt the arachnoid and pia mater, by an adventitious membrane. It 
 was chiefly found above the openings between the convolutions, and in some places 
 appeared to descend a little way between them. The arachnoid when detached 
 seemed to be healthy ; but the pia mater was in the highest state of vascularity 
 throughout ; and when the brain was cut vertically, the spaces between the convolu- 
 tions were most strikingly marked by a bright fine of vivid redness, produced by 
 the inflamed membrane. There was no eflusion in the ventricles, and no other 
 morbid appearance. 
 
 In another example, the whole surface of the brain was 'covered by a continued 
 stratum of yellow false membrane, lying between the arachnoid and pia mater, and 
 in some parts following the course of the pia mater through the whole depth of the 
 convolutions : the pia mater and arachnoid adhered together everywhere, very 
 firmly, by means of it: not a trace of it could be found either on the outer surface 
 of the arachnoid, or the inner surface of the pia mater : the arachnoid itself, when 
 separated, presented no unusual appearance, but the pia mater was everywhere ex- 
 cessively vascular. There was no serous effusion, and the brain and cerebellum were 
 perfectly healthy. 
 
 Now in this dissection there was unequivocal evidence of acute and extensive 
 inflammation of these membranes, or I should say, of the pia mater ; yet the symp-
 
 PIA MATER. 239 
 
 toms had been very obscure. The child in whom the disease occurred was conva- 
 lescent from a mild attack of scarlet fever. One evening he became very feverish, 
 and complained of his belly. Three days afterwards he had frequent vomiting, 
 followed by stupor, and some convulsive movements of his face and arms, and death 
 took place four days and a half after the feverishness began. We learn from this 
 case, that general and severe inflammation of the innermost membrane maj^ exist, 
 and prove fatal, without giving rise to any violent symptoms at all. 
 
 I must trouble you with one more history, because it atibrds another examjile of 
 what I have mentioned as being rare; viz., the effusion of the products of inflam- 
 matory action upon the outer surface of the arachnoid,- — marking therefore very 
 distinctly the inflammation of that membrane. It was evidently combined, however, 
 with inflammation of the pia mater also. A child, eight months old, died after more 
 than three weeks' illness ; which began with fever, restlessness, and quick breathing; 
 afterwards there were frequent convulsive affections, with much oppression ; and at 
 last severe convulsions, squinting, and coma. At an early period of the complaint, 
 a remarkable prominence of the anterior fontanelle was noticed ; in the second week 
 this increased considerably ; and in the third week, it was elevated into a distinct 
 circumscribed tumour, which was soft and fluctuating, and pressure upon it occa- 
 sioned convulsions. It was opened by a small puncture, and discharged at first some 
 purulent matter, afterwards bloody serum. No change took place in the symptoms, 
 and the child died four days after. 
 
 A deposit of thick flocculent matter mixed with pus was found covering the sur- 
 face of the brain to a considerable extent, and lying upon the free surface of the 
 arachnoid. There was a similar deposition also between the arachnoid and ftie pia 
 mater, and considerable effusion into the ventricles. 
 
 If the sketches I have been giving you afford a true outline of the phenomena 
 which attend acute inflammation of the pia mater, or of the pia mater and arachnoid 
 jointly, what, you may naturally ask, is the nature of those cases in which there is 
 high excitement, and much fever, and great delirium, and which are sometimes 
 spoken of as phrenitis, or as brain-fever ? Why these are instances of acute inflam- 
 mation of, the whole contents of the cranium ; of the brain and its membranes : 
 of the encephalon in short ; and, therefore, the disease has, not improperly, been 
 called encephalitis. Of this formidable malady I shall give you some account 
 to-morrow. 
 
 LECTURE XXIII. 
 
 Acute and general inflammation of the Encephalon. Period of Excitement. Modes 
 inivhich the disease may commence. Period of Collapse. Treatment. Deli 
 rium tremens. 
 
 Acute inflammation does sometimes appear to invade at once the whole of the 
 parts that are lodged within the skull ; or, beginning in one part, it extends rapidly 
 to all the rest. As the contents of the cranium are called, collectively, the encephalon, 
 so the disorder which I am about to consider has been named encephalitis. It is an 
 uncouth appellation, but it will serve its purpose. Cullen, and many others, apply 
 the term phrenitis to the same disease. You may choose between these names, 
 taking care to remember what they signify. The malady is sometimes described as 
 inflammation of the membranes of the brain. I believe "this to have arisen from the 
 circumstance that the effects of the inflammation, which become visible after death, 
 are otten more striking and obvious on the surface of the brain, or in its ventricles, 
 than in the cerebral substance itself. An abscess in the nervous mass can scarcely 
 be overlooked : a softening of the cerebral pulp may escape the notice of a hasty 
 or inexpert observer : and those changes of colour, which sometimes denote increased
 
 240 DISEASES OF THE BRAIN. 
 
 vascularity of the same part, may very easily be passed over without attracting 
 much attention. 
 
 Phreniiis, or encephalitis, or acute and general inflammation of the brain and its 
 membranes, as it occurs in adults, presents two periods, which are marked by differ- 
 ent symptoms, and in most instances are very distinctly observable. In the first 
 period what are called symptoms of excitement predominate ; the functions of the 
 organ are exaggerated as well as disordered : in the second period those symptoms 
 appear which are comprised under the term collapse. Sometimes these two sets of 
 symptoms, instead of ibllowing each other, are more or less mixed and confounded 
 together. But the distinction is real, and requires to be attended to. 
 
 The symptoms that characterize the period of excitement, are pain of the head, 
 often intense and deeply seated, or extending over a large part of it ; a sense of con- 
 striction across the forehead ; throbbing of the temporal arteries, flushing of the face; 
 injection of the eyes, which have a wild and briUiant look ; contraction of the pupils ; 
 preternatural sensibility to external impressions, amounting frequently to impatience 
 of light, and of sound ; violent delirium ; want of sleep ; paroxysms of general 
 convulsion ; a parched and dry skin ; a frequent and hard pulse ; a white tongue ; 
 thirst ; nausea and vomiting ; constipation of the bowels. 
 
 You are not to look for all these symptoms in every case, nor to conclude that 
 your patient has not inflammation of the brain because the phenomena I have been 
 enumerating do not all present themselves, or do not take place in any regular order 
 of succession. 
 
 In fact, we find, in actual practice, that encephalitis is apt to come on, to commence 
 I mean, as far as symptoms are concerned, in three or four different ways. 
 
 Sometimes there is a sudden alteration of manner, and the patient, complaining 
 probably of his head, becomes all at once and furiously delirious ; and fever is 
 lighted up. These are symptoms which cannot pass unnoticed, and which imme- 
 diately direct one's attention to the head. They may, however, be fallacious, as we 
 shall see by-and-by. 
 
 In other cases the first thing remarked is nausea and vomiting : and those symp- 
 toms may soon cease ; or they may continue several days, and even sometimes 
 throughout the whole course of the disease. Bitter fluids are brought up, yellow or 
 green, and evidently containing a good deal of bile ; and whatever is introduced into 
 the stomach, even a small quantity of the most simple drink, is immediately rejected. 
 With this state of matters there is generally much constipation, and the bowels refuse 
 to act except under the stimulus of strong purgatives. 
 
 It is important to attend to these symptoms ; for, occurring, as they usually do, 
 with headache, they may easily deceive a person who is not previously aware of 
 what they may portend. If the patient has not been previously subject to sick 
 headaches, and if the epigastrium and abdomen be natural, not tender, nor distended, 
 as they are apt to be when the stomach itself is in fault, we have the more reason to 
 look narrowly into the case, and to suspect that some serious mischief of which the 
 nausea is a token, may be going on in the brain. I would observe, by the way, 
 that where there is much vomiting of bile, persons are apt, both patients and their 
 doctors, to blame the liver, to set down the disorder as bilious ; but you ought to be 
 aware, that whenever vomiting is often repeated, or long continued, bile is to be 
 expected in the matters brought up : the action of the duodenum, as well as that of 
 the stomach, is inverted ; and the bile passes in the wrong direction. If you have 
 ever suffered from sea-sickness, you must know that after the puking has gone on 
 for a little while, bile is constantly voided. 
 
 Again, some cases of acute inflammation of the brain set in neither with sudden 
 and great disturbance of the intellectual functions, nor with sickness and vomiting, 
 but with a paroxysm of general convulsion, such as often ushers in an attack of me- 
 ningitis. This symptom, according to Andral, is a much more certain sign of cere- 
 l)ral inflammation, than the occurrence of active delirium ; and I quite agree with 
 him in so thinking. 
 
 It is probable (but I speak conjecturally only) that this diversity of symptoms, 
 marking the onset of encephahtis, may depend upon the part in which the m- 
 
 1
 
 ENCEPHALITIS. 241 
 
 flammation begins ; and that it is soon propagated from that part to the whole of the 
 organ. I should suppose that when nausea and vonriiting are the earliest symptoms, 
 the inflammation has taken its point of departure in the cerebral pulp ; in the sub- 
 stance of the brain ; and that when the attack comes on with a sudden fit of convul- 
 sion, the inflammation has commenced in the pia mater or arachnoid. This is con- 
 sonant with what we know of inflammation of those parts when they are separately 
 afl^ected. Again, it seems to me presumable that the cases which are characterized 
 by early and fierce delirium are cases in which the inflammatory action has invaded 
 the whole of the encephalon, substance and membranes, simultaneously. I say I 
 offer these as conjectures of my own : what it is of importance for you to remember 
 is, that inflammation of the brain does commence in the three several ways that I 
 have been describing. 
 
 There are some cases, however, that cannot be brought within even this general 
 rule. They begin in some irregular or obscure manner, or with some unusual phe- 
 nomenon. Andral states that he has seen a few striking instances of inflammation 
 of the brain, of w^hich the flrst sign was a sudden loss of the power of speech ; and 
 Dr. Abercrombie relates a very remarkable case in which the same thing happened. 
 I call it very remarkable both on account of the singular manner in which the dis- 
 ease first showed itself, and because it furnishes an example of encephalitis produced 
 by direct exposure to intense heat of the sun — insolation ; an event very uncommon 
 in our chmate. It occurred in the practice of a surgeon at Selkirk, in Scotland : — 
 
 "A young man, aged 16, bathed twice, on the 5th of June, 1818, in the river 
 Tweed. After coming out the second time he lay down on the bank and fell 
 asleep, without his hat, and with his head exposed to the direct beams of a hot sun. 
 On awaking, he was speechless ; but walked home, and seemed to be otherwise in 
 good health. He was bled and purged, and the next day recovered his speech, but 
 lost it again at intervals several times during the three or four following days. He 
 was forgetful, and his look was dull and heavy : he made little complaint, but when 
 closely questioned said he had a dull uneasiness at the back of his head. In a few 
 days more he had squinting and double vision, and a very obstinate state of bowels, 
 and his pulse was GO. After further bleeding the pulse rose to 86 ; but he sank 
 gradually into coma, and died on the 30th. 
 
 The substance of the brain in general was found highly vascular, and a very con- 
 siderable extent of it was in a state of softening mixed with suppuration. The ven- 
 tricles were distended with fluid, and the membranes in many places were much 
 thickened. One very curious circumstance (affording perhaps some explanation of 
 the readiness with which the inflammation was produced) was, that the cranium was 
 of very unequal thickness at its upper part ; in one spot, as big as a sixpence, it was 
 as thin as writing-paper, and transparent. 
 
 However, the phenomena which I mentioned at first constitute the common and 
 ordinary symptoms of acute inflammation of the brain and its membranes. They 
 continue for a variable period ; from twelve hours to two days, or more ; and then 
 they are succeeded by others, which characterize the second stage of the complaint, 
 or the period of collapse, as it is called. These result, I apprehend, from the events 
 and products of the inflammatory action ; the violence of which is over or abated. 
 The patient ceases to complain of headache ; instead of being excited or wildly deli 
 rious, he mutters indistinctly, and falls into a state of stupor, from which it is difficult. 
 and at length impossible, to rouse him. His vision and hearing are no longer pain- 
 fully acute, but dull, or perverted ; strabismus and double vision are not uncom 
 mon ; and the pupil, from being contracted to the size of a pin's head, becomes first 
 oscillating, then widely dilated, and ultimately motionless. The patient is not shalcen, 
 at this period, with violent convulsions ; but twitchings of his muscles, and startings 
 of their tendons come on, and some of his limbs are agitated with tremors, or become 
 powerless and palsied ; the countenance is ghastly and cadaverous ; cold sweats 
 break out ; the sphincters relax : at length the coma becomes profound, and life 
 ceases. 
 
 The disease, when it proves fatal, as it too often does, mostly runs a rapid course. 
 It may kill in as short a time as twenty-four or even twelve ^ours • «^r the natietu 
 16
 
 242 DISEASES OF THE BRAIN 
 
 may struggle on for two or three weeks. The morbid appearances met with in the 
 dead body are very various. Serous or puriform effusion into the ventricles, and 
 into the meshes of the pia mater ; layers of coagulable lymph between that mem- 
 brane and the arachnoid ; softening of the cerebral substance, Avith pus infiliered 
 into the softened parts; or great vascularity, shown by a pink or purplish molding 
 of its cut surface, giving it a stained appearance. 
 
 Let us next consider the treatment required for this frightful disorder. 
 
 It is quite plain that in an organ so essential to life, and of such dehcate organiza- 
 tion as the brain, and in which changes so irreparable in their nature as many of 
 those I have just enumerated, so readily take place under acute inflammation, we 
 cannot hope to be of much service unless we see and treat the case at an early 
 period. On this account it becomes exceedingly important to recognize the nature 
 of the disease, at its very commencement ; and, therefore, I have taken pains to 
 point out to you the various forms which it may assume, while it is yet within the 
 reach of remedial measures. 
 
 The principal of those measures are blood-letting, purging, and the application 
 of cold to the head. All the particulars of the antiphlogistic regimen are to be 
 rigidl}^ observed ; the patient should be kept as much as possible in silence, and 
 darkness, with his head high, and on a firm pillow. And the antiphlogistic reme- 
 dies are to be employed with decision and energy. 
 
 With respect to bleeding I can only repeat what I have said before : the blood 
 should be drawn in a full stream, and suffered to flow till some decided impression 
 is made upon the pulse ; or until syncope occurs, or is evidently at hand. After 
 the patient has rallied a little, blood should be taken hy cupping or leeches from the 
 back of the neck, or the temples, or the mastoid processes ; and these depletory 
 measures must be repeated according to the violence or continuance of the symp- 
 toms which first demanded them. 
 
 The application of cold to the head is a remedy of great importance in this disease. 
 The head must be first shaved, and the mere removal of the hair is sometimes fol- 
 lowed by a manifest abatement of some of the most urgent symptoms ; of the pain, 
 for example, and of the delirium. In cases such as I am now supposing, it will not 
 be enough to apply wetted cloths to the head : the application must be colder than 
 the ordinary temperature of the cold water ; and it may be made colder by ice ; and 
 the best way to ensure a permanent depression of the superficial heat is to put some 
 pounded ice with a little water into a thin and flexible bladder, and to lay it on the 
 patient's head : there should not be too much ice, or its weight may be injurious. 
 This is generally very grateful and pleasant to the feelings of the patient ; and we 
 often have the satisfaction of perceiving that, wnth the reduction of the external heat 
 of the head, there is also an evident mitigation of the violent symptoms ; the agi- 
 tation and delirium are calmed, and the patient sleeps, or recovers his senses. 
 
 Another excellent and most powerful method of applying cold, is by pouring cold 
 water in a slender stream upon the vertex of the head, until it produces some marked 
 effect. Of course this as well as all other strong measures, must be adopted with 
 great caution, and its influence closely watched : I mean it is not to be left to the 
 discretion, or indiscretion, of domestics and nurses. Dr. Abercrombie tells us that 
 he has sfen a strong rnan, submitted to the operation of this cold douche, "thrown 
 in a very few mmutes into a state approaching to asphyxia, Avho immediately before 
 had been in the highest state of maniacal excitement, with morbid increase oi 
 strength, defeating every attempt of four or five men to restrain him." Of the 
 efTect of this measure in a somewhat diffl'rent morbid condition, he gives an 
 instance, which I will quote, because it shows, in the first place, the striking power 
 of the remedy ; and, secondly, the simple mode of applying it. A strong plethoric 
 :hild, five years old, after being for one day feverish, oppressed, and restless, fell 
 rather suddenly into a state of perfect coma. She had been in that state about an 
 hour when Dr. Abercrombie saw her. She lay stretched on her back motionless, 
 nnd completely insensible; her face flushed and turgid. She was raised into a 
 Filling posture and a basin being held under her chin, a stream of cold water was
 
 ENCEPHALITIS. 243 
 
 directed against the crown of her head. In a few minutes, or rather seconds, shp. 
 was completely recovered ; and the next day was in her usual health. 
 
 This measure also is to be repeated, according to the circumstances of the case. 
 
 Some persons recommend that a constant dripping of cold water upon the patient's 
 shaven head should be kept up. This may easily enough be managed by means of 
 a sponge and funnel placed a little above the head. Andral mentions his attending 
 with another physician (M. Recamier) a young man who laboured under all the 
 symptoms of acute inflammation of the brain. Cold water was made to drop slowly 
 upon his head, and complete recovery took place, although no other active treatment 
 of any kind was adopted. 
 
 In strongly recommending this efficient remedy to your notice, you will not un- 
 derstand me to advise that it should supersede the use of copious blood-letting ; i* 
 is to be employed as an auxiliary to the lancet ; not as a substitute for it. 
 
 The third remedy which I named, that is to say, purging, is also of great im- 
 portance and efficacy. But it must be hard purging. There is a great tendency 
 to obstinate constipation in most cases ; and this must be overcome, and free and 
 frequent evacuations from the bowels obtained ; five grains of calomel and fifteen 
 of jalap should be followed in three or four hours by a strong black dose ; and 
 after that I should give, in such cases, three or four grains of calomel every four 
 hours, and repeat the black dose at least every morning, until the symptoms gave 
 way. If the mercury thus exhibited affect the gums, so much the better ; bat 
 we must not, in this disease, combine it with opium, to prevent its passing ofTby the 
 boAvels. 
 
 Dr. Abercrombie uses this strong language in reference to the value of purga- 
 tive medicines in acute inflammation of the brain: — "In all the forms of the dis- 
 ease, active purging appears to be the remedy from which we find the most 
 satisfactory results ; and although blood-letting is never to be neglected in the earlier 
 stages of the disease, my own experience is that more recoveries from head affec- 
 tions of the most alarming aspect take place under the use of very strong purging 
 than under any other mode of treatment. In most of these cases, indeed, full and 
 repeated bleeding had been previously employed, but without any apparent effect in 
 arresting the symptoms." He has found the croton oil the most convenient medi- 
 cine for this purpose. 
 
 Dr. Abercrombie is disposed to regard mercury as being useful in affections of 
 the brain, chiefly in virtue of its purgative operation: and the opinions of a phy- 
 sician of his large experience, and observing mind, must and ought to have great 
 weight. But I must not conceal from you my own persuasion that, in the early 
 periods of acute inflammation of the encephalon (and it is of the early periods 
 that I have hitherto been speaking), if the mercury comes in a short time to produce 
 its specific influence upon the gums, a great change for the better will often be per- 
 ceived. Such is the result of my own observation. Recollect, however, that you 
 are not to give calomel with the direct object of affecting the gums, but as part of 
 the purgative plan, and j^ou take the chance of its specific effect. You must not 
 combine opium with it, for two reasons ; first, you would thereby shut up the 
 bowels, and deprive yourself of the use of one of your best weapons ; and, secondly, 
 you would incur the risk of augmenting and perplexing your patient's head symp- 
 toms, and of puzzling yourself; since you would not be able to determine how much 
 of the coma that ensued was owing to the progress of the disease, how much to your 
 remedy 
 
 When the second order of symptoms have arrived, those which are included 
 under the general phrase of collapse, and which commonly result, I fancy, rather 
 from the products of the inflammation than from the inflammation itself; from 
 softening, that is, and from pressure exerted by efflised serum, or lymph ; when this 
 order of symptoms make their appearance, I believe the time for doing much good 
 bv active bleeding has gone by. If, however, blood-letting has not yet been em- 
 ployed, and especially if the pulse continue hard, whether blood has been already 
 abstracted or not, it will be right to give the patient the chance of that remedy. Of 
 the propriety of doing so, take the following illustration : — " A girl, aged eleven, nnd
 
 244 DISEASES OF THE BRAIN. 
 
 violent headache and vomiting, with great obstinacy of the bowels ; and these symp- 
 toms were followed by dilated pupils, and a degree of stupor bordering upon perfect 
 coma; pulse 130. She had been ill five or six days; purgatives, blistering, and 
 mercury to saHvation, had been employed without benefit. One bleeding from the 
 arm gave an immediate turn to this case, the headache was relieved, the pulse came 
 down, the vomiting ceased, the bowels were freely acted upon by the medicines 
 which they had formerly resisted, and in a few days she was quite well." (Aber- 
 CROMBiE.) I must recite one other case — from among many which go to the same 
 effect — to show the occasional influence of hard purging. " A young man who 
 had had cough and dyspnoea, and been bled for those symptoms, appeared conva- 
 lescent. One evening he became affected with headache, and some vomiting. 
 About midnight, having got out of bed to go to stool, he fell down in a state of vio- 
 lent and general convulsion. The convulsion returned during the night six or seven 
 times with such violence that one of the paroxysms continued without intermission 
 for an hour. The pulse during the night, varied from 60 to 120." (I should have 
 mentioned before this great and rapid fluctuation of the pulse in respect to its fre- 
 quency, as being a very common circumstance and sign, in inflammatory affections of 
 the brain.) " At first it was found impossible to bleed him, on account of the vio- 
 lence of the convulsions ; but about seven in the morning a full bleeding was ob- 
 tained, after which the convulsions ceased, except some slighter attacks during the day^ 
 which appeared to be arrested by pouring cold water over his head. The next day he 
 was oppressed ; with occasional tremors of the limbs, and some vomiting, and he had 
 one or two threatenings of convulsion. He took repeated doses of active purga- 
 tives with little effect ; and on the following morning he appeared to be sinking into 
 a state of perfect coma, with a pulse at 50. Croton oil was now given, which 
 operated powerfully seven or eight times. He passed a good night ; and the day 
 afterwards was free from complaint." 
 
 Having this evidence of the separate efficacy of the three remedies — blood-letting 
 strong purgatives, and the local apphcation of cold to the head — we have much en- 
 couragement to put them into combined operation in these very serious cases, espe- 
 cially when Ave have the opportunity of using them at an early period. ShoiiJd the 
 disorder happily yield to these measures, great care will long be required on your 
 part, and great prudence on the part of the patient and his friends, lest the recent 
 mischief should rekindle. A relapse is even more perilous than the first assault of 
 the disease. Such prudence and care will consist chiefly in the avoidance anc 
 denial of all that might excite and disturb the brain; whether it be a premature 
 return to animal food ; or indiscreet and fatiguing interviews and conversations ; or 
 the too early resumption of the cares and concerns of business. 
 
 Are we to employ blisters in this disease ? Not in the outset, during the period 
 of excitement. They only add to the irritation, and make matters worse. And 
 especially you should avoid putting them, as many are apt to do, upon the head 
 itsell", at that stage of the disease. We should not suppose, a priori, that they could 
 then, and in that place, have any beneficial effect. They cannot divert the blood 
 from the inflamed part ; but they may attract it towards the encephalon. If they 
 could be expected to do any good at all, it would be when they are placed upon the 
 feet or legs. But this kind of revulsion is better accomplished by means of mustard 
 poultices, or fomentations with hot water, which are often of much apparent service, 
 in addition to the measures already spoken of. Experience confirms what reason 
 teaches us to look for in this matter. 
 
 When, however, the patient had sunk into a state of coma, he has sometimes, in 
 my experience, emerged from that condition after a cap of bhstering plaster has 
 been put upon his head. It is only when the violent symptoms of excitement have 
 abated that I can venture to advise you to employ blisters: they may then be applied 
 to the nape of the neck, or behind the ears, or to the head itself. 
 
 The symptoms which I enumerated as marking the period of collapse or sinking, 
 are fearful symptoms ; but the conditions on which they depend are not, necessarily, 
 hopeless conditions. These symptoms do not always procped from fatal disorganiza- 
 L'cn of the bram, but sometimes (there is reason to beUeve) from simple exhaustion
 
 ENCEPHALITIS. 245 
 
 of the nervous power. And this is a point of critical importance. Patients appa- 
 rently moribund are occasionally saved by the judicious administration of stimu- 
 lants and restoratives; of ammonia, Hoffman's anodyne, beef-tea, wine, and, it may 
 be, of well-timed opiates. This plan of treatment you must therefore cautiously try, 
 when an extreme degree of collapse occurs. If the structure of the brain be already 
 seriously injured, and the disease irretrievably mortal, no harm can be done ; while 
 in doubtful cases, and when the symptoms resuh from mere depression of the vital 
 powers, the patient may be rescued ; and this chance in his disease must not be 
 thrown away. 
 
 Do you ask whether there be any mode of discriminating these opposite condi- 
 tions, one of which is within, and the other beyond, the range of possible recovery ? 
 I believe there is. If the tendency to death by coma be strong, the prospect is very 
 discouraging : if, on the other hand, the symptoms that mark the mode of dying by 
 asthenia predominate, you may hope to push the patient through. But to succeed, 
 you must watch him hour by hour. Pallor, a feeble and flying pulse, extreme de- 
 bility and tremors, coldness of the extremities, a want of power to respond to exter- 
 nal impressions ; these are alarming, but not absolutely desperate symptoms, espe- 
 cially if the mental faculties remain. Whereas profound stupor, partial palsy, 
 profuse sweats, are of the worst omen ; yet even these do not preclude the trial, 
 together with blistering the head, of internal stimuli ; and no other plan affords even 
 a gleam of hope. 
 
 There is just one caution that 1 wish to mention before I leave the subject of acute 
 encephahtis ; and it apphes to all cases of coma and insensibility, and especially when 
 there is any paralysis mixed with the coma : it is, that you should daily ascertain 
 that the bladder is emptied. Always make the attendants show you the urine that 
 has been passed ; and lay your hand upon the hypogastric region, and try whether 
 there is any undue hardness or prominence there, produced by the distended blad- 
 der. I shall revert to this matter more particularly at some future time ; and I con- 
 tent myself with merely suggesting its importance to you now, in all cases of head 
 affection. If the patient does not or cannot empty his bladder, of course it must be 
 emptied for him, by means of a catheter. 
 
 It would seem perhaps the most natural arrangement if I next proceeded to speak 
 of cerebral inflammations which are chronic, or partial. These forms of disease are 
 more common, in adults, than acute and general encephahtis. I shall be obliged also 
 to treat, separately, of inflammation of the brain as it is modified by its occurrence 
 in young children, — of what is called acute hydrocephalus. But before I touch upon 
 any of these, I am desirous to bring under your notice at once a very singular and 
 extremely interesting complaint, which is not, I am persuaded, in its essential nature, 
 inflammatory, but which may easily be mistaken, and has over and over again been 
 mistaken, for acute inflammation of the brain and its membranes, with the consider- 
 ation of which we have just been occupied. The mistake is the more serious, 
 because the remedies I have been recommending for encephalitis, and especially 
 blood-letting, not only are not required, but are in most cases positively injurious, in 
 the disorder of which I am now about to speak : and which is best known under the 
 appellation of delirium tremens. Nay, this affection of the nervous system may 
 actually be brought on, in a predisposed subject, by the abstraction of blood. I go 
 apparently out of my way in taking notice of this complaint now, but I do so that 
 I may have the opportunity of contrasting it with encephalitis, while the phenomena 
 of the latter disease are fresh in your memory. It certainly resembles it also in 
 many respects : and it has been regarded as an inflammatory disorder by some 
 excellent pathologists. 
 
 The symptoms which mark a decided attack of delirium tremens, and which 
 have sometimes been found so equivocal, are very striking. You will be sum- 
 moned to a man who is supposed to be mad, or to have brain fever. You find him 
 with a red face, perhaps, and injected eyes, talking wildly and incessantly, fidgetinj/ 
 with his hands, affected often with tremors of the limbs, havincr a rapid pulse, and 
 oathed in sweat. Now it is very natural that a person not on his guard should look 
 
 v3
 
 S4$ DISEASES OF THE BRAIN. 
 
 upon these symptoms as indicatino^ inflammation within the head. But if you look 
 closely into the matter, you will find in the state of the patient, and in his history, 
 some things very peculiar. The deHrium you will generally find to be, not a fierce 
 or mischievous delirium, but a bu>iy delirium : he does whatever you desire him to 
 do, but he does it in a hurried manner, with a sort of anxiety to perform it properly. 
 During the approach of the malady, while he is yet able to go about, he manifests 
 great impatience of any interference, or advice, or assistance, in his ordinary duties, 
 which he sets about in a bustling and blundering manner. His loquacity is extreme, 
 and he refers to matters that are not present before him : he is not altogether inattentive 
 to the objects and proceedings that are going on around him, but his mind wanders 
 away to other subjects. There is an odd mixture of the real and the ideal in his 
 thoughts and language. Sometimes he is ver}^ suspicious that those who are about 
 him intend him some injury ; or that he is surrounded by enemies. You will find 
 also that he does not sleep ; that he has not slept perhaps for several nights, but 
 been restless and rambhng ; and you will generally learn that he has been habitually 
 intemperate, or subject to some great source of care, or anxiety, or excitement : and 
 in many cases he has recently been somehow or other debarred from his customary 
 stfmulus. In addition to these points in his history, you will frequently be told that 
 having been unwell, first he has been kept upon low diet, and then, as the delirium 
 came on, he has been freely bled ; and that he has been none the better, but com- 
 monly the worse for the bleeding. When you gather such particulars as these 
 from his friends (for upon his own statements you cannot place any reliance), and 
 when you find the delirium to have the characters I have been attempting to do- 
 Bcribe, and especially when there has been obstinate watchfulness, and the tongue 
 is moist, and the skin is sweating, you may be pretty certain that j'our patient is 
 afTected, not with inflammation of the brain, but with dehrium tremens ; and that if 
 you bleed him further, you will make him worse. 
 
 But what are you to do under such a fearful state of things? Why the great indi- 
 cation is to procure sleep ; and the remedy which, in nine instances out of ten, you 
 will find successful, is opium. The beneficial effects of this drug, in tolerably 
 favourable cases of delirium tremens, are really surprising. I will give you an 
 example or two, which will be more instructive than any abstract description. 
 
 In the year 1831 I was requested, by a most respectable practitioner in this town, 
 to visit a patient of his whom he reported to have had phrenitis, for which he had 
 been freely bled, cupped from the back of the neck and purged ; and Avho, he 
 believed, was now rapidly sinking, and not likely to survive many hours. I found 
 the patient, a middle-aged man, with a red face, ferrety eyes, a frequent pulse, 
 bathed in perspiration, busy with his hands, which trembled a htlle, and talking 
 much and incoherently. He was particular!}' anxious that his lecfs should not be 
 scarified, told me he was willing to do any thing I pleased, if I would not scarify his 
 legs, nor let any one else scarify them. There was nothing the matter with his legs, 
 nor had it entered any body's head but his own, that they wanted scarifying. He 
 had not slept for several nights. He had been intemperate, especially of late, drink- 
 ing a good deal ; and somewhat anxious about his aflairs : he was a builder. 
 
 His former historj'^ was not very promising. He had brought up a good deal of 
 blood a few months before, and some years previously he had had jaundice ; latterly 
 he had been troubled with indigestion. 
 
 I saw him in the afternoon, and prescribed one-third of a grain of morphia : in the 
 evening he was just in the same state. I then directed half a drachm of laudanum 
 to be given immediately, and twenty drops every two hours afterwards, till he slept. 
 I said to the gentleman who had called me to the case, that I thought it very likely 
 our patient might be well the next day ; he smiled and shook his head. I was 
 obliged to leave London, early the next morning, for two or three days ; on my 
 return, I learned from the medical man that the patient took five doses of the laud- 
 anum, after which he fell asleep, and slept soundly, and for a long time, and then 
 awoke (to his attendant's extreme surprise and satisfaction) sane, and well. 
 
 I was asked by the apothecary of the Middlesex Hospital to see a publican in 
 inat neighbourhood. I found a large strong man between 30 and 40 years of age
 
 DELIRIUM TREMENS. 247 
 
 He had been Avithout sleep for several nights, somewhat incoherent, and (what is 
 not usual in such cases) violent, threatening and striking those about him because 
 they refused him access to strong drink. He was joint proprietor with another in a 
 gin-shop, and for some time previously he had been a sot, and daily muddled with 
 drink. He told me he was quite well; there was not much tremor. I found that 
 the object of his partner and relations in sending for me was that I might sanction 
 his removal to St. Luke's, for his strength made him altogether unmanageable, and 
 his insane and extraordinary conduct was hurting the business of the house. I 
 declined to take any part in consigning him to a mad-house, and recommended 
 morphia. After one full dose he soon slept ; and the next day he was quite rational, 
 and comparatively well. 
 
 These are the broad outhnes of dehrium tremens ; there are many other features 
 wanted to complete the portrait of the disease, which I shall endeavour to paint at 
 our next meeting. 
 
 LECTURE XXIV. 
 
 Delinum Tremens, concluded. Chronic Inflammation of the Brain. Softening, 
 Suppuration, Mscess, Induration, Tumours in the Brain. 
 
 I DREAV a rude outline, yesterday, of that singular and interesting malady usually 
 denominated delirium tremens. The disease is very common in this country ; for 
 its causes are in common and powerful operation. You will meet with it in every 
 walk of life : and you will be almost sure to witness several examples of it during 
 the course of every year, in any of our metropolitan hospitals. It is not a chronic 
 or vague complaint, likely to be treated with placebos, or by waiting upon nature. 
 Active measures are pretty certain to be adopted ; and, in many cases, one plan of 
 treatment, vigorously pursued, will hurry the patient to his grave ; another plan 
 will restore him to health with an almost magical celerity. It certainly bears a 
 strong resemblance to that most formidable disease, inflammation of the brain and its 
 membranes ; but the great remedy for encephalitis acts like a poison in pure deli- 
 rium tremens ; and the drug, by the timely and careful administration of which we 
 can often promise a speedy cure in dehrium tremens, is one which we must care- 
 fully avoid, in the earlier treatment, at least, of encephalitis. Accuracy of diagnosis, 
 therefore, between these different disorders, with similar outward signals, becomes 
 of the very highest importance. 
 
 Delirium — tremens. — There is delirium always ; and there is generally, but not 
 always, tremor. The name is a good enough name, in my humble opinion ; yet it 
 has been found fault with, because the trembling is not in all cases present; and 
 some have, therefore, christened it delirium e potu, or delirium ebriositatis : but 
 these terms are open to just the same objection as the other; for though the disorder 
 is most commonly connected with intemperate habits, that is not always the case. 
 One very curious fault has been discovered in the name : it is said that the delirium 
 cannot tremble ; and, therefore, that it is better to say, delirium cum tremore, or 
 tremcfaciens : and you would hardly suppose it, but there has been a sort of conten- 
 tion for the honour of thus mending the nomenclature of this disease. But they w^ho 
 do object to delirium tremens appear to see no harm in delirium ferox ; whereas it 
 is just as incorrect to say delirium is fierce, as to say that it trembles: it is the 
 patient who is furious, even as it is the patient who trembles ; and all this dispute 
 about a name is mere trifling. It matters not what we call a disease, so that the 
 name conveys no erroneous theory as to its nature or treatment. No such source 
 of error attaches itself to the term dehrium trenjens : and, therefore, if it be only ic 
 avoid the inconvenience of change, we will adhere to that term. 
 
 Recollect that the strong features of the complaint are sleeplessness ; a busy, but 
 not angry or violent delirium ; constant chattering ; trembling of the hands, and an
 
 248 DELIRIUM TREMENS. 
 
 eager and fidgety employment of them. To these are added other symptoms which, 
 though they are not so calculated to strike a looker-on, are of not less importance, 
 masmuch as they help to establish the diagnosis. The tongue is moist and creamy ; 
 ihe pulse, though frequent, is soft; the skin is perspiring, and most commonly the 
 patient is drenched in sweat. The sweat is usually described as having an offensive 
 or a peculiar smell : I cannot say that I have observed it to be so. The face also is 
 said to be pale ; but that, I know, is not always the case, and therefore this point 
 cannot be rehed upon as a distinguishing circumstance. In one of the instances 
 which I related in the last lecture, the face was flushed, and the eyes red and ferrety. 
 
 Let me remind you, in a few words, of the peculiar characters of the delirium. 
 If you question the patient about his disease, he answers quite to the purpose ; de- 
 scribes, in an agitated manner, his feelings, puts out his tongue, and does whatever 
 you bid him : but immediately afterwards he is Avandering from the scene around 
 him to some other that exists only in his imagination. Generall}'- his thoughts appear 
 to be distressful and anxious ; he is giving orders that relate to his business to per- 
 sons who are absent ; or he is devising plans to escape from some imaginary enemy : 
 he fancies that rats, mice, or other reptiles, are running over his bed, or that strangers 
 are in his room. He looks suspiciously behind the curtain, or under his pillow, and 
 he is perpetually wanting to get out of bed ; but he is readily induced to lie down 
 again. It is very seldom that he meditates harm, either to himself or to others ; there 
 is rather a mixture of cowardice and dread with the delirium. 
 
 All the points that I have been mentioning require to be investigated in every case 
 of this nature : and an inquiry into the previous history of the patient, into what the 
 French call the commemorative symptoms, is equally important. In a large majority 
 of instances you w^ill find that he has been an habitual drunkard ; and very frequently 
 that from some reason or other this habitual stimulus has been diminished or taken 
 away. Some accidental illness has befallen him, and he has been restricted to low 
 diet, and, as a sailor would say, "his grog has been stopped." When, with symp- 
 toms such as I described just now, you hear a history of this kind, you may be 
 satisfied that the disease is not inflammation of the brain, but dehrium tremens. I 
 beUeve that habitual intoxication of any sort may lead to this disorder; but distilled 
 spirits more surely than wine ; wine more than beer. I make no doubt either, that 
 what is alleged of the habitual use of opium, in preparing a person to suffer in the 
 same way upon its being withheld, is quite true, although I have had but few oppor- 
 tunities of noticing such cases. 
 
 But the disease is not confined to drunkards, although it is so commonly connected 
 w'ith that pitiable vice, as to have been called mania e potu. You meet with it occa- 
 sionally in men who have overstained their nervous system by other modes of strong 
 excitement. Long-continued mental anxiety, that state of mind in which gamblers 
 and great speculators (who are indeed gamblers) are accustomed to live, may cause 
 it ; any thing by which the mind is over-wrought. A well-informed medical man, 
 of temperate habits, told me a few days ago that he was on the brink of delirium 
 tremens in the year 1825. He had foolishly entangled himself in some of the specu- 
 lations which prevailed here like an epidemic at that period, and his mind was on 
 the tenter-hooks of suspense and apprehension for some time. He could not sleep, 
 and he found himself everlastingly chattering. It comes on in the course of certain 
 diseases ; as sometimes, for example, in apoplexy : and it is a very common result 
 of bodily injuries and accidents, and of surgical operations ; or, I should rather say, 
 that it often follows such diseases and casualties ; for it is, even then, the conse 
 quencc of the treatment and regimen to which the patients are subjected, rather than 
 of the surgical or medical complaint. And it is certainly more apt to occur, under 
 these circumstances, in old people ; and in those who, being younger, are known to 
 have been intemperate. So frequently does the delirium manifest itself upon the 
 ".essation of the accustomed spur, that the continually recurring stimulus has been 
 regarded as the predisposing, and the privation of that stimulus the exciting cause 
 of the affection. Sometimes, however, it comes on in men who are perpetually 
 fuddled, even although they have not intermitted their usual indulgence in drink. 
 VVe had a porter (an old soldier he had been) at the Middlesex Hospital, who was of
 
 DELIRIUM TREMENS. 
 
 249 
 
 great use to us as a subject to practice upon, and to show to the pupils. I never saw 
 him so drunk as to be unable to perform his duly : but I cannot conscientiously say 
 that I ever saw him sober. Every three or four months we were sure to have 
 him in the wards with delirium tremens. Sometimes he fell into the hands of one 
 physician, and sometimes of another; but in one of his attacks he slipped through 
 our fingers. I am not certain that he was not nominally my patient on the last and 
 fatal occasion : but assuredly he was never an example of the disease coming on 
 from the adoption of more temperate habits. We often find that the malady shows 
 itself immediately after an unusually severe debauch, which has disturbed the 
 stomach and bowels, and left behind it a proportional degree of exhaustion and 
 languor. 
 
 Without knowing why it should be so, my own experience would lead me to the 
 belief that delirium tremens is very uncommon among women. The number of beds 
 for females in the physicians' wards of the Middlesex Hospital is somewhat greater 
 than for males. On the men's side of the house cases of dehrium tremens are very 
 frequent: whereas I scarcely remember any on the women's. Yet each sex is 
 obnoxious to its main causes. The gin-shops of this town are said to draw a fearful 
 crowd of votaresses. And we might expect that the more sensitive character of the 
 female constitution would render them especially liable to this peculiar consequence 
 of the abuse of alcohol. My experience, however, is such as I tell yon. On the 
 other hand, Dr. Roots thinks that he has seen quite as many instances of delirium 
 tremens attacking females as males. The result of M. Rayer's observations is more 
 in accordance with my own. Of 176 patients seen by him, seven only (not one in 
 twenty-five) were women. A still smaller ratio is recorded by Bang, ten in 456 : 
 less than one in forty-five. The disorder appears to be more common in the summer 
 than in the winter months. 
 
 The pecuhar nature of the complaint, and the proper method of treating it, were 
 first brought into general notice in 1813 by a little work of Dr. Sutton's, of Green- 
 wich. He saw a good deal of the diseases of the smugglers, and of the customers 
 of the smugglers, who frequent the coast of Kent ; and he was struck by the different 
 event of this disorder in the hands of different practitioners, according as bleeding or 
 narcotics were adopted. It is the same disease which Dr. Abercrombie speaks of as 
 " a dangerous modification of meningitis, which shows oniy increased vascularity." 
 Dr. Bright also includes it among his cases of " Arachnitis." Both these eminent 
 physicians had learned, however, that the complaint requires a particular method of 
 treamient. Of late years many essays and papers on the same malady have ap- 
 peared in this country, in France, and in the United States, where the disorder is 
 common. But even now it is not so well understood, throughout the profession, as 
 it ought to be. 
 
 You may ask me, what is the essential nature of the disease : and I can only- 
 state in reply that it consists in nervous irritation. Some persons hold that this is 
 tantamount to no answer at all ; but I do not agree with them. They seem to think 
 that if you assign a state of the brain or nervous system which is not visible or tangi- 
 ble, you lose yourself in mere hypothesis. But we see a number of striking phe- 
 nomena in this and in many other forms of disease, for which phenomena we can 
 trace by our senses, in the organ affected, no physical cause ; yet we are sure that 
 they have a cause ; and we call that cause irritation : if we had given it some Chi 
 nese name, it would have been all the same. From certain symptoms we infer irri 
 tation ; just as from certain phenomena we infer gravitation. I do not mean to put 
 the two upon an equal footing ; or to pretend to say that the laws of irritatipn are 
 established wiih any thing like the certainty which belongs to the ascertained laws 
 of gravity : but we pursue the investigation of these laws in the same Avay in the 
 one case as in the other: and it is quite idle to object to an arbitrary term, like irri- 
 tation, because it is meant to represent something which makes itself known to us 
 only by its efl^ects. 
 
 Now I apprehend that we are borne out, by authentic facts, in believing that cer- 
 tain changes in the blood-vessels will lead t5 irritation, and at length to inflammation, 
 of a part. But there are other sourcs of irritation; and irritation in its turn wiJl
 
 250 DELIRIUM TREMENS 
 
 lead to changes in the blood-vessels. In the one case we bring oacK the blood-vessels 
 to their healthy condition, and the symptoms of irritation cease. In the other we 
 calm the irritation, and the previous effect of it upon the blood-vessels stops. In 
 other words, deviations from the natural and healthy state of the nervous system are 
 sometimes the cause, and sometimes the consequence, of disturbances in the sangui- 
 ferous system. Whether this be good philosophy, or whether it seem to you rational 
 and intelligible, I do not know ; but it is the best explanation that I can offer you ■• 
 upon this subject. 
 
 I apprized you, in the last lecture, that the great remedy in delirium tremens is 
 sleep ; and that our most powerful means of inducing sleep are to be found in opium. 
 The opium must be given in full doses ; and it must be fearlessly repeated if its 
 desired effect does not follow. If the patients pass many nights without sleep, they 
 will die. I have tried various forms of opium ; and I am quite satisfied with 
 morphia. Some persons, however, have not found it so successful as solid opium, 
 or as the common tincture, laudanum. You may try the one or the other, or the 
 one after the other, if you please. No particular rules can be laid down that will 
 suit all cases. After clearing out the bowels by a moderate purgative, you may 
 give three grains of solid opium ; and if the patient show no inclination to sleep 
 after two or three hours have elapsed, you may begin to give one grain every hour 
 till he does sleep. Or you may prescribe corresponding quantities of the acetate or 
 muriate of morphia : or of laudanum : or of the black drop : or of Battley's sedative 
 liquor. His room, meanwhile, should be kept dark and quiet. If he sleeps for some 
 time he will awake calmer and more sensible ; perhaps perfectly so : and you must 
 withhold the remedy, or continue it in smaller or less frequent doses, according to 
 the circumstances of the case. 
 
 Dupuytren found opiate enemata of great efficacy in the cases of traumatic deli- 
 rium which came under his care. That mode of administering the narcotic may 
 properly be adopted, if there be any impediment to its reception or retention by the 
 stomach. 
 
 Now sometimes this opiate treatment alone is quite enough : sometimes it is not. 
 You will meet with patients who resist very large doses of the drug ; but who prc- 
 senth'- sleep, or become composed, if j'ou give some of their accustomed stimulus 
 with it: "a hair (as the vulgar saying goes) of the dog that bit them :" if you put 
 their opiate dose into a glass of gin, or a pint of porter. Nervous exhaustion goes 
 along with and augments the nervous irritability. This I have continually expe- 
 rienced with hospital patients. And I rather think that you may get some clue to 
 the particular cases which require this treatment, by examining into the slate of the 
 digestive functions. If you learn that, notwithstanding the intemperate habits of 
 the patient, his appetite for food has continued unimpaired, and his digestion sound, 
 you will, I believe, generally find that good nourishing diet, strong broths for 
 example, and the opium, will suffice for the cure. But if the powers and natural 
 sensations of the stomach have been injured and perverted, as is too often the fact, 
 then a temporary recurrence to the habitual stimulus Avill frequently be necessary : 
 and it is well to ascertain, in such cases, what the stimulus has been, whether spirits, 
 or beer, or wine, and to order it accordingly. Of course this is not to be continued 
 after the patient has recovered from his delirium ; but the stimulus under these cir- 
 cumstances must be cautiously witWrawn. When the stomach retains its power 
 of digestion, the bad habit of drinking ought to be broken off at once : and if, after 
 sleep, you can get the patient to eat heartily of a beef-steak, or mutton-chop, I should 
 always advise it. 
 
 There are some things which I find it necessary to mention, for the sake of dis- 
 commending them. I know persons who in treating these cases combine calomel 
 with the opium. And they say that they cure their patients so ; and I make no 
 doubt that they do; neither can I doubt that the same success would have followed 
 the same quantity of opium without the calomel. In pure cases of delirium tremens 
 I advise you not to give calomel. I know no possible good it can answer : it is 
 itself a source of great irritation to the nervous system in many persons : and if it 
 romes to affect the mouth, you inflict upon j-our patient a superfluous discomfort;
 
 DELIRIUM TREMENS. 251 
 
 and, I believe, in many cases, a downright injury. You will be told also of digitalis, 
 as a specific remedy for the disease ; or you may read of it : but do not be led away 
 from the standard remedies which reason recommends, and large experience has 
 sanctioned. Knowing what we do of the power of opium generally, and of its 
 efficacy in this complaint in particular, I should consider myself guilty of a criminal 
 trifling with human life if I made experiments with digitalis, upon the loose reports 
 of some one or two persons, of whose credit or information I knew nothing ; and 
 whose dicta had been transferred perhaps from some foreign journal to fill a vacant 
 corner in one of our own. Of the combination of opium and antimony, which has 
 been much praised by good and competent judges, I am unable to tell you any thing 
 from my own experience. 
 
 In hospital practice it sometimes becomes necessary to confine the patient to his 
 bed by straps, or to muffle his limbs in a strait waist-coat : but this is a most unfor- 
 tunate necessity. Physical coercion, whether manual or mechanical, should never 
 be resorted to in delirium tremens, when by any means it can be avoided. The 
 angry feeling and mental fret which it produces, and the exhausting bodily struggles 
 to escape or resist the thraldom, are always highly injurious and full of danger to the 
 patient. A couple of strong and good-tempered attendants will not have much diffi- 
 culty in persuading and managing the sick man, who is seldom either boisterous or 
 obstinate : and if he be intractable by soft words, he will yield more patiently to 
 their gentle restraint than to the force of manacles ; while the appearance of coercion 
 need not be continued a moment after his acquiescence. 
 
 I have drawn the line between encephalitis and delirium tremens with sufficient 
 clearness, because I have taken well-marked forms of each. But I am sorry to add 
 that there are mixed cases, which are very puzzling when they occur, and exceed- 
 ingl}?^ difficult to treat; and which require opiates on the one hand, and moderate 
 depletion on the other. When the indications are uncertain, or equivocal, we must 
 carefully weigh the different symptoms, and we must cautiously try the remedies. 
 The circumstances that most distinguish the one form of the disease from the other 
 are to be found in the pulse ; which is hard and resisting in the earlier stages of in- 
 flammation of the encephalon, soft and compressible in delirium tremens : in the 
 tongue ; which is mostly parched and rough in the former, moist and creamy in the 
 latter : in the skin ; which is hot and dry in the one case, covered with sweat in the 
 other : in the countenance ; Avhich is flushed in inflammation, and mostly (though 
 not always) pale in delirium tremens : in the tremors ; which are not common in 
 the primary periods of inflammation of the brain : in the usual absence of headache 
 in delirium tremens : and in the peculiar characters, which I need not recount, of 
 the delirium in the two cases. If these symptoms contradict each other, as they 
 sometimes will, you had better act on the worst supposition, and presume that there 
 is inflammation, and employ antiphlogistic remedies : but you must not do so with 
 a strong hand ; you must use them cautiously, and watch their effects, and guide 
 thereby your subsequent treatment. Take a moderate quantity of blood from the 
 arm : observe Avhether it has the huffy coat : and note the condition of the patient 
 afterwards. In mixed or ambiguous cases it will be proper to combine calomel with 
 the opium. You will sometimes find a state resembling delirium tremens left after 
 the subsidence of acute inflammation of the parts within the cranium, and requiring 
 the treatment of dehrium tremens. 
 
 I do not know that there is much good to be expected from counter-irritation in this 
 disease. But after the more decided symptoms were gone by, I have sometimes 
 thought that the recovery has been accelerated by the application of a blistec to the 
 nape of the neck. 
 
 Inflammation of the brain, and delirium tremens, are distinct diseases. Hence, in 
 the mixed cases, of which I just now spoke, we may expect after death to find, and 
 we often do find, unquestionable traces of inflammatory action within the skull. But 
 pure delirium tremens frequently leaves behind it no morbid appearance whatever 
 m the brain or its membranes. In other cases there is serous liquid collected in tho 
 mterstices of the pia mater, or in the cerebral ventricles ; and I have on several 
 occasions seen the arachnoid thicker and less transparent than i^ naiuinl, and
 
 252 DELIRIUM TREMENS. 
 
 sprinkled over with little spots or streaks of a milk-white colour. Changes of this 
 kind we believe to be owing to chronic inflammation of the membrane. But, even 
 in these cases, I see no reason for thinking that the fatal disorder had any connection 
 with the morbid state of the arachnoid. We meet continually with like appearances 
 when there has been no delirium tremens ; and we have delirium tremens without 
 any such appearances. The habitual abuse of ardent spirits leads to chronic inflam- 
 mation in various parts and tissues of the body : in the blood-vessels, in the liver, in 
 the kidneys, and in the arachnoid. We need not be surprised at finding that mem- 
 brane thickened and partially opaque in the victims of delirium tremens ; since they 
 are chiefly men who have run a long course of intemperance. I believe that disease 
 to bear the same relation, and no other, to the chronic arachnitis in such persons, as 
 to the chronic hepatitis to which they are equally subject. There is but one morbid 
 condition which, since my attention was first directed to it, I have found constant in 
 persons dead of delirium tremens, and that is, a remarkably soft, pale, and flabby 
 state of the muscular tissue of the heart. 
 
 The chemist may be more Hkely to detect altered conditions in the brain, in these 
 cases, than the anatomist. Very lately Dr. Percy has obtained alcohol from the 
 brain of a person who died from excessive drinking ; and from those of various ani- 
 mals which had been killed by that poison. These facts are interesting, but they do 
 not help us much in our attempts to explain the phenomena of the disorder. 
 
 Cases, such as I related in the last lecture, where violent symptoms are calmed at 
 once, and the patient is rescued in a few hours from great apparent peril, make a 
 strong impression upon those who witness them ; and the practitioner gains amazing 
 credit, and is spoken of to all their acquaintances as a wonderfully clever man. It 
 is unfortunate that we are obliged to set off, against this advantage, a corresponding 
 danger, when the disease ends ill, of being blamed without our deserving it. When 
 these patients die (and they usually persist in their evil habits and die at last in one 
 of the attacks of the disease), when they so die, they are apt to die much in the 
 same way as patients who are poisoned by opium ; and if their friends are aware 
 that we have been giving large and repeated doses of that drug, they sometimes 
 have the charity to lay the death at our door: and you ought to be prepared for 
 this ; and I will conclude what I have to say upon the subject of delirium tremens 
 by relating a case, in which I have no doubt that I suffered (though quite unjustly) 
 under that kind of imputation. 
 
 Several years ago I was asked, one morning, by a general practitioner at the west 
 end of the town, to see a patient with him : of whom he gave me this account. The 
 man was about forty years old. He had been attacked some daj's before with sore 
 throat, common cynanche tonsillaris. The tonsils and fauces were so much swelled 
 that his deglutition was greatly impeded, and for four or five days he had not been 
 able to swallow^ any thing. The night before I saw him he had become dehrious, 
 and then had been largely bled, and he was worse in the morning. His bowels had 
 also been very much purged. 
 
 I found him propped up in his bed, whh a coronet of leeches round his head. He 
 was pale ; there was no headache, nor affection of his breathing; his pulse was not 
 very frequent, and it was quite soft and compressible. He was sweating profusely. 
 He answered the few questions I put to him readily and pertinently, and then went 
 talking on in a rambling way about his business. He was a hackney-man or stable- 
 keeper, in a large way. He said (I remember) that the boys were all ready to 
 start, that there were two pair of horses going down the road, and that he must go 
 and see after them ; and much more on the same subject. His mind was busy 
 about the execution of imaginary orders. He had not slept at all for some nights. 
 
 Upon my inquiring into his previous condition, his wife told me that without any 
 turn lor dissipation he had for some time been an habitual hard drinker; that he had 
 !«equent dealings with the coachmen to the various families which he furnished with 
 horses ; and that he was obliged to drink something with each of them ; so that every 
 aav he had many glasses of spirits, and a good deal of porter. She told me, also 
 th::t his mind had been anxious and uneasy; that the business was a large and
 
 DELIRILM TREMENS 253 
 
 narassing one ; that he had embarked a considerable sum of money in it ; and that 
 it had not turned out so prosperously as he had expected. 
 
 Putting all these things together, there could be no doubt, either as to the charac- 
 ter of the complaint, or as to the treatment proper to be adopted. Here was a man 
 who had been living a life of continued mental and physical excitement. Suddenly 
 the stimulus to which he had been accustomed, was taken away ; he could not swal- 
 low even such nourishment as his case required or admitted : then came on delirium 
 — a symptom not belonging to the disease in his throat — and protracted watchful- 
 ness. He is largely bled, and profusely purged, and he gets worse instead of better 
 under these remedies. At the same time his skin is moist and perspiring, and there 
 is no hardness in his pulse. 
 
 I recommended that the leeches' should be removed from his head; that he should 
 take immediately (for he could swallow now) two grains of opium, and afterwards 
 twenty drops of laudanum every two or three hours till he fell asleep. 
 
 Somewhat unluckily, his wife's brother — a very young man — was the apprentice 
 or assistant of a surgeon in the neighbourhood of town, and he came in to see his 
 relative. After hearing what I had said, he went home, and probably consulted his 
 books, and then came back again with doubts whether the complaint really was 
 delirium tremens after all. Whether in consequence of these doubts I cannot tell, 
 but for some reason or other only one or two doses of the medicine were taken. I 
 Jiad offered to see the patient again in the evening, but his friends said they would 
 send for me if he did not get better. They did not send. The patient did not sleep. 
 At night, therefore, at ten o'clock, three grains of opium were administered. The 
 result of this was, that he passed a quiet but a sleepless night. Perhaps (but I can- 
 not be sure of that) if the opium had been persisted with, the case might have termi- 
 nated otherwise. About eight o'clock the next morning I was summoned to him in 
 a great hurry ; when I got there he was dying, perfectly comatose, breathing sterto- 
 rously, with blue lips and contracted pupils. He had appeared so much better at 
 seven, that he was, for the first time, left alone for a quarter of an hour ; and when 
 they went back to him, he was changed in the manner I have described. 
 
 The general practitioner with whom I had first seen the patient — a very sensible 
 man — was much concerned at this issue of the case, and observed to me that doubt- 
 less our patient had been poisoned by the three grains of opium. I was able, how- 
 ever, to relieve his mind from this notion : and I have mentioned the case chiefly 
 for the sake of guarding you against similar misgivings, under similar circumstances. 
 The manner of dying was just such as opium will produce; but, then, death by 
 coma is also frequently the termination of delirium tremens. Effusion at length is 
 apt to take place into the ventricles, or into the meshes of the pia mater, and stupor 
 comes on, and the patient sinks. But in this instance I was certain that his death 
 had nothing to do with the opium he had taken, for this reason : that so long a space 
 of time had elapsed — nine hours — between his taking the opium and the coming on 
 of the comatose symptoms. Dr. Christison, in his elaborate and valuable work on 
 Toxicology, states it as the result of extensive inquiry into this subject, that when 
 opium has been swallowed in a poisonous dose, it almost always begins to act as a 
 poison within an hour; that very rarely indeed has its specific operation been post- 
 poned much beyond the hour, except, occasionally, when the person taking it was 
 intoxicated at the time. In one remarkable instance a drunken man took two ounces 
 of laudanum, and no material stupor followed for five hours. I guess that I incurred 
 the reproach of recommending a fatal plan of treatment in the particular case I have 
 now related ; but I am quite satisfied that the opium was innocent of the patient's 
 death, and I even think that his chance might have been much mended if the opi- 
 ate, m smaller doses perhaps, had been steadily continued. 
 
 We may be content to bear occasionally, these unfounded imputations when we 
 consider the other side of the account, and call to mind the far greater number of 
 instances in which spontaneous recoveries are credited to us as cures ; and the Doc- 
 tor, like Belinda's Betty, is "praised for labours not his own." 
 
 [The account given by the author, of the character, phenomena, causes, and treatme?nt 
 of delirium tremens, is, upon the whole, so very judicious, that it would scarcely appear to 
 
 w
 
 254 DISEASES OF THE BRAIN. 
 
 demand any other comment, than one of general approval. But as there exists a very decided 
 difference of opinion among American practioners in regard to the proper management ot 
 the disease, a few words upon this point may not be improper. 
 
 Four different plans of treatment have been recommended, and the results of their exten- 
 sive employment for a series of years, have been adduced, by their respective advocates, in 
 evidence of the superior efBcacy of each. One practioner cures all or nearly all his cases by 
 repeated emetics, another, by the free exhibition of alcoholic drinks, and a third, by opiates 
 n free doses, continued at short intervals, until sleep is procured — while a fourth considers 
 diat neither excitants proper nor opiates are necessary, but simply a state of tranquillity in a 
 quiet and darkened chamber — with perhaps an emetic to unload tlie stomach in the com- 
 mencement of the attack, and some gentle cathartic to keej? the bowels open — and when the 
 stomach will retain it, a light, nutritious, and easily digested diet. 
 
 The opiate practice is the one, in favour of the superior efficacy of which we have the 
 most imposing weight of evidence — and it is unquestionably the one that will, in the majo- 
 rity of cases, when judiciouslyand cautiously managed, the most promptly and effectually remove 
 /he symptoms of the disease. That the opiate practice has been abused, we are perfectly 
 aware. Under the supposition that opiimi to any extent that may be requisite to induce 
 speedy sleep can be administered in delirium tremens with perfect safety, we have cause 
 to fear that a state of coma has in more than one instance been induced from which the 
 patient has never awoke. We have never been in the habit of administering large doses of 
 opium, and have usually combined each dose with an equal quantity of camphor, and about 
 half a grain of ipecacuanha. In young, robust, and plethoric subjects, we believe that the 
 application of cups to the temples and nape of the neck, or even a moderate bleeding from 
 the arm, is an important measure in the commencement of the attack, which should not be 
 lost sight of. 
 
 That there are many cases of delirium tremens in which a perfect recovery maybe effected 
 without the administration of opium or of any stimulant is very certain — but our experience 
 has taught us, that when the disease occurs in confirmed inebriates, with a broken down 
 constitution, and in whom there is almost complete destruction of the proper functions of the 
 digestive organs, almost the only means by which it can be certainly and promptly arrested 
 is opium administered in moderate doses at short intervals. 
 
 The treatment of delirium tremens by alcoholic drinks, while we can have no doubt of its 
 very general efficacy, — is attended with an evil of too serious a character, to permit us to 
 give to it, under any circumstances, our sanction. It cannot fail, we are persuaded, to con- 
 firm tlie patient in his intemperate habits — and thus render him liable to a renewal of the 
 disease after a short interval. That it is not the only successful treatment we are convinced 
 from ample experience. In the practice of our preceptor as well as in our own, which has 
 extended now beyond a qtiarter of a century, we have had sufficient opportunities for testing 
 the value of the opiate practice in this disease, and have seldom been disappointed in its 
 effects. We do not say that the patient will invariably recover under it. There are cases, 
 in which, from the condition of the patient's system — the complication of the temulent deli- 
 rium with serious disease of the brain or other important organs, death is inevitable under 
 any plan of treatment : we believe, however, that in the general run of cases, the success of 
 a properly conducted opiate treatment will equal that of any other ; while in the old, broken 
 doM'n drunkard, it, or the stimulant practice, is the only one upon which any dependence 
 can be placed. Of the emetic treatment, as recommended by Dr. Klapp, we cannot, it is 
 true, speak from experience; in the very few cases in which we have'tried it, we were dis- 
 appointed in its effects. 
 
 On the subject of the proper treatment of delirium tiemens, the reader may consult with 
 profit Dunglison"s Practice of Medicine, 2d edition, vol. ii., page 274, and the able note by 
 Dr. Gerhard in Tweedie's Library, American Edition, vol. ii., page 237. — C] 
 
 I should next wish to put you in possession of what has been ascertained in 
 respect to partial and to chronic inflammation of the brain, as these are met with in 
 adults ; for I must speak of the head affections of children separately. But I really 
 do not know how to bring this part of the subject before you in a practical manner. 
 If I were first to describe symptoms, and then to state what organic changes had 
 been discovered after death preceded by them, I should have to tell you of different 
 bymptoms with the same morbid conditions, and of the same symptoms with different 
 morbid conditions, in various individuals. I believe the best method, upon the whole, 
 will be to describe the several morbid appearances which the brain is found to pre- 
 sent ; and then to mention the symptoms that have most commonly been observed 
 to occur in association with such morbid conditions. I must premise, however, that 
 the whole subject is full of uncertainty and apparent irregularity. Doubtless there 
 w some constant and uniform connection of cause and effect between the ?Jterea
 
 RAMOLLI 3SEMENT. 255 
 
 physical states of the brain and the altered manifestation of its functions : but we 
 nave not yet been successful in our search after those settled relations ; or we have 
 but partial and imperfect ghmpses of them. 
 
 One very remarkable condition of the brain has been several times mentioned m 
 these lectures ; viz., softening — ramollissement. A great deal of attention has been 
 paid to this condition of late years, both in France and in this country : and some 
 points in its pathology have been fairly made out. I will bring them together as 
 concisely as i can. In the first place, the softening varies greatly in degree, from 
 the consistence which naturally belongs to the cerebral substance, to that of thin 
 cream. In its minor degrees it may be easily overlooked ; and is more perceptible 
 by the touch than by the eye. The cerebral matter is less coherent, but it is not yet 
 discontinuous or broken down. It may be washed away, however, by letting a 
 slender stream of water fall upon it ; and the softened parts are thus easily distin- 
 guishable from those Avhich retain their natural consistence. In the next stage of 
 softening we recognize the complaint at once, for the softened parts undergo a change 
 of form by their own weight : parts that are prominent in the healthy state, as the 
 optic thalami, corpora striata, and convolutions, sink down, as it were, and are more 
 or less flattened. If you make a horizontal section through a part thus diseased, a 
 portion of the softened brain adheres to the knife, and is removed by it, and a de- 
 pression is left. In a still more advanced degree, the natural texture of the organ in 
 the softened part is entirely destroyed and confused by the change, diffluent : 3^ou 
 may pour the softened matter out. 
 
 The colour of the softened portions varies also considerably. Sometimes they are 
 unchanged in colour : sometimes they are quite white, and present a strong contrast 
 with the tint of the neighbouring parts : sometimes they are marked with various 
 shades of redness, from a rosy pink to an orange, or deep red, or even a mahogany 
 brown. Often there are red spots mixed irregularly with the softened cerebral pulp, 
 and giving it very much the appearance of a mixture of raspberries and cream. 
 In other cases we find the softened mass of a pale yellow, or straw colour, infiltered, 
 as it were, with purulent matter : and sometimes it is mixed with serous fluid. 
 
 Softening of the brain is usually partial. It may occupy any part ; but it is said 
 to be more frequently met with in the gray than in the white matter ; and more often 
 in the gray matter of the convolutions than of the more central parts of the brain. 
 
 You will find softening of the septum lucidum, and of the fornix, occurring 
 very frequently in connection with an accumulation of serous fluid in the lateral 
 ventricles. 
 
 Now it is well established that softening of the brain is a common result of two 
 very different morbid conditions. It is often caused by inflammation of the softened 
 part : it is often caused, also, if I may say so, by its starvation ; by the diminished 
 supply of arterial blood, in consequence of diseased blood-vessels. 
 
 Can we distinguish these two forms of softening from each other by their phy- 
 sical characters ? Why, sometimes, we can : and sometimes, it must be confessed, 
 we cannot. 
 
 The same parts that are most liable to have their consistence diminished through 
 an inflammatory process, are also most liable to be softened from defect of nutrition. 
 The most vascular parts of the brain, in short : the gray matter of the convolutions, 
 and the gray matter of the thalami, and corpora striata. 
 
 It is stated, however, that softening of the corpus callosum, septum lucidum, and 
 fornix, from obliteration of the arteries, is extremely rare. 
 
 If there be pus mixed with the softened brain, we know that there has been pre 
 ceding inflammation. Again, if we find the arteries impervious, we conclude that 
 the softening has not been inflammatory. Dr. Carswell states that the obliterated 
 arteries may occupy the softened cerebral substance, and often be seen ramifying 
 through it ; and that when this substance is removed by pouring water upon it, the 
 solidified vessels retain their situation, and feel sometimes as hard as fine wires. But 
 Xve come to the same conclusion if we find the larger vessels, the carotid or vertebral 
 arteries, obstructed by ossification ; and a large portion of the brain unnaturally soft. 
 
 We have no certain test of the nature of the softening in its being red. The red
 
 256 DISEASES OF THE BRAIN. 
 
 ness may be the result of inflammatory congestion ; but cerebral hemorrhage may 
 occasion softening ; and, on the other hand, softening may give rise to cerebral 
 hemorrhage. This may be said, however ; that the redness is seldom condderable 
 when the softening proceeds from obliteration of the arteries. When the softening 
 extends much beyond the redness, or the effused blood ; or when the redness occu- 
 pies several small portions only of the softened pulp; we may presume that the 
 blood was extravasated subsequently to, and in consequence of, the softening. On 
 the other hand, when redness and vascularity can be traced into the brain, some 
 way beyond the softened part, we may regard the softening as the consequence of 
 inflammation. And we adopt the same belief, with still greater confidence, when 
 around the softened and disorganized pulp we find the cerebral substance hardened, 
 and of a uniform reddish colour. 
 
 In attempting to make the diagnosis between these two forms of softening, we get 
 some assistance by noticing the age of the patient. The ossification, which gives 
 rise to the obliteration of the arteries, is almost pecuhar to the advanced periods of 
 life ; whereas inflammatory softening may occur at any age ; in children, in adults, 
 or in old persons. 
 
 Some of the French pathologists have laid down this rule, as the result of their 
 experience in regard to softening of the brain — that it is attended, during the earlier 
 part of its progress, with a permanently contracted state of the flexor muscles of one 
 or more of the limbs. " In some cases the contraction of these muscles amounts 
 only to a slight degree of stiffness ; in others it reaches such an extent, that if the 
 arm be the part affected, the hand is clenched, and remains pressed against the 
 shoulder ; or, if the leg, the heel is carried up to the hip." Sometimes this tonic 
 spasm is so strong that you cannot extend the limb ; and the attempt to do so gives 
 the patient pain. After a certain time the rigidity is succeeded by complete relaxa- 
 tion ; the contracted limb has become utterly palsied. 
 
 I beheve that this is a valuable diagnostic symptom of softening, and especially of 
 inflammatory softening — when it occurs. But it is often wanting. I vinsh I could 
 tell you something more certain and constant in respect to the symptoms of this 
 interesting change ; but the facts which I have myself observed, and which have 
 been recorded by others, will not permit me to do so. Dr. Abercrombie even goes 
 so far as to say, that judging from the cases that have fallen under his own notice, 
 there is no foundation for the statement that ramollissement is distinguished by tonic 
 contraction of one or more limbs : that the same thing is met with in connection 
 with affections of the membranes, without any disease of the cerebral substance; 
 and with the encysted abscess of the brain ; and that it is frequently observed in 
 cases of typhus fever where there is much cerebral disturbance, but which terminate 
 favourably. I will give you the general resuh of his experience in this matter as 
 being untinctured with any wish to reduce his facts into conformity with a precon- 
 ceived opinion, or hasty generalization. He states that " the cases which terminate 
 by ramollissement seem in general to be characterized by convulsion, more or less 
 extensive, followed by paralysis and coma ; the convulsion ceasing for some time 
 before death, and being succeeded by the coma." But he saw one case in which 
 "the convulsion continued with the utmost violence till the very time of death." In 
 another instance "there was no convulsion at all, but a sudden attack of palsy, 
 exactly resembling the ordinary attack of hemiplegia from other causes." In two 
 cases he found " ramollissement of very limited extent, in connection with symptoms 
 of long standing, both cases being at last rapidly fatal by a sudden attack of convul- 
 sion." In other cases "there was extensive destruction of the cerebral substaiK.e, 
 without either paralysis or convulsion, and even without coma." 
 
 When you find the softened substance infiltered with purulent matter, you may call 
 the case one of suppuration of the brain. But suppuration also occurs in another form ; 
 viz.., in the form of abscess. The pus is contained in a regular well-defined cavUy, 
 surrounded by cerebral matter in a healthy or in a hardened state. Now in suppt ja- 
 tion occurring in the brain, there is the same puzzling diversity of symptoms as in C3«es 
 of simple softening. Still, in the main, there seems an approach to the same order of 
 srymptoms : convulsions in the earher period constituting the most prominent featvire
 
 RAMOLLISSEMENT. 257 
 
 of the disease ; paralysis in the latter. I will take one of Dr. Abercrombie's cases 
 in illustration of the formation of encysted abscess in the brain. 
 
 A girl, aged eleven, thin and delicate, after having complained for some days of 
 headache, was seized on the 11th of January, with convulsions, which continued 
 about half an hour: paralysis of the right arm followed the attack of convulsion. 
 She was bled from the arm, and purged, and cold was applied to her head ; and she 
 was much benefited by this treatment. On the 13lh the headache was much abated, 
 and she had recovered a considerable degree of motion of the arm. On the 15th the 
 headache increased again, and the arm became more paralytic, and she was agam 
 bled: and on the 16th and 17th the power of moving the arm was greatly improved. 
 On the 18th, after being affected with increase of headache, and some vomiting, she 
 became convulsed, the convulsion being confined entirely to the head, and to the 
 right arm ; the head was drawn towards the right side, with a rolling movement of 
 the eyes ; the arm was in constant and violent motion. She was sensible, and com- 
 plained of headache. Being bled to eight ounces, the convulsion ceased instantly, 
 and the headache was relieved; but the right arm remained in a state of complete 
 paralysis. Her pulse, during the five following days, fell from 100 to GO ; some 
 headache continued; she had occasional vomiting: and the convulsive attacks 
 returned several times ; they were entirely confined to the right arm, which after 
 the 2-M, was left in a state of permanent palsy. Hitherto no other parts of the Dody 
 had been affected by the convulsion ; but on the 24th it attacked the right thigh and 
 leg, and left them powerless. The former remedies were repeated without any 
 effect. The thigh and leg went through a course precisely similar to that described 
 in regard to the arm, and on the 29th were permanently incapable of motion. 
 
 She was now, therefore, paralytic of the whole right side ; she had no return of 
 convulsion, was perfectly sensible, and made little complaint. Gradually she became 
 dull and oppressed, and at length fell into a state of perfect coma, and died on the 
 14th of February, a litile more than a month after the commencement of her illness. 
 
 In the upper part of the left hemisphere of the brain there were two distinctly 
 defined abscesses, containing together from six to eight ounces of very foetid pus. 
 They were lined by a firm white membrane ; and a thin septum of firm white matter 
 separated them from each other. The one was in the anterior part of the hemi- 
 sphere, very near the surface ; and the other immediately behind it. In the poste- 
 rior part of the right hemisphere there was a small abscess containing about half an 
 ounce of pus. There was no serous effiision in any part of the brain, and no other 
 morbid appearance. 
 
 In this very interesting case it is worth remarking how the convulsion preceded 
 the paralysis, and how the palsy was more than once diminished by antiphlogistic 
 measures. 
 
 It is remarkable to conclude — it can hardly be called a conjecture — that in such 
 cases of partial disease of the brain as I have hitherto mentioned, the occurrence of 
 convulsion, or of rigidity, marks the inflammatory stage ; and the supervention of 
 permanent paralysis denotes the period of softening or suppuration, of complete dis- 
 organization, that is, of the texture of the brain in that part. 
 
 Partial inflammation of the brain, especially when it is chronic, sometimes pro- 
 duces a totally different change from any that have yet been described. Instead of 
 becoming softer, or being converted into pus, the inflamed part is indurated ; cornea 
 to resemble in consistence portions of brain that have been for a short time immersed 
 in weak nitric acid. In this state it is often unusually vascular and injected. When 
 the induration is greater in degree, the hardened part assumes the appearance of 
 wax, or of boiled white of egg, or (as Andral says) of Gruyere cheese, ind contains 
 but litile blood, but is, on the contrary, distinguished by its pearly whitt.iess. That 
 these changes are the result of slow inflammatory action is the more probable, be- 
 cause they are sometimes found to exist around an old apoplectic clot or cell ; the 
 blood effused having acted as a cause of inflammation of the neighbouring part, just 
 as any foreign substance might do. In the progress of cases in which partia' indu- 
 ration is effected, convulsive movements are common, but paralysis does not appear 
 to be so frequently present. The symptoms may go on for months, and often rerr.iu 
 17 w2
 
 253 DISEASES OF THE BRAIN. ' 
 
 and are ap'ain aggravated by paroxj'sms. These cases are the more interesting', 
 because they ofler a greater probability of cure than those that are attended with 
 an opposite condition of the cerebral mass. 
 
 Besides these varieties of inflammation, and their consequences, the brain is often 
 infested with fiimoKrs, which also jxive rise to a great diversity of symptoms. There 
 are fibrous tumours which grow rather around the nervous matter than within it, 
 and ai'e connected with the dura mater. They have been found at almost all parts 
 of the surface of the brain ; at its base, at its sides, and towards its summit. Scro- 
 fulous tubercles are also not uncommon : these are embedded in the nervous sub- 
 stance, and assume a round form, for the reason I formerly mentioned, viz., because 
 the tubercular matter that is separated from the blood is not cast into any particular 
 mould (as it is when it is effused into the small bronchial tubes), but poured forth 
 into the homogeneous pulp, which exerts an equal degree of pressure upon it on all 
 sides. These scrofulous tubercles of the brain are infinitely more frequent in chil- 
 dren than in adults ; and they are more commonly met with in the cerebral hemi- 
 spheres than in any other part of the brain, occupying the cortical and medullary 
 substance indifferently. They sometimes appear to originate in the pia mater. 
 They differ from pulmonary tubercles in this respect, that they are seldom numerous 
 in the same brain. Sometimes one only is found. They vary in magnitude from 
 the size of a large pin's head to that of a hen's Q%g\ and they are sometimes even 
 bigger than that. The substance of the brain immediately surrounding these tuber- 
 cles may be unchanged, in which case it is probable that the tubercles themselves 
 give rise to no particular symptoms, the cerebral matter of the spots they occupy 
 having been gradually absorbed to make room for them ; but at length important 
 alterations take place in the neighbouring texture ; congestions of blood, or soften- 
 ing, or suppuration ; and then the ordinarjr consequences of these changes declare 
 themselves outwardly. 
 
 Cancerous tumours occur also in the substance of the brain. They usually 
 occujiy a large portion of it before they extinguish life. Hydatids are sometimes 
 found there. 
 
 Now of the occurrence of these various local maladies of the brain it is necessary 
 that you should be aware, for you may expect to meet with them frequently in prac- 
 tice. And it is right also that you should be aware that they do not disclose their 
 precise nature by any peculiar symptoms, or succession of symptoms. They all, 
 sooner or later, disturb the functions of the organ in which they are situated ; and 
 they may all disturb them exactly after the same fashion. We may judge, some- 
 times, y>'0/;? other circumstances, that the disease is of this or of that character. If 
 we see scrofulous or cancerous disease in other parts of the body, we infer that the 
 symptorns which denote disease of the brain are caused by scrofulous or cancerous 
 tumours there situated ; but from the symptoms themselves, we can only learn that 
 there is some morbid condition of the brain. 
 
 I attended, recently, with Dr. Latham, a youth, whose symptoms led us to believe 
 that he had tubercular disease of the ])eritoneum ; a very formidable complaint, 
 which I shall m.ore particular!}'' describe hereafter. We thought it probable, also, 
 although there were no physical signs of pulmonary disease, that his lungs con- 
 tained crude tubercles. After some time, he went down to the coast ; and was 
 there attacked with a fit of general convulsions. Up to that period he had shown 
 no sj^mptoms whatever indicative of organic disease Avithin the head. On being 
 apprized of this seizure, we expressed in a letter to the physician then attending 
 him, our opinion that it had resulted from the presence of scrofulous tumours in the 
 patient's brain. The convulsions returned a k\v days afterwards with great violence, 
 and he died. It was as we had conjectured. The peritoneum vv'as found studded 
 with innumerable miliary tubercles : there were a few crude tubercles, of some size, 
 nround the roots of the lungs ; and two large masses of the same sort in the brain. 
 Here, you see, we were directed to a correct special diagnosis of the cerebral dis- 
 ease, simpl}' by the evidence which had satisfied us that scrofulous tubercles existed 
 in other parts of the body. 
 
 [For a more full account of the present state of our kno'wledge in regard to tubercles of 
 "'\c brain, see the Editor's Treatise on Diseases of Children, page 57'2. — C.J
 
 HYPERTROPHY. 259 
 
 In the case of specific tumours there is really nothing to be done by way of cure 
 We must then treat the symptoms, and seek to alleviate them as they arise. When 
 it appears hkely, or not unlikely, that the cerebral symptoms may be the result of 
 cerebral inflammation, we must give the patient the chance of being benefited by 
 some of the remedies of inflammation : we must treat the case in this instance upon 
 the most favourable supposition. The class of remedies from which most may be 
 hoped in equivocal cases, are local bleeding, counter-irritation, and especially the 
 cautious and regulated employment of mercury. I have stated to you before, that 
 I have known several obscure but threatening symptoms of brain disease clear 
 entirely away, when the gums were made sore by mercury, and kept slightly tender 
 for some little time. It is possible that we may sometimes do our patients harm by 
 this mercurial treatment. We may, now and then, accelerate the arrival of death 
 in persons whom nothing could save ; but we must not be deterred from giving them 
 this chance of being rescued from a disorder which may be susceptible of cure, but 
 which, if unchecked, will be inevitably fatal. 
 
 LECTURE XXV. 
 
 Hypertrophy of the Brain : Atrophy. Acute Hydrocephalus ; Premonitory 
 Signs ; Different Modes of Attack ; Stages of the Disease ; Anatomical Cha- 
 racters ; Causes. 
 
 There is a very curious morbid condition of the brain, to which I shall advert 
 before I take up the consideration of certain cerebral diseases as they occur in chil- 
 dren. The condition of which I am about to speak I was totally ignorant of till I 
 had been for some years in practice. In the spring of 1833 I admitted a young 
 woman, 19 years old, into the Middlesex Hospital. Her countenance was sallow, 
 and her lips pale. She complained of pain in her chest and limbs ; of great and 
 increasing debility, and wasting ; and of nightly perspirations. She had some 
 cough, and a frequent pulse ; and although no morbid sounds were audible in her 
 lungs, I suspected that they might contain small or scattered tubercles. She had 
 been in the hospital scarcely a week, when she had a violent fit of epilepsy ; and 
 when she was somewhat recovered, she told us, for the first time, that she was sub- 
 ject to such attacks. The convulsions recurred on the same day, and she became 
 insensible, and remained so during the whole of the next day, and till the evening 
 of the day after, when she died. During this period of insensibility she had many 
 convulsive fits ; the pupils were dilated, the pulse 100, small and feeble. Leeches 
 were applied to the temples, a blister to the neck, and afterwards to the shaven head, 
 and other measures were used, but in vain. 
 
 When the surface of the brain was exposed by the removal of the skull-cap, and 
 of the dura mater, it was observed that the convolutions were remarkably flattened, 
 so that the little furrows between them were nearly efl'aced ; and the surface of the 
 arachnoid membrane was perfectly dry. These are not very unusual, though they 
 are^ unnatural appearances. I had often seen such before : and I ventured to sa3r 
 that we should find some cause of strong pressure in the central part of the brain ; 
 efTusion of serum into the ventricles, or a large extravasation of blood. But to my 
 great surprise, and much to the discredit of my prophecy, we found nothing of the 
 kind. The ventricles were even smaller than natural, and contained scarcely any 
 moisture. The skull-cap was afterwards examined, and the bone was found to be 
 uncommonly thick, dense, and heavy ; and its inner surface, without being rough, 
 was very irregular. I regret that, in tliis examination, the state of the blood-vesseis 
 of the brain, and the consistence of the cerebral matter itself, were not particularly 
 noticed. In the record made at the time by my clinical assistant, it is merely stated 
 that the brain was otherwise healthy. There was no disease in the lungs. 
 
 This dissection interested me much, for I had never seen nor heard of any thing
 
 260 I DISEASES OF THE BRAIN. 
 
 like it before. But upon looking into some modern authors, I discovered that the 
 same phenomena had been noticed by two or three observers, who had very properly 
 (as it seems to me) considered them as the result of hyi:)ertroj)hy of the brain. There 
 is a very good memoir upon the snbject, by M. Dance, pubhshed in the fifth volume 
 of Breschet's Repertoire (T Jlnatomie : and Andral gives an account of the disease 
 in his Pathology. It appears that Morgagni had not overlooked it, for he speaks of 
 instances in which the brain seemed too big for its bony enclosure. When, in these 
 cases, the skull is sawn through, the upper loose portion of bone starts up, as if 
 moved by a spring, and the edges of the bone remain widely apart. Laennec, also, 
 in Corvisart's Journal, states that upon opening the bodies of persons whom he had 
 thought affected ^vith hydrocephalus, he had been surprised at finding a very smali 
 quantity only of fluid in the ventricles, while the convolutions on the surface of the 
 brain were strangely flattened ; proving that the cerebral mass had undergone strong 
 compression, which could only have arisen from its preternatural volume, and undue 
 nutrition. 
 
 Besides the characters I have mentioned, the hypertrophied and compressed brain 
 is firmer and tougher than natural ; it contains but httle red blood ; and sections of 
 it are seen to be unusually dry and pale. 
 
 In several of the cases of hj-pertrophy of the brain recorded by authors, the pa- 
 tients had suffered epileptic fits, or rather paroxysms of convulsion ; and in some of 
 them the convulsions terminated in paralysis. Andral states that the intellectual 
 faculties have been observed, in some instances, to become dull and obtuse. Many 
 of the patients were subject to severe headaches. All these symptoms are common 
 to various cerebral complaints. The diagnosis of this rare disorder can be no better 
 than conjectural ; and its treatment we have still to seek. 
 
 Andral remarks, what is very true, that hypertrophy of the brain, i. e., an undue 
 and disproportionate development of that organ, may, and does happen, without 
 giving rise to any morbid phenomena at all. But, in such instances, the brain-case 
 is equally enlarged in capacity ; so that no pressure upon the cerebral mass results 
 from its own preternatural growth. It is only when the brain increases faster than 
 the bony sphere which contains it, that the hypertrophy becomes a disease. In my 
 patient there was also, in one sense, hypertrophy of the skull ; the bone was consi- 
 derably thicker, and more compact and heavy, than is usual ; but the capacity of 
 the cavity had not undergone a proportional augmentation ; nay it might, for any 
 thing I know, be diminished in consequence of the increased thickness of the bone ; 
 the case may have been one of concentric hypertrophy of the bone, without any 
 fault of the brain itself; but what makes this the less probable is, that in other cases, 
 the skull has been found of the ordinary thickness and density ; but too small for its 
 contents. 
 
 It is of some importance for you to be aware that the brain, and its case, may bp 
 extravagantly developed without there being any disease, or any symptoms of dif> 
 ease. M. Scoutetten gives an instance of this which he observed in a child fiv3 
 years old. Its head was as large as that of a well-grown adult person. The skull 
 was from a line and a half to two Hnes in thickness. The dura mater adhered firmly 
 to the bone, and the cerebral mass exactly filled up the cranial cavity. The superior 
 and posterior part of the brain was developed beyond measure, so that to reach the 
 ventricles it was necessary to make an incision nearly three inches in depth. There 
 was nothing unusual to be remarked in any of the cerebral functions of this child ; 
 It was just like other children of the same age in respect of intellect. It died of 
 acute inflammation of the bowels. 
 
 The late Dr. Sweatman met with just such another child a few years ago : and I 
 refer to his description of it the rather, because cases that occur near home are 
 always more interesting, and satisfactory, than those which we merely read of in 
 foreign authors. Dr. Sweatman had never read of any thing of the kind : but in 
 August, 1834, a httle boy, two years old, was brought to him on account of the size 
 of his head It had been gradually increasing from the age of six months, till it had 
 become so large as by its weight to prevent the child from continuing long in the 
 upright posture. The boy was active and lively, though thin. He never had any
 
 HYPERTROPHY. 261 
 
 fit or convulsion ; but occasionally seemed uneasy, and then would relieve himself 
 by laying his head upon a chair. He had never squinted nor was he subject to 
 drowsiness, or starlings during sleep ; and his pupils contracted naturally. His 
 appetite was good, and all the animal functions were properly performed. Dr. 
 Sweatman got Mr, Mayo to see the child with him : they both set it down as a case 
 of hydrocephalus, but agreed in thinking that in the absence of symptoms it would 
 be wrong to risk disturbing his digestive organs by active medicines. In the early 
 part of 1835 the child died of inflammation of the chest, and Dr. Sweatman and Mr. 
 Mayo examined the head. I here show you a cast of it. It measured from ear to 
 ear, over the vertex, twelve inches ; from the superciliary ridges to the occipital, 
 thirteen inches ; and in circumference twenty-one inches. The anterior fontanelle, 
 which was quite flat, measured across its opposite angles two inches and a quarter 
 by one and a half; the posterior fontanelle was completely closed, as was the frontal 
 suture. There was no absorption of bone at any part ; on the contrary it was 
 becoming thicker. The dura mater adhered with great firmness to the skull ; and 
 a layer of false membrane, as big as a crown-piece, was found upon its upper and. 
 anterior part. Beneath the arachnoid at that part there was slight jelly-like effusion. 
 In all other respects the organ was sound. The convolutions were perfectly distinct, 
 and retained their proper rounded shape. All the ventricles were found empty, 
 and not dilated. The surfaces, however, of the medullary matter, exposed by differ- 
 ent sections, presented very unusual vascularity. 
 
 The lesson we learn from cases of this kind is, that we are not to regard every 
 child that has a very large head as a hydrocephalic child ; and especially that we 
 are not to inflict upon such a child a course of mercury, or other active remedies, 
 unless some morbid symptoms appear. The nimia cura medici may in these, as in 
 many other cases, destroy health ; produce disease where none existed before. 
 
 [The subject of Hypertrophy of the Brain would appear to demand a more extended notice 
 than has been given in the text. There is reason to believe that the disease is of more fre- 
 quent occurrence than is generally suspected, and that to it are to be ascribed n any cases of 
 convulsions, epileptic attacks, inflammation and softening of the brain, and even of idiocy, in 
 which the connection has heretofore been entirely overlooked ; we know that hypertrophy 
 of the brain has, in more than one instance, been mistaken for chronic hydrocephalus, and 
 that even the operation of tapping the brain has under such circumstances been proposed, 
 nay, probably performed. 
 
 Hypertrophy of the brain, or at least a condition of that organ predisposing it to undue 
 and more or less rapid augmentation in bulk, is often congenital. Thus children are not 
 unfrequently born with heads of dimensions far exceeding the usual standard — ■while, in 
 other instances, the head soon after birth is found to augment rapidly in bulk, disproportion- 
 ately to the growth of the rest of the body, and within a short period to attain an enormous 
 magnitude. 
 
 When the cranium is developed in the same ratio with the brain, at first no morbid symp- 
 toms arc produced, or only slight ones. In almost every case, however, we have observed 
 more or less apathy, dullness, and drowsiness, to accompany these cases of undue develop- 
 ment of the brain, from a very early period. 
 
 After, however, the disease has existed for some time, and particularly when there is a 
 disproportion between the morbid development of the brain, and the expansion of tlie 
 cranium, the patient becomes affected with apathy to external objects, a disposition to som- 
 nolency — great irritability of temper, giddiness, habitual headache, attended with sevm-e 
 exacerbations at irregular intervals, and inordinate appetite. The intellect becomes more 
 and more obtuse, verging occasionally upon complete idiocy. There is, usually, a debility of 
 the muscles of the extremities, particularly of the inferior, which constantly increases, until, 
 finally, complete paralysis results. 
 
 The bowels are usually torpid, and the pulse remarkably slow. In many cases, the 
 muscles are affected with convulsive twitchings, at first slight, and occurring at long irre- 
 gular intervals, but gradually becoming more severe and frequent, until regular convul- 
 sive paroxysms ensue. The convulsions, not unfrequently, assume all tlie characteristics of 
 epilepsy. 
 
 In some cases there suddenly ensues a considerable reduction, and, occasionally, an entire 
 abolition of sensibility. In other instances, the patient is suddenly attacked with acute deli- 
 rium, quickly followed by complete coma and death. J^'aniawas observed byAndral in one 
 case. In the majority of cases that have fallen under our notice, the patients have been 
 mc lined to fat.
 
 262 DISEASES OF IHE BRAIN. 
 
 The disease is divided by Andral into two stages: — 1st. The chronic, marked Ly few 
 symptoms, or simply by slight obtuseness of intellect — more or less headache, either perma- 
 nent or intermittent — vertigo, apathy, drowsiness, broken at irregular intervals by convulsive 
 paroxysms. All of the foregoing symptoms may occur, simultaneously or successively, in 
 the same case, or only one or a part of them may be present. 2d. The acute stage, marked 
 by sudden attacks of violent convulsions, idiocy, epileptic paroxysms, deep coma, or the 
 ordinary symptoms of acute hydrocephalus. 
 
 The prognosis in cases of hypertrophy of the brain is not necessarily unfavourable. As Dr. 
 Lees correctly remarks, the affection of the brain is rather an error of development than an 
 actual disease, and the excess of nutrition will often cease, and the brain may even leturn to 
 its normal state. Many patients who have laboured under cerebral hypertrophy have entirely 
 recovered, others will arrive at puberty, or even a more advanced age, with but little suffer- 
 ing or inconvenience, while others again die at an early age from the accidental occurrence 
 of hyperEemia of the brain, convulsions, or meningeal inflammation. In some instances death 
 occurs suddenly during an attack of convulsions — or, the patient becoming more and more 
 comatose, death finally ensues without a struggle. The chief danger arises from the very 
 great susceptibility of the hypertrophied brain to disease, especially upon the occurrence of 
 any accidental affection of one of the other organs, or of either of the affections incident to 
 childhood. 
 
 Upon dissection, the brain is found to be enlarged in size, the convolutions being flattened — ■ 
 the blood-vessels containing a diminished amount of blood, the cortical substance exhibiting 
 iu consequence a morbid paleness, with but little or no serum within the ventricles or be- 
 neath the membranes. The substance of the brain is in many cases increased in density. 
 Sometimes, according to Sims, the hyjiertrophy is confined to one lobe, or to the corpora striata 
 or thalami; in all cases, the hypertrophy is chiefly confined to the cerebrum, the cerebellum 
 being seldom much, if at all atfected. Instances occasionally occur in which the vessels of 
 the brain are injected with blood ; others where a slight amount of reddish serum is found 
 at the base of the brain, — and others again with a clot of blood within the substance of the 
 brain, and rupture of the fibres of its medullary portion ; in all these cases, it will be found, 
 upon an inquiry into their history, that death was preceded by symptoms of cerebral disease, 
 in addition to those which properly belong to simple hypertrophy of the brain. 
 
 It is important to distinguish the hypertrophied state of the brain from chronic hydroce- 
 phalus, to which, particularly in its advanced stages, its phenoiuena bear a strong resem- 
 blance, so much so as to have caused the two to be not unfrequently confounded. Drs. Lees 
 and Muncmeyer point to a particular and very striking projection of the parietal protube- 
 rances, in hypertrophy of the brain, as a valuable guide in our diagnosis, while Dr. Henms 
 Green suggests the difference in the sensation communicated to the fingers when pressed upon 
 the fontanelles in children aflected with the two diseases, as a diagnostic sign. The sensation 
 being that of a tense membrane filled with water in cases of hydrocejohalus, and of a firm 
 solid substance in cases of hypertrophy. Dr. Mauthner, in his work on Diseases of the Brain 
 (Viciuia, 1S44), lays down the following diagnosis between these two affections : — In hyper- 
 trophy, it is the posterior part of the skull which is first observed to become abnormally 
 prominent, the projection of the forehead occurring subsequently; whereas, in chronic hydro- 
 cephalus, the enlargement of the forehead is one of its first results. The latter affection is 
 usually associated with a general emaciated condition of the body; the former with a leuco- 
 phlegmatic habit, and an increased deposition of fat. The constitutional symptoms likewise 
 differ in the two aflections — restlessness, convulsions, and sopor, mark the early stages of 
 chronic hydrocephalus, while spasmodic aflections of the respiratory organs are among the 
 earliest indications of hypertrophy of the brain, but seldom occur until the advanced stage 
 of hydrocephalus. (See Condie on Diseases of Children, 2d edition.) — C] 
 
 Having told you what I know of hypertrophy of the brain, it is proper that I 
 should say a word or two respecting the opposite condition ; of atrophy of the cere- 
 bral mass. There are two forms of this affection : one is congenital, and results from 
 imperfect development, or an arrest of development, of the brain in its foetal state. In 
 the other the change appears to take place in consequence of disease, either in the 
 membranes of the brain, or perhaps in its arteries ; though the effect of disease in 
 '.he arteries is usually softening, which is a species of atrophy. But in the atrophy 
 to which I am now alluding, the volume of the atrophied part is diminished, not its 
 consistence. And the diminution of size may extend only to a few convolutions : or 
 it may be most manifest in the interior of the organ ; in the optic thalami and corpcra 
 .striata for example. There is still another alteration to which some have applied the 
 term atrophy, though improperly, I think : I allude to those cases, which I shall 
 speak of more particularly soon, in which the form and disposition of the cerebral 
 substance is altered, the convolutions being unfolded, and the nervous matter spread
 
 i 
 
 ACUTE HYDROCEPHALUS. 263 
 
 ■9Ut by a large collection of fluid in the interior cavities of the brain, constituting the 
 disease called chronic /lydroccphahis. I hav^e not much to say upon what may be 
 styled atrophy proper of the brain : that it will give rise to symptoms we cannot 
 doubt, but that it shows itself by any pecuhar or characteristic symptoms is what I 
 have not discovered. 
 
 I shall content myself, on this subject, with showing you Cruveilhier's representa- 
 tion of a strongly pronounced example of atrophy of the entire cerebrum on one 
 side. The drawing from which this engraving was made, was painted from the 
 body of a patient who died in the Hotel-Dieu, dropsical, in consequence of disease 
 of the heart. He was forty-two years old. When you look at the engraving you 
 will perceive that the left side of the cerebrum is diminutive compared with the 
 right. It filled up, however, a larger space than it appears to do in the plate ; for 
 the lateral ventricle on that side was distended by a quantity of serous fluid, which 
 ran out when the ventricle was punctured ; and then the surface of that side of the 
 brain sank down, and collapsed. Still the convolutions on that side, and all the 
 dimensions, are remarkably less than on the other. The anterior lobe projected half 
 an inch further on the right than on the left side. The frontal bone, you will observe, 
 is much thicker; twice as thick on the atrophied as on the natural side; and the 
 frontal sinus very wide and open. The internal parts of the brain are all diminished 
 in proportion. There was a large quantity of serous liquid filling and distending 
 the subarachnoid areolar tissue. The nervous matter was whiter and harder on the 
 atrophied side. One very curious thing is, that the left lobe of the cerebe/liwi was 
 the bigger of the two; but there was no such marked difference between them as 
 between the two sides of the cerebrum. 
 
 Now, the patient, in whom this singular disproportion between the two sides of his 
 brain was met with, had been incompletely hemiplegic, as long as he could recollect, 
 on the right side ; and the imperfectly palsied limbs were shrunk and withered, and 
 the fingers of the hand contracted. Yet he had managed to walk about with the 
 help of a stick ; and there was nothing remarkable, one way or the other, in the state 
 of his intellectual faculties. 
 
 The same condition has been seen on both sides of the brain : the organ itself 
 existing in miniature, as it were, and lying at the lower part of the vaulted cavity 
 of the cranium : the intermediate space being filled up with water. Tn long-standing 
 cases of this description you hiust not suppose that the nervous matter has been 
 compressed into a smaller compass by the effused fluid ; but that the fluid has been 
 poured out to fill that part of the skull which is empty of brain, and which must 
 be filled with something. This condition of the cerebrum is accompanied by idiotcy. 
 
 I proceed in the next place to the consideration of that disease to which the name 
 of acufe hydrocephalus has been given. By that term 1 desire to signify wjfumma- 
 tion of the brain, as it frequently occurs in children, and especially in scrofulous 
 children. The inflammatory character of the disorder, though not always very 
 clearly expressed in its symptoms, is sufficiently attested, in many of the fatal cases, 
 by the changes discovered within the cranium. 
 
 I made some observations, in the last lecture, respecting the nomenclature of 
 diseases, and said something in defence of the name delirium tremens. Now it must 
 be confessed that the complaint we are about to consider was unfortunately named, 
 when it was called hydrocephalus. I repeat that it matters not at all how we deno- 
 minate a disease, provided that its title does not involve any erroneous notion of its 
 nature. I think hydrocephalus a bad name, because it reminds us of one circumstance 
 only of the malady, viz., the serous effusion, which so far from being the caicse, or 
 the essence, is only a frequent effect of the disease ; nay, it is no uncommon effect 
 of other morbid conditions also, besides inflammation. But hydrocephalus, or water 
 in the head, is an appellation so established, both among ourselves and with the 
 public, that I cannot venture to propose any change. 
 
 After what I have already stated in respect to inflammation of the brain in adults, 
 you will be prepared to hear that acute hydrocephalus (remember, I restrict that 
 term to the same inflammatory malady as it occurs in strumous children) — I say vow
 
 264 DISEASES OF THE BRAIN. 
 
 will not be surprised to learn that acute hydrocephalus furnished a great variety of 
 symptoms ; and many variations in the mode of their coming on, and in their combi- 
 nation, and succession. 
 
 It is of the greatest importance to recognize acute hydrocephalus in its earliest 
 stages ; and even to look out for indications of its approach. I shall, therefore, de- 
 scribe those changes in the state of the young patient, which have been found to be, 
 in many cases, premonitory that the disease was impending. But such symptoms 
 Hre by no means always followed by acute hydrocephalus ; nor is acute hydroce- 
 phalus always preceded by such symptoms. Still, when they do occur, they should 
 put us upon our guard. 
 
 The precursory symptoms to which I allude consist chiefly in a morbid state of 
 the nutritive functions. The child loses his appetite ; or his appetite becomes capri- 
 cious : he sometimes appears to dislike his food, and sometimes devours it voraciously: 
 his tongue is foul, his breath offensive, his belly enlarges, and sometimes is tender ; 
 his bowels are torpid, and the evacuations from them unnatural ; the stools are pale 
 and contain but little bile ; or they are dark, with vitiated bile, foetid, sour-smelhnaf, 
 shni}', or scybalous ; and the child loses his former healthy aspect, becomes paler, 
 and thinner. Even already there are obscurer indications of derangement in the 
 cerebral functions ; the child is heavy, languid, and dejected ; his customary spirit 
 and activity are gone ; he gets fretful and irritable, and is manifestly uneasy ; and 
 sometimes he shows a little unsteadiness and tottering in his gait. 
 
 In very young children, when the disorder is at hand or incipient, an unnatural 
 wakefulness is often observable. A frequent sudden cry or scream, a clenching of 
 the little fists, and a turning in of the thumb towards the palm of the hand, givt 
 warning also of the approaching malady. 
 
 Now when this sort of alteration is observed in a child who has anj'- hereditary 
 title to scrofula, or bears the marks of the strumous diathesis, or is even a precocious 
 and particularly clever child, and still more if he present any other indications of 
 strumous disease, there will be much reason to apprehend that mischief is brewing 
 within his head. I advert to these tokens of scrolula, because the inflammation, in 
 a majority of cases, if not in all, is of a scrofulous character. But there is this 
 peculiarity in it, which distinguishes it from scrofulous inflammation in most other 
 parts, viz., that it occurs in an organ of a very delicate structure, and one which is 
 essential to life, its progress is more rapid, and it is more necessary to treat the 
 disease promptly. 
 
 It has been made a question whether the derangement of the digestive organs that 
 has just been described is or is not the cause of the affection of the brain ; or whether 
 both the abdominal and cerebral disorder are not common and concurrent effects of 
 the same cause. It is said that the stomach and bowels are more in the way of being 
 acted upon by injurious influences than the brain, and that, therefore, the complaint 
 may be supposed often to originate in their derangement ; and great good, it is alleged, 
 is done, the disease of the brain is often prevented, by remedying the disordered 
 condition of the stomach and bowels. On the other hand, it may be stated that a 
 similar derangement of the digestive organs often comes on and lasts long in children, 
 without leading to hydrocephalus ; and hydrocephalus often attacks a child in whom 
 no such symptoms of abdominal disease have appeared. We can never be certain, 
 therefore, that hydrocephalus has been prevented, in any given case, by remedies 
 addressed to the digestive organs. I cannot think the question is one of much prac- 
 tical imi^ortance. Whether the disturbances of the nutritive functions cause the 
 brain disease, or merely indicate it, they are equally valuable in directing our atten- 
 tion to ihe head. 
 
 In these little patients any source of irritation seems to act as an exciting cause : 
 aurgical operations, which are sometimes necessary at that tender age — falls or in- 
 juries of any kind — painful dentition. 
 
 There arc, at least, three several ways in which tliis disease may make its attacks ; 
 and with these it is proper that you sfiould be acquainted. 
 
 In the first place, it may come on gradually ; after such symptoms as have already 
 bf!en s[)ouen of as being premonitory. Probably this is the way in which it most
 
 ACUTE HYDROCEPHALUS. 265 
 
 frequently commences. After a period, of uncertain duration, in which the child has 
 complained of occasional pains in the belly and head, and signs of derangement of 
 the stomach and bowels have been present, the pain in the head begins to be more 
 severe and to recur more frequently. It is not mere headache, but generally a sharp 
 shooting pain, recurring at intervals ; sometimes it affects one side of the head more 
 than the other ; the little patients wake and shriek out with the pain, and this in 
 children is a very characteristic symptom. As coma comes on, this shrieking gives 
 place to an habitual moaning, which is scarcely less characteristic. Very often ic 
 the beginning of the disease there are pain and stiffness at the back of the neck ; 
 sometimes there is much pain of the limbs in the early periods, and in some chil- 
 dren extreme tenderness of the scalp, so that they cannot endure to have the head 
 shaved. The pain of the head becomes complicated with vomiting, and both these 
 symptoms are aggravated by motion. Very often nausea is excited by the erect pos- 
 ture, and the patient begs to lie down. The child sighs frequently, and looks grave 
 or sad ; his eyes are pained by a strong light, so that he knits his brows. The pulse 
 becomes rapid, and the disturbance and irregularity in the abdominal functions 
 increase. This stage of the complaint may last tea days or a fortnight, the child 
 becoming daily more weak, and more peevish, and looking more and more ill. 
 
 In the second form of attack there are no premonitory symptoms ; or they occur 
 for a very short while only before the disease sets in suddenly and violently, with 
 acute pain in the head and high fever ; or with convulsion : the face is flushed, the 
 eyes are brilliant ; there is intolerance of light and of sound, and there are pain and 
 tenderness of the abdomen. In short, the disease, when it commences in this man- 
 ner, is very like an attack of continued fever. You may find these varieties described 
 in Dr. Cheyne's excellent treatise on this disorder. "We are led to suspect," he 
 says, " some deeply-seated evil from the frantic screams and complaints of the head 
 and belly, alternating with stupor, or rather lowness, and unwilhngness to be roused ; 
 and we are struck with the great irritability of the stomach, which exists in a degree 
 beyond what we generally find it in the fevers of this country ; retching and vomit- 
 ing being brought on by a change of posture, and certainly by every attempt to sit 
 up in bed ; and the disordered state of the bowels, which attends this irritability of 
 the stomach, is also remarkable : and when at any time the child has a little respite 
 from the violence of these symptoms, we find our suspicions confirmed by his looks ; 
 for when the features do not express pain or terror, there is not unfrequently a vacancy 
 of look, the eyes being set, with an expression of dejection which is peculiar to cer- 
 tain diseases of the brain." The mode of attack which has now been described, 
 although the most regular in its progress, is not so common as the first, nor as the 
 third, which I have yet to mention. The third way in which the disease makes its 
 advances is very insidious : the head symptoms supervene upon the subsidence of 
 some other malady : presently after the disappearance of an eruption from the scalp ; 
 during the dechne of scarlet fever, small-pox, hooping-cough, or any inflammatory 
 or febrile complaint; and even after painful dentition. In these cases the early 
 symptoms are often but slightly marked, or do not take place at all ; the sudden 
 occurrence of convulsions or paralysis affording the first evidence that the brain is 
 implicated. This is the most dangerous form of hydrocephalus. It has received the 
 expressive title of water-stroke. 
 
 In whatever way the disease makes its invasion, it is apt to be attended with many 
 and variable symptoms; and different observers, with a view of facilitating their 
 description of the disease, and of making it more intelligible and more easily remem- 
 bered, have divided the symptoms into groups, and considered each group as charac- 
 teristic of a particular stage of the malady. But they have not all done this in the 
 same way. It may be of use, however, to inform you of the different classifications 
 which have thus been proposed. Dr. Whytt, who was a most the first person in 
 this country who wrote upon this disease (I believe Dr. Paisley of Glasgow was the 
 first : you may see his paper in the third volume of the Edinburgh Medical Es- 
 says), Dr. Whytt, I say, whose description is an extremely good one, took the pulse — 
 which undergoes very remarkable variations in the course of the disease — as th» 
 ground of his division. He makes three stages of it therefore ; the first, in which
 
 ^i 
 
 26G DISEASES OF THE BRAIN. 
 
 the pulse is frequent; the second, in which it is slow and irregular ; and the thiio, 
 in which it again becomes frequent and feeble. These successive fluctuations in 
 the pulse are to be noticed in very many cases. Dr. Golis, again, an eminent Ger- 
 man writer on hydrocephalus, whose little work was translated by the late Dr. 
 Gooch, as being the best book on the subject that he was acquainted with, makes 
 four stages, according to what he believes to be the condition of the brain in each. 
 First, he has the period oi tiirgescence, which corresponds with that period in which 
 the premonitory symptoms occur; secondly, the TpexioA oi infiaimnation ; thirdly, 
 the period of ejfusion ; fourthly, the period of palsy. The two last would appear 
 to be almost identically the same. Dr. Cheyne makes three stages ; which he finds 
 marked, not like Dr. Whytt, by the state of the circulation, but by the state of the 
 nervous system. Thus he calls the first the period of increased sensibilily, when 
 every stimulus produces an impression more than proportioned to its common effects. 
 In the second stage, that of diminished sensibility, the child is not easily roused, his 
 pupil is dilated, and his pulse slow ; he is lethargic, with obstinately costive bowels. 
 The third stage with him is that of palsy and convulsions, in which there is squint- 
 ing, rolling of the head, stupor, convulsions, with a rapid thready pulse. 
 
 Cases often occur, however, that baffle all these attempts at classification. Con- 
 vulsions, instead of being among the last, are not seldom among the very Jirst symp- 
 toms. The pulse is sometimes remarkably slow at the outset ; sometimes frequent 
 through the whole disease ; and sometimes petfectly natural. 
 
 I do not make these statements to magnify the difficulty of distinguishing the dis- 
 ease ; for the diagnosis is really not so difficult as it has sometimes been represented ; 
 but to show you that you must not trust to any succession of symptoms, still les^s to 
 any one symptom, as being pathognomonic. 
 
 The symptoms that occur during the first stage are very variable, as you may 
 suppose from what I have said of the different modes in which the disease is apt to 
 set in. Those that are most constant are, pain of the head, severe shooting pain, I 
 say, it seems to be, for the child puts its hand there, and cries out frequently, " Oh ! 
 my head ;" restlessness ; inability to sit up ; very disturbed sleep, with grinding of 
 the teeth, and from this sleep the child often starts apparently in terror, and with a 
 scream. The head is hot externally ; the little patient is annoyed by light and by 
 noise ; the pupils are contracted most commonly during this stage ; the child is un- 
 wilHng to be disturbed, and, therefore, does not reply readily to questions; but the 
 replies, when made, are correct and rational. This stage is marked, also, by vomit- 
 ing, a total loss of appetite, a white tongue, offensive breath, costive bowels, unna- 
 tural stools, green often, or black, like tar, scanty and high-coloured urine. Dr. 
 Golis says that the abdomen, which has been tumid and tender, perhaps, sinks down 
 and becomes flat, without any increased excretion by stool ; and that this is a very 
 characteristic symptom. The pulse in this stage is frequent and sharp. In short, 
 the symptoms are such (in general) as indicate very plainly that inflannnatory action 
 is going on within the head. Now the symptoms that characterize this first stage of 
 the complaint sometimes rapidly pass into those which belong to the second. They 
 may not be present for more than a few hours; or they may last a day or two, or 
 several days ; it is very seldom, I believe, that they continue longer than a week. 
 The period answers, in the general character of the symptoms, to the period of 
 excitement in encephalitis, w^hich I repeat is very much the same disease, modified 
 by its occurrence in the adult and otherwise healthy subject. 
 
 So, also, the second stage of acuie hydrocephalus corresponds, in its general 
 features, with the period of collapse in encephalitis. The pulse becomes irregular, 
 extremely variable and fluctuating, and often slow : it is easily accelerated, however, 
 by the smallest exertion — by taking the child out of bed, or even raising him into a 
 sitting posture. With this slowness of the pulse come on a diminution of sensibility, 
 and general heaviness and stupor; the pupils dilate, the light is no longer trouble- 
 some, the vision is imperfect, often it is doubtful whether the child sees at all. If 
 the eye be closely examined and watched, the degree of light remaining the same, 
 the size of the pupil will frequently be seen to fluctuate or oscillate, till at last it is 
 wide open and immovable. While this goes on squinting takes place, and double
 
 ACUTE HYDROCEPHALUS. 267 
 
 Vision when the child can yet see any thing. One or both eyes are turned in, or 
 more rarely outwards. Noises do not now disturb or irritate the child — who hes on 
 his back, with the eyes half closed, in a state of drowsiness or stupor, which is oc- 
 casionally interrupted by some cry or exclamation expressive of pain. Convulsions 
 frequently occur, but not uniformly; slight and partial spasmodic twitchings; or 
 general and long-continued convulsions ; paralysis ; sometimes hemiplegia. The 
 urine and stools are passed unconsciously. Sometimes the shild, with feeble and 
 tremulous hands, is incessantly picking his lips, or boring his fingers into his ears 
 or nostrils. 
 
 This stage may last a week or two. And what is remarkable, it is often attended 
 with remissions, sometimes sudden and sometimes gradual — deceitful appearances 
 of amendment, and even of convalescence. The child regains the use of its senses ; 
 recognizes those about him again ; appears to its anxious parents to be recovering ; 
 but in a day or two it relapses into a state of deeper coma than before. And these 
 fallacious symptoms of improvement may occur more than once. 
 
 The third stage does not differ materially in the character of the symptoms that 
 accompany it, from the second, except that the pulse again becomes frequent, nay, 
 uncommonly rapid : beating sometimes 200 strokes in the minute, so that you can 
 scarcely count it. Dr. Whytt, in one instance, reckoned more than 210 pulsations. 
 The child rolls its head perpetually from side to side ; moans continually ; waves its 
 hands in the air, or one hand, the other frequently being palsied ; sometimes there is 
 paralysis of one side, and conv^ulsive twitchings of the other. The circulation is 
 very unequal ; one part of the body will be found hot and dry, and another covered 
 with a cold sweat : the cheeks are alternately pale and flushed ; the child is raving, 
 or insensible ; the rapid pulse gets more and more weak ; and at length the patient 
 expires. In many instances death takes place in the midst of a strong convulsion. 
 This last period is of very uncertain duration ; it may be over in a few hours, or it 
 may last a fortnight. 
 
 For my own part, I conceive that for all practical purposes it would be quite 
 enough to make two stages only of this disease. In the first the symptoms are those 
 of inflammation of the parts within the cranium, or of some of those parts ; in the 
 second, we have the symptoms that result from the consequences and products of the 
 inflammation, from softening, and from the effusion of serum. And frequently these 
 sets of symptoms are, in some respects, common to both these causes ; and more 
 frequently still they are mixed up together, effusion taking place, yet the inflamma- 
 tion going on. And we may understand how the whole collection of symptoms may 
 vary and fluctuate, and assume an uncertain character, according as the inflamma- 
 tory process has ceased, or is still in progress ; according as it exists alone, or is 
 mingled with the further source of cerebral disturbance that is furnished by its own 
 events ; and according as the inflammation may have come to an end, while its 
 events remain behind, and declare their presence by appropriate signs in proportion 
 to their place and extent, and their various kinds and combinations. 
 
 What are these events ? In other words, what are the morbid appearances pre- 
 sented after death in acute hydrocephalus ? 
 
 In some cases we find traces of inflammation of the membranes of the brain ; a 
 firm attachment of the skull-cap to the dura mater : occasionally some adhesion of 
 the opposite surfaces of the arachnoid membrane to each other. Very commonly 
 there is an effusion of serous fluid beneath the arachnoid in the meshes of the pia 
 mater, and especially in the depressions between the convolutions. You would 
 suppose, upon looking at this collected fluid through the arachnoid, that it had the 
 consistence of jelly, but it is not so ; if you divide the arachnoid by means of a sharp 
 scalpel, a perfectly limpid fluid makes its escape. Not unfrequently there are layers 
 of coagulable lymph interposed between the arachnoid and pia mater ; this is a most 
 unequivocal evidence of foregone inflammation ; and it is more frequently met with 
 in the strongly marked cases. When portions of the cerebral mass are removed by 
 shcing it, a great number of red points are often observed, speckling its cut surface ; 
 I mention this appearance just to say, that, to the best of my belief, it does not war- 
 rant any conclusion in repect to the state of the brain before death. We find th.ef.»
 
 268 DISEASES OF THE BRAIN. 
 
 red spots numerous in many cases, where there had been no cerebral affection rnani 
 fested during hfe ; and they are not always to be seen when we are certain that there 
 was inflammation. 
 
 [The gray substance of the convolutions, in cases in which the sub-arachnoid tissue is 
 strongly injected, is usually of a pale rose, or bright red colour. The lining membrane of 
 the ventricles is occasionally injected, opaque, or covered with a pseudo-membranous exuda- 
 tion, or with numerous white flocculi, which become very apparent when the membrane is 
 immersed in water. It is often easily separated from the cerebral substance. The plexus 
 choroides is very often injected, and thickened ; sometimes, however, it is pale and dis- 
 coloured, and lined with small hydatiform cysts : this latter appearance has, also, been found 
 in the cellular texture of the pituitary gland. — C] 
 
 With respect to the nervous matter itself it is said to be sometimes softer than 
 natural, and occasionally it has been found infiltered, as it were, with serous fluid ; 
 wet, and so rendered soft, Gohs describes an instance of this kind, in which, 
 he says, the fluid could be expressed from the cerebral substance as from a 
 sponge. 
 
 [In some cases the substance of the brain has been found of a firmer consistence than 
 natural, and to a certain extent hypertrophied. A case is related by Golis, in which, upon 
 opening the skull, tlie whole brain expanded, so that it could not again be replaced within the 
 cranium. The convolutions are sometimes flattened, apparently from pressure against the 
 ckulL— C] 
 
 But the most common and characteristic change is softening of the central parts 
 of the brain, tvith an elusion of serous fluid iiito the ventricles. Generally the 
 effiised fluid is thin and watery ; serosity rather than serum. It contains less animal 
 matter, perhaps, than any other animal production. Dr. Bostock found that of 103 
 parts, 98.6 consisted of water, 1 part of salt, and .4 only of animal matter. It is not, 
 therefore, in common, coagulable by heat. The quantity effiised is uncertain ; 
 speaking generally, it varies from two to six ounces. 
 
 [In many cases the amount of effused fluid is very trifling ; in some scarcely a trace is to 
 be discovered. The efibsion may take place in the arachnoid or sub-arachnoid tissues, or in 
 the ventricles, or in all these parts at the same time. The greatest amount is generally met 
 with in the lateral ventricle — occasionally the quantity is so great as to enlarge the posterior 
 cornea, elevate the fornix, rupture the septum lucidum, and thus establish a free communi- 
 cation between all the ventricles. The cellular tissue of the choroid plexus may also be 
 distended with serum. When the serous efi'usion in the brain is considerable, it is often 
 found also in the spinal canal. — C] 
 
 But the effused fluid is not always clear and limpid ; sometimes it is turbid, like 
 whey, or even puriform, with flocculent shreds floating in it. These have been con- 
 sidered as flakes of coagulable lymph ; but I question whether, in many cases, they 
 are not merely fragments of the softened and broken-down materials in the neigh- 
 bourhood ; for the septum lucidum, the fornix, and other parts forming the walls of 
 the ventricles, are very commonly found soft, and pulpy, or entirely disorganized.* 
 The septum lucidum is perforated perhaps by a ragged irregular opening, the 
 softened portion having fallen out ; the fornix has lost its consistence, and often its 
 flgure, or falls asunder when the most gentle attempt is made to raise it, Dr, Aber- 
 crombie holds not only that this softness is the result of inflammation, which I think 
 cannot reasonably be doubted, but that the inflammation of these central white pans 
 constitutes the essence of the disease, in very many cases of acute hydrocephalus ; 
 and what bears him out in this opinion is the interesting fact, that this softened con- 
 dition of the septum lucidum, fornix, and corpus callosum, may be fatal without any 
 effusion of serum, and without any other morbid appearance, although with all the 
 symptoms which are usually considered to indicate acute hydrocephalus. He 
 rt4ates two striking examples of this kind; one of them was as follows, — A woman 
 became affected with violent pain in her head, shooting from temple to temple. 
 She was extremclv restless, tossing from one side of the bed to the other ; her eyes 
 were slighil} suffuspd, and impatient of the light; pupils contracted ; the pulse tiO, 
 soft and rather weak. She was repeatedly bled, both generally and topically, and 
 
 [• This is the opinion of Barthez and Rilliet.]
 
 ACUTE HYDROCEPHALUS. 269 
 
 used purgatives, cold applications to the head, blistering, &c. For three days she 
 was nnuch relieved by these measures : the violent pain was removed, and she com- 
 plained of pain only when she moved her head. She was quite sensible, but 
 oppressed, and inchned to lie without being disturbed. At the end of four days her 
 speech became affected, of which she was aware, for she said she felt a difficulty in 
 getting out her words. Then came stupor, and at times incoherence, and double 
 vision, and at last coma, and dilated pupil. She died on the eighth or ninth day of 
 the disease. 
 
 The fornix and septum lucidum were found broken down into a soft white pulpy 
 mass ; there was no effusion in the ventricles, and no other disease in any part of 
 the brain. 
 
 [In the cells of the arachnoid membrane there is often deposited a concrete yellowish 
 matter, either soft and inelastic, or somewhat firm, elastic, and of a shining appearance. It is 
 deposited either in patches, or in lines bordering the blood-vessels; and, as is the case with 
 all the indications of inflammation in this disease, it is more commonly met with at the base 
 than at the summit of the brain. Granulations and miliary tubercles are often interspersed 
 in its midst. The whole base of the brain is often covered with a continuous layer of the 
 yellowish gelatinous deposit alluded to. This deposit differs from the matter effused in in- 
 flammation occurring in persons unaffected with tuberculous disease ; the difference is thus 
 traced by Barthez and Rilliet (^Malad. des Enfants, tom. iii). The former is almost always 
 solid, the latter almost always fluid ; the former occurs more especially at the base of the 
 brain, the latter upon its convex surface ; the former is of limited extent, particularly when 
 upon the surface of the hemispheres, the latter may spread over the greater portion of the 
 surface of the brain ; finally, the former is almost invariably found in the cells of the pia 
 mater, while the latter occurs habitually in the great cavity of the arachnoid. — C] 
 
 Not unfrequently scrofulous tubercles are discovered in the substance of the brain ; 
 and it is probable that these would have been more frequently met with if they had 
 always been carefully looked for. They consist almost universally of a cheesy kind 
 of matter, hke that of large tubercles in the lungs. 
 
 [Tubercles, varying in size from that of a pin's head to that of a pea, are very generally 
 found scattered irregularly over the surface of the pia mater, following it between the con- 
 volutions ; occasionally, however, they occur in distinct patches of an inch or more in extent. 
 They are commonly hard, and semi-transparent, sometimes opaque and of a whitish, grayish or 
 yellowish colour. They are found upon all parts of tlie surface, the convex and lateral portions 
 as well as the base, in the infractuosities of the convolutions, and in the fissures. According to 
 Rilliet and Barthez, they are more frequent upon the convex surface of the hemispheres than 
 at the base. Dr. Hamernjh (^Schmidt's Jahrbucher, 1845) fo;md them more frequently at or 
 near the base of the brain. They are much more abundant upon the brain tlian the cere- 
 bellum. They are met with, also, imbedded in the gray matter of the brain, and are her* 
 often surrounded by a halo of redness, usually connected with an enlarged vessel, ramifying 
 from the pia mater. More rarely, tubercles are detected in the medullary portion of the 
 brain, where they are often overlooked in consequence of their pale, semi-transparent, yellow- 
 ish tint. The plexus choroides, is, also, often covered with tubercles. They are very com- 
 monly met with, likewise, on tbe serous membranes of the thorax and abdomen, in the lungs, 
 and occasionally in the substance of the liver. In twenty-seven ovtt of thirty-three cases of 
 hydrocephalus, Barthez and Rilliet found tubercles or granulations, associated with inflam- 
 mation of the pia mater; in four cases the meningitis was unattended by any trace of tuber- 
 cular deposition in the encephalon ; and in two cases, the granulations or meningeal tubercles 
 were unattended with any traces of inflammation. In all the thirty-three cases the symptoms 
 were nearly identical. — C] 
 
 You will find a good deal said by writers on this disease, of morbid appearances 
 found in other parts besides the brain, and especially in the abdominal organs, — 
 enlargement of the liver, inflammation of its peritoneal covering, a preternatural 
 development of Peyer's glands, tuberculous matter in the glands of the mesentery. 
 One remarkable change is very often seen, viz., intussusception of the small intes- 
 tines. This probably takes place a short time only before death, and appears to be 
 the result of spasmodic or irregular movements of the bowels, analogous to those 
 which are observed in the voluntary muscles. The intussuscepted portions arc 
 easily pulled out, and show no marks of inflammation. 
 
 There have been endless discussions respecting the true pathology of acute hydro- 
 cephalus, and it may be proper that I should offer you a few remarks upon thi* 
 point, before I proceed to the treatment of the disease 
 
 x2
 
 270 DISEASES OF THE BRAIN. 
 
 I need not, I conceive, take any further pains to convince you that the disease is 
 essentially inflammatory. We are inevitably led to that conclusion by the symptoms, 
 which nearly resemble those that occur when undoubted inflammation has arisen 
 from injuries of the head : by the appearances on dissection, which are always such 
 as inflammation may have produced, as softening and effusion of serum ; and 
 frequently such as nothing but inflammation could have produced, as suppuration, 
 and the formation of adventitious membranes : and lastly, by the unequivocal relief 
 given by blood-letting, and other evacuations, the blood drawn being sometimes also 
 sizy. 
 
 Many persons, as I have already hinted, lay great stress, when discussing the 
 pathology of acute hydrocephalus, upon the previous unhealthy state of the nutri- 
 tive apparatus. They hold that the primary disease — the /o;is et origo mali — lies 
 in the stomach, or bowels, or hver ; and that the brain affection is secondary, and 
 caused by sympathy with these distant parts : and this opinion they fortify by refer- 
 , ring to the frequency of organic disease, met with after death, in the abdominal 
 viscera. In accordance with these views of its origin, they propose to cure, or to 
 prevent, hydrocephalus, by redressing the fauhy condition of the digestive organs. 
 
 Now this, in my judgment, is not only an erroneous, but an unsafe doctrine : for 
 it tends to divert our attention from the head, and to suggest a feeble and inadequate 
 plan of treatment. The grand predisposing cause of acute hydrocephalus is cer- 
 tainly the scrofulous diathesis, and this is why we see the complaint run so often in 
 families : so that one child having died of that disorder afl^ords much ground for 
 apprehending that others, belonging to the same family, will become victims to it. 
 The constitutional tendency is hereditary, and children born with it are liable and 
 likely to have strumous disease set up in various organs at once, or perhaps in suc- 
 cession ; not, however, a succession of cause and effect, but of common relation to 
 one pervading disposition. We need not be surprised that scrofulous inflammation 
 should affect the brain and abdomen at the same time. When we find obvious 
 organic disease of the brain, scrofulous tubercles for instance, which must have been 
 antecedent to the hydrocephalus, it would be just as absurd to look to the abdomen 
 for the cause of the hydrocephalus, as it would be to seek in the brain for an expla- 
 nation of the cause of jaundice or of dysentery, when the liver or the colon w'as 
 known to be diseased. 
 
 I do not mean to assert that the morbid conditions of the brain and of the abdomen 
 are perfectly independent each of the other. The vomiting that is so constant a 
 feature of acute hydrocephalus, the constipation that is so common a consequence of 
 head affections, affords familiar evidence of the influence which cerebral disorders 
 may exercise upon the abdominal functions. Conversely, any disease in other ptyts 
 of the body may react injuriously upon the brain, and may sometimes be regarded 
 as an exciting cause of disease in that organ. 
 
 The period of life is also a strong predisposing circumstance ; acute hydrocephalus 
 being very much more frequent during infancy and childhood than at any subsequent 
 time. It is said that fifty children are attacked by it in the first five months of life, 
 for one child that has it afterwards. But it may occur at any age up to the twelfth 
 or fourteenth year. After that period it is comparatively rare. 
 
 Whatever tends to deepen and aggravate the scrofulous diathesis — improper or 
 msufficient nutriment, exposure to cold, inadequate clothing, impure air — may be 
 regarded as Vi predisposing cause of acute hydrocephalus. And whatever tends to 
 call scrofulous disease into action, may be reckoned among the possible exciting 
 causes of acute hydrocephalus. Any general irritation may bring it on. It some- 
 times supervenes upon the drying up or repression of eruptions, as tinea capitis, or 
 sores behind the ears. Such eruptions, therefore, occurring in strumous children, 
 we must not attempt to cure suddenly ; and free purging should be employed when 
 they begm to disappear. The irritation produced by difficult and painful dentition 
 IS a very frequent exciting cause ; and this is a source of danger which, in many 
 cases, may be obviated by timely and judicious management. Violent heating 
 exercise has sometimes, apparently, kindled the cerebral inflammation. Among the 
 4'xciting causes we may place all physical injuries which, jar and stun the brain.
 
 ACUTE HYDROCEPHALUS. 271 
 
 blows on the head, falls from a height, although the head may not be the part struck i 
 and all moral agencies which shock or strongly disturb the nervous system ; severe 
 bodily pain, violent fits of anger, sudden fright. Golis goes even so far as to say 
 that great terror and distress of mind in the mother during the latter months of preg- 
 nancy may lead to the occurrence of acute hydrocephalus in the child ; and he brings 
 forward this curious fact in support of his opinion : — A large proportion of the chil- 
 dren that were born in Vienna soon after the bombardment of that place by the 
 French, in 1809, were seized with convulsions within a month after their birth, and 
 died of inflammation within the cranium ; effusion of coagulable lymph between the 
 membranes, and of serum in the ventricles, being discovered on dissection. ^ 
 
 LECTURE XXVI. 
 
 ^citfe Hydrocephalus, continued. Prognosis and Mortality tf the Disease. 
 Treatment ; Blood-letting ; Purgatives ; Cold ; Mercury ; Blisters. Pro- 
 phylaxis. Spurious Hydrocephalus. Chronic Hydrocephalus, or Dropsy of 
 the Brain. Shape of the Head and Face. Anatomical Conditions. Symp- 
 toms. 
 
 The disease, of which I described the symptoms in the last lecture, acute hydro- 
 cephalus, is a very dangerous disease : and, when once it is fairly established, many 
 more die of it than recover. Our chance of saving the patient's life, by appropriate 
 treatment, is always greater in proportion as the complaint, or the tendency to the 
 complaint, is detected ear/?/; and for that reason the precursory symptoms possess 
 so high an importance. 
 
 When our treatment commences while the symptoms are as yet rather those of 
 the ppecursory state, than of the confirmed disease, it is impossible to say how many 
 of those cases which, under such treatment, terminate favourably, would otherwise 
 have ripened into well-marked hydrocephalus; and we must be content to have it 
 said, VN-ithout its being possible for us to refute the assertion, that not all of the dis- 
 orders which we treat as acute hydrocephalus are really instances of that complaint. 
 We must act upon the worst supposition, and not wait until the nature of the symp- 
 toms demonstrates that the malady is present, while it demonstrates also, at the same 
 time, that it is well nigh hopeless. These are cases which peculiarly demand de- 
 cision on the part of the medical man ; and we are bound to act, in some instances 
 upon very shght indications ; as when, for example, we perceive what Ave thinV 
 threatenings of acute hydrocephalus in a scrofulous child, or in a child belonging 
 to a family in which others have already been cut off by that disorder. 
 
 It has been supposed, by some, that the case is hopeless after effusion has taken 
 place, but we cannot be sure of that ; nay more, there are no symptoms by which 
 we can ever ieWfor certain that effusion has taken place, 
 
 I remember to have heard it gravely maintained, in the debating societies which 
 I sometimes attended when a student, that there are no such things as absorbents, 
 and no absorption, in the brain ; and therefore that perfect recovery from serous 
 effusion in that organ is impossible. [There is no evidence that the effusion within 
 the cranium is the cause of danger, or even of the symptoms which mark the latter 
 stage of the disease. — C] But this notion is refuted by plain and well-known facts. 
 We shall see hereafter, that blood poured forth within the nervous pulp is capable 
 of being removed by absorption. How an opinion so palpably erroneous could 
 ever have found credit, except with that class of men who can or will believe nothing 
 which they cannot see, I am at a loss to guess. 
 
 The prognosis, always doubtful or bad, is a little better when the disease is vio- 
 lent, and occurs in tolerably healthy subjects, than when it creeps on slowly and 
 insidiously, and in weakly, scrofulous patients. In the former case there is more 
 room for the adoption of active measures ; and the diseaso is more hkely to be ame-
 
 272 DISEASES OF THE BRAIN. 
 
 nable lo remedies, and less likely to be obstinate ; it is also less likely to depend 
 upon a permanent cause, such as "the existence of a scrofulous tumour in the brain. 
 
 The probable issue of the disease is often judged of by the state of the pulse. 
 The quick pulse belonging to the earh^ stages of the disease will become slow ; but 
 it may become slow in two very different ways : it may diminish in frequency in a 
 gradual and moderate manner, and then we may hope that the alteration proceeds 
 from the progressive declension of the fever ; or it may drop suddenly, which would 
 be a reason for our fearing that the second stage of the disease was about to estab- 
 lish itself. We must take care, under the former circumstances, not prematurely to 
 assert that the disorder is on the decline, and the patient safe. On the other hand, 
 if the pulse has been morbidly slow, a gradual and slight increase in its frequency 
 must be considered as a favourable omen ; while its rapid and great acceleration 
 would show that the disease was passing into its worst and final stage. 
 
 I have already cautioned you against being misled by that deceitful truce, and ap- 
 parent improvement, which is apt to take place in the course of the disease. If the 
 signs of amendment continue, or make progress, during two or three entire days, we 
 may venture to admit a little more hope. But the patient can never be considered 
 secure while any approach to what are thought symptoms of effusion remains ; 
 while the pupil continues dilated, for example ; or even so long as it does not con- 
 tract briskly under a strong light. 
 
 The prognosis is especially bad when acute hydrocephalus supervenes upon othei 
 disease ; or when it is engrafted (as it sometimes is) upon the chronic form of the 
 disorder. It is very seldom that the acute form subsides into the chronic. 
 
 To show you that Ave are warranted in the expectation of sometimes carrying our 
 patient through this most perilous malady, 1 will mention a few statistical facts that 
 have been recorded in respect to its mortality. Dr. Odier, of Geneva, states that, 
 upon an average, eighteen cases of acute hydrocephalus occur every year in that 
 place ; and of these six get well ; i.e., the recoveries are to the deaths as one to two. 
 Dr. Golis, to whose work I referred in the last lecture, and who had the charge of a 
 large institution for children in Vienna, gives an account of thirty-seven cases, out 
 of which five recov^ered. He had seen, upon the whole, forty-one instances of reco- 
 very from acute hydrocephalus. Dr. Mills, who has also written on the disease, has 
 narrated twenty-eight cases, all of which died but seven ; and JMr. Brichetau lost 
 four out of eleven. Adding these together, and taking the average, we have seventy- 
 six instances of the disease, and nineteen recoveries; exactly one in four. The 
 cases in which recovery took place were mostly those in which antiphlogistic mea- 
 sures were adopted earh). 
 
 The treatment of acute hydrocephalus is difficult to conduct ; and scarcely less 
 difficult to describe and teach. The disease being essentially an inflammation, 
 requires, in its earlier periods at least, the remedies of inflammation. But we must 
 ever bear in mind that our patients are children ; and, for the most part, weakly and 
 scrofulous children. Their time of fife, and the presence of the strumous diathesis, both 
 forbid that strenuous appliance of antiphlogistic remedies which might be proper and 
 necessary in adults of strong and healthy frame. We take our weapons, however, in 
 either case, from the same armoury. 
 
 The only event of the inflammatory process compatible with the safety of the 
 patient is resolution. To this end, therefore, must our efforts be earnestly directed. 
 If the child be feverish, the pulse sharp, the head hot, the cheek flushed, the pain 
 severe, and if, moreover, the case be seen early, there need be no doubt about the 
 propriety of abstracting blood. It is a matter of obvious importance to ascertain how 
 far we may safely and beneficially carry this measure, in the diseases of infants. 
 Dr. John Clarke, a physician of large experience (the elder brother of the present 
 Sir Charles Clarke), found that very young children would very well bear the lo^s 
 of blood, even to fainting, once or twice : but that their vital powers were apt to 
 a'iirk if the bleeding, to that extent, was oftener repeated. It is better, in my opinion, 
 to apply leeches to the temples, or to the mastoid processes, of these little patients, 
 than to cut one of their veins. Recollect that, upon very young children, leeches 
 produce an effect tantamount to that of venesection. Their bites bleed more freely
 
 •ACUTE HYDROCEPHALUS. 273 
 
 than in grown persons, on account of the greater activity of the capillary circulation 
 in children. No general rule can be prescribed in respect to the number of leeches 
 to be used ; three will take as much blood in one case as half a dozen in another ; 
 but assuming that one leech will, on an average, cause the discharge of one ounce 
 of blood, we may apply three of them to a strong infant of six months, when the 
 symptoms are violent. Of course the further efiiux of blood must be stopped if syn- 
 cope occurs. In older children the quantity of blood requisite to be taken will be 
 somewhat larger: six ounces drawn from a vein is a full bleeding, I should say, for 
 a child five or six years old. I mention these quantities as mere approximations, as 
 guides to what you may expect to find practically needful : the true measure and 
 test of salutary blood-letting being in this, as well as in other inflammations, the 
 effect it has at the time. The first bleeding, in what manner soever the blood is 
 taken, should be a sufficient one ; should produce some decided and manifest im- 
 pression. By attending to this rule you will break the force of the early disease 
 more surely, and more safely too, than by drawing blood in frequent driblets ; a mode 
 of using the remedy calculated to subdue the patient rather than to overcome his 
 .nalady. You must afterwards go on with the leeches to the head, or you must with- 
 .-old them, according to the exigency of the particular case ; according to the state 
 of the pulse, the continuance or the cessation of the pain, the increase or diminu- 
 tion of the fever, the previous strength and condition of the child, and so forth. And 
 let me once more admonish you that, as you have to deal, in general, with scrofulous 
 children, any superfluous removal of blood, the abstraction of more than is required 
 for extinguishing the inflammation within the head, will be likely to prove injurious 
 to the general system ; and even dangerously to depress the vital power. After the 
 full formation of the comatose state, a further prosecution of the bleeding has some- 
 times been rapidly followed by death. 
 
 The next in rank and importance to bleeding come purgatives. They are to be 
 exhibited with the threefold view of correcting depraved secretions, of clearing the 
 ahmentary canal of its irritating contents, and above all, of deriving, as the phrase 
 is, from the head ; producing a discharge of the watery parts of the blood, and 
 taking ofT the stress from the cerebral arteries. The best forms of purgative medi- 
 cine to be used for these purposes with children, consist of calomel and jalap, or 
 calomel and scatnmony ; and if these do not act freely, senna and salts must be 
 given in aid of them. I have already made you acquainted with Dr. Abercrombie's 
 high estimate of the efficacy of purgatives in inflammation of the brain, whether in 
 the child or in the adult. Dr. Whytt, again, states that he never saw even tempo- 
 rary relief of the symptoms produced by any other means than those which increased 
 the evacuations. Purgatives are to be administered, therefore, at an early period. 
 But sometimes the stomach is so irritable that it rejects them. A previous bleeding 
 will often correct this ; and it is no small part of the benefit derived from the ab- 
 straction of blood, that it prepares the way for the more efleclual operation of aperi- 
 ents and of mercury. A large clyster will often be of service, both in seltlmg the 
 stomach, and in procuring stools, when there is much vomiting, and a continual 
 rejection of medicine given by the mouth. Dr. Cheyne mentions a form of medi- 
 cine by- which he sometimes succeeded in quieting the irritable stomach, and pro- 
 curing evacuations; he would give a drachm or two of magnesia, saturated with 
 lemon juice, every two or three hours. You may sometimes get calomel and scam- 
 mony, however, to remain on the stomach, when almost every other medicine is 
 rejected. The purgative plan should be steadily persisted in for several days. 
 
 To show you how torpid the bowels are apt to be in this disease, and how diffi- 
 cult It sometimes is to procure evacuations from them, I may mention the following 
 circumstances which I heard Dr. Alison relate as having occurred in the practice of 
 his uncle, the late Dr. Gregory, of Edinburgh. He had one patient who took \AS) 
 grains of calomel in the course of five days ; yet his bowels were not relieved till he 
 had also taken two doses of jalap, the first of 30, and the second of 35 grains. In 
 another case, a child of twenty-eight months took in nine days 3.30 grains of calo 
 mei (nearly 40 grains a day) ; and in six of these days 136 grains of jalap (more 
 than 20 grains a day) : the effects were a gentle purging from the jalap, none fro/n 
 18
 
 274 DISEASES OF THE BRAIN. 
 
 the previous calomel, and but slight salivation. The child recovered after having 
 been nearly in a comatose state. Of course large doses of this kind are never to be 
 given, uulil tiie inefficiency of smaller ones has been ascertained. 
 
 Cold applied to the head : — I have before given you examples of its power. It 
 is especially useful in the early periods of the disease, when there is rnucb heat, 
 and when evacuations have been obtained. I am doubtful about the propriety of 
 keeping ice in contact with the surface of the head in very young children. It will 
 in many cases be sufficient to lay a linen rag wet with cold water (or spirit and 
 water, to promote evaporaiion), upon the child's head, taking care to renew it fre- 
 quently, not merely as often as it gets dry, but as often as it gets hot ; or water may 
 be poured from a pitcher upon the head, a basin being held under the chin. Dr. 
 Darwall states that he has known cases, which seemed utterly hopeless, retrieved 
 by letting water fall in a small succession of drops upon the scalp, and coniinuing 
 it until the head no longer recovered its high temperature upon intermitting the 
 dropping. I need scarcely say that under all circumstances it is expedient to keep 
 the head somewhat elevated. The influence of this mode of applying cold to the 
 head is increased, and perhaps rendered safer, by immersing the lower extremities 
 of the patient at the same time in warm water. 
 
 Different opinions have been held in respect to the value of mercury in this dis- 
 ease. Knowing how powerful an influence it has in controlling inflammatory action, 
 and that the inflammation in acute hydrocephalus often leaves behind it traces show- 
 ing that it was of the adhesive kind, I should not omit giving mercury ; but (as 1 
 stated when upon the subject of encephalitis) I should not give it with the direct 
 object of affecting the gums, of producing ptyalism. I believe the evidence respect- 
 ing the efficacy of mercury carried to salivation in acute hydrocephalus is this : — ■ 
 that some few very desperate cases have got well, the improvement commencing at 
 the time when the mercurial influence on the system was becoming apparent ; and 
 that in other cases, the occurrence of salivation has been followed by no alleviation 
 of the symptoms, but the disease has run on, unchecked, to its fatal terminaiion. In 
 truth it is a very difficult matter to salivate a child; there is a great reluctance in 
 the system, at the earlier periods of hfe, to take on the specific mercurial action ; and 
 the disinclination seems peculiarly strong during the presence of this disease ; and 
 the younger the child, the more difficult is it to affect the gums. Perhaps this may 
 be couL-idered fortunate ; for when salivation does take place in these little patients, 
 it sometimes proceeds to an alarming extent. Dr. John Clarke, who employed 
 calomel largely in a variety of diseases, never saw more than three instances in 
 which salivation was produced in children under three years of age. 
 
 If you are desirous of taking the chance of the specific influence of mercury 
 doing good, you had better give calomel as a part of the purgative plan, and rub in 
 some of the mercurial ointment; you had better do this than lock up the child's 
 bowels by combining opium with the calomel ; not to mention the injurious effects 
 of opium upon young children in general, and in the early period of head affections 
 in parUfcuIar. The calomel should be given steadily, in equal doses, at equal in- 
 tervals. Green evacuations from the bowels, resembling wet tea-leaves or chopped 
 spinach, usually follow its continued administration ; and this appearance (like 
 the rising of the gums in adults) is generally regarded as a proof that the influ- 
 ence of the mineral is felt by the system, and that it is doing all the gQod of which 
 it is capable. 
 
 Upon the whole, I believe it will be found that they who have had the most ample 
 experience of this perilous disease, have ended with the conviction, that moderate 
 local dep''etion, and the regulated exhibition of mercury in small quantities, afford, 
 generally, a better chance of success than the large bleedings, and the full and fre- 
 quent doses of calomel, which have sometimes been recommended. 
 
 Of blisters I may repeat the substance of what I stated when we were considering 
 encephalitis. I sliould abstain from them at the commencement of the disease. 
 Even when applied at a distance from the head, they are apt to prove a source of 
 hurtful irritation in these young and susceptible subjects. But in the second stage 
 ttf the malady, I believe blisters are often of good service. They may be applied
 
 ACUTE HYDROCErHALUS 275 
 
 to the nape of the neck, or to the head : and several may be applied in succession ; 
 or the ulcerated surface may be kept open by the help of irritating ointment, such 
 as the unguentLim cantharidis, or the ceratum sabins. 
 
 These are the main remedies to which we trust in the treatment of acute hydro- 
 cephalus : bleeding, purgatives, cold, in the outset ; mercury and blisters, of more 
 equivocal efficacy than the former, in the more advanced stages of the disease. 
 When there is much irritability towards the decline of the disorder, or in its latest 
 period, opiates may cautiously be tried ; they sometimes have appeared to be ex- 
 tremely beneficial : two or three grains of Dover's powder furnish a very eligible 
 form of opiate in such cases. 
 
 [Dr. Wood (Prac. of Med. vol. 2, page 636) remarks : " One additional remedy should be 
 employed in this form of meninsritis, from its supposed influence over the scrofulous habit 
 of body, and in the hope, that if it do not promote the absorption of the tuberculous matter, 
 it may possibly prevent its deposition. I allude to iodine. I would commence with it in 
 such doses as the stomach of the child could bear, and continue it throughout the treatment. 
 The iodide of potassium, or the compound solution of iodine (U. S. Ph.) should be einployed. 
 The iodide of mercury might widi great propriety, be substituted for the calomel at the stage 
 at which it is desirable to aim at the mercurial impression; and, in this case, the other 
 preparations of iodine should be abandoned." — C] 
 
 I do not feel called upon to say any thing, in addition to what I stated m a former 
 lecture, about other remedies that have been proposed in acute hydrocephalus ; 
 digitalis, colchicum, squills, antimony. These may be useful, when they act as 
 diuretics : but they have no specific virtue. I have told you the remedies which I 
 beheve to be the best ; and which will save the patient, when judiciously used, if 
 the case be within the compass of our cure : and you will do well to learn how to 
 manage these powerful means. I am confident you will find that more to your pur- 
 pose than trying now this and now the other remedy, because it is new, or because 
 some persons tell you they have been wonderfully successful with it. 
 
 [When the disease has reached the paralytic stage, its fatal termination is usually supposed 
 to be inevitable ; but Dr. Christie, of Scotland, and Dr. Woniger. of Hamburg, have each re- 
 cently reported a case, in which a cure was effected after paralysis had occurred, by the 
 administration of iodine. Dr. Christie employed a solution, containing sixteen grains of iodide 
 of potassium, and four grains of iodine to one ounce of water, given in the dose of a tea- 
 spoonful every four hours, at the same time diat a weak ointment of the biniodide of mer- 
 cury was rubbed ujjon the child's scalp. Dr. Woniger gave a solution of one drachm of 
 iodide of potassiu!!!, dissolved in half an ounce of water, in the dose, at first, of forty, and 
 subsequently of fifty drops every two hours. In the case of Dr. Christie, the first indication 
 of improvement occurred in thirty-six hours after the employment of the iodine was com- 
 menced with, but in Dr. Woniger's case, not until after the end of seventy-two hours. In 
 bjth the recovery is said to have been complete and permanent. — C] 
 
 Let me say a word in reference to the prevention of this disease : concerning 
 which your advice will be sure to be asked again and again. In families, in which 
 acute hydrocephalus has occurred, or wliich show decided marks of the scrofulous 
 diathesis, the earliest attention should be paid to any deviation from the healthy con- 
 dition of any of the functions. W^eaned children in such families should be kept 
 upon a nourishing but light and unstimulating diet ; consisting of well-dressed vege- 
 tables, farinaceous substances, and a moderate proportion of animal food. Particular 
 care should be taken to keep the bowels regular ; not that weakening purges should 
 be given, but the bowels should be fairly relieved at least once every day. Any 
 disturbance of the digestive organs should be immediately corrected ; by antacids, 
 laxatives, change of diet, and sometimes by mercurials, as the hydrargyrum cum 
 creta. Such children should also, if possible, be brought up in the country, and bo 
 freely exposed to mild and dry air; and in winter great care should be taken to have 
 ihem sufficiently clothed. During the hazardous period of dentition, the state 
 of the teeth and gums must be sedulously attended to. There is good reason foi 
 believing that a seton or an issue in the neck or arm has been very serviceable in 
 warding off and preventing attacks of the disease. Dr. Cheyne mentions some 
 striking instances of the good effect of establishing an artificial irritation at some 
 distance from the brain, when there has been a disposition to disease in thai organ.
 
 276 DISEASES OF THE BRAIN. 
 
 There is another caution, too, which you will often find reason for suggesting : 
 and that is, not to press or encourage the development of the mental faculties m 
 children who are quick and intelligent beyond their years. Parents are apt to be 
 proud of the early acquirements of their little ones : they are not aware that such 
 precocity of the mind implies danger to the health of the body ; and they provide 
 them with instructors, and to a certain extent abridge their hours of exercise and 
 amusement, that they may do justice to their cleverness. But it is our duty to 
 admonish them of the risks they are thus running: to advise them to think only, 
 for the present, of corroborating the corporeal strength of the child ; and to avoid 
 over-cultivation of his intellect until this dangerous period of his existence is got 
 over. 
 
 There is still one point remaining, and one of the utmost importance, in relation 
 to the acute hydrocephalus of children. I told you in the last lecture that, in general, 
 the diagnosis was not very difficult. But there is a form of disorder very apt to be 
 mistaken and treated for acute hydrocephalus, by those who are not forewarned ; and 
 one which may be rendered fatal, if the remedies of acute hydrocephalus be di- 
 rected against it. Encephahtis, whether it occur in the child or in the adult, has its 
 spurious double. As, in morals, every virtue has its corresponding vice, which apes 
 its actions and assumes its garb, so is it also with many opposite bodily disorders : 
 and it is of great moment that we should be capable of discerning the essential dif- 
 ference of character that lurks beneath external similarity of feature. It is a most 
 curious, but unquestionable fact, that anxtnia of the brain, a diminution of its natural 
 supply of red blood, and exhaustion of the nervous power, will produce symptoms 
 very much resembhng those which result from the diametrically opposite condition. 
 To excess of pressure on the one hand, and to defect of pressure or support on the 
 other, there are many phenomena in common. If you pay no regard to the state of 
 the general circulation, as indicated by the temperature and b}' the pulse, you will 
 find the actual symptoms of syncope, and of apoplectic fullness, to be identically the 
 same. When a human being bleeds to death — as many do from wounds, from ute- 
 rine hemorrhage and so on — what do we see ? Why the patients may have nervous 
 delirium, become convulsed, and then insensible, with a wide and fixed pupil. The 
 outward visible signs of concussion and of compression of the brain are very much 
 alike. The vulgar always confound them, and are clamorous that a vein should be 
 opened ; a measure which would be proper and useful in the one case, but mur. 
 derous in the other. It is the same with the functions of other parts : we have pal- 
 pitation of the heart when that organ is insufficiently supplied with blood ; 
 palpitation when it is over-loaded ; dispnoca, or hurried breathing, when the lungs 
 are congested ; hurried breathing when blood does not arrive in them plentifully 
 enough. You must see that the importance of distinguishing between the causes 
 of these analogous phenomena is immense. Several authors in modern times have 
 noticed the condition of the brain to which I now wish you to attend, and -which 
 may be called spurious hydrocephalus. Dr. Marshall Hall, Dr. Abercrombie, and 
 the late Dr. Gooch — each of these three physicians appears to have discriminated 
 ibr himself the spurious from the genuine disease; but their several accounts of it 
 were made public in the order of time in which I have here mentioned their names. 
 Dr. Gooch's Essay is entitled — " Of some Sijmptoms in Children erroneously attri- 
 buted to Congestion of the Brain." His description of the disorder in question is 
 very graphic. It is chiefly indicated, he says, by heaviness of head and drowsiness. 
 The age of the little patients whom he had seen so affected was from a few months 
 to two or three years ; they were generally small of their age and of delicate health, 
 or had been exposed to debilitating causes. The ph3'sician finds the child lying on 
 its nurse's lap, unable or unwilling to raise its head ; half asleep; one moment open- 
 ing it? eyes, and the next closing them again, with a remarkable expression of 
 languor. The tongue is slightly white, the skin is not hot, at times the nurse re- 
 marks that it is colder than natural ; in some instances there is now and then a slight 
 and transient flush. In all the cases that Dr. Gooch saw, the bowels had been 
 already disturbed by purgatives ; the symptoms had invariably been attributed to 
 t't)ngr3tion of the brain ; and the remedies employed had been leeches and cold lotions
 
 SPURIOUS HYDROCEPHALUS. , 277 
 
 to the head, and purgalives-^especially calomel. Under this treatment the patients 
 had gradually got worse, the languor had increased, the pulse become quicker and 
 weaker, and at the end of a certain number of days the children had died. In two 
 instances he had known coma to come on during the last few hours ; stertorous 
 breathing, and dilated and motionless pupils. 
 
 Dr. Hall describes a very similar set of symptoms : the face pale, the cheeks cool 
 or cold, the eyelids half closed, the eyes unattracted by any object put before them, 
 the pupils unmoved on the approach of Hght, the breathing irregular and suspirious, 
 the voice husky. These symptoms are sometimes preceded by irritabihty, and a 
 feeble attempt at reaction ; in which case the diagnosis requires extreme care and 
 circumspection. He attributes the disorder, which he calls the " hydrocepha/ozJ 
 disease," principally to exhaustion. In early infancy the exhaustion has its origin 
 chiefly in diarrhoea, or catharsis ; in the latter periods of infancy, in the loss of blood, 
 with or without a relaxed condition of the bowels. The diarhoea is often produced 
 by improper food, and frequently succeeds weaning; or it results from the ill-timed 
 administration of purgative medicine. The exhaustion from loss of blood generally 
 follows the application uf leeches, for some previous complaint — or for this very com- 
 plaint itself, when incipient, and misunderstood. 
 
 I will take one of Dr. Gooch's cases in illustration, and give it you in his own 
 words. "I was going out of town (he says) one afternoon, when a gentleman drove 
 up to my door in a coach, and entreated me to go and see his child, which he said 
 had something the matter with its head, and that the medical attendant of the family 
 was in the house, and was just going to apply leeches. I went with him immedi- 
 ately, and when I entered the nursery I found a child ten months old, lying in its 
 nurse's lap, exactly in the state which I have already described ; the same unwilling- 
 ness to hold its head up, the same drowsiness, languor, absence of heat and all 
 symptoms of fever. The child was not small of its age, and had not been weak ; 
 but it had been tvcaned about two months, since which it had never thriven. The 
 leeches had not been put on. I took the medical gentleman into another room, related 
 the foregoing case (z. e., a case in which a child had been leeched out of its life), 
 and several similar to it, which had been treated in the same way, and had died in 
 the same way. Then I related to him a similar case which I had seen in the neigh- 
 bouring square, which had been treated with ammonia and decoction of bark, and 
 good diet, and which had recovered ; not slowly, so as to make it doubtful whether 
 the treatment was the cause of the recovery, but so speedily that at a third visit I 
 took my leave. He consented to postpone the leeches, and to pursue the plan which 
 I recommended. We directed the gruel diet to be left olT, and no other to be given 
 than ass's milk, of which the child was to take at least a pint and a half, and at 
 most a quart, in the twenty-four hours. Its medicine was ten minims of the aro- 
 matic spirit of ammonia in a small draught every four hours. When we met the 
 next day the appearance of the child proved that our measures had been right; the 
 nurse was walking about the nursery with it upright in her arms. It looked happy 
 and laughing. The same plan was continued another day ; the next day it was so 
 well that I took my leave, merely directing the ammonia to be given at longer inter 
 vals, and thus gradually withdrawn ; the ass's milk to be continued, which kept the 
 bowels sufficiently open without aperient medicine." This case contains both a pic- 
 ture of the morbid state and a summary account of the treatment it requires. Instead 
 of the sal volatile, you may occasionally substitute with advantage from five to ten 
 drops of brandy m^ixed with arrow-root. You are to restrain diarrhoea if it exists ; 
 give the child plain nourishing diet — there is none so good for it as that furnished 
 from a mother's breast ; caution the nurse or mother against raising it into the upright 
 position ; keep its extremities warm with flannel ; and if the season permit, let a 
 current of mild fresh air blow freely over it. 
 
 Bear in mind, then, the distinctive characters of this spurious hydrocephalus — the 
 pale, cool cheek ; the half-shut, regardless eye ; the insensible pupil ; the interrupted 
 sighing respiration : and when the mere symptoms are more ambiguous, your judg- 
 ment concerning the true nature of the case will be much aided by tracing the man 
 Her m which they came on, and the causes to which they seem to be attribuiah!c 
 
 y
 
 278 DISEASES OF THE BRAIN. 
 
 In very young children — in respect to whom the question is most likely lo arise — ■ 
 you may often determine between contjestion and exhaustion, between fullness and 
 emptiness, between too much and too little pressure, by a very simple and easy test, 
 which is not adverted to, so far as I remember, by any of the three writers whom I 
 have mentioned. I mean, by taking notice of the slate of the unclosed fontanelle. 
 If the symptoms proceed from plethora, or inflammation, or an approach to inflam- 
 mation, you will find the surface of the fontanelle convex and prominent, and you 
 may safely employ, and expect benefit from, depletion. If, on the other hand, the 
 symptoms originate in emptiness and want of support, the surface of the fontanelle 
 will be concave and depressed ; and in that case leeches, or other evacuants, will do 
 harm, and you must prescribe better diet, ammonia, and so forth. 
 
 All that has hitherto been said has reference to acjde hydrocephalus, which is an 
 injiammatlon. I have next to speak of chronic hydrocepbalus, which is a dropsy. 
 From some cause, not well understood, a watery fluid collects within the skull, most 
 commonly in the ventricles of the brain ; and this occurring at the earlier periods 
 of life, before the whole of the brain-case has become solid, the containing parts j'ield 
 to the increasing pressure, and the size of the head is augmented in various degrees; 
 at the same time the cerebral functions are more or less deranged. This droj^sy of 
 the cranial cavity often commences before the period of intra-uterine life is com- 
 pleted, and the head of the foetus becomes so large, that it cannot pass with safety 
 into the' world. Accordingly, many of these infants perish at the moment when 
 their separate existence commences ; — nar.centcs moriunlur. The pressure of the 
 maternal pelvis is fatal to them ; or the diseased head bursts ; or it is crushed by the 
 accoucheur, to preserve the life of tbe mother. The skull is emptied of its contents, 
 and the shell, if I may so call it, collapsing, passes through the natural outlets. 
 
 In many cases, however, the dropsical skull is expelled entire and unhurt, and the 
 infant lives for a shorter or longer period. Sometimes the fluid does not begin to 
 accumulate till after birth : in a few days, however, or after some weeks, or some 
 months even, the head is perceived to enlarge with a rapidity quite disproportionate 
 to the growth of the other parts of the body ; and enlarging, it becomes misshapen 
 also. The intervention of the membranous partitions called fontanelles and oj.'en 
 sutures, between the ununited bones, allows the centrifugal pressure of the gradually 
 accumulating water to modify the shape of the head. These membranous inter- 
 spaces are unnaturally wide, and more numerous than in healthy children. Never- 
 theless the process of ossification goes on, but the bones are extremely thin. We 
 see little islands of bone in seas (as it were) of membrane. By degrees, if the child 
 survives, the proportion of membrane to bone becomes less and less, and at length 
 the whole brain-case is hard, and firmly closed up, its surface exhibiting an unusual 
 number of joinings ; there are man}'- ossa triqueira. 
 
 In the mean time the direction and relations of the loose and yielding bones are 
 altered. The os frontis is tilted forwards, so that the forehead, instead of slanting a 
 little back, rises perpendicularly, or even juts out at its upper part, and overhangs 
 the brow. The parietal bones bulge above towards the sides; the occiput is pushed 
 back ; and the head becomes long, broad and deep, but flattened on the top. This, 
 at least, is the most ordinary result. In some instances, however, the skull rises up 
 in a conical form, like a sugar-loaf. Not unfrequently the whole head is irregularly 
 deformed, the two sides being unsymmetrical. Some of these rarer varieties of form 
 are fixed and connate ; others are owing, probably, to the kind of external pressure 
 to which the head has been subjected. 
 
 While the skull may be rapidly enlarging, the bones of the face grow no faster 
 than usuil, perhaps not even so fast ; and the disproportion that resuhs gives an odd 
 and pecuhar physiognomy to the unhappy beings who are the subjects of this 
 calamity. They have not the usual round or oval face of childhood. The forehead 
 ?s broad, and the outline of the features tapers towards the chin. The visage is 
 triangular. The great disproportion of size between the head and the face is diag- 
 nostic of the disease, and would serve to distinguish the skull of a hydrocephalic 
 ohild from that of a giant. Heartless parents sometimes make a wTetched profit of
 
 CHRONIC HYDROCEPHALUS. 279 
 
 the deformity. A penny show of that kind existed very recently in the immediate 
 vicinity of this college. 
 
 When, after deaih, we explore the physical causes of these singular deviations 
 from the natural figure and bulk of the cranium, we find that they proceed from the 
 pressure of accumuiaied water: the complaint is manifestly a dropsy. But the 
 situation of the water, and the condition of the brain itself, are subject to some curious 
 varieties. 
 
 In a certain number of cases the brain is incompletely formed ; deficient in some 
 of its parts, or even altogether wanting. That portion of the cranial caviiy which 
 should contain the nervous pulp is filled up by a thin pellucid fluid. From some 
 unknown cau^e, operating during the period of intra-uterine life, the progressive 
 formaiion of the brain has been arrested. Marks of imperfect development are often 
 visible in other parts of the same infants ; they have a hare-lip, a bifid spine, or a 
 fissured palate. It is in cases of this kind generally that the skull, unnaturally small 
 })erhaps, is pinched up into a conical peak, and has considerable thickness. They 
 are obviously hopeless cases. To the physiologist they are subjects of much inte- 
 . est ; for the practical physician they have none. 
 
 But in the majority of instances, when the infants survive their birth, the liquid 
 :3 contained in the central cavities or ventricles of the brain, which are expanded into 
 ' ne. The convolutions are unfolded, and the cerebral matter is spread out into a 
 iiollow sphere; the irregularities of the surface have disappeared; the whole of the 
 brain is smoothly extended in a thin layer, immediately beneath the bones and the 
 membranes that connect them, and surrounds the inclosed liquid like a bag. Less 
 frequently a different state of matters is seen. The liquid, instead of being included 
 within the cerebral substance, lies in contact with the dura mater; while the brain, 
 perfect in all its essential parts, is at the bottom of the cavity. The difference, how- 
 ever, is more apparent than real ; the two conditions are substantially the same, only 
 that, in the one case, the solid parts that lie around the ventricles gradually expand 
 as the fluid slowly collects, much as an air-balloon dilates in proportion as gas is in- 
 troduced within it ; while in the other case the seams, or connnissures (as they are 
 technically called), that unite the hemispheres of the brain, give way, or are deficient, 
 so that the ventricles, and the general sac of the arachnoid form together one huge 
 cavity ; the hemispheres are turned aside, or folded back ; the surfaces that naturally 
 have a central aspect look upwards, and seem to constitute the summit of the cere- 
 brum. This was the state of the parts within the immense skull from which the 
 largest of the casts before you was taken. It belonged to a man named Cardinal, 
 who died in Guy's Hospital, in 1825, and of whom Dr. Bright has given a very 
 .mteresting account. 
 
 Now some of the consequences of this distension of the brain and skull with 
 watery fluid are simply mechanical. The child is top-heavy. His large unwieldy 
 head is too much for the muscles of his neck to sustain without faligue ; or even, 
 when they are unassisted, to sustain at all. He walks gertly and carefully, like a 
 person balancing a heavy load upon his head ; or he holds and partly carries his 
 liead with his hands, as a milkmaid steadies and supports her pail ; or he reclines the 
 weight of his burden upon the chair, or table, as he sits. 
 
 But far more important effl'cts of the disease are those which relate to the three 
 great functions of the brain. The child is soon found to be deaf or blind ; or palsied 
 in one or more of its limbs ; or idiotic ; or all these. In other words, the special 
 senses, the power of voluntary motion, and the mental faculties, are apt to be defec- 
 tive or perverted. Instances, however, do occur, in which these functions are, for 
 some time, but little deranged. The greater number of those who are afflicted with 
 dropsy of the brain either recover or die during their infancy. Still, a few survive, 
 bearing their complaint to the adult period, and even to old age ; and in some of 
 these individuals who, with excessively large heads, have yet numbered many years 
 of existence, the intellect and the senses, if not entii-e and perfect, have been suffi- 
 ciently effective to answer the common wants and purposes of social life : the moral 
 emotions strong, the feelings lively and correct, the memory tolerably retentive, the 
 reasoning powers respectable. Dr. David Monro relates the case cf a hydrocephalic
 
 280 ^ DISEASES OF THE BRAIN. 
 
 girl, SIX years old, whose head measured two feet four inches in circumference. She 
 is described by him as being "as hveiy and sensible as most of her age," and as 
 " having a strong memory." Dr. Brighl's patient, Cardinal, was nearly thirty years 
 of age when he died. He was born in 1795. At the time of his birth, his head 
 was only a little larger than natural ; but it had a pulpy feel, as if it were almost 
 destitute of bony matter. A fortnight afterwards, it began to increase rapidly; and 
 when he was five years old, it was but little less, according to his mother's account, 
 than when he died. He could not walk alone till he was nearly six, and then only 
 on level ground. If he attempted to run, or to stoop, he fell down. He was sent to 
 school when he was about six, and soon learned to read well and to write tolerably ; 
 but writing he soon gave up, because, as he was near-sighted, it obliged him to stoop, 
 which he could not conveniently do. When a candle was held behind his head, or 
 when his head happened to be between a spectator and the sun, the cranium ap- 
 peared semi-transparent ; and this was more or less the case till he was fourteen 
 years old. About the age of twenty-three, epileptic fits began to occur ; and after 
 that his health, which previously had been very good, failed somewhat. The ossifi- 
 cation of the skull was not complete till two j^ears before his death, the anterior 
 fontanelle being the last part that closed. It has been mentioned that he was near- 
 sighted ; but he was very quick of hearing, his taste was perfect, and his digestior? 
 good. Dr. Bright states that his mental facukies were very fair, and his memory 
 tolerable ; but it was not retentive of dates. It was said that he was never known 
 to dream. There was something childish and irritable in his manner, and he was 
 easily provoked. He died, at last, of fever and diarrhoea. There were seven or 
 eight pints of fluid within the cranium, in contact with the dura mater. On the base 
 or floor of the skull lay the brain, with its hemispheres opened outwards, like the 
 leaves of a book. 
 
 How comes it that the cerebral functions are thus sometimes fulfilled, or ^o on so 
 well, when the machinery through which the mental powers are manifested — the 
 instrument whereon and whereby the immaterial principle mysteriously operates — 
 is so palpably and greatly deranged ? How comes it that life, and especially the life 
 of the mind, subsists at all ? These questions open very interesting considerations. 
 It would appear, from such cases as I have been referring to, that the curious 
 arrangement and collocation of the several parts of the brain are rather a matter of 
 convenient package than of necessary relation. The pulp which furnishes the 
 medium of sense and thought, and volition, is there, but it is disposed in an unusual 
 shape. In neither of the two varieties of the malady that have been described as 
 being compatible with prolonged existence, is there any necessary diminution of the 
 cerebral mass. The brain itself, which forms a bag in the one case, and is split in 
 halves in the other, has been found to weigh quite as much as a healthy brain at the 
 same period of life. There has been no loss, therefore, of substance ; the pressure 
 iias been gradual, and it has not been made to act injuriously by counter-pressure ; 
 no effectual resistance has been afforded by the rigidity of the brain-case ; and thus 
 the unopposed distending force neither causes absorption of the cerebral pulp on ;he 
 one hand, nor, on the other, induces coma, or convulsions, or idioc}-, by its com- 
 pression. 
 
 Most commonly, however, the mental and voluntary functions are maimed or per- 
 verted ; and these serious calamities make parents look at a large head in a young 
 child with anxious solicitude. But you are aware, after what I stated on this sub- 
 ject in the last lecture, that the head may be extravagantly large Avithout dropsy of 
 the brain and without disease. 
 
 .We have just seen that, while the brain itself is gradually unfolded, or its hemi- 
 spheres are parted and turned aside, bj' the liquid accumulating within the cranium, 
 the I unctions of the organ ma}' suffer but little, so long as the yielding brain-case 
 permits the expansion or separation of the nervous substance, without inordinate 
 pressure. But as soon as undue pressure begins to be exercised, then morbid symp- 
 'oms arise, or the defects that have previout^h^ shown themselves are aggravated. 
 Hence that period of life becomes a perilous period, at which the skull, by the 
 rlosure of its fonianelles and sutures, loses its capability of further expansion. In
 
 CHRONIC HYDROCEPHALUS. 281 
 
 some raie cases, the closed sutures re-open under the augmenting pressure, and a 
 respite it> thus obtained. Dr. Baiilie has recorded an instance in which this hap- 
 pened in a boy seven years old. A similar case is mentioned in Dr. Yeat's work 
 on hydrocephalus. The patient was a boy nine years of age. The sutures of his 
 skull separated agaui after having been united ; and it was remarked that the teeth 
 in the jagged edges, whereby the bones interlock with each other, were much fewer 
 •han is usual, ll this be always so when the sutures give way, it will serve to faci- 
 litate our understandmg how such a separation can take place. The skull may, 
 however, go on expanding, although the sutures are permanently closed ; there still 
 being left intervals between the several points of ossification, which intervals are 
 covered by membrane oniy. The beautiful preparation on the table, showing this 
 remarkable state of the cranium, I have borrowed for your inspection from Dr. Sweat- 
 man's museum. 
 
 Indeed, although I have spoken of this complaint as being especially a disease of 
 childhood, it does occasionally commence long after the skull has become a complete 
 case of bone. Enlargement of the head, in these cases, is impossible ; but this cir- 
 cumstance, and the symptoms it is apt mechanically to produce, form the only differ- 
 <mces between the disorder as it affects the child and the adult. In both cases dis- 
 •iirbance of t-he cerebral functions arises, and at length convulsions or coma closes 
 fhe scene. In both, a dropsical state of the ventricles of the brain constitutes, often, 
 •he only morbid change presented after death. A young and distinguished lawyer 
 of my acquaintance had one or two attacks of rather sudden loss of consciousness 
 while engaged in the Court of Chancery ; by degrees he became dull, stupid, for- 
 getful, and, at length, insensible. In this condition he died. A large quantity of 
 serous liquid was found distending the ventricles of his brain. No other alteration 
 could be detected. 
 
 Dr. Baiilie describes a case of chronic hydrocephalus that occurred in a man fifty 
 years old. Six ounces of fluid were contained in the lateral ventricles. He had 
 been paralytic on the right side of the body ; and for eleven months before his death 
 had lost the recollection of his own language, with the exception of four or five 
 words, which he employed, with different intonations, to express his various wants. 
 
 The celebrated Dean of St. Patrick's afforded another instance of the same dis- 
 ease, attended with a similar interruption of the power of discoursing. The case, as 
 related in Sir Waller Scott's Life of Dr. Swift, is curious, and contains an early 
 suggestion of a piece of practice which, in our own time, has met with more flxvour. 
 '^ A few days afterwards he sunk into a state of total insensibility, slept much, and 
 could not, without great difficulty, be prevailed on to walk across the room. This 
 was the effect of another bodily disease : his brain being loaded with water. Mr. 
 Stevens, an ingenious clergyman of his chapter, pronounced this to be the case 
 during his illness, and upon opening his head it appeared that he was not mistaken ; 
 but though he often entreated the Dean's friends and physicians thai his skull might 
 be trepanned, and the water discharged, no regard was paid to his opinion or 
 advice." 
 
 He remained from October 1742, to October 174.5, in a state of silence, with few 
 and slight exceptions ; and died in the 7f^th year of his age. 
 
 Gohs also mentions three instances in which this disease began in advanced life ; 
 two of the patients were above seventy years old ; the third, who was a {)hysician 
 at Vienna, likewise died in the decline of life, having sufliired under the disorder for 
 ten years. 
 
 Now, what can we do in these wretched cases? Seldom much good, I am afraid 
 Yet something we must try, for parents will flatter themselves with hopes of a cure : 
 and to say the truth, there have been, under judicious management, a sufficient num- 
 ber of recoveries to forbid our despairing in any case, and to make it incumbent 
 upon us to employ carefully all those measures which have occasionally brought the 
 disease to a favourable termination. Golis even afflrms, that of the cases which 
 began after birth, and which he saw and treated early, he was frj-tnnate enough to 
 save the majority. 
 
 y2
 
 282 DISEASES Of THE BRAIN. 
 
 LECTURE XXVII. 
 
 7\eatme.nt of Chrome Hydrocephalus; Irdcnuil Remedies: Mechanical Expedi- 
 ents; Bandages, Tapping. Symptoms of Spinal Disease. Inflammatory co)\r 
 ditions of the Spinal Marrow. 
 
 The cure of chronic hydrocephalus maybe attempted by internal remedies, or by 
 external mechanical expedients, or by both. 
 
 The internal remedies by which most good appears to have been affected, and 
 from which, therefore, most is to be hoped, are diuretics, purgatives, and above all, 
 mercury, which is believed by many to have a special and powerful influence -in 
 promoting absorption. Conjointly with these, the abstraction of small quantities of 
 blood from the head, by means of leeches, has been found beneficial. 
 
 Golis advises that calomel should be given in half-grain doses, twice a day ; or 
 if that quantity should purge too much, in doses containing only one-fourth of a 
 grain. At the same time he would rub a scruple or two of mercurial ointment, 
 mixed with ointment of juniper berries, upon' the scalp, every night. He recom- 
 mends that the head should be kept constantly covered also by a woollen cap. In- 
 fants require, he says, no other nutriment than good breast milk ; while older patients 
 should take a moderate quantity of meat. In mild weather they should be as much 
 as possible in the open air. Under this plan of treatment he affirms that he has 
 known the circumference of the head decrease by half an inch or an inch, in a period 
 of six weeks or three months; and that perseverance in this method has frequently, 
 in his experience, been followed by perfect recovery, both of the mental and of the 
 bodily powers. If no improvement should be perceptible in two months, he advises 
 that diuretics should be given, ivith the former remedies : the acetate of potash, or 
 squills, or both : that an issue should be made in the neck, or in each arm, and 
 be kept discharging for several months. And he thinks that when convalescence 
 has once begun, it may often be much accelerated by minute doses of quina ; the 
 fourth of a grain, for example, thrice daily. 
 
 In a disease so unpromising as chronic hydrocephalus, we are warranted in trying 
 any plan that has been found, or supposed, to be useful. An apothecary of consi- 
 derable experience — now dead — once took the pains to write out and send me the 
 particulars of two cases in which he had seen a peculiar mode of administering 
 mercury successful. I will give you them nearly in his own words. 
 
 In the year 1817, he had under his care a .ad, named Scott, labouring under 
 chronic hydrocephalus. He had been ill tw: or three years, was nearly blind, had 
 very little use of his lower extremities, f.id could not walk across the room without 
 support. He suffered violent pains \ii his head, and was unable to bear the least 
 pressure on his scalp. His bowels were constipated, and his pulse " oppressed." 
 Cupping and blistering, the bh^e pill, drastic purgatives, and ordinary diuretics, tried 
 in combination and succession, gave him temporary relief; but no |)ermanent benefit 
 was obtained. Dr. Go'.ver then suggested a plan which he had himself found suc- 
 cessful in such caset;, and which had first been used by Dr. Carmichael Smith, who 
 had recorded ten cases of recovery under its adoption. Dr. Gower's plan was to 
 rub down ton grains of crude mercury with about a scruple of manna, and five 
 grains o( fresh squills; this was to be one dose: and it was to be repeated every 
 eight hours. 
 
 My informant rubbed the quicksilver down with conserve of roses, and then added 
 ♦.he fresh squills, making the whole into the consistence proper for pills with liquo- 
 -ice powder. The patient took this dose three times a day, for nearly three weeks, 
 without any ptyalism being jiroduced. Its eflects were great prostration of strength 
 and loss of flesh, with gradual relief of all the boy's sufferintis. It operated profusely 
 by the kidneys. The medicine was continued twice a day, and at length once, for 
 another fortnight ; when all the symptoms of the disease had disappeared. The boy 
 was greatly emaciated. He was then oraered an ounce and a half of Griffith's
 
 CHRONIC HYDROCEPHALUS. 283 
 
 mixture thrice daily ; "tnd soon regained his health and strengt]' tki got quite well. 
 He remained well eight years afterwards. 
 
 The success obtained in this case led to the pursuance of a similar course in that 
 of the son of a well-known fishmonger in Old Bond Street. He was about twelve 
 vears old, and afflicted in nearly the same manner as Scott, except that the pain in 
 his head was more acute, and caused violent screaming: reliff had been repeatedly 
 given for a time, b}^ cupping. The physician in attendance was unwilling to try 
 the plan, when it was proposed to him, but said that he would give what was equi- 
 valent — small doses of blue pill, with squills in powder. The result was salivation 
 in a few days, without any amendment. In about three weeks, the local elfects of 
 the mercury having subsided, and the patient then suffering extreme pain in the 
 head, loss of sight, and want of power over the lower extremities, my informant was 
 desired to adopt any measures he thought fitting. The medicine was given as in 
 the former case, and with the same happy consequence. It acted, as before, without 
 producing ptyalism, but with a great reduction of strength and flesh. Health was 
 restored by steel, after the symptoms of hydrocephalus had disappeared. This cure 
 also was permanent. 
 
 I think you will give me credit for not being over-fond of recommending Avhat 
 may be called conundrums, instead of well-tried and approved means of cure ; but I 
 say that in such a complaint as chronic hydrocephalus, we have generally the oppor- 
 tunity of testing the virtues of many reputed remedies, one after another ; and we 
 are not to despise or neglect any measures that have been found beneficial, merely 
 because they are out of the way, or because we cannot see in what manner they can 
 excel the more common formuloe. 
 
 You will observe that these were cases in which the disease came on some time 
 after the sutures of the skull had closed. 
 
 {Dr. Hannay relates a case of chronic hydrocephalus, in the Eflinburgh Med. and Surg. 
 Journal, in which he attributes the recovery of the patient mainly to the application to the 
 scalp of a liniment, composed of powdered ipecacuanha and olive oil, each two drachms, 
 and half an ounce of suec. Dr. Hannay remarks, that the application of this liniment, three 
 or four times a day, is followed in about thirty-six liours, by a papular and vesicular eruption ; 
 and he is of the opiniwi, that as chronic hydrocephalus often succeeds to the suppression of 
 eruptions on the scalp, the use of this counter-irritant ^vill prove in many cases extremely 
 useful — its effects are much more manageable than those of the tartar emetic ointment, 
 which, in this disease, has been found advantageous. — C] 
 
 The mechanical remedies of chronic hydrocephalus are two : and they have a 
 totally opposite mode of action. By the one, the brain is compressed ; by the other, 
 it is lightened of its pressure : yet both of them have proved successful. What does 
 this show ? what, but a confirmation of the doctrine that there are different states of 
 the eneephalon, very dissimilar in their e.'^sential character, yet having some S3'mp- 
 toms in common ; and those the most likely of all to catch our attention. Such 
 common symptoms resemble an algebraical symbol, which derives its value from the 
 plus or minus sign prefixed. Surely it is of vital importance to study, and if we can, 
 to settle, the differences wheivby these inverse condiiions, requiring contrary reme- 
 dies, may be discriminated. 
 
 Bamluging the head is one of these two expedients ; punctnrlas:; it the other. 
 Neither of them is practically applicable after the bones of the skull have united. 
 
 Bandages appear to have been suggested by the notion that the increase of the 
 fluid within the head, and probably some of the symptoms too, might depend, more 
 or less, upon the want of firmness and proper resistance in the outer containing 
 parts; in the feeble and half solid skull. A certain amount of support and pressure 
 is requisite for the due exercise of the cerebral functions. Beyond this amount all 
 mcrease of pressure is hurtful. The middle point of safety it may be hard to hiu 
 It is certain that the easy yielding of the bony walls of the head, by reason of the 
 membranous interspaces that exist in the early periods of life, proves oftentimes ilu 
 safety of these patients. If the skull did not expand as the water gathered, morbid 
 symptoms would ensue. Great nicety must therefore be requisite in the use of this 
 remedy. While the head is palpably enlarging, compression b}' means of plasters
 
 284 DISEASES OF THE BRAIN. 
 
 or bandages would probably be mischievous. When the disease is stationary, and 
 the unconnected bones of the skull are loose and fluctuating, and the child is pale 
 and languid, much benefit may be expected from moderate and well-regulated sup- 
 port. The late Sir Gilbert Blane was the first, I believe, to suggest this mode of 
 treatment ; but its safety and efficacy have been more recently demonstrated by Mr. 
 Barnard, who has related several examples of complete success from the employment 
 of bandages. In these cases the children were pale, bloated and feeble, with flabby 
 muscles : the bones of their heads were movable and floating, and the functions of 
 the brain more or less impaired. Mr. Barnard applied strips of adhesive plaster, 
 about three-quarters of an inch wide, completely round the heads from before back- 
 Avards : covering the forehead from the eyebrows to the hair of the head, as low 
 down on the sides as the ear will permit, and lapping over each other behind. Then, 
 cross-strips are carried from one side of the head to the other over the crown ; and 
 lastly, one long slip, reaching from the forehead, within half an inch of the root of 
 the nose, over the vertex to the nape of the neck. In his first trial of this plan, but 
 never afterwards, Mr. Barnard laid pieces of linen, wetted with cold water, over the 
 plasters. The only internal medicine given was castor oil, to regulate the bowels. 
 The effects, in all this gentleman's cases, were these : a gradual diminution of the 
 size of the head ; mitigation, and ultimate disappearance, of all head symptoms, such 
 as strabismus, rolling of the eyes, starting of the muscles, and convulsions : and at 
 the same time, increased tone of the muscular system, with an improved appearance 
 of the skin and of the secretions from the bowels. These are striking results. They 
 show that, in certain conditions of chronic hydrocephalus, a part of the danger arises 
 from a lack of due support and confinement of the brain ; and they prove that com- 
 pression alone may be equal to the cure. To such cases. Dr. Arnott's air-press 
 would seem, from the facility with which its equable compressing force may be regu- 
 lated, to be especially adapted. 
 
 But in children who are not of this pale anxl feeble habit, and in whom ossification 
 of the skull goes on, the period when the walls cease to j'ield is the period of 
 danger. The water continuing to accumulate, inordinate pressure begins to take 
 place. Under these circumstances, the application of bandages or plasters must, if 
 nothing else be done, be insufficient or unsafe. The brain-case being no longer 
 capable of expansion, there remains to be attempted a reduction of the quantityof 
 the liquid which it contains. 
 
 Now, any considerable diminution of the accumulated fluid, through the agency 
 of mere absorption, is scarcely to be expected ; even although we endeavour to aid 
 that process by applying leeches and cold to the head, and by purgatives, or diuretics, 
 or diaphoretics. Some mode, more certain and elTectual, of emptying the distended 
 cavity, has therefore been earnestly sought after; and the second mechanical expe- 
 dient of which I have spoken oflxn-s a very sure method of attaining this object. He 
 must have been a bold pliysician who first proposed to decant the water from the 
 brain, by means of a perforation, made with a trocar, through the membrane of the 
 fontanelle, through the membranes of the brain, and through even the expanded 
 cerebral substance itself. But the success of the project has amply vindicated his 
 happy audacity. It is not a very new suggestion, but it has received particular 
 attention in this country of late years: and though tapping the bruin in chronic hy- 
 drocephalus has been denounced as useless and cruel by some high continental autho- 
 rities, by Golis and Richter especially, it furnishes one of the best of the few chances 
 of safety to the patient. Of course I mean ultimate safely, for the operation itself 
 ;s attended with the present risk of accelerating the patient's death. Other means, 
 however, faihng, we are justified in advising that hazard. We have to consider that 
 by performing the operation we incur the danger of abbreviating the existence of a 
 being, whoso life, without it, could scarcely be long continued, or capable of enjoy- 
 ment : but then we afford some chance of a perfect cure. A speedy death, or an 
 uncertain life of mental and bodily imbecility, or complete restoration: these are the 
 three events to be looked at. Of the three, the second is, in my judgment, incom- 
 parably the worst ; and if the case were my own, if I had to decide the painful
 
 CHRONIC HYDROCEPHALUS. 285 
 
 question in reference to one of my own children, I would accept the alternative of 
 probable speedy death on the one hand ; possible complete recovery on the other. 
 
 To say the truth, the immediate danger is not so very great as you might suppose ; 
 provided that the operation be skilfully and cautiously performed, and only a mode- 
 rate quantity of water drawn off at a time. That even a very rough operation is 
 not necessarily fatal we learn from a singular case related by Mr. Greatwood. A 
 child, fifteen months old, afflicted with chronic hydrocephalus, fell down, and struck 
 the back part of its head against a nail, which penetrated the skull. Above three 
 pints of water gradtially flowed out at the orifice thus made, and the child was 
 cured. 
 
 I will mention a few instances in which tapping the brain has been performed ; 
 for I know no better mode of showing you the manner in which the operation 
 should be done, the cautions to be attended to in doing it, and what kind of success 
 it has had. 
 
 There is an account of the performance of this operation by Lecat, in the Philo- 
 sophical Transactions for the year 1751. This date is subsequent to the period 
 when the Rev. Mr. Stevens suggested the propriety of trepanning Dean Swift's cra- 
 nium. In 1778, Dr. Remmet, of Plymouth, punctured the head of a hydrocephalic 
 child on five several occasions, with a lancet, and took away, in all, no less than 
 eighty ounces of fluid ; five pints, as pints were measured in that day. The child 
 died seventeen days after the last tapping. A very interesting case of the same kind 
 is related by Dr. Vose, of Liverpool. His patient was an infant seven months old. 
 Its head was more than twice the ordinary size. Three operations were performed ; 
 the first with ^ couching needle. Upwards of three ounces were on that occasion 
 evacuated ; and it was estimated that about the same quantity dribbled away after- 
 wards. The child thereupon became very weak, but was presently revived by some 
 cordial medicine. About six weeks afterwards, the liquid having collected again, an 
 opening was made with a bistoury, and eight ounces were removed ; and nine days 
 after that, twelve ounces more, without any bad consequences. The head dimin- 
 ished in size, the patient got apparently well, and the case was published as a suc- 
 cessful one. Unfortunately, however, the complaint afterwards returned, and the 
 child died of it. 
 
 Mr. Lizars, of Edinburgh, operated upon a little patient of his twenty times in 
 the course of three months ; using a small trocar. Dilatation of the pupils, and 
 squinting, which had previously existed, ceased immediately upon the escape of the 
 water. The child recovered. Another very striking and instructive instance is 
 recorded by Mr. Russell, of Edinburgh. The patient was an infant three months 
 old, with an enormous head ; twenty-three inches in circumference, and fifteen 
 inches and a half from one ear to the other. The child was afltcted with strabis- 
 mus, and a perpetual rolling of the eyes. The usual routine measures, compression 
 among the rest, had been employed without any success. By four operations per- 
 formed at intervals of about ten days, the size of the head was considerably reduced: 
 but, the fluid continuing to collect, calomel was given in small and frequent doses, 
 and the gums became sore, and the child got well. At eight months old the dimen- 
 sions of the head were less, by four inches in circumference, and by two inches and 
 a half across the vertex, than they had been before the first tapping ; and the sutures 
 had entirely closed. 
 
 But Dr. Conquest, of Finsbury Square, has, more than any other person, given 
 authority to these operations. In a paper published in the Medical Gazette in March, 
 1838, he tells us that he had then tapped the heads of nineteen children for this com- 
 plaint, and in ten of the nineteen cases the children survived. Ho introduces a small 
 trocar through the coronal suture below the anterior fontanelle, and cautiously makes 
 pressure upon the head afterwards by means of strips of adhesive plaster; and he 
 closes the wound in the integuments carefully after each time of punciuring. The 
 greatest quantity of liquid withdrawn by him at any one time, has been twenty 
 ounces and a half; and the greatest number of operations on any one child has been 
 five, performed at intervals of from two to six weeks. The largest tota) quantity of 
 water removed was fifiy-seven or fifty-eight ounces by five successive tappings.
 
 280 DISEASES OF THE BRAIN. 
 
 This expedient, therefore, though doubtless hazardous, is really a valuable one. 
 The rules relating to its performance may be brieflj"- summed up. The operation 
 should scarcely be had recourse to until other means have failed. The trocar should 
 be small, and it should be introduced perpendicularly to the surface, at the edge of 
 the anterior fontanelle ; so as to be as much as possible out of the way of the longi- 
 tudinal sinus, and of the great veins that empty themselves therein. The fluid 
 should be allowed to issue very slowly; and a part of it only should be evacuated 
 at once. The instant that the pulse becomes w'eak, or the dilated pupil contracts, or 
 the expression of the child's countenance manifestly alters, the canula should be 
 withdrawn, and the aperture in the skull closed. Gende compression should be 
 carefully made to compensate, in some degree at least, the pressure that has been 
 removed with the fluid. Should the infant become pale and faint, it must be placed 
 m the horizontal posture ; and a few drops of sal volatile, or of brandy, mixed with 
 water, may be given. Sometimes slight inflammatory action comes on in the course 
 of a day or two after the tapping. When this happens, we must apply cold lotions, 
 and leeches, and use the other remedies which I mentioned before, as proper to sub- 
 due such inflammation. 
 
 I once got a surgeon to perform the operation upon the infant of a poor woman, 
 after I had tried in vain all the other measures I have spoken of. To our horror, 
 when the trocar was withdrawn from the canula, instead of clear serosity, a fine 
 stream of purple blood spouted forth. The opening was at a considerable distance from 
 the longitudinal sinus ; but the trocar was not so delicate as it might have been, and 
 I presume that one of the larger superficial veins had been pierced. I do not think, 
 either, that the instrument was introduced in a sufficiently perpendicular direction. 
 Of course the risk of hitting a vein is increased when the trocar is carried obliquely 
 inwards : and a larger portion of the cerebral mass is also wounded. We naturally 
 thought it was all over with the child, which presently became deadly pale and faint. 
 A verdict of infantidde by misadvenliire stared us in the face. But under the use 
 of stimulants the infant revived again; no hemorrhage went on internally, as we 
 apprehended it would ; but the child, after a day or two, seemed very much the 
 better for the loss of blood. This amendment, however, did not last; and the 
 mother, who had been terrified by the immediate consequences of the operation, 
 feared to come near me, lest I should w'ish to have it repealed ; and at length our 
 patient died, I was very desirous to examine the interior of the head ; but this was 
 not permitted. 
 
 On one subsequent occasion I have witnessed the operation. The subject of it 
 was an infant about eight months old. Four months after its birth, its head was 
 observed to grow inordinately large. At the time of the operation the fontanelles 
 were exceedingly tense ; the child screamed frequently, occasionally vomited, and 
 was slightly convulsed ; the features were pinched, and the eyeballs distorted down- 
 wards ; but the pupils were not dilated. Four ounces of transparent liquid were let 
 out by puncturing the anterior fontanelle. A few hours afterwards the child was 
 tranquil, and much improved in aspect; the distortion of the eyeballs had disap- 
 peared. Three ounces more were taken away the next day. For two days there- 
 after all the symptoms appeared to be mitigated ; but the skull was flaccid ; yield- 
 ing, like a broken egg, to the gentlest pressure. On the evening of the fourth day 
 after the first tapping, the respiration became hurried, the child grew dull, and, befSre 
 nr'dnight, expired. In this case it appeared to me that the chance of success was 
 baulked by the want of external support subsequently to the tapping. 
 
 You will not expect me to draw^ any comparison between the merits of compres- 
 sion and paracentesis, as substantive remedies. They are opposite measures, and 
 adapted to different and opposite conditions of the brain. The one repairs defect of 
 pressure ; the other relieves its excess. To hold the balance even requires much 
 care, a steady and gentle hand, an accurate judgment, and incessant vigilance. 
 Either expedient may suffice, alone. Both may be (and have been) profitably em- 
 ployed in the same case, in succession, according to its varying circumstances. If 
 .he \^lls of the head be tight and firm, the trocar should precede the bandage ; if
 
 CHRONIC HYDROCEPHALUS. 287 
 
 jax and movable, compression should be cautiously tried, and followed, if need be. 
 by the puncture. 
 
 ' [Dr. Whitney relates, in the Edinburgh Med. and Surg. Journal, an instance of the success- 
 ful puncture of the brain in a case of chronic hydroceiThalus. By the first operation, nine 
 ounces of fluid were drawn off, and in three weeks subsequently, by a second operation, five 
 ounces more. Neither operation was succeeded by any bad symptom, and the recovery of 
 tlie child appears to have been complete. Two eases are related by Professor Wutzer, and 
 Dr. Butcher, in the Austrian IMedical Journal, in which the puncture of the brain was unsuc- 
 cessfully employed. In the first, a child seven months old, death occurred in six days ? '°' 
 the first operation; in the second case, of a child sixteen months old. the operation \."<«f 
 repeated, after an interval of four weeks, anil seven weeks after the second puncture, tht, 
 child died in convulsions. Dr. West (^Report for 1844-45) states that oi sixty recorded cases 
 in which puncture of the brain was performed, seventeen, or one in 85, had a favourable te 
 mination ; or,_in other words, the recoveries have been to the deaths in the proportion of 28 
 per cent. — C] 
 
 I have now done with the inflammatory affections of the brain : in conjunction 
 with which I have also considered some other morbid conditions, that are either con- 
 nected with inflammation of the contents of the cranium, or resemble it in some of 
 their phenomena. Thus, I have spoken of delirium tremens, which is apt to be 
 mistaken for inflammation of the brain : of soflening from disease of the cerebral 
 arteries, which is liable to be confounded with inflammatory softening: of tumours 
 of different kinds, which tend to produce inflammation, or symptoms like those 
 belonging to inflammation : and of chronic hydrocephalus, which sometimes is the 
 sequel, sometimes the precursor, of acute hydrocephalus ; and has other points of 
 analogy with that disease, the encephalitis of children. • 
 
 \_Me'ningitis encephalica. — Under this name. Dr. Brockman has recently described a peculiar 
 form ol' cerebral disease incidental to childiiood, in which the membranes of the medulla 
 oblongata and pons varolii are chiefly affected. 
 
 Dr. B. has met with fourteen cases of this affection. It was, at first, observed by him as a 
 sequel of scarlatina, but subsequently, he has seen it to occur most I'equently as an idio- 
 pathic affection. 
 
 It is sometimes associated with general disease of the brain ; at others, it is uncomplicatecL 
 Notwithstanding, in its earlier stages, it is unattended by any serious symptoms, it is an affec- 
 tion fully as dangerous as cerebral meningitis. The first stage, or that of simple hypertemiaj 
 generally continues for one or two days. The child is dull and heavy, and the occiput is 
 often hot; the bowels, however, are regular; there is no vomiting, no intolerance of light, 
 nor any disturbance of sleep. The general dullness of the patient, and vague complaints of 
 some uneasy sensation in the head, increase as the inflammatory stage sets in ; the heat of 
 tlie occiput is augmented ; the head becomes retracted, as in the ordinary cases of acute hy- 
 drocephalus; and convulsive twitchings of the limbs occur, similar to the eflects of light elec- 
 tric shocks, which recur every iew minutes while the patient is awake, but cease during 
 sleep. The general febrile symptoms continue during the third stage ; the pulse, however, 
 diminishes in frequency and fullness, but does not become either irregular or intermittent. 
 The general disquietude of the child subsides, by degrees, into a comatose condition, in which 
 the head becomes still more retracted, but unattended with strabismus, or any morbid con- 
 dition of the pupil; the peculiar air of stupidity that characterizes hydrocephalic patients is 
 ■wanting. Two pathognomonic symptoms, however, indicate the occurrence of the stage of 
 eflusion. One of these is deafness ; the other difficult articulation, and dhncidty in moving 
 the tongue — both of which occur at the same time, probably from paralysis of the motor 
 nerves of the tongue. The deafness and affection of the tongue usually occur suddenly; 
 sometimes they are first observed upon the child awaking from a quiet sleep. They are, 
 according to Dr. Brockman, tlie earliest and most certain indications of the occurrence of 
 effusion. This stage continues, sometimes, for three, and sometimes for fourteen, days. Its 
 termination is in fatal paralysis, the occurrence of which is often preceded by various singt*- 
 lar nervous phenomena — as sudden pauses in the respiration, or equally suddan syncope. In 
 some cases, however, the paralysis does not follow, but the anomalous symptoms subside, 
 and die jiatients gradually recover; until, indeed, the paralytic stage is fully established, tho 
 recovery of die patient is still possible. 
 
 In the uncomplicated cases of the disease, upon examination after death, the cerebrum m 
 general, presents an extremely pallid and ana'mic condition, in striking contrast with the 
 cerebellum, the vessels of which are turgid with blood, while its substance, also, is often i^ 
 a state of marked hyperaemia. The hyperamia increases in intensity towards tlie centr-ij 
 portions of the encephalon ; and the membranes covering the pons varolii and medulla ob^ 
 '•ngata are found in a most decided stale of inflammation ; the portion of inflanieil .iistu
 
 288 DISEASES OF THE BRAIN 
 
 brane is perfectly isolated, and not more, usually, than a square inch in extent — the mem 
 brane of the cerebellum being entirely free from any indications of inflammation. There is 
 ordinarily an effusion of a serous fluid into the sub-arachnoidal tissue; sometimes to the 
 extent of several ounces ; occasionally a gelatinous matter is effused, and, in some cases^ the 
 efi'usion is of a purulent character. 
 
 This form of the disease is most frequently observed in children from three to ten years 
 of age. and who had previously enjoyed good health. 
 
 The treatment recommended by Dr. Broclcman, in its first two stages, is depletion, by 
 leeches to the posterior part of the head, cold applications to the scalp, and the free adminis- 
 tration of calomel, which latter may be continued during the stage of effusion. Here, how- 
 ever, it becomes necessary to support the strength of the patient ; for this purpose ammonia 
 is directed by Dr. B., but he remarks that, in some cases, the administration of wine may be 
 required. According to his experience, powerful counter-irritants, as a large blister, or the 
 actual cautery, prove, also, sometimes beneficial. — C] 
 
 Before I take up the subject of apoplexy, and of cerebral hemorrhage, I wish to 
 direct your attention to the inflammatory conditions of the spinal cord. 
 
 The whole pathology of this portion of the nervous system is extremely interest- 
 mg ; but it has not yet been so thoroughly made out as to enable any one to give a 
 very systematic or satisfactory account of it. In addition to those numerous difficul- 
 ties with which I showed you in a former lecture that the entire subject of the dis- 
 eases of the nervous apparatus is beset, there is this further obstacle to our studying 
 diligently the structural changes of the spinal marrow — that much labour and ex- 
 pense cf time are required for exposing the interior of the vertebral canal; which is, 
 therefore, too often neglected in examining the dead body. 
 
 There are certain points in the anatomy and physiology of the spinal cord which 
 it is necessary that you should bear in mind, if you would have any clear notions 
 even of what has been learned in respect to its pathology. 
 
 1. In the first place the spinal cord (including the medulla oblongata) is the seat 
 and centre of that remarkable property, the reflex function ; by which so many of 
 the automatic movements of the body are regulated. 
 
 2. In order that we may feel, or be conscious of, what occurs in any part of the 
 trunk or limbs, and in order that our will to move any such part should be obeyed, 
 it is necessary that there should be a continuity of nervous matter between the part 
 in question and the brain. If the cord be cut across at any point, or so crushed as 
 to be thoroughly disorganized at that point, a complete abolition of sensation and of 
 vohmlary motion ensues in all those parts of the bod}^ that receive their sentient and 
 motor nerves from that portion of the cord which lies beyond the place of the injury, 
 reckoning from the brain. What is true in this respect of the mechanical division 
 of the cord, is equally true of such disease as pervades and spoils the nervous matter 
 composing it. 
 
 Now it follows from this, that the effects of disorganizing forms of disease — as 
 well as the effects of injury — must Tary greatly according to the part of the cord 
 they occupy. 
 
 Thus any injury or disease affecting the whole thickness of that portion of the 
 spinal marrow which is contained within the upper cervical vertebrae, is inevitably 
 fatal at once ; producing suffocation by paralyzing those muscles through the play 
 of which the motions of respiration are performed. You know that the intercostal 
 muscles and the diaphragm have at all times the main share in carrying on the me- 
 chanical actions of respiration ; and probably they execute the whole action in every 
 case of ordinary breathing. Now the miercostal muscles are furnished with motor 
 nerves frorifi the spinal cord, all along the dorsal vertebrae ; and the diaphragm is 
 principally supplied by the phrenic nerves, which are chiefly derived from the third 
 and fourth cervical nerves. These muscles obey the will; but they act also inde- 
 pendently of the will. The pneumogastric and trifacial nerves, with respect to them, 
 are excito-motor^^ nerves, and call into play a reflex power which is transmitted from 
 the n.edulla oblongata. Hence any profound injury of the spinal cord, above the 
 origin of the phrenic nerves, stops both the voluntary and the involuntary movements 
 of the respiratory muscles, and the individual perishes by apnoea, in as strict a sense
 
 AND SPINAL CORD. 289 
 
 as though the access of air to the lungs had been suddenly prevented by a hgaiure 
 drawn tightly round his windpipe. 
 
 Again, when a segment of the cord, however small, is disorganized in its cervical 
 part, between the origin of the phrenic and the origin of the upper intercostal nerves, 
 the breathing is not instantly suspended ; but is performed entirely by means of the 
 diaphragm, the intercostal muscles having no share in it. The ribs cease to rise and 
 fail; and the abdomen is alternately protruded, and sinks back again. In each case 
 I suppose the disease of the cord to be such as suffices to paralyze the parts supplied 
 with nerves from it, beyond the seat of the disease. If disease of this kind occur 
 below the giving out of the intercostal nerves, the breathing is not affected ; we have 
 paraplegia only, palsy and loss of feehng in the lower extremities, and, perhaps, in 
 the hips, or even higher. Now a person in this condition may live a long time. 
 When the disease is situated between the origin of the intercostal nerves and the 
 origin of the phrenic, he may live a few days, but he seldom lives a week, and 
 never survives a month : and when the disease is higher still, in the very upper part 
 of the cord, above the origin of the cervical nerves, he perishes outright. The kind 
 and degree of disease, therefore, being the same, the character of the symptoms, and 
 the amount of danger, differ remarkably according to the seat of the disease. 
 
 3. Although sense and voluntary motion cease upon the disruption of the commu- 
 nication with the brain, the excito-molory functions of the separated portion of the 
 cord are not necessarily suspended. On the contrary, they seem to acquire increased 
 activity. The automatic power is apt to run riot, as it were, when the controlling 
 influence of the sensorium is withdrawn. All of you have probably seen the hmbs 
 of a recently decapitated frog thrown into violent action by the stimulus of galvanism. 
 I have witnessed the same thing in the human body after death by hanging. What 
 is still more curious, you may have unequivocal manifestations of similar phenomena 
 in the living body. I have lately been informed, by Dr. William Budd, of a case 
 in which a man was afflicted with paraplegia, in consequence of disease of the ver- 
 tebral column. He was totally deprived of the power of moving his lower extremi- 
 ties. Sensation in them was almost, yet not entirely extinct. A sharp pinch, or the 
 prick of a pin, he could feel; but slight friction he was quite unconscious of: yet 
 (as he himself said) his limbs were not; for when the inner edge of the foot was 
 brushed or tickled by the hand of another person, the corresponding leg, over which 
 he had no voluntary control, would start up, and be briskly convulsed. The same 
 thing took place, in both limbs, whenever he passed his urine or feces; so that he 
 was obliged to have an apparatus of straps and ligatures to keep the legs down on 
 such occasions. I have seen something like this myself.* 
 
 4. Distinct and different filaments of the spinal cord connect themselves with, or 
 help to form, different nerves which emerge from the cranio-spinal axis. A know 
 ledge of this fact enables us to understand how it happens (as it sometimes does 
 happen,) that the upper extremities are bereft of sensibility, or of voluntary motion, 
 or of both, by disease of the cord, while the same functions remain perfect in the 
 lower and more distant limbs. Here the disease must have spared those strands or 
 filaments of the cords which pass down to connect themselves with the nerves given 
 off at the lower part of the spine ; while it has affected those strands or filaments 
 only which belong to certain nerves from the upper part. 
 
 •S. Under the sagacious researches of Dr. Marshall Hall, the physiology, and witri 
 it the whole pathology, of the spinal cord is undergoing, at this very time, a com 
 plete reformation. I know of no modern discovery so fruitful of important practical 
 consequences, or so likely to improve our remedial management of nervous disor- 
 ders, as the singularly interesting truths which he is even now engaged in demon 
 strating and enforcing. I do not profess to teach you this new physiology. I touch 
 only, as I pass along, upon some of its cardinal points, to which 1 may have occasion 
 to refer in future. We are considering how the signs of spinal disease may vai y 
 according to the particular location of that disease; and I would have you remark, 
 
 * This very interesting case has since been published, in detail, with several otLera * 
 Bcmbling it, in the 22d volume of the Medico-Chirurgical Transactions. 
 
 19 z
 
 290 DISEASES OF THE 
 
 here, that inasmuch as all the acts of ingestion and expulsion, all the inlets and out- 
 lets of iho bod}', are governed by the spinal marrow, with its corresponding apparatus 
 of incident and motor nerves — it is to be expected that disease in the upper part of 
 the true spinal system should affect the orifices which answer to that part, and which 
 are principally inlets — the larynx, the gullet, the cardia: while disease in its lower 
 portion will be lik'ely to disturb the natural functions of the lower orifices — the 
 rectum and anus, the bladder and urethra, the os uteri — which are chiefly outlets. 
 
 G. You must bear in mind also the grand discovery of Sir Charles Bell, that the 
 two roots by which each spinal nerve arises have distinct and different functions ; 
 the anterior roots being composed of motor fibrils, the posterior of sensiferous. 
 
 It is not so clear, although that opinion is, I believe, a prevalent one, that the 
 anterior columns of the spinal cord are subservient to the purposes of motion, and 
 the posterior to the faculty of sensation. This has been inferred, too hastily perhaps, 
 from the ascertained endowments of the anterior and posterior roots of the nerves: 
 and cases are cited which appear to favour such a notion : but then other cases go 
 completely to contradict it. Thus Mr. Stanley has recently published an account of 
 a patient who died in St. Bartholomew's Hospital. For some time before his death 
 he had been completely unable to move his lower limbs, throughout their entire ex- 
 tent ; while there was no discoverable impairment of sensation in any part of either 
 limb. The spinal cord was the only organ found diseased : and the disease was 
 strictly limited to its posterior half or columns. This portion of the cord, in its 
 whole length, from the pons to its lower end, was of a dark-brown colour, and ex- 
 tremely soft and tenacious. The anterior half, in its entire length, exhibited its 
 natural whiteness and firm consistence. The roots of the spinal herves were un- 
 altered. 
 
 It was remarkable, and illustrative of the difficulty of these subjects, that with 
 the change of structure which the cervical portion of the cord had undergone in 
 this instance, there was no defect either of motion or of sensation in the upper 
 limbs. 
 
 7. We must not forget that the brain, and the spinal cord, which are distinct from 
 but yet continuous with each other, sympathize largely and mutually under disease. 
 This circumstance throws an additional obscurity over the study of their morbid 
 conditions. It is one, however, which we cannot avoid, but which we must estimate 
 and allow for, in our observation of diseases, as we best may. 
 
 8. There are a few remarks made by Dr. Abercrombie in relation to some of 
 the anatomical dispositions of the cord and its investing membranes, which may 
 help us to comprehend better some of their morbid contingencies. Thus, with 
 respect to the dura mater of the cord, it is practically of importance to recollect 
 " that it adheres very slightly to the canal of the vertebrae by a very loose cellular 
 texture; and that it adheres very intimately to the margin of the foramen magnum. 
 In this manner a cavity is produced betwixt the membrane and the inner surface of 
 the spinal canal (external, i. €., to the membrane), which cavity may be the seat of 
 effusion, and which has no communication with the cavity of the cranium. On the 
 other hand, the space between the dura mater and the pia mater (or membrane im- 
 mediately covering the cord), communicates freely with the cavity of the cranium; 
 so that fluid may pass easily from one to the other, according to the position of the 
 body." 
 
 1 shall pursue the same order, in speaking of the inflammatory affections of the 
 ^pinal cord, as I followed in respect to the analogous conditions of the encephalon. 
 And, first, let us inquire vvhat has been noticed of inflammation of the membranes 
 of the cord. They may undergo inflammation, independently of the substance of 
 the cord, and independently of the brain: but this is not very common. Usually, 
 when we have meningitis of the cord, we have the same disease also within the era 
 nium ; usually, also, with meningitis of the cord, we have more or less inflam 
 ■nation of the nervous matter composing it. The commonest symptoms of in- 
 riammation of the meninges of the cord (for I do not pretend to speak of the several 
 membranes separately), appear to be pains, often intense, extending along the spine.
 
 SPINAL CORD. 291 
 
 and stretching into the Hmbs, and aggravated usually by motion, and simulating 
 therefore rheumatic pains : rigidity or tetanic contraction, and sometimes violent 
 spasms, of the muscles of the back and neck, amounting in some instances to 
 perfect opisthotonos : a similar affection of other muscles, also, as those of the upper 
 or lower extremities : a sense of constriction in various parts, in the neck, hack, 
 and abdomen, as if those parts were girt by a tight string : feelings of sufToca 
 tion : retention of urine : obstinate constipation : and with these symptoms, rigois 
 often. 
 
 You are not to expect all the symptoms which I have been enumerating in 
 every case ; they will vary according to the seat and extent of the inflammation. 
 We need not wonder at the spasmodic symptoms, when we recollect that the 
 nerves which issue from the body of the cord receive a covering from its pia 
 mater. The pain felt along the course of the spine itself is said to be aggravated 
 by percussion of the spine, but not by simple pressure ; and this seems very 
 likely. 
 
 I know of no way in which I can so well hope to awaken an interest in you 
 about these diseases, or to offer you instruction respecting them, as by instances. 
 The following I take, abridging it somewhat, from Dr. Abercrombie. A man, 
 twenty-six years old, had for several years been subject to suppuration of the left 
 ear, suffering ocasional attacks of pain on that side of the head, which were fol- 
 lowed by a more copious discharge from the ear. In the first week of April he 
 became ill, with pain of the forehead and occiput, disturbed sleep, and loss of appe- 
 tite, but no fever. At the end of the week he complained of pain extending along 
 the neck. This pain gradually passed downwards in the course of the spine, and 
 deserted the head; and, at last, after many days, it fixed itself with intense severity 
 at the lower part of the spine, shooting thence around the body towards the crest of 
 the ilia. He became affected, also with great uneasiness over the whole of the ab- 
 domen, and had much pain and difficulty in passing his urine. About the end of 
 the second week in April his suffl^rings had become extreme. He could not lie in 
 bed for five minutes at a time, but was generally walking about the house in a state 
 of great agitation, grasping the lower part of his back with both his hands, and 
 gnashing his teeth with the intensity of the pain. He had no interval of ease, and 
 was sometimes incoherent and unmanageable. On the I6th, he went to take a warm 
 bath, walking down three stairs, and into an adjoining street, with little assistance. 
 His speech afterwards became somewhat affected : there were convulsive twitches 
 of his face, and difficulty of swallowing. Some transient squinting also was ob- 
 served. The pulse was now very frequent. On the 18th, while sitting in a chair, 
 he suddenly threw his head backwards with great violence, fell immediately into a 
 state of coma, in \vhich he remained for two hours, and then died. During the 
 whole disease there had been no paralysis, except the slight affection of his speech ; 
 no difficulty of breathing ; no vomiting ; and no convulsion except the twitching of 
 his face the day before his death. The pulse was small and irregular. The bowels 
 were easily kept open, but the pain in his back was much increased by going to 
 stool. Two days before his death he had several attacks of shivering; and much 
 purulent matter was discharged from his left ear during his illness. 
 
 Upon a very careful examination of his body, every part of the brain was found 
 to be in a most healthy state. Some gelatinous deposit was found under the ?7ic- 
 dulla oblongata ; and purulent matter flowed, in considerable quantity, out of the 
 spinal canal. The spine being entirely laid open, the cord was seen covered with 
 a coating of purulent matter, which lay betwixt it and its membranes. The matter 
 was most abundant at three places ; at the upper part, near the foramen magnum — 
 about the middle of the dorsal region — and at the top of the sacrum : but it was 
 also distributed over the other parts with much uniformity. The substance of the 
 cord was soft, and separated in some places into filaments. All the other viscera 
 were healthy. 
 
 You may find several interesting examples of this form of disease in Ollivier a 
 Treatise on the Spinal Marrow. The prominent symptom was generally pam, 
 referred to some part of the spine, and increased by motion; and what is curious.
 
 292 DISEASES OF THE 
 
 sometimes little complained of except upon motion. In general, also, it extended 
 along some of the limbs, and was accompanied by muscular rigidity or tetanic 
 spasms. Palsy occurred in one case ; but this seemed to have been owing to soft- 
 ening of the cord itself. Constantly there was increased sensibility ; a circum- 
 stance which OUivier thinks calculated to distinguish inflammation of the membranes 
 from inflammation of the substance of the cord ; the latter being usually attended 
 with diminished sensibility. In the case that I have quoted from Dr. Abercrom- 
 bie, the intense pain underwent no remission or abatement. In one of Ollivier's 
 examples, there was at the commencement of the disease, a striking inlermittence of 
 the pain ; it came on with intense severity at ten at night, and lasted till three in the 
 morning. 
 
 The causes of spinal meningitis are not always to be discovered. It sometimes 
 extends from within the cranium. It may be excited by external violence to the 
 spine, of which a good specimen has been recorded by Sir Charles Bell. — A 
 Avagoner sitting on the shafts of his cart, was thrown off by a sudden jerk, and 
 pitched upon the back of his neck and shoulders. He was taken to the Middlesex 
 Hospital, where he lay for a week, without complaining of any thing except stiff 
 ness of the back part of the neck. He could move all his limbs with freedom. On 
 the eighth day after his admission he was seized with general convulsions and locked 
 jaw. He then became affected with a singular convulsive motion of the jaw, which 
 continued in violent and incessant movement for about five minutes. This was fol- 
 lowed by maniacal delirium. He then sank into a state resembling typhus fever; 
 and after four days was found to be palsied and insensible in his lower extremities. 
 The day before his death he recovered sensation in his legs. 
 
 On dissection, a great quantity of purulent matter was found within the spinal 
 canal. It appeared to have formed about the last cervical and the first dorsal ver- 
 tebras, and to have dropped down, by its own gravity, to the lower part of the canal; 
 where it produced palsy and anaesthesia of the inferior limbs by the pressure it 
 occasioned. 
 
 [Cerebho-Spixal Mexingitis has attracted considerable attention recently from tlie cir- 
 cumstance of its having occurred as an epidemic in different parts of France and Ireland. 
 In 1844 the disease prevailed extensively among the civil population of Gibraltar. Accord- 
 ing to M. Rollet, who describes the disease as it occurred at Nancy, {Bulletin de I'Acad. Roy. 
 de Med. viii. 43,) cerebro-spinal meningitis occurs in two forms j in the one, there are no 
 signs of lesion of \^ nervous centres themselves, no affection of sensation or motion, though 
 tliere are all the symptoms of inflammation of the membranes; at first, rigors, then maliase, 
 tinnitus aurinm, vertigo, violent pain in the head, extending along the vertebral column, agi- 
 tation or restlessness, slight delirium, and moderate fever, or absence of fever. In the second 
 form there is affection of the intellectual faculties, and also of the functions of sensation and 
 motion, and more or less complete abolition of all the senses. In this latter form the appear- 
 ances upon dissection were, great vascularity of the cerebral arachnoid ; a layer of plastio 
 purulent matter covering the whole inner surface of the pia mater and the brain, and a con- 
 siderable collection of the same matter at the base of the brain, about the pons varolii and 
 medulla oblongata. The cerebrum was slightly punctated, but not softened. The choroid 
 plexus was injected; the cerebellum softened; and the arbor vitae of a blood-red colour. 
 Beneath the spinal arachnoid there was the same kind of purulent matter as beneath the 
 cerebral arachnoid ; and opposite the third dorsal vertebra, a consitlerable collection of pus, 
 as well as opposite the last dorsal vertebra. The substance of the spinal cord appeared 
 healthy. The lesions here described exactly correspond with those described by MM. Fanre- 
 Villar, Chauffard, and Forget, by whom accounts of the disease have been given as it pre- 
 vailed in Versailles. Avignon, and Strasburg. 
 
 Morbid changes from inflammation have also been noticed in the alimentary canal, but 
 these M. Rollet regards as merely accidental coincidences. M. Forget, however, attaches 
 great importance to them. 
 
 ]\I. Rollet remarks, that, in those cases in which the substance of the brain is affected, 
 mere is an almost continual tendency to intermission, or, at least, remission, which alternates 
 about every three hours with an exacerbation ; this he regards as merely characteristic of tho 
 enoephalo-meningitis, and not as an evidence of tlie disease partaking of the nature of remit- 
 tent fever, which is the view taken by M. Gassaud. 
 
 According to Dr. Mayne, by whom an interesting account is given of the disease as it 
 occurred m Ireland during the year 1846, (Dublin Quarterly Journal of Medical Sciences, for 
 August, 1846,) its general pathological characters were nearly vLniformly the samf where.'ei
 
 SPINAL CORD. 293 
 
 examined. The serous membrane covering the brain and spinal marrow was invariably 
 found to be the seat of extensive inflammation, and unlike the more ordinary forms of arach 
 nitis, tlie spinal arachnoid always sullered much more severely than the cerebral, in the 
 post-mortem examinations made by Dr. Mayne, the scalp and dura mater exhibited but little 
 undue vasciUarity ; the pia mater covering the hemispheres of the brain was congested, and 
 the large veins in their way to the several sinuses appeared remarkably turgid. The free 
 surface of the cranial arachnoid felt dry and clammy, and had lost its transparency in many 
 places, particularly at the base of the brain, but there was no lymph or other inflammatory 
 eflusion in the sac of the arachnoid. Lymph of a yellowish or greenish hue appeared on the 
 surface of the encephalon, beneath the serous tunic: this occurred sparingly on the upper sur- 
 face of the hemispheres, and there only along the sulci ; but at the base of the brain it was 
 found in greater quantities, especially in the sub-arachnoid space corresponding to the circle 
 of Willis, where many of the cerebral nerves at their origin were fairly imbedded in it. Li 
 the spinal canal, a similar exudation filled the sub-arachnoidal space ; it there existed in 
 sufficient abundance to envelope the cord completely; it also extended down to the lowest 
 extremity of the cauda equina, investing each of the spinal nerves at its source ; but in the 
 vertebral canal, as in the cranium, the cavity of the arachnoid contained none of this morbid 
 secretion. The substance of the brain and spinal marrow appeared remarkably free from 
 lesion, there was no unusual vascularity, induration, or softening apparent, nor did the ven- 
 tricles betray any evidence of inflammation. 
 
 Li many of the cases rejDorted, however, the brain and spinal marrow are stated to have 
 been occasionally implicated ; in some, the ventricles of the brain contained inflammatory 
 efliisions, and the choroid plexus appeared unusually vascular ; in others, more or less of 
 the substance of the brain and spinal marrow was found in a state of softening ; in a certain 
 number, sero-purulent eifusion was detected at the base of the brain, and in the theca verte- 
 bralis ; but in every instance the serous membrane was the part essentially engaged, whilst 
 tlie nervous material seldom suffered, and when affected it was only accidentally involved. 
 the disease having been, in such cases, evidently propagated to the substance of the cerebro- 
 spinal axis from its membranous investments. 
 
 A remarkable feature of this malady is the class of persons on whom it has seized. Li 
 Ireland, so far as has been ascertained, boys under twelve years of age have been, with few 
 exceptions, its only victims ; the seven cases reported by Dr. Darby were all boys, and only 
 one of them had passed his twelfth year; in Belfast ten cases of the disease were noted, all 
 occurring in boys from seven to twelve years of age ; and in Dr. Maynes' experience, indi- 
 viduals of tlie same description were alone attacked. Dr. Gillkrest, in his account of the 
 epidemic at Gibraltar, (^3Ied. Gaz., July, 1844,) states, that in the majority of cases the dis- 
 ease occurred in patients between two and fifteen years of age, and few only were attacked 
 severely above the age of thirty. It is a curious circumstance that in France the disease 
 occurred, for the most part, among the conscripts who had lately joined their regiments. 
 Although females have been very rarely attacked, yet they are not exempt from it : one of 
 Mr. M'Dowel's patients at the Hardwicke Hospital was a girl of seventeen, and the other a 
 woman of thirty-six years. 
 
 The symptoms by which the disease commences are, in general, of a very formidable 
 character, and its accession is usually sudden and quite unexpected ; in the majority of 
 cases the patient was in his ordinary health and spirits up to the very moment of the seizure, 
 and had experienced no premonitoiy symptoms to warn him of his danger. Ii:^four of the 
 cases at the South Dublin Union, the boys had eaten a hearty dinner, and retired to bed in ap- 
 parent health, when the disease, all at once, declared itself. In many instances it commences 
 with severe pain in the abdomen, followed immediately by vomiting, and not unfrequently 
 by purging. In the worst cases, these symptoms are accompanied by marked collapse, tho 
 extremities are cold and bluish, the pulse is at this time a mere thread, and altogether the 
 disease assumes very much the aspect of cholera. After the laj^se of a few hours, reaction, 
 more or less perfect, ensues ; the muscular system then presents characters which may be 
 considered almost pathognomonic. The muscles of the extremities, and those of the neck in 
 particidar, become remarkably rigid, the head is drawn back upon the vertebral column, and 
 firmly fixed in that unnatural position ; no efforts of the patient can bend it forward, neither 
 can the attendants do so, at least by the employment of any justifiable force. The counte- 
 nance at this period often assumes very much the tetanic expression ; twitchings of the mus- 
 cles of the face sometimes ensue; the patient loses, in a great measure, the power of moving 
 his extremities, so that he is quite unable to assume the erect position ; the surface becomes 
 hot, the pulse full and frequent, from 120 to 140; the stomach often continues irritable, 
 whilst an insatiable thirst torments the sufferers, and the epigastrium evinces marked ten 
 derness upon pressure. 
 
 Symptoms of a still more distressing nature quickly supervene ; the patient maybe seized 
 With general convulsions of a frightful severity, requiring personal restraint to protect him 
 from injury, or he may be in a semi-comatose condition, constantly moaning and grinding hi!« 
 teeth, or evei crying incessantly. Towards the close of his suflerings, he generallv merge>«i 
 
 z2
 
 294 DISEASES OF THE 
 
 into perfect coma, the pulse becomes slow and laboured, the po\%'ers of speech and degluti- 
 tion fail, his stools are passed involuntarily, and death finally closes the scene. All this may 
 occur in a surprisingly short space of time ; some of the cases ran their course in forty-eight 
 hours, and the greater number terminated about the fourth day, whilst some few were pro- 
 Jonged over a fortnight or three weeks. Examples are on record of death from the disL-a^e 
 in so short a period as fifteen hours. 
 
 Notwithstanding, in some instances, an exalted sensibility of the cutaneous surface gene- 
 rally was obssrved, such as pain more or less intense in the head, heat of scalp, congestion 
 of the conjunctiva, strabismus, intolerance of light, &c. ; yet. in many, no such evidence 
 occurred, until the laboured pulse, the dilated pupil, the profound coma, or the severe con- 
 vulsion, told but too plainly that the death struggle was at hand. 
 
 When the sensibility of the cutaneous surface generally was in a state of exaltation, the 
 patient complained of being " sore all over," and winced, upon the slightest touch, or refused 
 to change his position in bed, from the pain consequent upon the slightest movement; (the 
 observation of this symptom is due to Dr. MDowel ;) but far more frequently a diminution 
 of tactile sensibility and confirmed stupor, afforded grounds for the worst anticipations. 
 
 Dr. ]\Iayne more than once noticed irregular and laboured respiration as a leading symp- 
 tom ; and this, in itself, provided there was an absence of stethoscopic evidence of thoracic 
 disease, would constimte a valuable diagnostic. 
 
 Notwithstanding that the distressing tenderness of the epigastrium, associated with cDnti- 
 nued irritability of stomach, would seem to indicate decided disease of that viscus, Dr. M. 
 has nevertheless found the abdominal viscera absolutely healthy in the post-mortem exami- 
 nation of two cases, in which diese symptoms persisted in a very marked manner to the 
 close. 
 
 The fatality of the disease, as it appeared in Ireland, was very great. The same is true 
 in regard to the French epidemics. At Avignon, M. Chauffard lost no less than twenty-nine 
 of his first patients ; and, according to statistical calculations, not less than eighty per cent, 
 of the cases noted during the epidemic in France terminated fatally. ]\I. Faure-\ illar lost 
 66 out of 154 cases ; M. Forget 24 out of 40. M. Tourdes states that of 195 soldiers attacked, 
 122 died. In Gibraltar, according to Dr. Gillkrest, 42 deaths occurred among 450 persons 
 attacked. The line of treatment most likely to prove successful requires our fullest consi- 
 deration. It is much to be feared. Dr. M. remarks, that where sjTnptoms denoting extreme 
 collapse show themselves from the commencement, all tlie resources of our art will prove 
 unavailing. The prompt application of the most powerful excitants to the cutaneous surface, 
 particularly mustard and turpentine, aided by heat and friction, and directed especially to 
 the region of the spine, and to the extremities, seems to promise some advantage. Difl'usible 
 stimulants should be employed as sparingly as possible, seeing that an intense inflammation, 
 affecting the very centre of animal life, must remain to be combated after reaction sets in. 
 General and topical depletion, so soon as it can be borne with safety, and the early and free 
 exhibition of mercury, both by the skin and stomach, should constitute our chief dependence. 
 Even this active treatment will often disappoint us. In one case, the jugular vein was 
 opened by Dr. M. within a few hours after the accession of the disease, and blood was 
 drawn in a fill stream, as long as the boy's strength would permit; this was followed up, 
 at short intervals, by relays of leeches to the ten>p]es and inastoid processes; tlie mercurial 
 plan was, at the same time, most energetically pursued, and blisters, with mercurial dress- 
 ings, were applied to the head, and along tlie spine. Yet all was of no avail ; the patient 
 died in convulsions, on the fourth day. In other cases, the same measures have been 
 attended with perfect success. 
 
 The French physicians, who have described the epidemic form of cerebro-spinal meningi- 
 tis, are not agreed as to the most successful plan of treating the disease. AI. Faure-Villar 
 tried, it is said, all rational methods, but declares that no one seemed superior to the rest. 
 M. Forget recommends the antiphlogistic plan of treatment at the commencement of the 
 case, and subsequently opium. M. Rollet found that all the cases of simple cerebro-spinal 
 meningitis — that is to say, of inflammation of the membranes without lesion of the nervous 
 centres themselves — yielded to simple but energetic antiphlogistic treatment, aided by coun- 
 ter-irritants to the skin. One remedy only he found adequate to control the more violent 
 eases, when the brain and spinal cord also suffered, and this was cauterization. In one case 
 which is detailecf, the actual cautery was applied at twelve distinct spots along tlie spine, 
 besides counter-irritants 
 
 M. Gaussuud, who regards the disease as a subintrant cephalalgic fever, produced by 
 marsh miasmata, affirms that, of 162 soldiers attacked, only two died afler he commenced to 
 neat them with medium doses of sulphate of quinia, at the same time that he employed 
 purges, and, at the commencement, venesection. M. Chautlard failed to cure the malady by 
 d.itiphlogistic means, the most prompt, direct, and energetic — by revulsives, purgatives, calo- 
 mel, as well as by various tonics. Opium, however, he found to triumph o,ver it, but it was 
 necessary to give it in large doses. The sulphate of quinia was advantageously combined 
 with the opium. Before this plan was adopted, only one case, we are told, was cured out
 
 SPINAL COR . 295 
 
 of thirty. Afterwards, the disease was less fatal than in sporadic cases. M. Tourdes agrees 
 with M. Chauifard that the usual antiphlogistic means were of no avail ; but he cannot con- 
 firm all that the latter has said in favour of opium. — C] 
 
 Inflammation of the substance of the spinal cord leads to the same changes in 
 its texture which have been already spoken of as being often the results, in the brain, 
 of inflammation of the cereim/ matter. Softening — induration — suppuration. I 
 need not, therefore, again describe the physical characters of these alterations. 
 
 The symptoms which flow from inflammation of the nervous pulp of which the 
 spinal marrow is composed, are by no means uniform ; nor can we expect that they 
 should be so, when we recollect what has been already stated of the different effects 
 that must ensue according as different parts of the cord happen to be implicated. 
 The phenomena will vary likewise, according as the inflammation is acute or chronic. 
 If we recollect how many parts of the body depend for their power of motion, and 
 for their sensibility, upon the integrity of ihe spinal cord, we shall not be surprised 
 at the diversity and multiplicity of the symptoms produced by disease of the cord. 
 Tracking inflammation and its events from the upper portion of the spinal marrow 
 downwards, we should expect to find, and we actually do find, some such an arrange- 
 ment of symptoms as the following. Convulsive atfections of the head and face, 
 inarticulate speech, loss of voice, trismus, difficult deglutition, spasmodic breathing, 
 irregular action of the heart, constriction of the chest, vomiting, pain of the belly, 
 sensation of a cord tied round the abdomen, dysuria, retention of urine, incontinence 
 of urine, constipation, tenesmus, involuntary stools : and with respect to the volun- 
 tary muscles corresponding to these parts of the spinal marrow, convulsions, or palsy ; 
 or palsy succeeding to convulsions. 
 
 I must again have recourse to examples, to put you, more fully than an}'- attempted 
 abstract picture could put you, in possession of such forms of inflammation of the 
 cord as you may expect to meet with in practice. 
 
 A man, fifty-six years old, was exposed to severe cold, while travelling on the out- 
 side of a coach. After this he Xvas attacked with pain in the right arm and leg, most 
 severe about the shoulder, but affecting the whole side, and he had also considerable 
 headache. He soon perceived some loss of power in the affected hmbs ; and the 
 progress of this was very curious. It began at the upper part of the arm, and 
 extended downwards so gradually, that he w^as able to ivi'ite distinctly, after he had 
 lost the power of raising the arm, or bending the elbow. Then the leg became 
 affected in the same gradual manner, and after ten or twelve days from the com- 
 mencement of the disease, the whole leg and arm had become completely paralytic. 
 Some pain continued in the parts, and it was occasionally severe, especially in the 
 leg. Repeated blood-letting, and purgatives, and blistering, were employed. His 
 mind remained quite entire. His pulse was 84, and rather weak ; after some time 
 the Irfl arm became paralytic, rather suddenly ; but it was not so completely motion- 
 less as the limb on the right side ; the left leg was not at all affected. Slight delirium 
 occurred, but passed off again. At the end of two months after the exposure to the 
 cold, he again became delirious, and his pulse got feebler and rapid : he then fell 
 into a state of stupor, muttering incoherently, but answering questions distincll)"- 
 when he was aroused. He lost his speech a few hours before death. For the last 
 eight or ten daj-s there had been considerable sloughing of the sacrum. 
 
 The brain was found to be healthy throughout. Much bloody fluid was dischaig^id 
 from the spinal canal into the cavity of the cranium before the spine was laid open. 
 On displaying the spina! cavity itself, the cord was found in a state of complete 
 softening, from the second to the last cervical vertebra. The portions above and 
 below that part were quite healthy. (Abercrombte.) 
 
 Comparing this case with the one I detailed of meningitis, we find that pain was 
 present in both, but more severely so in the case of inflammation of the membranes ; 
 we find also, that stiffness and spasm of the mitscles markedihe meningitis ; palsy, 
 the inflammation of the substance of the spinal cord. In neither of them were the 
 intellectual functions disturbed till towards the last. I beheve that the character? 
 now pointed out belong to these forms of disease respectively. 
 
 I shall take, from the same store-house, one more case, in wliich both the mem • 
 
 z3
 
 296 DISEASES OF THE 
 
 branes and the cord were simultaneously inflamed ; and which, therefore, was ana 
 logons to encephalitis. And I quote it the rather because it possesses one or two 
 pomts of peculiar interest. A young man, of unhealthy constitution, eighteen years 
 old, had suffered for some time from ulcers in various parts of the body, accompanieH 
 by exfoliations of bone from the leg, thigh, and sacrum. For several months before 
 his fatal attack he had a sore on his head, as big as a shilling, with caries of the 
 bone beneath it. At length he began to complain of pain in the loins, without fever. 
 On the 2d of October this pain had increased ; it was chiefly «eated among the lower 
 dorsal vertebrae, and extended downwards in the course of the ureter, with a fre- 
 quent desire to pass urine. Then the pain descended lower, into the sacrum, and 
 the symptoms referable to the bladder ceased. But soon afterwards pain in the "belly 
 came on, and numbness of the inner sides of the thighs, and retention of urine ; and 
 in two days after this there wexe perfect palsy of both thighs and legs, without loss 
 of feeling, retention of urine, and involuntary stools. He had still some pain in the 
 )ower part of the dorsal region. He died at length, on the Mill of October, having 
 continued quite sensible till about six hours before. There had not been the smallest 
 approach to a renewal of power of the lower extremities, but their sensibility 
 remained. There was palsy, but no ansesthesia. 
 
 All was quite sound in the brain, except some old thickening of the dura mater in 
 the neighbourhood of the diseased bone. In opening the spinal canal, some purulent 
 matter flowed out, during the. sawing, from about the middle of the dorsal region; 
 and one of the vertebrae at that place was found carious. There was an extensive 
 deposit of flocculent matter, having a purulent appearance, upon the outside of the 
 membranes of the cord. Bloody sanious fluid was discharged from beneath its dura 
 mater, and its pia mater was highly vascular. The substance of the cord was found 
 most extensively disorganized along nearly the whole extent of the dorsal portion. 
 The anterior columns of this part were completely broken down into a soft diffluent 
 pulp ; on the posterior part the cord was more entire. When the cord was taken 
 out, and suspended, it hung together by the posterior columns of the dorsal portion, 
 while the anterior part of it fell off" entirely, in a soft half-fluid state. The parts 
 above and below the diseased portion were quite firm and healthy. 
 
 The complete palsy in this instance, going along with the destruction of the ante- 
 nor columns ; and the persistence of the sensibility, the posterior columns being 
 comparatively entire ; invest the case with a remarkable degree of interest. We 
 might infer from it that the anterior half of the cord is the channel through which 
 the power to move the hmbs is transmitted, while their sensations are carried along 
 its posterior half; but we are checked from so concluding, by such cases as the one 
 recorded by Mr. Stanley. These apparent inconsistencies may puzzle, hut they 
 ought not to discourage you. That time, and our advancing science, wiU at length 
 explain and reconcile them I cannot doubt. Meanwhile they teach a lesson which 
 many practitioners much need — viz., that it is unphilosophical and unsafe to draw 
 general conclusions from single cases of disease. 
 
 At the time when these cases were noted, the peculiar reflex properties of the 
 spinal cord were not understood. Henceforward we shah study its diseases from a 
 new point of view, and with a clearer vision. 
 
 Much may be learned in regard to the effects of inflammation, or any other cause 
 of disorganization, confined to a limited portion of the cord, by observing what takes 
 place in those injuries in which the bones of the vertebral column are broken, or dis- 
 placed. Of course I do not dwell upon these accidents, for they belong to surgery-, 
 but I have seen a good many of them, and watched them with deep interest. The 
 symptoms are much more uniform than when inflammation occurs within the verte- 
 bral canal, independently of external injury; simply because the injury to the cord 
 IS more definite and local. But such cases are very valuable objects of study to the 
 physician. I remember several that occurred when I was a dresser in St. Bartholo- 
 mew's Hosjiita! ; and I will state very briefly the particulars of one, as an exemplar. 
 In the year l>!i20, a man was brought there who had been thrown out of a tilt cart, 
 in consequence of a dray running foul of it. He had pitched upon his head, which 
 •*howed, however, no trace of injury. When picked up, he was found to be power-
 
 SPINAL CORD. 297 
 
 leys, both in the upper and lower extremities. His stools passed from him without 
 his being- aware of it, and it was necessary to use the catheter to empty his bladder. 
 He breathed entirely by the diaphragm — that is, his thorax was motionless, and his 
 abdomen rose and fell with every alternate act of inspiration and expiration. These 
 symptoms are perfectly distinctive of injury to the cord between the origins of the 
 j.hrenic and intercostal nerves. He suffered pain about the middle part of the neck 
 b<'hind. He went on exceedingly well for four or five days, and then the nurse very 
 foolishly acceded to his recjiiest to be turned on his side, which caused his death in 
 a very tew minutes. This is not the only instance that I have known, in which life 
 has been suddenly extinguished by similar imprudence. The lesson may be useful. 
 There was another patient in the same hospital, who had fractured the cervical por- 
 tion of the spinal column. Among other remedial measures, the surgeon had 
 directed that his head should be shaved. The barber had performed half his 
 task, and was turning, with his hands, the unfortunate man's head into a more con- 
 venient position for completing it, when he suddenly expired. The twist was fatal 
 to him. 
 
 On the examination of the body of the patient whose case I was mentioning, a 
 very remarkable state of the spinal column was found. The fifth and sixth cervical 
 vertebras were dislocated from each other without any fracture : a thing which has 
 sometimes been pronounced impossible. The articular processes were fairly sepa- 
 rated ; and the vertebrse were also forced asunder by the detachment of one of them 
 from the intervertebral substance. The nervous matter of the cord opposite the 
 point of dislocation was quite soft. 
 
 There is one very common and distressing consequence of such disease of the 
 spinal marrow as produces paraplegia, not particularly noted in any of the cases 
 which I have related, but always to be looked for. The muscles, by means of which 
 the bladder empties itself, are liable to participate in the palsy ; and then the bladder 
 empties itself no longer. The urine accumulates in it, and distends it, and even the 
 ureter becomes distended ; and in this way not only the present but the prospective 
 danger is increased. For the foundation of future disease in the kidneys is often 
 thus laid, even when such distension of the bladder by its retained contents occurs 
 independently of any disease of the spine ; as it may do from stricture ; from en- 
 largement of the prostate ; or even from the voluntary retention of the urine beyond 
 a certain period, through feelings of delicacy. You are to look out, I say, for this 
 distension of the bladder, and relieve or prevent it by the introduction of a catheter 
 through the urethra. You must not be deceived by being told that the patient passes 
 plenty of water ; that it even runs from him. Incontinence of urine is, in fact, in 
 these cases, though it may sound paradoxical, a sign of retention of urine. The 
 urine dribbles away because the bladder admits of no further distension ; it over- 
 flows and runs out at the natural orifice, but the bladder remains constantly full and 
 stretched. You must make an examination, therefore, of the hypogastric region 
 with your hand. If you find that part of the belly hard and resisting, and giving 
 out a dull sound on percussion, you may be sure, in these cases (where there is para- 
 lysis of the lower extremities, and the water dribbles away), that the bladder is full, 
 and has lost the power of expelling its contents. Sometimes you may recognize the 
 fluctuation of the urine in the distended bladder, and ascertain the globular shape of 
 that organ. It will rise even beyond the umbilicus. But what I chiefly wished to 
 point out to you is the circumstance that the bladder becomes diseased, and the urine 
 altered in quahty, under this state of palsy. The urine becomes thick, ropy, and 
 alkaline, and exhales a very offensive ammoniacal smell; and the inner surface of 
 the bladder is found, after death, to be thickened, red, and covered with adiiesiv© 
 mucus — in a state of chronic inflammation, in short.
 
 298 DISEASES OF THE BRAIN. 
 
 LECTURE XXVIII. 
 
 h 
 
 Inflammatory and Structural Diseases of the Spinal Cord, continued. Treatment. 
 wipopkxy. Its General Symptoms and Diagnosis. Different forms of the 
 
 attack. Predisposition to ..Apoplexy — Natural, and Accidental. Precursory 
 
 Symptoms. 
 
 Allow me to repeat that the structural diseases of the spinal cord will most clearly 
 reveal themselves, by their symptoms, to him who most distinctly perceives, and 
 most accurately bears in mind, the physiology of that part of the nervous system. 
 But to the best informed, and the most sagacious, they are too frequently obscure and 
 perplexing. 
 
 Disease occupying a portion only of the cord, but affecting the whole thickness of 
 th?.*, portion, from centre to circumference, will be hkely to disturb, or suspend, the 
 functions of sensation and voluntary motion in all the parts supplied with motor or 
 sentient nerves from that portion of the cord, and from the portion beyond it. So 
 that a great variety of symptoms depend, when the amount of disease is the same, 
 upon the place of the disease. A total interruption of the conducting function of the 
 cord, in the neck, above the origin of the phrenic nerves, extinguishes hfe by stop- 
 ping the actions of respiration. A similar intefruption in the cervical part of the 
 cord, above the origin of the intercostals, but below the origin of the phrenic nerves, 
 destroys life as certainl)', but not so rapidly, nor in exactly the same manner. We 
 find the lungs loaded with frothy serous fluid in sqch cases ; we find the bladder 
 inflamed ; and, often, sloughing of the integuments and muscles of the nates and 
 hips. A similar interruption below the dorsal vertebrae is not necessarily fatal, 
 even when it is attended with permanent paralysis : but it usually is so, sooner or 
 later. 
 
 It is commonly believed that disease affecting the anterior columns only of the 
 cord, will be likely to disturb, or to suspend, the power of voluntary motion in the 
 corresponding parts ; to produce spasm or palsy : and that disease affecting the pos- 
 terior columns alone will be likely to alter or abolish the faculty of sensation in the 
 corresponding parts : to cause pain, tingling, nuinbness or complete amfthesia. But 
 I have mentioned certain facts which contravene this opinion. Suspend your judg- 
 ment respecting it. Neither the minute anatomy nor the physiology belonging to 
 the question is yet conclusively settled. 
 
 There seems no reason to doubt that disease aflfecting the lateral half only of the 
 cord will be likely to derange both the sensibility and the power of movement, in 
 the corresponding part on the same side of the body alone. 
 
 If you impress upon your recollection the facts thus summarily stated, you will 
 find in them. I think, a key to many of the phenomena which accompany, and 
 denote, more or less plainly, disease of the spinal marrow. 
 
 Inflammation of the membruites of the spine is most apt to declare itself h\ pain, 
 mcreased on motion, of the spine and of the limbs ; and by rigidity and spasm of 
 the muscles of the neck and back. Inflammation of the cord itself, which readily 
 passes into, or rather produces, softening of its substance, is most commonly marked, 
 first, with convulsive movements of some parts of the body ; secondly, by palsy of 
 those parts, with or without ansesthesia. The same may be said of suppuration 
 ■when it occurs as an event of inflammation ; and the pus may be collected into an 
 abscess in the nervous matter of the cord, or it may be difl^used and mixed with 
 softening. 
 
 Now I need not dwell upon the treatment proper to be adopted in inflammation of 
 the spinal cord and its membranes. Mutatis mutandis, it is the treatment already 
 recommenaed in inflammation of the brain and its membranes. When the inflain 
 matioh ]s acute, we must take blood freely ; from the arm, or by cupping-glasses 
 along the sides of the spine. Blood enough may be taken by cupping along this 
 tract to produce the effect of general bleeding as well as of local. Perfect rest in
 
 APOPLEXY. 290 
 
 the horizontal postu/e must be strictly enjoined Mercury will generally be 
 proper. 
 
 In more chronic forms of inflammation within the spinal canal, we still have a 
 capital remedy in cupping: and counter-irritation in various ways, but more espe- 
 cially by means of issues made on one or both sides of the spinous ridge, is also, in 
 many cases, of most essential and unquestionable service. 
 
 Great care must be taken, when there is palsy of the bladder, not only (as T 
 admonished you in the last lecture) that the urine be regularly drawn off, but also 
 that the patient be kept dry and clean: for if great attention be not paid to this point, 
 sores will form where the urine remains in contact w'ith the skin, to the great increase 
 of his suffering, and of his danger. Indeed, take what pains we may, there is gene- 
 rally a strong disposition to the formation of sloughs upon the sacrum and hips in 
 cases of paraplegia. They result from the perpetual pressure made upon those 
 projecting points ; from the feeble state of the circulation in the palsied parts ; and 
 (often) from the irritation of the urine and feces, which are passed without the 
 patient's consciousness. 
 
 When the patient is kept clean and dry, and the surfaces on which the weight of 
 his body has been supported begin to be red and angry, you may protect them by a 
 plaster: or by rubbing them with brandy you may sometimes prevent the skin from 
 breaking: or, what is best of all, you may put your patient upon one of Dr. Arnott's 
 hydrostatic beds; and then the pressure will be equally distributed over all that 
 portion of the body which comes in contact with the water-proof material of the bed. 
 
 To bring this outline of the diseased states of the spinal cord up to that point in 
 which we left those of the encephalon, I may state that, like tlie brain, the spinal 
 marrow may become hardened by chronic inflammation ; and, like the brain, it may 
 be encroached upon by tumours ; fibrous, scrofulous, or malignant. With respect 
 to these, all that I can now say likely to be of any practical benefit to you, is that 
 the symptoms they occasion are those of slowly increasing paralysis, without fever 
 or what is called reaction : and that the locality, and extent, and effects of the para- 
 lysis, will vary according to the part of the cord in which these changes occur, and 
 the depth to which they affect it. 
 
 I proceed, in the next place, to a perfectly distinct class of diseases of the brain 
 and spinal cord ; to the apoplectic afft'Ctions : and especially to cerebral hemorrhage, 
 and spinal hemorrhage. 
 
 When a person falls down suddenly, and lies without sense or motion, except that 
 his pulse goes on beating, and his breathing continues, he is said to have been 
 attacked with apoplexy. He appears to be in a deep sleep ; but this is not all, for 
 you cannot awaken him by the same means which would rouse a healthy man. He 
 is not in a state of syncope, for his pulse beats, perhaps with unnatural force ; and 
 often his face, instead of being pale, is flushed and turgid ; and his respiration goes 
 on, though it may be laboured and- stertorous. What I now denominate apoplexy, 
 is the very same state which has so frequently been mentioned already in these lec- 
 tures : it is coma occurring suddenly, or coming on (at least) with rapidity. What 
 is coma? it is that condition in which the functions of animal life are suspended, 
 with the exception of the mixed function of respiration ; while the functions of 
 organic life, and especially of the circulation, continue in action. There is neither 
 thought, nor the power of voluntary motion, nor sensation : but the pulmonary 
 branches of the par vagum continue to excite, through the medudla oblongata, the 
 invohmtary movements of the thorax. When this upper part of the cranio-spinal 
 axis becomes involved in the disease, and its reflex power ceases, the breathing 
 ceases also, and the patient is presently dead. 
 
 It is a common question — how would you distinguish apoplexy from the effects ot 
 a narcotic poison? If you were summoned to a person in the state I have been de- 
 scribing, how could you tell whether he was afllicted with apploplexy, or labouring 
 under the influence of a large dose of opium, or merely dead-drunk? Why, so far 
 as the condition of the cerebral functions is concerned, you cannot discriminate the 
 one from the other. In each case there is profound coma ; but the cause of vhe
 
 300 DISEASES OF THE BRAIN. 
 
 coma is different in each, and you must seek to ascertain that cause in the history 
 and other circumstances of the patient : you inquire whether he is known to have 
 been drinking, you try if you can perceive the odour of spirits, or of wine, in his 
 breath ; or you endeavour to make out whether he has been low-spirited, or in 
 known difficulties ; in short, whether it is likely that he may have swallowed poison. 
 But from the actual condition of his sensorial functions, you cannot solve the question. 
 
 Yet let me say, thus in the outset of our remarks upon apoplexy, that it is often 
 /)f great importance that the diagnosis should be determined. A man was found 
 lying in Smithfield in a state of total insensibility, and motionless, except that he still 
 breathed. He was carried into St. Bartholomew's Hospital. The house-surgeon 
 thought he smell the smell of gin in his mouth ; and thereupon very properly made 
 use of the stomach-pump. By means of it he discharged a large quantity of ardent 
 spirit ; and in the course of a few minutes the man revived, shook his ears, and 
 walked away. If the gin had been suffered to remain in his stomach, and if the 
 remedies of apoplexy had been vigorously put in force, the absorption of the poison 
 would have been thereby accelerated ; and the debauch would probably have had a 
 fatal termination. The same remarks apply still more urgently to the case in which 
 opium, or any other strong narcotic poison, is lying in the stomach. Even when 
 there is no great danger, either in the person's state, or in the remedies used for it, it 
 is not a very pleasant or creditable thing to make a false point of this kind. If we 
 do err, however, we had better err on the safe side. The father of the late Professor 
 James Gregory, of Edinburgh, (who used to relate the case in his lectures,) was once 
 called out very late in the evening to visit an old gentleman of that place. He found 
 him in a completely comatose condition ; his wife crying, and his household all 
 plunged in grief and distress. They told him that the patient, whom he now saw 
 in a fit, had come home, and upon the servant's opening the door to him, had fallen 
 into the passage, on his back, in a state of insensibility. Dr. Gregory learned, how- 
 ever, that he had been at the "Club," and he knew well enough that this club was 
 composed of choice spirits, fond of their cups; although the gentleman's wife did 
 not know as much. Therefore he ventured to express his " hopes" to the wife that 
 her husband was drunk : a charitable view of the case, at which she was extremely 
 affronted and indignant. He persisted, however, in his opinion, and not long after- 
 wards the patient began to recover his senses. It turned out that he had partaken 
 more fiberally than the rest of the club, and was the first to be intoxicated. Two of 
 his companions carried him home quite incapable of motion ; but not hking to intro- 
 duce him themselves to his wife in that predicament, they placed him with his back 
 against the door, rang the bell, and decamped. Of course when the servant came to 
 open the door, his master tumbled sense^less on the floor. I need not point out to you 
 the ridicule which the phys'cian would have brought upon himself, and the damage 
 he might have inflicted upon his patient, had he busily apphed, in this case, the 
 ordinary remedies of apoplexy. 
 
 The state of coma, such as I have described as being characteristic of apoplexy, 
 may terminate in one of three ways. It may cease, more or less rapidly, and leave 
 the patient in perfect health. What is the exact condition of the encephalon during 
 the continuance of the coma, in such cases, no one can positively tell. But the oc- 
 currence of temporary coma, under the influence of a narcotic poison, and the 
 perfect disappearance of the coma as the effects of the drug pass off, teach us that the 
 functions of the brain may be almost totally suspended for a time by causes which 
 do not injure its texture. It is possible that, when there is no poison at work, the 
 coma may depend upon that presumed disturbance of the balance of the arterial 
 and venous circulation within the cranium, which I mentioned in a former lecture. 
 It may be that the force and rapidity of the circulation in the cerebral vessels un- 
 dergo some great alteration. It is still more probable (to my mind) that a temporary 
 Mress upon the cerebral blood-vessels (produced by a determination of blood towards 
 the head, through the arteries, or by a detention of blood in the obstructed veitis) 
 may really exercise pressure enough to cause transient coma. But these are mere 
 conjeciures. 
 
 In the second place, the apoplectic coma may terminate, more or less quickly, in
 
 APOPLEXY. 301 
 
 death. And on examining the brain, we may find a large quantity o. extravasated 
 blood; or a considerable effusion of serous fluid in its ventricles, or beneath the 
 arachnoid ; or we may detect no deviation whatever from the healthy structure and 
 natural appearance of the organ. The congestive pressure (if it indeed existed) has 
 left no prints of its action. 
 
 Fatal coma, without obvious disease in the brain to account for it, results, not un- 
 frequently, from an inbred poison, of which the agency was not recognized until a 
 recent period : the poison of unpurified blood. When speaking of the general 
 pathology of dropsy, I mentioned a peculiar renal disease — first detected and 
 described by our distinguished countryman, Dr. Richard Bright — which unfits the 
 kidney for what is probably its most important office ; that of removing urea from 
 the system. When this excrement, thus retained, accumulates in the blood beyond 
 a certain amount, it is very apt, among other injurious tendencies, to cause death in 
 the way of coma. 
 
 Dr. Abercrombie has given to that form of apoplexy, which destroys life, but 
 leaves no traces behind it, the name of simple apoplexy. And this name, for its 
 convenience I shall retain. Of the other two kinds of quickly fatal apoplexy, that 
 in which blood is found extravasated, is more common than that in which there is 
 effusion of serum only. The one has been called sanguineous apoplexy ; a better 
 term is cerebral hemorrhage : the other has been named serous apoplexy. 
 
 Thirdly, the apoplectic coma may terminate in partial or imperfect recovery. One 
 or all of the cerebral functions may be left impaired ; the mind enfeebled ; the 
 power of motion limited or lost in some parts of the frame ; the faculty of sensation 
 benumbed or extinguished : the unhappy subject of the attack remaining more or 
 ■ ess crippled in body, and more or less maimed in intellect. In these cases, when at 
 {englh we have an opportunity of examining the brain, we almost always find that 
 there has been extravasation of blood, to a small or moderate extent. I say almost 
 always, because I have myself, in more than one instance, carefully looked for 
 such appearances, after such a series of symptoms., without finding them. Oc- 
 casionally, instead of a clot of blood, we meet with circumscribed softening of the 
 brain. 
 
 The attack of apoplexy does not always occur in the same manner : and Dr. 
 Abercrombie has pointed out three several ways in which it is apt to come on. 1 
 am confident, from the result of my own observation, that the distinctions laid 
 down by Dr. Abercrombie are just and true ; and it is of importance that you 
 should be aware of them. " In the first form of the attack, the patient falls down 
 suddenly deprived of sense and motion, and lies like a person in a deep sleep ; 
 his face generally flushed, his breathing stertorous, his pulse full and not frequent, 
 sometimes below the natural standard. In some of these cases convulsions occur ; 
 in others, rigidity and contraction of the muscles of the limbs, sometimes on one 
 side only." 
 
 Now, respecting persons seen in this condition, the immediate prognosis is un- 
 certain. Some die in a short time, and much blood is found extravasated within the 
 cranium. Some die after a rather longer interval, and then we often find serous 
 effusion only, and that of no great amount. And in some that die early, no effusion 
 either of blood or of serum can be detected. Some recover altogether, without any 
 ill effect of the attack remaining. Others recover from the coma, but are left para- 
 lytic of one side, and with some imperfection of speech, or of one or more of the 
 senses. And this paralysis and imperfection may disappear in a few days, or gra- 
 dually subside, or remain for life. 
 
 In the second form of the attack, the coma is not the earliest symptom. The dis- 
 ease generally begins with a sudden attack of pain in the head. The patient 
 becomes pale, faint, and sick, and usually vomits ; and sometimes, but not always, 
 falls down in a slate of syncope, or resembling syncope, with a bloodless and cold 
 skin, and a feeble pulse. This also is occasionally accompanied by some degree of 
 convulsion. Sometimes he does not fall down, the sudden attack of pain being 
 accompanied only by slight and transient confusion. In either case, he commonly 
 recovers in a short time from these symptoms, and is quite sensible, and able ii.» 
 
 2a
 
 302 DISEASES OF THE BRAIN. 
 
 walk ; but the headache does not leave him. After a certain interval, which may 
 vary from a few minutes to several hours — and Dr. Abercrombie records cases in 
 which it was even much longer — the patient becomes heavy, forgetful, incoherent, 
 and sinks into coma, from which he never rises again. In some instances, paralysis 
 of one side occurs ; but perhaps more often, there is no palsy observed. 
 
 The disease, when it comes on in this way, is much more uniform, and of much 
 worse omen, than when it commences after the former fashion. It is of great use 
 to know this ; for to an inexperienced eye the cases do not seem so terrible as those 
 in which the patient becomes profoundly comatose from the very first. The appa- 
 rent amendment is fallacious, and apt to lead one into giving a false prognosis. 
 Very few persons come out of the coma, and a large quantity of blood is usually 
 found extravasated in the brain. These cases are not, as Dr. Abercrombie well 
 observes, apoplectic in the outset. They differ remarkably from the first set of cases. 
 If there be at the ver}^ beginning some loss of sense or motion, it goes off again in 
 a very few minutes, or perhaps in a few seconds : the prominent symptom, at the 
 commencement, is sudden and violent pain in the head, with faintness, sickness, anci 
 often with vomiting. The pain continues, and is sometimes confined to one side of the 
 head ; the face is pale and ghastly, the pulse weak, and often frequent or irregular ; 
 but the patient is quite conscious, and in full possession of his intellect. At length 
 he recovers his natural temperature, his countenance improves, and the pulse becomes 
 stronger and steadier : then his face gets flushed, he feels oppressed, answers ques- 
 tions slowly, and at last sinks into stupor and fatal coma. The period between the 
 first attack and the commencement of the coma is variable. Sometimes the stupor 
 succeeds the pain and faintness so rapidly, that the case comes greatly to resemble 
 those in which coma is the first symptom, and takes place suddenly ; but still a short 
 period of sense, commonly with complaint of great pain, may be observed. But the 
 interval may be a quarter of an hour, or many hours, or even two or three days. 
 " Upon inspection,", says Dr. Abercrombie, " we find none of those varieties and 
 ambiguities, which occur in the apoplectic cases, but uniform and extensive extra- 
 vasation of blood." [I should state that he calls the first class of ca^es apoplectic 
 cases, the coma being present from the first : and the second class, which we are 
 now considering, he calls cases not primarily apoplectic.'] The symptoms in this 
 form of attack depend, no doubt, upon the giving way of some one of the cerebral 
 vessels. At the moment when the vessel is ruptured, a shock is given to the brain ; 
 a temporary derangement of its functions occurs ; but this passes off. The circu- 
 lation then goes on as before, until such a quantity of blood has escaped from the 
 ruptured vessel as is sufficient to produce coma. There is no part of Dr. Aber- 
 crombie's book more admirable and clearly put than that which is occupied with 
 these important distinctions, which I give you very much in his own words. He 
 points out the close analogy which exists between this variety of apoplexy, and the 
 result of external injuries, when they occasion extravasation of blood on the surface 
 of the brain. The hurt person recovers from the immediate effects of the accident, 
 walks home perhaps, and after some time becomes stupid, and at last comatose. 
 The surgeon trephines the skull, and discovers blood upon the dura mater; and the 
 blood being removed, the coma goes off. We cannot help our patients by a similar 
 expedient; though the opinion has been broached that trepanning the skull will, at 
 some future period, be a common practice in apoplexy. Dr. Abercrombie conjec- 
 tures that after the rupture has taken place, the hemorrhage is sometimes stopt by 
 the formation of a clot at the orifice in the vessel, but at length the blood bursts out 
 again, and proves fatal. He relates two cases in which this probably happened ; in 
 one of them an interval of three days, and in the other an interval of a fortnight, 
 elapsed between tiie first attack, and the supervention of coma. The portions of 
 blood extravasated at the two distinct periods may sometimes be distinguished by 
 their appearance — their colour and consistence. 
 
 The third form of attack is characterized by sudden loss of power on one side of 
 the body, and frequently by loss of speech, without loss of consciousness ; or at most 
 with a very temporary suspension of consciousness. The patient is sensible, listens 
 to and comprehends your questions, and answers them as well as he is able, either
 
 APOPLEXY. 303 
 
 oy words, which in most cases he articulates imperfectly, or by gestures The 
 further progress of the cases that commence in this way is marked by considerable 
 variety. Sometimes the hemiplegia passes gradually in a short time into apoplexy. 
 Sometimes the patient soon gets well, the palsy leaving him entirely. Or a gradual 
 recovery takes place, which is not complete for some weeks or months. Or the 
 patient rallies up to a certain point, and there the improvement stops ; he regains the 
 power of moving his leg, but it drags somewhat after him ; or the leg recovers, but 
 the arm remains feeble, or his speech continues to be inarticulate. And in another 
 variety of this form the patient neither improves on the one hand, nor becomes apo- 
 plectic on the other, but is confined to his bed, paralytic, and perhaps speechless, 
 though in possession of his faculties in other respects, and dies at last worn out and 
 exhausted, some weeks, or months it may be, after the attack. In the outset of these 
 cases there is not always complete hemiplegia, sometimes the arm only is affected, 
 sometimes (but much more rarely) the leg only. Or some other voluntary muscles 
 are the first to lose their power. 
 
 Now the appearances discovered after death, in cases that have thus commenced 
 (Dr. Abercrombie calls them the class of paralytic cases), are, as in the apoplectic 
 cases, inconstant. Much the most common of all — according to my own experience — 
 is the extravasation of blood, to a moderate or small amount, and definite extent, in 
 the substance of the brain. But sometimes nothing is found, upon dissection, to 
 account for the symptoms, or slight serous effusion only. The same symptoms attend 
 some cases of softening of the brain also ; or inflammation and its consequences. In 
 a vast majority of cases, I repeat, this sudden hemiplegia inarks an attack of cerebral 
 hemorrhage. 
 
 You will not find that all cases of apoplexy commence exactly in the one or the 
 other of the three ways which I have been describing. But most attacks range 
 themselves in one of these classes, and by attending to the points of distinction, I 
 make no doubt that you will often derive much assistance from them in regard to 
 diagnosis and prognosis ; and that the distinctions themselves will give a higher inte- 
 rest to your study of this complaint, than it would possess if all the forms of attack 
 were jumbled together in one common description. 
 
 In treating of this large subject, this multiform disease, the main points will best 
 be made intelligible by my breaking what I have to say into separate heads. I have 
 told you the different ways in which the disease may make its assault. I will next 
 say something of the persons who are most liable, cseieris paribus, to attacks of 
 apoplexy : and afterwards of the symptoms which in many cases, though not in all, 
 precede the seizure, and lead us to fear that it may be impending. It is of great 
 importance to attend to these threatenings ; for, as you will readily conceive, the 
 chief good that medicine can do in such cases, is in the way of prevention. After the 
 attack has taken place, the effect of our treatment must be very uncertain. A large 
 effusion of blood upon the brain will be fatal in spite of us : and a smaller amount of 
 extravasation we cannot remove ; and the best that the patient can expect in too many 
 cases, is long-continued or permanent palsy, a weakening of the mental powers, and 
 sometimes a state nearly approaching to idiocy. Also, when once an apoplectic fit 
 has happened, it is the more likely, on that very account, to happen again. These 
 are quite sufficient reasons why we should not neglect the warnings ; the symptoms 
 which are apt to precede and herald the attack of apoplexy. 
 
 The classes of persons in whom, cseteris paribus, attacks of apoplexy are espe- 
 cially to be apprehended, are those whose ancestors have suffered the same disease ; 
 those who possess a particular conformation of body ; and, above all, those who 
 have reached a certain period of life. No doubt apoplexy may and does occur in 
 persons whose progenitors have escaped it ; in persons of every conceivable snape 
 and make ; and in persons of all ages. But it is much more frequent in the classes 
 I have specified, than it is among persons not comprehended in those classes. 
 
 The first and second class sometimes concur, ?". e., a particular conformation of the 
 body is transmitted from parent to child, and with it is transmitted a proclivity to 
 apoplectic disease. But even when there is nothing particular in their bodily form. 
 or in their habits of life, practical men of large experience declare that they who
 
 304 DISEASES OF THE BRAIN. 
 
 come of an apoplectic stock are themselves more than ordinarily liable to apo- 
 plexy. _ 
 
 The pattern of body which is most prone to apoplexy is denoted by a large head 
 and red face, shortness and thickness of the neck, and a short, stout, squat build. 
 This remark is as old as the time of Hippocrates. However, apoplexy is common 
 enough in men and women who are thin, and pale, and tall. Ceteris paribus, cor- 
 pulent people are more in danger of apoplexy than spare people ; but it attacks both 
 the one and the other. 
 
 Advanced life is certainly a very strong predisposing cause, and the reason of this 
 will be apparent when we come to inquire more particularly into the morbid appear- 
 ances presented after death by apoplexy. The disease begins to be common after 
 50: but it does sometimes occur even in young children. I am speaking principally 
 of that form of apoplexy which depends upon cerebral hemorrhage, which is by 
 far the most frequent of all its forms. 
 
 Of sixty-three examples of cerebral hemorrhage, collected and carefully examined 
 by Rochoux (who has written a very good treatise on this affection), two only hap- 
 pened between the ages of 20 and 30 ; eight between 30 and 40 ; seven between 
 40 and 50 ; ten between 50 and 00 ; twenty-three (or more than one-third of the 
 whole) between 60 and 70 ; twelve between 70 and 80 : and one between 80 and 
 90. To analyze this table a httle further : it appears that of the sixty-three casss 
 seventeen only took place before 50 ; forty-six after that age. There are also twice 
 as many victims to the disease between the ages of 60 and 70, as between 70 a^d 
 80. And from this fact Rochoux has drawn, I conceive, an erroneous conclusioKi ; 
 and I mention it that, in case his treatise falls in your way, j'ou may not be led by 
 it into what I imagine would be a mistake. There being twenty-three cases between 
 the ages of 60 and 70, and only twelve between the ages of 70 and 80, Rochoux 
 infers from this that the disposition to cerebral hemorrhage decreases after the age 
 of 70 ; which would be a most unaccountable thing, and quite inconsistent with 
 what I believe to be the true pathology of the disease. But I make no doubt that 
 the difference in the actual numbers observed in these two decennial periods de- 
 pended upon the number of persons alive, at the same time, of the ages of 60 and 
 70 respectively. There are always more persons living whose age ranges from 
 60 to 70, than from 70 to 80 ; and therefore more persons die of apoplexy in the 
 former period. In all probability, if the exact truth could be ascertained, of a given 
 number of persons, there are more attacked with apoplexy between 70 and 80 than 
 between 60 and 70. 
 
 All these three kinds of predisposition are beyond our power. We cannot exter- 
 minate the hereditaiy tendency ; nor remodel the plan upon which the body is con- 
 structed ; nor arrest, or put back, the clockwork of human life. But we may guard 
 and caution persons, thus predisposed by nature towards apoplexy, against many of 
 its exciting causes. 
 
 A strong predisposition to apoplexy is, moreover, engendered by certain other 
 diseased conditions ; and over some of these conditions our art enables us to exercise 
 more or less control. 
 
 One of these I referred to just now — the kidney disease discoverea by Dr. 
 Bright. 
 
 Disease of the cerebral blood-vessels is a very common and a ver}' pregnant cir- 
 cumstance of predisposition. I shall revert to this when I describe more particularly 
 the anatomical characters af cerebral hemorrhage. 
 
 Diseases of the chest influence very materially and injuriously the circulation in 
 the head. Without going into detail respecting complaints with wliich I am obliged 
 to suppose that you are as yet unacquainted, I may state, by anticipation, that impe- 
 diments to the free transmission of blood through the heart and lungs constitute the 
 mode in which thoracic disorders predispose to apoplexy. The pletliora capitis 
 produced by such impediments is frequently visible in the turgid and livid features, 
 and in the distended jutrular veins. 
 
 The cessation of habitual discharges, of the catamenia, of bleeding piles ; the 
 drying up of old sores ; the heaHng of long established issues and setons ; all have
 
 APOPLEXY. 305 
 
 an unquestionable tendency, by causing or augmenting plethora, to generate a pre- 
 disposition to apoplexy. 
 
 And large observation of the habits of those who fall victinas to this terrible ma- 
 lady, leaves no room for doubting that intemperance often paves the way for its inva- 
 sion. The continued abuse of ardent spirits, in particular, lays the foundation of 
 many of those morbid conditions of the sanguiferous system, and of the viscera, 
 which constitute the predisposition we are now considering. 
 
 Among the premonitory symptoms, headache is of frequent occurrence : but the 
 same symptom is abundantly common in persons who are in no danger of apoplexy : 
 it derives its minatory character from the concurrent circumstances. Headaches 
 awaken our fears when they begin to be troublesome in advanced life. They are, 
 then, still more formidable if they are accompanied by vertigo; or, without any 
 other evidence of gastric derangement, by nausea and retching. Sometimes, as I 
 just now told you, severe headache ushers in, and almost forms a part of the apo- 
 plectic attack. 
 
 Vertigo itself, even without headache, is a very common precursor or warnmg of 
 an approaching seizure. It is sometimes slight and transient ; sometimes almost 
 habitual. Although vertigo may depend upon other causes than mischief within the 
 head, we cannot regard it without apprehension when it often occurs in old persons. 
 It should teach us to obviate as entirely as we can all the known exciting causes of 
 apoplexy. The principle of these I shall by-and-by describe to you. 
 
 Transient deafness, or transient blindness, blindness or deafness for a few seconds 
 or minutes, is another of these warning symptoms. The late Dr. Gregory, of Edin- 
 burgh, used always to mention in his lectures the case of Dr. Adam Ferguson, the 
 celebrated historian, as affording one of the strongest illustrations he ever met with 
 of the benefit that may be derived from timely attention to the avoidance of those 
 circumstances which tend to produce plethora and apoplexy. It is, perhaps, the 
 most strikmg case of the kind on record. Dr. Ferguson experienced several attacks 
 of temporary blindness some time before he had a stroke of palsy ; and he did not 
 take these hints so readily as he should have done. He observed that while he was 
 deiivering a lecture, his class, and the papers before him would disappear, vanish 
 from his sight, and reappear again in a few seconds. He was a man of full habit ; 
 at one lime corpulent and very ruddy, and, though by no means intemperate, he 
 lived fully. 1 say he did not attend to these admonitions; and at length, in the 
 sixtieth year of his age, he suffered a decided shock of paralysis. He recovered, 
 however, and from that period, under the advice of his friend. Dr. Black, became a 
 strict Pythagorean in his diet, eating nothing but vegetables, and drinking only water 
 or milk. He got rid of every paralytic symptom, became even robust and muscular 
 for a man of his time of life, and died in full possession of his mental faculties at the 
 advanced age of n inety -three : upwards of thirty years after his first attack. Sir 
 Walter Scott describes him as having been, " long after his eightieth year, one ot the 
 most striking old men it was possible to look at. His firm step and ruddy cheek 
 contrasted agreeably and unexpectedly with his silver locks ; and the dress which he 
 usually wore, much resembling that of the Flemish peasant, gave an air of peculi- 
 arity to his whole figure. In his conversation, the mixture of original thinking with 
 high moral feeling and extensive learning, his love of country, contempt of luxury, 
 and especially the strong subjection of his passions and feelings to the dominion of 
 his reason, made him, perhaps, the most striking example of the Stoic philosophei 
 which could be seen in modern days." 
 
 This anecdote, which I have made use of as a wrapper for some medical instru*. 
 tion, will not be the less acceptable to you when I add that the remarkable man to 
 whom it relates was the great-uncle of my friend and present colleague in this 
 school. Dr. Robert Ferguson. 
 
 Very frequently slight and partial paralysis is the forerunner of an attack of apo- 
 plexy- Double vision is one form in which such hmited palsy is apt to show itself. 
 It is evidently connected with some degree of squinting; i. e., some one or more of 
 the muscles that move the eyeball are paralyzed ; the person cannot direct each 
 eye to the same object at the same time. This is a very suspicious symptom. Dr 
 20 2a2
 
 306 DISEASES OF THE BRAIN. 
 
 Gregory was acquainted with a sportsman who one day, when out shooting, disputed 
 with his gamekeeper as to the number of dogs they had in the field. He asked how 
 he came to bring so many as eight dogs with him. The servant assured him there 
 were but four; and then the gentleman became at once aware of his situation, 
 mounted his horse and rode home. He had not been long in the house when he 
 was attacked with apoplexy, and died. 
 
 Sometimes the slight and local paralysis shows itself in a faltering or inarticulate 
 mode of speaking. The rapidity of the movements of the tongue requisite for dis- 
 tinct utterance is so great, that the slightest weakness of any one of its muschs is 
 rendered obvious. We see this in one very comition form of what may in truth be 
 considered a kind of apoplexy ; viz., in drunkenness. In many persons the very- 
 first symptom of their becoming intoxicated is their inability to speak plainly. " Clip- 
 ping the King's Enghsh " is the slang expression for it ; and the same thing often 
 takes place in respect to the more proper forms of apoplexy. 
 
 It is a curious circumstance, by the way, and one which is illustrative of what 
 we meet with in disease, that different sets of muscles are chiefly aflected by inebri- 
 ation in different persons ; the same sets being always the first afTected in the same 
 persons. Thus, some men, when drunk, lose (as I have just stated) the proper 
 command over the muscles of the tongue, and falter in speech, while they can 
 walk very well : others reel and stagger, having lost, in a greater or less degree, the 
 power of moving and governing their limbs, and of balancing themselves, who yet 
 can speak quite fluently and plainly: and in a few cases, drunken persons become 
 delirious, who still retain the power of distinct articulation, and of directing their 
 steps aright. This being so, we need the less wonder at the variety in the nature 
 of the warnings that precede the apoplectic attack. 
 
 In many instances there is numbness or debility, or total palsy of one limb, or of 
 a single finger, or even of a sohtary muscle, as of the levator palpebrse. The patient 
 cannot grasp your hand with firmness, or sign his name in his usual way, or pick 
 up a pin, or snuff a candle, or manage an obstinate button, or tie a knot in a thread 
 cleverly : or, perhaps, one of his eyelids droops, and the eye is half closed. Some- 
 times, on the contrary, the patient stares at you, friglxlfully, w^ith one eye, which he 
 cannot shut. 
 
 The numbness also assumes various characters, according to its place and degree. 
 One patient will tell you that he feels as if his limbs were muffled in flannel; ano- 
 ther, that he is uncertain whether, in walking, his foot has reached the ground or 
 not. A gentleman, since dead of apoplexy, assured me that, when sitting, he did 
 not know how far his breech covered the seat of the chair. 
 
 All these symptoms are modifications of the function of voluntary motion ; or of 
 the function of sensation. Nor are manifestations wanting, among these precursory 
 circumstances, of a derangement of the other and nobler function, of which the brain 
 and nervous system form the material instrument. I mean the function o^ thought. 
 
 Thus one very deplorable warning is the loss of memory. All persons find, as 
 ■.hey grow older, that they do not retain so tenaciously in their recollection things 
 which have recently occurred, as things which happened when they were youno-. 
 This partly depends upon the degree of atteniion which we pay to different circum- 
 stances. Those events which strongly excite the curiosity, and rivet the attention 
 of the boy, become familiar to the man, and he gives them but little notice, and is 
 very apt to forget them. But the loss of memory that threatens apoplexy is some- 
 thing more than this. It is sometimes partial, and extends to certain sets of things 
 (•nly. For example, some p-^rsons entirely forget certain words, while they recollect 
 others perfectly. Common words are often thus forgotten, while unusual or remark- 
 able words are remembered ; or a wrong word is chosen. One w-ord is used for 
 another that sounds something like it. Thus one of my patients, meaning to accuse 
 a certain individual o[ perjury, always called it purging: and many other words he 
 changed after the same fashion. But in truth the modifications of a partial loss of 
 memory that have been known to precede apoplexy are both odd and endless : some 
 people forget their own names, or the names of their children. Dr. Gregory, who 
 u^d paid particular attention to these precursory symptoms, and who had a large
 
 APOPLEXY. 307 
 
 practice foi a great number of years to furnish them, used to mention a case of this 
 kind. After some efforts his patient could recalJ to his recollection what his Chris' 
 tian name was, but he could not think of his surname. About twelve months after 
 his memory began to fail in this strange manner, he was found dead in his bed. 
 Another gentleman, for some time before his death, could never recollect the name 
 of the street in which he lived. Upon one occasion of his visiting Edinburgh, he 
 called on Dr. Gregory, and partook of a hearty breakfast, having forgotten that he 
 had breakfasted before he came out. On the same day he attended, with Dr. Gre- 
 gory, the funeral of a young lady who had been his ward ; the funeral took place in 
 the country ; and when they returned together in the carriage, the doctor found that 
 his friend had forgotten all that he had been doing. Next day he met him in the 
 street, and saluted him with all the kindness of an old acquaintance at first meeting; 
 saying he was happy to have flillen in with him now that he was in town, and 
 totally forgetful of their former interviews. 
 
 Connected with this failure of memory, there is often an unnatural degree of 
 drowsiness. Sometimes, without any permanent affection of the memory, there is a 
 temporary confusion or suspension of thought ; the patient suddenly loses the train 
 of ideas in which his mind had been occupied ; stops short in the middle of a sen- 
 tence, and endeavours, in vain, to recover the broken thread of his discourse. 
 
 Among the mental conditions that bespeak a tendency to apoplectic disease, I 
 have several times noticed a strange and vague dread, of which the person can give 
 no reasonable explanation ; a sense of apprehension and insecurity not accounted 
 for by the apparent state of his general powers and functions ; a painful degree of 
 indecision and irritability ; with a dislike and fear of being left alone. One patient 
 of mine described his " nervousness" of this kind, by telling me that in descending 
 a staircase, especially a winding one, he was obliged to turn round, and come down 
 backwards, as one descends a ladder ; or even to sit down, and so sHp, stair by stair, 
 from the top to the bottom. Yet with the assurance given him by a friend's arm, 
 or by a convenient baluster, he could walk down stairs without difficulty. He had 
 no actual vertigo. 
 
 I say, all these, and many other signs that indicate a disposition to apoplexy, are 
 well worth j^our study ; because a knowledge of them may enable you to ward off 
 the threatened attack by medicine, by regimen, and by admonition to the patient on 
 the subject of such exciting causes of the disease as are within his own control. 
 They show that, even before the stroke descends, there is some morbid process going 
 on within the head. 
 
 LECTURE XXIX. 
 
 Apoplexy continued. Symptoms characterizing the Apoplectic State. Pressure 
 the ordinary Physical Cause. Hem,iplegia. Affection of Involuntary Muscles. 
 Anatomical Characters. Situation of the Clot of Blood. Disease of the Cere- 
 bral Blood-Vessels. 
 
 We were engaged with the subject of apoplexy. I requested your particular 
 attention to the three-fold mode in which that fearful disorder has been observed to 
 make its attack. In the first, the coma is sudden and deep ; the condition of the 
 patient, thus struck in an instant senseless and motionless, warranting those epithets 
 which the ancients applied to the victims of this disease, of attoniti and siderati, as 
 if they were thunder-smitten or planet-struck. In the second form of the attack, the 
 earliest symptom is acute pain of the head, with sickness and faintness ; the coma 
 supervening usually in no long time. The third form is ushered in by sudden 
 hemipl?gia, which may or may not lead to loss of consciousness or stupor. The 
 cases which range themselves under the one or the other of these three forms of 
 attack are called respectively, by Dr. Abercrombie, apoplectic cases; cases not p^'i
 
 308 DISEASES OF THE BRAIN. 
 
 marily apoplectic ; and paralytic cases : and so as you bear in mind what these 
 terms really imply, they appear unobjectionable. 
 
 I next pointed out the classes of persons in whom an attack of apoplexy is chiefly 
 to be apprehended : those, namely, in whose famihes that disease has been known 
 to be common: those who have large heads, thick necks, red faces, square shoul- 
 ders, and a short stature ; although persons of quite the opposite configuration are 
 by no means exempt from it : and lastly, and above all, those who have passed the 
 middle period of life, and are advancing towards old age : and more particularly is 
 apoplexy to be apprehended in people of this description when they have already 
 suffered what are called head symptoms ; which symptoms have reference to the 
 three great functions of the brain and nervous system : voluntary motion, sensation, 
 and thought. Such symptoms consist, therefore, in slight and often transient para- 
 lytic aflections, double vision, a dropping of one eyelid, occasional inarticulate speech, 
 weakness, perhaps, of a single finger: headache, giddiness, unnatural sounds in the 
 ears, numbness or tingling of the extremities, which last are all modifications of sen- 
 sibility : some impairment of the intellect, shown most commonly bj^ partial and 
 strange defects of memory, and temporary confusion of thought. When several or 
 any of these symptoms occur, and especially when they become habitual in persons 
 in the decline of life, we have reason to dread the supervention of apoplexy ; and to 
 exhort and protect our patients against its ascertained exciting causes. 
 
 When the apoplectic state is fully formed, in what manner soever the attack may 
 have commenced, it is marked by most or all of the following circumstances. The 
 patient lies totally unconscious of all that may be going on about him. He rephes 
 to no questions, he is unmoved by the cries and lamentations of his family ; in fact, 
 he does not hear them. His pulse is infrequent, often full, perhaps intermitting. 
 His breathing is peculiar, being slow, sometimes interrupted or irregular, attended 
 with snoring or stertor during inspiration, and a puffing out of the cheeks, like the 
 action of one who smokes a pipe, during e:rpiration. Both these peculiarities are 
 referable to the same principle, and both denote a profound sensibility to all external 
 impressions. There is no longer any voluntary attempt to breathe, yet the involun- 
 tary movements of respiration subsist: the medulla oblongata still responds to the 
 impressions which reach it from the lungs and from the skin, still prompts contraction 
 of the muscles that enlarge the capacity of the thorax ; but the loose curtain of the 
 palate, and the fips and cheeks, are passive. By the vibrations of the one the stertor 
 is occasioned ; the mouth is closed by the mere elasticity of the others, and the flaccid 
 cheeks flap outwards with the explosion of the air, as it escapes when the chest again 
 collapses. The countenance is frequently turgid, and livid ; the blood which tinges 
 It is already but half arterialized ; the pupils are commoni}' contracted. The limba 
 lie motionless : either they are all absolutely palsied ; or (what probably is often the 
 case) the capacity of motion remaining, the 7vill to move them is wanting. If you 
 raise one of them it falls passively down again, when you leave hold of it, hke a dead 
 limb. Sometimes, however, they are rigid and stiff". Sometimes one is stiff, and 
 the others limber. And sometimes one or more of them, or those of one side, tremble, 
 or are distinctly convulsed. You find perhaps that the patient is unable to swallow. 
 If you put fluids into his mouth, they appear to choke him, or they run out again at 
 the corners of his lips. His bowels are usually torpid ; but if they act, the evacua 
 tions are passed in the bed without his knowledge or concern. His urine also flows 
 involuntarily ; or is retained in the distended bladder until it fairly overflows, and 
 dribbles away perpetually. 
 
 When the attack terminates in death, that event is preceded, I believe in almost 
 every case, by profuse perspiration, which bursts forth from every part of the surface 
 and is often cold and clammy. The pupils are sometimes at this period dilated : and 
 I have more than once seen them of unequal size. The pulse becomes more fre 
 quent, the breathing more rare, and at last it ceases altogether. 
 
 In this description you will perceive that something more is included than pure 
 coma. The absence of consciousness — implying the suspension of thought, of sen- 
 sation, and of volition — marks plainly the afl^ection of the cerebrum. The symptoms 
 which diversify the apoplectic state, and distinguish one case of the disease from
 
 APOPLEXY. 309 
 
 another, proceed from an associated or consecutive affection of the spinal cord. 
 There may, indeed, be merely coma ; profound and invincible sopor only. In this 
 condition a morsel of food, or a spoonful of drink, passed far back into the pharynx, 
 is instantly carried onwards by an act of deglutition : the excrements are duly 
 retained, and duly voided : the limbs are simply passive and motionless ; neither 
 stiff, nor convulsed. But in the severe cases, inabihty to swallow, laxity of the 
 sphincters, spasms, rigidity, tremors of the voluntary muscles — more or fewer of 
 these adjuncts to the coma — are very apt to present themselves : and they denote, I 
 say, the direct or indirect extension of the morbid influence on which the apoplexy 
 depends, to the cranio-spinal axis. 
 
 An easy and interesting criterion of the degree in which the reflex apparatus may 
 be concerned has been pointed out by Dr. Hall. The orbicularis is the sphincter 
 muscle of the eyelid. Touch the eyelashes, and the lids involuntarily close ; even 
 during sleep the movements of the shut lids are apparent. If, in apoplexy, they do 
 not respond to this mechanical stimulus, we know that the true spinal functions are 
 gravely implicated. 
 
 On the other hand, many of the morbid phenomena just mentioned may occur, 
 without any affection, from first to last, of the intelligence. But to these forms of 
 disease, although the nature of their exciting cause may be the same, the term 
 apoplexy cannot properly be apphed. 
 
 This state, so appalling and painful to look upon, but fortunately so devoid of 
 suffering for the patient — this suspension of the functions of animal life — depends, 
 we have reason to believe, upon pressure applied to the brain, the oi^an subservient 
 to those functions. 
 
 That excess of pressure is a vera causa is obvious, and that it is adequate to the 
 production of coma is capable of demonstrative proof. It is not enough to show that 
 they often exist together, for the coincidence must be casual. Neither does their 
 occasional disjunction, real or apparent, furnish any conclusive argument against the 
 general proposition, that coma, in many and in most cases, is the result of pressure 
 upon the encephalon. 
 
 Coma may exist without pressure. In other words, coma acknowledges other 
 causes also, besides pressure. It is produced by many narcotic poisons ; by the cir- 
 culation of venous blood through the arteries. In these cases we have no proof of 
 any compression of the cerebral substance. 
 
 The other disjunctive condition is much more puzzling, and has led some persons 
 to question or deny the general proposition. Can there be unnatural pressure, yet 
 no coma? It would seem so. Serum,'pus, blood, have been met with in the brain, 
 foreign matters have penetrated the cranium, and coma has not occurred. 
 
 The force of this difficulty is lessened by the consideration that foreign substances 
 may be present within the skull, without occasioning any preternatural degree of 
 pressure. We read of bullets being carried about for some time in the brain. In 
 such instances it is probable that a portion of the contents of the skull was forced out 
 at the time of the injury ; or that coma has come on, and gone off again, in conse- 
 quence of the gradual absorption of the cerebral matter to make room for the foreign 
 body. The same explanation may be applied to the chronic accumulation of water 
 within the cranium, and to the slow growth of tumours. 
 
 Further, it is open to conjecture that it is not on every part of the brain that the 
 same degree of pressure made will produce the effect ascribed to it. It is stated in 
 Mr. Mayo's Physiology, as the result of actual experiments on animals, that lateral 
 pressure against the hemispheres of the brain produces no observable ill conse- 
 quence ; but that vertical pressure, pressure downwards, occasions stupor, " which 
 is attributable to the compression of the medulla oblongata." Now it is obvious that 
 some injuries of the brain may tend more than others to cause pressure in that 
 direction. 
 
 I confess that the difficulty is not wholly relieved by these considerations. But it 
 is a difficulty which cannot invalidate the evidence of numerous facts that attest the 
 agency of pressure, as, at least, one cause of coma. The presumption of such 
 agency arises whenever coma immediately succeeds to pressure ; and it .3 converted
 
 310 DISEASES OF THE BRAIN. 
 
 into certainty if, upon the removal of the pressure, the coma immediately departs 
 Now the annals of physic are full of instances of this kind. In experiments upon 
 animals, stupor has been brought on, and made to cease, at the pleasure of the ope- 
 rator, by applying pressure to the exposed brain, and by remitting that pressure. 
 Na)', the experiment has been tried on the human brain itself. A man wno had 
 undergone the operation of trepanning, and had recovered, was in the habit of exhibit- 
 ing himself for money in Paris, where Haller saw him. He suffered the spectators 
 to make pressure upon his brain, where it was covered b}'' the integuments only. 
 This always put him into a state of coma or deep sleep ; but sensibility and tiie 
 power of voluntary motion returned at once when the pressure was taken off. 
 
 A most remarkable example of the occurrence of coma from pressure upon the 
 brain, and of the removal of the coma by removing the pressure, was afforded by a 
 patient who was in St. Thomas's Hospital under the care of Mr. Cline. Mr. Green, 
 who Avas Mr. Chne's nephew, was in the habit of relating the case in his lectures 
 here. It is quite pertinent to my present purpose. One of Mr. Cline's apprentices 
 was visiting the depot at Deptford, and discovered there a man who had been for 
 some time in a state of unconsciousness : and he had him removed to St. Thomas's. 
 His main symptoms were apparent insensibility to all surrounding objects, and a 
 total incapacity to make any communication to those about him ; except that his 
 attendants learned to infer, from certain instinctive movements or gestures, that he 
 felt hunger, or thirst, or a want to reUeve his bowels. His fingers were permanently 
 bent towards the palm of the hand, and his eyes were turned upwards, so that the 
 corneas were completely concealed beneath the upper lids. 
 
 Upon examining this man's head, Mr. Cline found that there had been fracture 
 with depressure of one of the parietal bones. He trepanned that part, and elevated 
 the bone. The patient seemed to feel the operation ; and as soon as it was con- 
 cluded, his eyes and fingers were restored to their natural position. On the evening 
 of the same da\% he sat up in bed, and though at first stupid and incoherent, soon 
 became rational and well. 
 
 When he had entirely recovered his senses, it was ascertained that the last thing 
 he remembered was his serving on board a vessel which made a capture off Minorca. 
 He was wounded in the engagement, -and carried afterwards to the hospital at Gib- 
 raltar. All this happened upwards of twelve months before the operation. So that 
 one whole year of this patient's life was a complete blank, because during that 
 period, a httle piece of bone was pressing upon his brain. 
 
 Cases of this kind show very convincingly, the connection that subsists between 
 pressure on the brain and coma, and their relation to each other as cause and effect. 
 The pressure and the coma begin together ; the coma continues as long as the pres- 
 sure continues ; and it ceases when the pressure is removed. The old definition of 
 the cause of a morbid condition is completely satisfied : " Prtesens morbum facit, 
 mutata mutat, sublata toUit." 
 
 From this digression — not altogether foreign to our subject — I return to the consi- 
 deration of the pathology of apoplexy. 
 
 If the patient recovers from the coma, he may live a few hours, or days, or he 
 may live for many years. Sometimes, as the coma departs, all the natural functions 
 are gradually restored ; but much more commonly paralysis remains. You already 
 know that it is apt to affect one moiety of the body only. If a line be drawn from 
 the vertex to the perineum, dividing the body into two halves, which, as far as the 
 exterior is concerned, are symmetrical, all the voluntary muscles that lie on one side 
 will be found powerless ; or if they are not all so, those which are palsied are 
 situated on the same side of the line. And this state of things is called hcmipl(2;ia. 
 Paraplegia, that condition in which all the parts below a tranverse line are palsied, 
 though it sometimes results from cerebral disease, is much more commonly the con- 
 sequence of mischief in the spine. 
 
 Now, of this hemiplegia, when it is complete, there are several particulars worthy 
 of your notice ; and there are many things worthy of your notice when it is incom- 
 plete. But we will take one of these predicaments at a time. By complete hemi- 
 plegia, I mean palsy of all the voluntary muscles of one side. The patient may
 
 APOPLEXY. Sii 
 
 ivill the motion of his leg, or arm, but they no longer obey the act of volition ; if 
 they are lifted by anotlier, and then let go, they drop down like logs of wood. You 
 will find that, in well-marked cases, the intercostal muscles of the palsied side do 
 not contract. The muscles of the face, also, are some of them inert on the same 
 side. I have known many persons who have thought that the muscles of the face, 
 in hemiplegia, when they were affected at all, were affected on the opposite side of 
 the body from that to which the palsied limbs belonged. But they never could have 
 examined actual cases of hemiplegia with any attention. How the error arose I 
 cannot tell, but I have known a professed anatomist make it. I guess that it may 
 have arisen from one of two causes. An anatomist who had not looked closely upon 
 disease, would expect, and not unnaturally, that the face and limbs v/ould be affected 
 on opposite sides of the body, seeing that the nerves w'hich supply the muscles of 
 the face are given off above the place where those fasciculi of nervous matter which 
 are called the anterior pyramids, decussate each other. And a common observer, 
 who was not an anatomist, would be apt to conclude that the side towards which the 
 mouth was drawn was the affected side : whereas it is just the reverse. The face is 
 drawn to the healthy side, because the muscles on that side are no longer counter- 
 acted and balanced by the corresponding muscles of the palsied side. The blank 
 half of the face is that wliich answers to the paralyzed limbs. On that side the 
 patient cannot frown, or smile. He presents a singular spectacle, which I do not 
 dwell upon now, because I shall return to it again when I have to speak of certain 
 important varieties of local palsy. What I wish you to bear in mind at present is, 
 that when the muscles of the face are affected in hemiplegia, the ride is that they 
 are palsied on the same side with the limbs. But there is no rule, they say, without 
 an exception : certainl}'- the exceptions to this rule are very uncommon. I have not 
 had leisure to look over the records of the very many cases of this disease which my 
 position as physician to an hospital has brought under my observation ; but I do not 
 recollect more than two exceptions : and one of them, as it happens, is now exhibited ' 
 in the person of one of my patients in the Middlesex Hospital. Some of you have 
 seen the woman. It is a well-marked exception : but in this instance the hemiplegia 
 followed a blow on the head, and I suspect that a double injury was inflicted ; that 
 the palsy of the face results from mischief on one side of the brain, and the palsy of 
 the limbs from mischief on the other. This I only conjecture ; because the pheno- 
 menon is so rare.* 
 
 Then, again, with respect to the tongue: when put out beyond the lips, its point 
 is commonly turned to one side. To which side ? Why toivards the palsied side. 
 For what reason? Clearly because the muscles that protrude the tongue are power- 
 less on that side, and in full vigour on the other. That half of the tongue which 
 corresponds with the sound side is pushed further out than the other half, and there- 
 fore the tongue bends to the palsied side. Such is the usual fact, and such the ex- 
 planation of it. But there are more numerous exceptions to this than to the paralysis 
 of the external facial muscles. Sometimes the tongue comes out straight ; some- 
 times the patient cannot protrude it at all; and sometimes, even, it deviates towards 
 the sound side. But the rule is as I have stated it. 
 
 This also has been noticed of the tongue in such cases ; that the patient has been 
 able, after some effort, to thrust it suddenly out, and then has required a certain 
 interval of time before he could do so again ; as if the spent nervous power was 
 slowly regenerated. With these different affections of the tongue, the patient's 
 speech is variously altered. His voice is thick, muttering, inarticulate, or unintelli- 
 gible. Sometimes, even though he may be quite conscious and rational, he is unable 
 to utter a syllable ; and seems vexed at finding that his attempts to speak are fruitless. 
 
 Supposing the patient to recover, wholly or partially, from the paralysis, it is th'.' 
 leg, in nine cases out of ten, ay, and in a much larger proportion than that, whicii 
 recovers first and fastest: sooner and quicker than the arm, I mean. And another 
 fact, quite analogous to this, is, that when one of the extremities alone 's affected 
 
 * Tills patient died afterwards, at lier own home ; and no opportunity was given o: i.i 
 specting the body.
 
 312 DISEASES OF THE BRAIN. 
 
 \vith paralysis, it is, in nineteen cases out of twenty, the arm that is so affected. I 
 give you again the rules ; they are Hable to occasional exceptions. The reasons that 
 have been assigned in explanation of this curious circumstance I shall lay before you 
 by-and-by ; after I have had an opportunity of describing the morbid appearances 
 discovered v^-iihin the cranium in these cases. 
 
 This, then, is one way in which the hemiplegia may become, or be from the first, 
 incomplete : viz., in extent. One limb may be powerless and the other strono-. 
 But the palsy may also be incomplete in degree. The patient maybe able to move 
 and use his limbs, but they are feeble. He cannot bend hi? fist firmly ; nor lift his 
 arm beyond a certain height. Or his leg feels heavy to him, and trails a little behind 
 as he walks : he is unable to stand upon that limb ; or to plant his foot securely, or 
 with the usual precision. In short, there are innumerable gradations of paralysis, 
 from slight weakness of the affected muscles to perfect immobility. 
 
 Besides the palsy, there is often anxstliesia also. But this is by no means so con- 
 stant a symptom as the paralysis. The function of sensation (wherefore I cannot 
 tell) is less frequently abolished or perverted than the function of voluntary motion. 
 When the sensibility is lost, or blunted, or any how modified, it is so, commonly, in 
 the same parts that are affected with paralysis. But sometimes there is anaesthesia, 
 and no palsy ; and, more strange still, there has been sometimes anaesthesia of one 
 side, and palsy of the other. As a general rule, the aneesthesia is less common, and 
 less intense than the palsy ; and is much sooner recovered from. 
 
 The mental faculties are, in some few instances, quite unhurt by the attack : too 
 frequently, however, they suffer irreparable damage. Of many persons, a striking 
 alteration is evident in the whole character and temper. The brave man has become 
 timid ; the prudent man foolish ; the calm and cheerful man peevish and impatient. 
 There is no longer the same power of attention, the same capacity for business, the 
 same clearness and comprehension of thought. And whatever other changes may 
 be observable, there are two ways, especially, in which the patient, after he has 
 emerged from the coma, is very apt to be affected : viz., by a defection of memorj^ 
 more or less partial ; and by a peculiar tendency to emotion, particularly the emo- 
 tion of grief : he will weep for very slight causes, sometimes long after the attack of 
 apoplexy has passed over. This is very curious. I should have stated before that 
 the same readiness to shed tears, and to be immoderately affected by trifling causes 
 of emotion, is sometimes noticed among the precursory symptoms of apoplexy. 
 
 Tracing these cases onwards still further — such cases, I mean, as do not perfectly 
 recover — we find that the palsied limb wastes. Inaction of the muscles, according 
 to the principle which I explained to you in a very early part of these lectures, leads 
 to lessened nutrition, and a consequent diminution of bulk : in one word, to atrophy. 
 Sometimes, indeed, the size of the helpless limb is maintainetl, or even augmented, 
 by ihe supervention of oedema. The motion of the blood in its veins not being aided 
 by the play of its muscles, the areolar tissue becomes infiltered with serous liquid. 
 
 Again, these palsied limbs are usually colder than their fellows. This probably 
 is owing to the diminished circulation of blood through the capillaries : there is not 
 so much blood converted into venous from arterial ; and less animal heat is deve- 
 loped. This has been observed even when the main artery of the part has beat as 
 forcibly as in the corresponding part on the other side. 
 
 It is necessary to be aware that these palsied parts do not resist the influence of 
 cold or of heat so well as the sound parts. When the sensibility is blunted, we can 
 readily understand how the limb may become burned, from the absence of any warn- 
 ing pain that an injurious degree of heat is applied : but this is not all, A lower 
 degree of temperature thay would injure a sound part has often been found prejudi- 
 cial to a palsied part : and if these palsied parts get chilled by frost, they more 
 readily vesicate and inflame, on the return of heat, than other parts : merely warm 
 vvater will sometimes act upon them like scahlvig water. I say a knowledge of 
 I his fact is of practical moment. That degree of warmth which the palsied limb 
 fails to generate for itself, we must accumulate for it by warm clothing: and we 
 Miust tike care that it is never exposed to any artificial temperature which exceeds a
 
 APOPLEXY. 313 
 
 certain point. We sometimes see mischief done by applying hot bottles or bricks — ■ 
 too hot — to such limbs. 
 
 In speaking of the palsy, I have dwelt especially on the loss of action and power 
 observed in the voluntary muscles ; but the strictly involuntary muscles do not alto- 
 gether or always escape. The pulse, as I have stated, will often become slow or 
 irregular in the apoplectic attack : and the bowels are usually very obstinately cos- 
 tive ; their peristaltic motion, which results from the contraction of involuntary mus- 
 cles, is suspended or diminished. Now the old writers on apoplexy puzzled them- 
 selves with devising explanations of the fact that the involuntary muscles are so little 
 affected in this disease. But the true reason is not far to seek. The involuntary 
 muscles — so called because they never acknowledge the mandates of the will — ■ 
 appertain to the functions of organic Hfe. Their movements (as I have heretofore 
 had occasion to show you) are not necessarily dependent upon any influence derived 
 from the nervous centres; and might continue, provided a due supply of arterial' 
 blood were kept up, though there was no brain at all. Foetuses having no brain, 
 ray, some unfurnished with either brain or spinal marrow, have nevertheless grown, 
 in other respects, to their full size. It is well known that the action of the heart 
 may go on for some time, even after its removal from the body. 
 
 In truth it seems, at first sight, more difficult to explain why the organs of invo- 
 luntary motion are sometimes affected, in apoplectic and paralytic diseases, than 
 why, in general, they are not. But some elucidation of this matter I have also 
 attempted to give in a former part of the course. The organs of involuntary motion, 
 though not dependent upon the brain and nervous system, are yet liable to be influ- 
 enced through their medium ; as we know by the effect produced upon those organs 
 by certain emotions of mind. Dr. Wilson Philip has shown clearly, by his experi- 
 ments, that the way to afiect the action of the heart, and of the other involuntary 
 muscles, through the brain and nervous system, is to act upon a large portion of 
 that system at once. Hence any disease which inflicts extensive damage upon the 
 encephalon Avill be likely to disturb and weaken the functions of the heart and ali- 
 mentary canal. 
 
 Conversely, when we find, in a case of apoplexy, the involuntary muscles sensi- 
 bly affected, we may infer, I believe, that the injury done to the nervous matter is 
 great and serious. 
 
 Let us next, with the view of further elucidating the pathology of this disease, 
 direct our attention to the appearances which are met with after death, in the most 
 common forms of the complaint. 
 
 I shall pass over those cases in which no morbid condition is detected, simply 
 reminding you that the altered relation of the venous to the arterial circulation in the 
 brain may perhaps account for the symptoms, and for the extinction of life : or the 
 altered velocity of the blood circulating in the brain may account for them : or, what 
 is more probable still, a determination of blood towards the head, or a detention of 
 blood in the head, sufficient, by tightening the full vessels, to occasion extraordinary 
 pressure upon the nervous pulp, may account for them : or the presence of some 
 poisonous substance in the circulating blood (such as urea) may account for them. 
 
 I pass over, likewise, those cases in which serum only is found effused beneath 
 the arachnoid, or into the ventricles. A moderate quantity of serous fluid poured 
 out rapidly during life would certainly occasion a degree of pressure adequate to the 
 production of fatal coma. How the serum comes to be so effused, it is not always 
 easy to say. Yet there is one condition of the blood-vessels of the brain which, 
 when it can be proved to exist in a given case, is sufficient to account for the effu- 
 sion. Any real or virtual retardation of the blood in the cerebral veins would lead 
 to what is tantamount to dropsy, there, as well as in any other part of the body ; 
 and intelligible causes of such retardation are known sometimes to be .n operation. 
 
 But I wish to consider more particularly the appearances that are met with in 
 the brain after death by cerebral hemorrhage^ which, after all, is the most conunon 
 source of apoplectic and paralytic disorders. 
 
 Tn the first place (as I have more than once stated before) the popular notion that 
 hemorrhage is owing to the giving way of a considerable blood-vessel — although this 
 
 2 b
 
 314 DISEASES OF THE BRAIN. 
 
 n 
 
 notion seldom has reference to the brain, because the blood cannot reach the ex- 
 ternal surface of the body, and therefore does not strike the popular sense— 
 I say this notion is more true of cerebral than of any other hemorrhage. Much 
 more true, especially as regards the brain than as regards the lungs, to which 
 latter organ the bursting of a blood-vessel is, in vulgar parlance, most commonly 
 ascribed. 
 
 This comparative frequency of hemorrhage from the actual rupture of vessels 
 may, in some measure, be accounted for by their peculiarities of texture and re- 
 lation. The blood-vessels distributed ■within the cranium are long and slender. 
 Excepting the sinuses, the coats of both arteries and veins are thinner and weaker 
 than in other parts of the body : the middle tunic of the arteries has not more 
 than one-half its ordinar}^ thickness ; and the outer or cellular coat is of such ex- 
 treme tenuity that doubts have been entertained concerning its existence. These 
 vessels, moreover, are not protected, as elsewhere, by investing sheaths of cellular 
 membrane, and rsceive but slight support from the soft and delicate substance by 
 which they are immediately surrounded. They are hkewise very subject to a par- 
 ticular form of disease, by which their natural fragihty is much increased : and lying 
 near to the heart, and in the primary direction of the blood as it is driven from the 
 left ventricle, they have been thought especially liable to sustain the additional mo- 
 mentum arising from the more forcible contractions of that chamber; whether these 
 are determined by occasional transient causes, or depend upon permanent organic 
 disease of the heart itself. On this point, however, I shall have something more to 
 say hereafter. 
 
 Still there is no reason, I think, for doubting, that hemorrhage by exhalalion 
 may take place, though rarely, from the free surface of the brain, or rather of its 
 investing membranes. But the rule is, that it proceeds from the mechanical rupture 
 of a blood-vessel. 
 
 In cerebral hemorrhage, the blood may be effused in one or other of three differ- 
 ent situations ; viz., upon the external surface of the brain, i. e., upon or between the 
 membranes ; or into one or more of its ventricles ; or into the very substance of the 
 brain itself. In the two former situations it is sometimes, perhaps, poured out by 
 exhalalion : in the latter, which is infinitely the most common, it always proceeds 
 from the rupture of one or more blood-vessels. 
 
 It is necessary to remember that even when blood is found spread over the surface, 
 or distending the ventricles of the brain, it frequently has not been originally poured 
 out in those situations. If the hemorrhage into the substance of the brain be con- 
 siderable in amount, the blood generally forces a passage, by laceration of the cerebral 
 tissue, either into the ventricles, or (less frequently) to the surface ; or even in both 
 these directions at once. 
 
 In some rare cases blood is found effused beneath or into the pia mater, over a 
 small space onlj% as between one or two of the convolutions, and nowhere else. 
 Sometimes it is spread in a thin layer over the whole of one hemisphere, and is found 
 nowhere else. Sometimes blood is discovered in one or more of the ventricles, and 
 nowhere else ; but all these are comparatively unfrequent events. 
 
 When the blood is effused into the substance of the brain, and does not break a 
 passage out, either in the one direction or the other, its pressure is not necessarily 
 or immediately mortal. The patient, as I have already explained, may survive for 
 weeks, or months, or years ; and the clot of blood will, in the mean time, undergo 
 very remarkable changes. 
 
 The cell, or cavity, in which the extravasated blood is contained, varies much as 
 to its fiize. It is sometimes scarcely of sufficient ca])acity to receive a large pea: 
 sometimes it occupies nearly the whole of one hemisphere. It is seldom, however, 
 1 repeat, that a communication is not formed between the original cavity and the 
 surface in the one direction, or the ventricles in the other, when much blood has 
 been shed. Frequently a direct opening is made bj^ the blood from one lateral 
 ventricle to the other through the septum lucidum ; sometimes it passes from the one 
 to the other through' the foramen of Monro ; and even the chamber of the septum 
 lucidum itself has been found distended by a certain quantity of blood. 
 
 I
 
 APOPLEXY. 315 
 
 If the clot of blood in an isolated cavity be examined soon after its effusion, it is 
 found to be of a soft f^elatinous consistence, and of a dark colour, much like blat-k 
 currant jell}'. The sides of the cavity are irregular and ragged ; and the cerebral 
 substance of which they are formed is generally, to the depth of a line or two, 
 moist, soft, and as if stained of a reddish or yellowish colour, which is fainter in 
 proportion as it is more distant from the coagulum, and gradually loses itself in the 
 natural tint of the surrounding parts. This latter condition would seem to depend 
 upon a slow imbibition of the serous portion of the effused blood, mixed with some 
 of its colouring matter. It begins to manifest itself about the third day from the 
 attack, and is most apparent from the eighth to the twelfth day ; at which period, 
 under ordinary circumstances, the whole of the serum has been removed, and the 
 process of absorption seems to be in active operation. By degrees this stain dis- 
 appears ; the coagulum becomes more and more compact ; assumes first a brownish, 
 and subsequently a pale red or even yellowish hue ; diminishes continually in mag- 
 nitude; and at length may be entirely reabsorbed. 
 
 In the mean time the walls of the cavity are becoming less uneven, and clothe 
 themselves, by degrees, as they contract upon the shrinking coagulum, with a dis- 
 tinct membrane of a yellowish colour, sometimes of extreme delicacy, and resem- 
 bling the serous membranes ; sometimes thick and apparently fibrous. When the 
 opposite sides of the cell at length meet, they adhere together, and a true cicatrix 
 ensues, the place of which is marked by a sort of fibrous knot, forming a remark- 
 able contrast with the softer texture around it ; or less frequently by a similar indu- 
 ration of a linear form. In this case, the sides of the collapsed cavity are sometimes 
 found to be merely applied to each other, without actual adhesion. When, from the 
 great extent of the original cavity, or from some other cause, its parietes are not 
 ultimately brought into mutual contact, there remains a kind o^ cyst, lined by a smooth 
 yellowish membrane ; sometimes traversed by a few slender threads of areolar 
 tissue which cross each other in various directions ; sometimes filled with a soft, fine, 
 orange-coloured spongy tissue, in which a number of minute blood-vessels ramify; 
 sometimes containing a gelatinous or serous liquid ; and sometimes apparenllj' empty, 
 having been occupied by some kind of aeriform fluid. 
 
 It is impossible to assign the precise period within which these remarkable 
 changes may be accomplished. Dr. Abercrombie has detailed an instance in which 
 a coagulum, that m.ust have been of very considerable size, had entirely disappeared 
 in less than five months. In another of his cases it was seen to be partially absorbed 
 at the end of three months. " On the other hand, Moulin found a small coagulum 
 not quite gone at the end of a year : and Riobe observed some of the blood still 
 remaining in a cavity of small extent after twenty months. In two cases Serres 
 found a hard coagulum of blood remaining; in one at the end of two, and in the 
 other at the end of three years." 
 
 It has been said that the cicatrization of the cavity takes place much more slowly 
 and imperfectly when the effused blood has passed across and torn the fibres of the 
 brain, than when it has been poured out in a direction parallel to those fibres, so as 
 to separate without breaking them. 
 
 Dr. Abercrombie states that he had never seen any thing to satisfy him that the 
 cysts are capable of being obliterated by cicatrization. iXeilher have I. But Dr. 
 Sims, Dr. Bright, and several of the French pathologists of approved credit and ac- 
 curacy, agree in their description of this obliteration of the cells. And you should 
 bear in mind that a small cicatrix in the brain may very easily escape notice, if not 
 expressly sought for; especially as the examination of that organ is often conducted, 
 viz., by cutting away thick slices from the hemispheres in rapid succession, in order 
 to arrive as soon as possible at the lateral ventricles and the base of the brain. 
 
 It frequently happens that a patient has suffered, during life, several distinct attacks 
 of apoplexy or of cerebral hemorrhage ; and that as many cells are met with after 
 death, exhibiting respectively various stages of that process of repair which has jus'l 
 been described. 
 
 These are the changes that mostly take place in the coagulum, ana its containinjij 
 cell, when the hemorrhage does not prove fatal, and the patient, recovers more or
 
 316 DISEASES OF THE BRAIN. 
 
 less completely. But the same changes do not always, or necessarily, occur. Instead 
 of being- gradually removed by absorption, the extravasated blood appears occasionally 
 to become a solid, organized, and consequently living mass, deriving its nourishment 
 from the arteries of the brain. A man, whose case is related by Andral, was smitten 
 with apoplexy, and remained thenceforward, for many years, hemiplegic. At lengtli 
 he died, of some other complaint, in the wards of La Charlie. When his brain was 
 examined, there was found, in one of the hemispheres, a mass of a pale red colour 
 and fibrous appearance, traversed by numerous small blood-vessels which anasto- 
 mosed with those of the brain : the surrounding nervous matter retained its natural 
 aspect ; and there was no appearance of any cyst. 
 
 I have yet to mention another, and a fatal consequence of hemorrhage into the 
 substance of the brain. It is not, I think, a very frequent consequence ; yet it de- 
 serves attention the more, because the risk of its occurrence may perhaps be lessened 
 by judicious treatment in the outset. The clot sometimes provokes suppurative 
 inflammation of the cerebral matter around it: or it may be that the nervous pulp, 
 being bruised or torn bj^ the first violent irruption of the blood, suppurates spontane- 
 ously afterwards. It is affirmed (by what French author I forget) that the patient 
 cannot be considered secure against this consecutive mischief, until eight days of 
 safety have elapsed from the period of the apoplectic seizure. 
 
 Instances of this result of cerebral hemorrhage, according to my experience, are 
 not, I say, very common. I have before me some memoranda of the last case of it 
 that I saw. 
 
 I received on the 3d of September, a note, written in a remarkably clear and neat 
 hand, desiring that I would call upon the writer, as he had had a severe attack of 
 apoplexy a day or two before. 
 
 I concluded that the note had been penned by some member of the patient's 
 family, and I expected to see him in his bed, paralytic probably, or manifestly ill. 
 But I found a stout active gentleman, walking about in his drawing-room, apparently 
 in perfect health, and declaring that he felt so. He showed me, however, a paper 
 written by a surgeon, who on the previous day had brought him to town from a dis- 
 tance, and who had been obliged to return immediately. The paper stated that 
 
 Mr. had suffered a sudden and decided fit of apoplexy on the 30th of August; 
 
 that he was then freely bled ; that perfect consciousness was not restored, nor the 
 force of the pulse subdued, till twenty ounces of blood had issued from his arm; 
 and that on the evening of the same day sixteen ounces more were drawn. 
 
 Mj'^ patient spoke of going down to his country-house, where he had, he said, " a 
 good deal of shooting to do." I dissuaded him from this, and enjoined perfect quiet 
 for at least a fortnight to come. 
 
 The next day, after a long and imprudent conversation with a friend, he suddenly 
 lost the thread of his discourse, and could not recover it. Then he became confused, 
 and misapplied words. I asked him how he felt. He answered, "not quite right," 
 and this he repeated very many times, abbreviating it first into " not right," and at 
 length into " n'ight." Wishing to mention " camphor," he called it " pamphlet." 
 I mention these as specimens. On the 5th it was evident that his right arm and leg 
 were weak in comparison with the others ; but their sensibility was unimpaired. By 
 slow degrees the weakness degenerated into complete palsy, and the right side of 
 the face became motionless. Gradually also he grew heavy, stupid, comatose, 
 unable to swallow, with a fixed pupil ; and so, on the morning of the 15th of Sep- 
 tember, he died. 
 
 We examined his head the next day. On the left side, the dura mater adhered 
 to the skull-cap with morbid firmness. During the endeavour made to detach it, a 
 tablespoonful, or more, of a dirtj'-looking, greenish, very offensive pus spurted forth. 
 This was found to have proceeded from an abscess, which must have contained 
 iwo ounces of pus, and which was situated in the upper part cf the left hemisphere 
 of the cerebrum. The walls of the abscess looked as if they \vere coated with a 
 'layer of yellowish plaster. In the centre of this cavity was a small, fibrous, tough 
 mass o'" a dull red colour ; the coagulura, doubtless, of blood effused on the 30th of
 
 APOPLEXY. 317 
 
 August. In front of the abscess the brain seemed natural, but its consistence waa 
 that of hquid custard. 
 
 It has long been Icnown that hemorrhage does not occur in all parts of the sub- 
 stance of the brain inditferently. Morgagni had remarked the frequency of sanguine 
 ous effusions in or near the corpora striata and optic thalami ; and more extensive 
 subsequent research has amply verified the general correctness of his observation. 
 Rochoux, in the treatise on apoplexy which I mentioned before, published in 1814, 
 has given a tabular account of the morbid appearances observed by himself in the 
 heads of 41 persons, dead after attacks of cerebral hemorrhage. 
 
 In so many as 24 of these, i. e., in three-fifths of the whole number, the blood 
 was extra vasated in the corpus striatum ; in two others in the optic thalamus ; in 
 one it was effused into the substance of both the corpus striatum and the optic thala- 
 mus of the same side ; and in another, beneath the corpus striatum : so that alto- 
 gether there were 28 cases out of 41, or seven-tenths of the whole number, in which 
 the clot was confined to the corpora striata, optic thalami, and their immediate neigh- 
 bourhood. In the remaining three-tenths the blood was found collected in several 
 other parts of the cerebral mass ; five times in the middle of one of the hemispheres ; 
 twice towards the posterior part of the ventricles ; twice in the inner and anterior, 
 and three times in the inner and posterior portion of the hemispheres ; and once in the 
 middle lobe. 
 
 In Andral's Pathological .Anatomy you will find a much more extensive table 
 relating to the same subject, and constructed by him from various authentic sources 
 It leads to the same general conclusions. Thus, among 392 cases of hemorrhage 
 into the nervous substance, there were 202 (or more than one-half) in which the 
 blood was extravasated at once into the corpora striata, the optic thalami, and that 
 part of the hemispheres of the brain which is on a level with those bodies. In 61 
 cases (or about one-seventh of the whole number) it was confined to the corpus stri 
 atum. In 35 (or one-eleventh of the whole) it was limited to the optic thalamus; 
 making, in all, 298 instances (or more than three-fourths of the whole number) in 
 which the sanguine effusion occupied the corpora striata, optic thalami, and their 
 immediate vicinity. 
 
 The result of my own observation coincides entirely with this, although I cannot, 
 at present, reduce it to a numerical statement. 
 
 From the same table we may infer also the comparative infrequency of hemor- 
 rhage into the cerebellum. It is mentioned as having occurred in 21 of the 92 cases ; 
 or in about 1 in 19. 
 
 Dr. Craigie states that the parts which are the seat of the hemorrhage may be 
 arranged, in the order of frequency, as follows : — the corpus striatum ; the optic 
 thalamus ; the hemispheres ; the pons varoUi ; the crura of the brain ; the medulla 
 oblongata ; and the cerebellum. 
 
 It is natural to seek for some physical explanation of the causes which determines 
 the extravasation of blood in certain parts of the brain more frequently than in 
 others. Some light may, perhaps, be thrown upon this inquiry, by a consideration 
 ot the sources of hemorrhage, in various forms of its occurrence. 
 
 I stated before that the blood may sometimes be poured out by exhalation, in 
 those less frequent forms of cerebral hemorrhage to which M. Serres has applied the 
 term meningeal apoplexy, and in which the blood is found distending the ventricles, 
 or spread, like a cap, over the surface of the hemispheres, without any laceration of 
 the cerebral matter. This supposition rests, however, rather upon the analogy drawn 
 from what is known to occur in other parts of the body, than upon any decisive and 
 unequivocal evidence. Blood has not unfrequently been discovered in each of these 
 situations, when the most careful scrutiny has failed to trace its source to any ruptured 
 vessel. Yet we cannot doubt that such rupture may have existed — either in some 
 one or more of the numerous vessels of the pia mater, in the one case, or of the 
 plexus choroides in the other — and yet have escaped detection by the most vigilant 
 eye. In Dr. Abercrombie's book there are two interesting examples of extravasa- 
 
 2b2
 
 318 DISEASES OF THE BRAIN. 
 
 tion upon the surface of the brain, without any obvious source of the hemorrhage ; 
 the one detailed by Dr. Hunter, of Edinburgh, the other by Dr. Barlow, of Bath. 
 
 That the hemorrhage proceeds from rupture of some of the vessels composing the 
 choroid plexus, rather than from the membrane that lines the inner surface of the 
 ventricles, when the effused blood is confined to those cavities, is the more probable, 
 because the vessels have been actually found broken (as in cases of ventricular he- 
 morrhage, described by De Haen and Cruveilhier), and because they are liable to 
 well-marked disease of a nature to render them more than usually fragile. The 
 arteries, for example, which belong to that plexus, are subject to a peculiar kind of 
 alteration that I shall presently mention as frequently pervading the whole arterial 
 system of the brain ; and its veins are often partially enlarged and varicose. This 
 latter condition has sometimes been mistaken for a collection of small hydatids. 
 
 But hemorrhage into the substance of the brain depends always upon rupture of 
 some one or more of its blood-vessels ; and it is to this fact of the rupture of vessels 
 ihat we must chiefly look for an explanation of the peculiar liability to hemorrhage 
 of certain portions of the brain ; the corpora striata, namely, the optic thalami, and 
 the parts immediately adjacent to these. The corpora striata are not only of much 
 softer consistence than most other parts of the brain, but they are also traversed by 
 more numerous as well as by larger blood-vessels than are other parts. These facts, 
 and the conclusions to which they point, did not escape the sagacity of Morgagni. 
 "On some occasions (says he) when I have cut the corpora striata into pieces hori- 
 zontally, I remember to have observed in the external anterior part of each, a little 
 pit, as it were, across which lay a very conspicuous blood-vessel. And on other 
 occasions, upon cutting obliquely and slowly, 1 have remarked, in the same situation, 
 man)'- red lines, Hke threads, which were in fact blood-vessels running parallel to one 
 another, and of a larger size than elsewhere." In truth, you may often notice the 
 open mouths of a cluster of such vessels that have been divided. Morgagni saw in 
 this anatomical fact a probable solution of the pathological fact that the parts in ques- 
 tion are the most common seals of extravasation. In corroboration of these views it 
 is worth remarking that the corpora striata are especially subject to laceration and 
 sanguine effusion, while the surrounding parts remain unhurt, in violent concussions 
 of the brain. And when injections are forced into the cerebral blood-vessels in the 
 dead body, it is in the very same parts, the corpora striata above all others, that a 
 sort of factitious hemorrhage is produced by the rupture of vessels, and the escape 
 of their contents. 
 
 I have mentioned some original peculiarities of texture and relation, which majr be 
 thought to predispose the blood-vessels of the brain, more than others, to laceration. 
 But the main predisposing cause of that event is, doubtless, their great liability to 
 disease. Except the commencing portion of the aorta itself, there are no arteries in 
 the body so frequently found in a morbid state as the cerebral arteries. And the 
 change to which they are most subject is that deposition between their tunics, some- 
 times of a substance resembling albumen or soft cartilage, sometimes of actual phos- 
 phate of lime, to which we commonly apply the term ossificafion. This earthy or 
 cartilaginous deposit exists usually in whitish patches of a roundish or oblong form, 
 disposed at various distances from each other: sometimes in a succession of bony 
 rings, with healthier portions of the artery between them. One effect of this morbid 
 condition is to diminish the bore of the affected artery, and to make it of unequal 
 capacity. And as this variation of calibre impedes the free passage of the blood, it 
 tends indirectly to increase the pressure of that fluid against the sides of the vessel. 
 Another eflect is to deprive the coats of the artery of their natural elasticity, and to 
 diminish their power of cohesion ; and thus to render them v/eak and frangible, and 
 at length unable to sustain the increased impulse of the blood. This condition occurs 
 in the smaller ramifications as well as in the larger trunks of the cerebral arteries. 
 
 'rhere is yet another occasional cause of hemorrhage. The arteries at the base 
 ol the brain are subject to aneurism, and to consequent rupture. Morgagni has 
 reported cases of aneurism afl^ecting the internal carotid and basilar arteries. Serres 
 has described a case of apoplexy resulting from perforation of the basilar artery, 
 which was dilated, not far from its superior bifurcation, into an aneurismal pouch as
 
 APOPLEXY. 319 
 
 big as a hen's egg. Dr. Baillie records an instance where both the internal carotids, 
 on the side of the sella turcica, were distended into little aneurisms, one of the aneu- 
 risms being about the size of a cherry, the other somewhat smaller: and similar 
 examples are related by other writers. I have seen two such myself; a beautiful 
 preparation of one of them is preserved in the museum of the College of Physicians. 
 
 LECTURE XXX. 
 
 Apoplexy continued. Relations between the Symptoms and the Appearances found 
 in the brain after death. Exciting Causes. Prognosis. Treatment. 
 
 I LEFT off in the last lecture, after having described the appearances discoverable 
 within the head, at different periods subsequent to an attack of cerebral hemorrhage ; 
 and pointed out the various sources of the hemorrhage ; and endeavoured to explain 
 how it happens that the blood so much more commonly proceeds from a ruptured 
 vessel in or near the corpus striatum and optic thalamus, than in any other part 
 of the brain. 
 
 Some account of the connection traceable, in these cases, between the physical 
 injury done to the brain and the symptoms, has already been given by anticipation. 
 I proceed to touch upon certain points, relative to that connection, which have not 
 yet been noticed. 
 
 One of the most remarkable circumstances Avhich dissection teaches us, when 
 there has been partial palsy, is, that the palsy is on the one side of the body and 
 the hemorrhage of the brain on the other. This is a very general law. But excep- 
 tions to it are said to have been observed. Morgagni mentions such Dr. Brigh*' 
 has recorded a somewhat doubtful case of exception. I have never met with any : 
 and I cannot help suspecting that in some of those which are said to have occurred, 
 mistakes have been made : that either they have been incorrectly observed, or inac- 
 curately described. You may consider the rule as almost, if not altogether, universal. 
 
 This crossing over of the morbid effect of the extravasated blood, or of any other 
 diseased state, has long been attributed to that crossing over of nervous fibres which 
 takes place at the upper part of the spinal cord. Just where the medulla oblongata 
 and the medulla spinalis unite, the anterior pyramids decussate each other, and send 
 their fibres mutually to the opposite side of the body. All this of course you kuow. 
 The right anterior pyramid is continued into the centre of the left half of the spinal 
 cord ; and the left anterior pyramid into the centre of the right half of the cord. 
 Now supposing, as we have every reason to suppose, that the nervous influence, 
 whatever may be its nature, travels in the course of the fibres of the brain, we see 
 in this decussation of the anterior pyramids an easy and pleasing solution of the 
 phenomena in question. But then comes this serious clifHcully. How does it happen 
 that the muscles of the face and tongue — which are supplied by nerves that arife 
 from the nervous centres above the place of decussation — how does it come to pass 
 that these muscles sustain the same cross injury, and arc paralyzed on the same side 
 on which the limbs are paralyzed ? And again, how does it happen (as it certainly 
 does) that hemorrhage into the cerebellum should have a similar cross influence ? 
 
 These seeming anomalies have never been satisfactorily explained. Indeed I do 
 not know that any one has undertaken to explain them except Mr. Mayo : whose 
 peculiar speculations concerning hemiplegia — first promulged, as they were, in this 
 place ; coming, as they do, from so eminent a physiologist ; and being, as I deem 
 them, in many respects, erroneous ; — demand here a brief consideration. 
 
 He takes some pains, in the first place, to show that the morbid influence is con\- 
 municated from one side of the brain to the limbs of the other side of the body, by 
 means of the fibres of decussation already described. This point did not, I thinli. 
 require any laboured demonstration; but he has made a happy use of two facut 
 previously ascertained, which, taken together, afford a very neat proof that the t-aat
 
 320 DISEASES OF THE BRAIN. 
 
 ference of the morbid influence, or privation of influence, from one side to the other 
 actually takes place in that very part of the nervous system where the decussatino 
 fibres meet, 'Vhefads are stated by Dr. Yelloly, in the Medico-Chirurgical Wan 
 soctions. Sir Astley Cooper divided the right half of the spinal cord of a do?, in 
 the space between the occiput and the atlas; immediately, that is, after the cord ha? 
 emerged from the skull through the foramen magnum : the result of this division ol 
 the cord was hemiplegia, paralysis of the limbs, on the same side -with the injury 
 The bridge by which the morbid effect crosses over must therefore be above thai 
 point. We have got a limit on one side. And a case observed by Dr. Yelloly gives u? 
 a limit on the other. He examined the head of a man who had died hemiplegic ; 
 and he found a tumour, as big as a filbert, imbedded in and pressing upon the ric^hi 
 side of the anmdar protuberance. The palsy had existed on the left side. The 
 bridge of communication must consequently lie below that point. It must lie, there- 
 fore, between the two points now indicated ; i. e., it must be either in the medulla 
 oblongata, or just at the junction of the medulla oblongata with the medulla spinalis. 
 Now in this very interval, and here alone, a decussation of the nervous filaments is 
 tound to exist. There can be no doubt that the decussating fibres form the channel 
 of communication. 
 
 Supposing (what perhaps is questionable) that the prevalent notion respecting the 
 uses of the anterior and posterior columns is correct, Mr. Mayo next explains, more 
 clearly than I have found it explained by any previous writer, that the decussation 
 of the anterior pyramids accounts both "for the palsy and for the anaesthesia, which 
 are apt to accompany cerebral hemorrhage into the opposite side of the brain ; inas- 
 much as the decussating fasciculi, on plunging into the opposite column of the spinal 
 marrow, strike into its centre ; and implicate themselves nearly as much with the 
 posterior, as with the anterior, i. e., nearly as much with what is thought the sen- 
 tient, as with what is thought the motor portion of the cord. The wonder seems to 
 be why the numbness is not more constant ; why it is infrequent in comparison with 
 the afl^ection of the voluntary muscles. 
 
 Mr. Mayo holds that palsy does not result from "the interruption of the ordinary 
 supply of nervous stimulation furnished by the brain " — for this reason, that in living 
 animals the brain has been gradually removed, sliced away, yet sensation, and the 
 power of voluntary motion, have subsisted ; and that instances of acephalous human 
 infants, which have survived their birth, show the medulla oblongata and spinal cord 
 to be sufficient, tuithont the brain, for the production of sensation and voluntary 
 motion. He conjectures, therefore, that the immediate cause of the hemiplegia is 
 " a depressing injhience, or shock,'"' (a withering inflitence he elsewhere calls it,) 
 "originating in the brain when in certain states of lesion, and propagated from it to 
 the medulla oblongata and the spinal marrow." 
 
 Now it can scarcely be doubted, at least I cannot doubt, that the inference here 
 drawn from the movements observed in acephalous monsters, and in animals after 
 amputation of their brain, is a wrong inference. They are purely automatic move- 
 ments, independent of sensation and of the will, and derived from the reflex endow- 
 ment of the cord : and if this be so, the main foundation of Mr. Mayo's argument 
 is cut away. His prime error, which has led him still further astray, is that of attri- 
 buting sensation and volition to the spinal cord. For my own part, I can form no 
 distinct conception of any positive and persistent depressing influence, except 
 pressure. But mere pressure Mr. Mayo repudiates; asserting that in many cases 
 of hemiplegia from cerebral disease there is no pressure. And this maybe granted: 
 although even in cases of softening, such as he refers to, the mere absence of sup- 
 port in some parts of the brain might lead to the subsidence or settling down of other 
 parts, so as to cause pressure upon the medulla oblongata. I took some pains, in 
 the course of the last lecture, to show you that pressure is adequate to the produc- 
 tion of coma and general paralysis ; and pressure on a nerve in its course we are 
 sure is capable of occasioning local paralysis : so that the theory would not seem 
 ven,' wild, which should ascribe the hemiplegia resulting from cerebral hemorrhage, 
 •»r cerebral disease, to the benumbing influence of pressure. 
 
 Now. if Mr. Mayo's notion, that some " shock " or " withenng influence " is trans-
 
 APOPLEXY. 321 
 
 mitted from the injured brain, could be proved to be true ; or, on the other hand, if 
 it could be established that this influence is no other than the benumbing influence 
 of pressure; either supposition would plausibly account for these facts, viz., that 
 " in general hemiplegia from cerebral lesion, the palsy of the leg is (commonly) less 
 complete, and is sooner recovered from, than palsy of the arm," and that when one 
 of these limbs only is aflected, it is (commonly) the arm alone. The shock, or the 
 pressure, would be most felt in proportion as the part was nearer the origin of the 
 pressure ; and less felt in propurtion as we receded from the source of the injurious 
 influence. 
 
 But, unfortunately, I was obliged to insert the word [commonly) in the statement 
 just made of the facts : which word Mr. Mayo does not employ. To make either 
 his theory, or the theory of pressure, perfectly satisfactory, either the arm alone 
 should be affected ; or the aflection of the arm should always accompany and be 
 more intense than, or at any rale not less intense than, the affection of the leg. But 
 this is not the case. Since Mr. Mayo's observations were published, I have met 
 with two or three instances and pointed them out to him, in which the leg alone, or 
 the leg first, has been palsied, from cerebral disease. And Andral, among seventy- 
 five cases of cerebral hemorrhage collected for another purpose, which 1 shall pre- 
 sently advert to, met with twelve in which the leg only was affected. It is a great 
 pity that these stubborn facts should thus cross and thwart what might else be 
 esteemed a very pretty theory. 
 
 I confess that, to my mind, the phenomena of hemiplegia are the most easily 
 accounted for by the very hypothesis which Mr. Mayo rejects, viz., that the paralysis 
 depends upon a simple interruption of the nervous influence, a breaking up, or an 
 obstruction, of the road by which the changes leading to sensation travel in the one 
 direction, and the mandates of volition in the other. We may easily conceive that 
 the conducting fibres which lie between the sensorium and the muscles of the les: 
 may alone be torn across, or severed by a process of softening, or strongly compressed, 
 while the residue of the conducting apparatus is entire. This notion, of some breach, 
 or other impediment in the channels of communication, seems more consonant with 
 what we know both of the physiology and of the pathology of the brain, than any 
 other that I am acquainted with. 
 
 I must not omit to give you Mr. Mayo's explanation of the other and main 
 difficulties to which I referred — viz., that when one side of the cerebrum is injured, 
 the muscles of the other side of the face are paralyzed ; and /hat hemiplegia, 
 resulting from disease of the cerebellum, affects also the opposite side of the body : 
 — and having given you it, I shall leave it, without further comment, to your consi- 
 deration. 
 
 Mr. Mayo's words are : " Where the decussating fasciculi of the anterior pyramid 
 plunge into the opposite half of the spinal marrow, they are implicated, in a wonder- 
 ful closeness of intermixture, with fibres which, in their upward course, bend towards 
 the places of origin of the ninth and seventh, and of the eighth and fifth nerves of 
 the palsied side. May it not be supposed that this interlacement may be a sufficient 
 means of communicating the palsying influence to the ascending fibres, which are 
 in close relation to the affected cerebral nerves ?" 
 
 Again, " How is the fact to be accounted for, that hemiplegia of the opposite side 
 is produced by lesion of one hemisphere of the cerebellum/ I have little doubt that 
 the. following explanation of the phenomenon will eventually prove to be correct. 
 The fibres of the anterior pyramids pass through the pons varolii. The |x)ns varolii 
 consists in great part of filaments which issue from each hemisphere of the cerebel- 
 lum. These filaments may easily be supposed to convey a depressing: influence 
 from the diseased hemisphere. But in their course they come immediately upon 
 the filaments of the anterior pyramid of the same side ; and they are so implicated 
 widi the latter, with such a singular closeness of reticulation, and often with so much 
 that looks like an actual interchange of filament, that it is far from unlikely that they 
 may transmit to the descending fasciculi of the pyramid a shock which may ihence 
 be communicated to the same part at which a cerebral lesion exerts us paralyzing 
 lorce." 
 
 21
 
 322 DISEASES OF THE BRAIN. 
 
 I will only say further of this hypothesis, that if the explanation it furnishes of the 
 facts in question be not the best and most satisfactory in the world, it is the best and 
 most satisfactory that we yet possess : and that, at any rate, we may make use of it 
 lo bind those facts to our recollection, until some better theory shall be devised. 
 
 There is one very curious law asserted, by Andral, in respect to hemorrhage of 
 the cerebel/tnn. If the blood is effused into one side of the cerebellum, and nowhert- 
 else, the palsy that ensues follows, I repeat, the general rule ; it takes place in the 
 Umbs of the opposite side of the body. But supposing hemorrhage to take place on 
 one side of the cerebrum, and on the other side of the cerebellum, simultaneously . 
 what then, think you, happens? Doubtless you would expect that there should be 
 palsy on both sides of the body. Hemiplegia on the one side, from the effusion into 
 the brain proper ; hemiplegia on the other side, from the effusion into the cerebel- 
 lum : double hemiplegia; that is to say, general palsy. But it is not aiways so, in 
 fact. The cerebral affection seems to overpower and master that of the cerebellum. 
 Whatever the explanation may be, the palsy has been found to occur on the side 
 opposite to the lesion in the brain proper ; and not to occur on the side opposite to* the 
 lesion in the little brain. This is a very singular fact, of which Andral relates four 
 or five examples. But 1 suspect ihat they will ultimately take their place among 
 the " anomalous" cases. As facts multiply, the law will, 1 conjecture, be found to 
 be a different one. 
 
 The complex structure of the brain, and the dissimilar consequences that ensue, 
 in different cases, from its injury or disease, leads directl}?^ to the belief not only that 
 the organ subserves several distinct functions, but also that separate parts or sections 
 of it hold peculiar and definite relations with other portions of the body. Ingenious 
 men have even attempted to settle these points experimentall^^ By wounding or 
 removing various portions in succession of the cerebral mass in living animals, and 
 comparing the resuUs, they have endeavoured lo assign to each portion its particular 
 province and function. But to say nothing of the remarkable differences which exist 
 between the cerebral functions in man and in the inferior animals, there is an una- 
 voidable source of fallacy common to all such experiments. We cannot reach the 
 particular spot in the brain upon which the contrived injury is to be inflicted, with- 
 out penetrating and hurting various other parts : and fronn these combined injuries 
 (dangerous, indeed, and often fatal in themselves) arise symptoms which the experi- 
 menter may erroneously conclude to be characteristic of the lesion originally in his 
 contemplation. 
 
 Much more accurate and satisfactory data for the determination of this interesting 
 class of questions, would seem to be furnished by the spontaneous operation of dis- 
 ease, and especially of the disease we are now considering. The injury done to the 
 cerebral substance by the irruption of blood is not less sudden, nor less mechanical, 
 than in the exf)erimen-ts or contrived observations to which I have alluded. It is 
 capable, also, in many instances, of exact appreciation in regard to its extent ; the 
 parts which lie round the seat of the effusion remain undisturbed ; and above all, 
 the organ that is the subject of our observation is the human brain itself. 
 
 Attempts have accordingly been made to connect particular symptoms with the 
 disorganization of particular parts of the brain. These attempts can boast, as yet, 
 .t must be confessed, but little success. Very few, if any, of the conclusions hitherto 
 advanced upon this intricate subject can be relied on. Yet it is proper that you 
 should be informed of them. 
 
 Because palsy of the arm is, in general, more complete, and more persistent, than 
 palsy of the leg, it has been maintained that the former, the paralysis of the arm, is 
 to be ascribed to hemorrhage of the corpus striahmi, which seems to be more com- 
 mon than any other; and upon similar grounds hemorrhage of the optic thalamus 
 has been supposed to determine paralj'sis of the kg. So much iiave these distinc- 
 tions been confided in, that the honour of having first pointed them out has actually, 
 in France, been made a subject of dispute. Now it is plain that one example of 
 the contrary effect of these particular lesions, would suffice to upset the whole theory : 
 but many such exceptions have, in fact, been noticed. It was with the view of set- 
 nng this question that Andral collected and collated the seventy-five cases of cere-
 
 APOPLEXY. 323 
 
 bral hemorrhao^e to which I lately referred. In each of these seventy -five cases the 
 clot of blood was sufficiently limited to allow of that case being applied towards the 
 solution of the controverted points. 
 
 In forty of the seventy-five, both the leg and the arm were paralyzed together 
 And where was the place of the hemorrhage in these forty cases ? Why, in twenty 
 one of them the corpus striatum was the only part injured ; and in nineteen of them 
 the optic thalamus was the only part injured. Thus you see, according to the theory 
 just explained, in about one-half of the cases the arm alone should have been pal- 
 sied ; and in about half, the \eg alone : whereas both leg and arm were palsied in 
 them all. 
 
 Again, in twenty-three of the seventy-five cases the palsy was confined to the arm. 
 Therefore, according to the theory, the injury should have been confined to the cor- 
 pus striatum. What was the fact ? Why, in this class of cases also there was as 
 nearly as possible an equal sharing of the injury between the two parts. In eleven 
 of the twenty-three the corpus striatum alone suffered ; in ten the optic thalamus 
 alone ; in two the space between them. 
 
 Once more : there were, as I stated before, twelve out of the seventy-five cases in 
 which the leg alone was palsied. Consequently, in all of these twelve, if the theory 
 Avere sound, there should have been damage of the optic thalamus only. But in ten 
 of them the mischief was confined to the corpus striatum ; in two only to the optic 
 thalamus. 
 
 Gall had conjectured that the faculty of speech was placed under the governance 
 of the anterior lobe of the brain : and Bouillaud has endeavoured to support that 
 opinion by a number of facts observed in connection with cerebral hemorrhage ; but 
 Cruveilhier has brought forward several curious instances in which the loss of speech 
 was a prominent symptom, while the disease was not found in the anterior lobe, but 
 in some other part of the brain. 
 
 Andral, with his accustomed industry, has accumulated evidence upon this point 
 also. 
 
 In thirty-seven cases of cerebral hemorrhage observed by himself, or by others, 
 in which the morbid condition occupied one or both of the anterior lobes, the power 
 of speech was abolished twenty-one times, and unaffected sixteen times. 
 
 On the other hand, he has collected fourteen cases, in which the power of speech 
 was lost, yet no alteration had taken place in the anterior lobes. In seven of these 
 fourteen cases the lesion was situated in the middle lobes ; and in the other seven in 
 the posterior lobes of the brain. 
 
 There can be no doubt that there are certain distinct parts of the brain which in 
 fluence respectively the upper and lower Hmbs ; inasmuch as they are often sepa 
 rately palsied : and since the loss of speech is occasionally the only, or the most 
 prominent symptom, while in other cases the speech is not affected at all, we cannot 
 but believe that this faculty is under the special guidance of some definite part 
 within the cranium. But the facts that I have just been quoting, show, in the most 
 convincing manner, that we are not able, as yet, to allot these separate functions to 
 their proper spots in the cerebral mass. 
 
 I dwelt some little time, in a previous lecture, upon the circumstances that give 
 ivarning to the patient, or to his physician, that the former is in danger of being 
 smitten with apoplexy. The great use of being acquainted with these circum- 
 stances, and of looking out for them, consists in the opportunity and the authonhj 
 which they furnish, for enforcing, upon the person in whom they manifest them- 
 selves, the absolute necessity of avoiding all the avoidable exciting causes of the 
 disease. But our means of advising him will be very imperfect if we have not 
 carefully considered what these exciting causes are. I propose to devote n few 
 mmutes, therefore, to the consideration of the circumstances that are apt to bring on 
 the attack. There are many cases of apoplexy in which we cannot trace the ope- 
 ration of any such causes : but in many other cases their influence is decidedly 
 marked ; and the avoidance of them, while it is important to all who show a dispo-
 
 324 DISEASES OF THE BRAIN. 
 
 sition to apoplectic disease, is especially so to those who, having once suffered an 
 attack, have reason to dread a repetition of it. 
 
 In the first place, any thing which is calculated to hurry the circulation, and to 
 increase the force of the heart's action, is likely to operate as an exciting cause of 
 apoplexy : simply by augmenting the momentum of the blood against the sides of 
 the cerebral vessels, which in advanced life are so often diseased and weak 
 Strong bodily exercise, therefore, is a thing to be avoided by all persons in whom 
 the predisposition to apoplexy has declared itself. It is of much importance to make 
 patients aware of this ; for many persons think, when they labour under uncom- 
 fortable bodily feelings of any kind, they may get rid of them by a brisk walk ; or 
 by galloping some miles over the country on horseback. 
 
 Another dangerous state for such persons arises whenever the free escape of the 
 blood from the head is suddenly obstructed. I have adverted to this before. 
 Certain diseases, chiefly thoracic, which tend to keep the veins of the head inordi- 
 nately full, rank among the predisposing causes of apoplexy. But, upon the very 
 same principle, various conditions, which are temporary only, may operate as ex- 
 citing causes. By what is called " holding the breath," whether upon an inspi- 
 ration or expiration, the transit of the blood through the lungs is impeded : and the 
 check is felt (through the pulmonary artery, right chambers of the heart, and great 
 veins) in the vessels of the head. And this effect is increased when straining is at 
 the same time performed ; that is, when a deep breath is taken and retained, while 
 some muscular forcing effort is made. 
 
 Under this principle fall a number of bodily acts, which, however harmless in a 
 healthy frame, are not without peril to a person having a predisposition to apoplexy. 
 The motion of the blood in the lungs, and therefore in the head, is checked in the 
 acts of coughina:, vomitinn;, sneezingf laucrhinfr, crvinaf, shoutinof, and so forth. You 
 cannot have looked at a person in a violent paroxysm of coughing without seeing 
 that it produced a determination of blood to the head, or rather a congested state of 
 the veins of the head. The jarring pain in the head which is apt to follow each 
 succession of the cough depends upon this principle : which is often strikingly illus- 
 trated in young children labouring under hooping-cough. They turn purple in the 
 face, and become giddy ; and not uncommonly ecchymosis of the conjunctiva occurs, 
 giving fearful evidence of what might just as readily take place ivithin the cranium. 
 It is not very unusual for the whole of the white part of the eye to become sud- 
 denly blood-shot in these violent fits of coughing; and convulsions even have hap- 
 pened under the like circumstances. 
 
 Straining at stool is a common exciting cause of apoplexy in those who are pre- 
 disposed to it. And this is one of the worst dangers attending costiveness of the 
 bowels in old people ; but it is one which it is often in our power effectually to obvi- 
 ate. It is more within our control than a bad cough could be. Any kind of strain- 
 ing, indeed, is equally perilous. A very good proof of this danger was recently 
 afforded by a patient of my own. He was attacked with apoplexy on his way to 
 Ascot races ; and upon recovering somewhat, was found to be paralytic on one side 
 of the body. He was brought back to town, where I saw him. After some time 
 he regained the power of using the affected limbs to a very considerable extent; so 
 as to be able to walk about and follow his business, which was that of a job-master, 
 or proprietor of a livery stable. I cautioned him seriously, inter alia, against strain- 
 ing: but I suppose he forgot my caution. For, while dressing one morning, he 
 tugged violently in attempts to pull on a damp boot, and in the midst of his efforts 
 fell back insensible ; and from this relapse he never fairly recovered. 
 
 To the same pr.nciple is to be referred a variety of things from which a patient, 
 in danger of this disease, must most carefully abstain. Lifting heavy weights ; leap- 
 ing ; striking a hard blow ; playing on wind instruments ; even long and loud 
 talking. Dr. Abercrombie relates two instances of fatal apoplexy brought on (as it 
 wouW seem) by a sustained exertion of the voice : one of the attacks happened to a 
 clergyman during the delivery of his sermon ; the other to a htcrary man while 
 speaking in a public assembly. In both cases a large quantity of blood was found 
 ex'ravq.sated within and upon the brain. Dr. James Gregory' used to mention a
 
 APOPLEXY. 32S 
 
 patient of his, an officer in tlie army, who had apoplexy, and in wiom the attack 
 had been preceded by pains of the head and giddiness, upon his giving the word of" 
 command, and particularly when dwelling upon the last sound : that is, when he 
 made a long expiration. Precisely of the same kind is a case told by Van Swieten, 
 of a singer who was obliged at length to abandon her vocation by reason of gradually 
 increasing vertigo whenever she had to hold a high note. Violent emotion is another 
 exciting cause. Large fires, crowded rooms, the heat even of the sun, favour the 
 access of apoplexy, and therefore ought to be shunned by those who have a ten- 
 dency to that disease. The warm bath is not without hazard to such persons. This 
 is so well known, I understand, at Bath, that the physicians there will not allow 
 paralytic patients, in whom the paralysis has been connected with apoplexy — hemi- 
 plegic patients, for example — to go into their hot baths. The excitement of drunken- 
 ness, and the venereal excitement, are not uncommon causes of apoplexy, especially 
 in old persons. I had a man of middle age under my care during the spring oif 
 1837, in whom a most awful attack of apoplexy came on under circumstances such 
 as I have just referred to. He had dined at a large festive party, and afterwards 
 accompanied a woman, with whom he was acquainted, to a brothel : and he was 
 struck with palsy during the act of intercourse. He was long unable to speak; and 
 he still remains, and probably will ever remain, a cripple ; incompletely hemi- 
 plegic. 
 
 I have been since consulted upon the case of an old gentleman residing in France, 
 in whom an attempt at sexual connexion was attended with similar consequences. 
 
 " The Gods are just, and of our pleasant vices 
 Make instruments to scourge us." 
 
 Posture, again, has no small effect upon apoplectic people. Giddiness, and some 
 degree of confusion of thought, are apt to be occasioned, in most persons, by long 
 stooping. There is one peculiar posture or position mentioned by Dr. Fothergill as 
 being very unsafe, especially for short-necked persons, viz., that position which is 
 assumed when Ave turn the head to look backwards for any length of time, without 
 turning the rest of the body; in fact, a twisting of the neck. In this attitude the jugular 
 veins are more or less obstructed. He gives an account of a man who was seized with 
 apoplexy as he was crossing the Thames in an open boat ; he having kept his eye 
 fixed upon a particular ship until, and after, he had been rowed past her. On the 
 very same principle, tight ligatures worn about the neck, and compressing the ju- 
 gular veins, may bring on apoplexy; the wearing a tight neck-cloth, for example. 
 A continental writer informs us that a Swedish officer, who was desirous that his 
 men should look well in the face, caused them to wear tight stocks, and the conse- 
 quence was, that in a short time a great many in that regiment died of apoplexy. 
 Dr. Abercrombie quotes from Zitzilius the case of a boy who had drawn his neck- 
 cloth very tight, and was whipping a top, stooping and rising alternately. After a 
 short time he fell down apoplectic. The neckcloth being loosened, and blood drawn 
 from the jugular vein, he speedily recovered. 
 
 There is one very powerful exciting cause of apoplexy, in those predisposed to it, 
 which I need only refer to now, because the facts that have been observed in proof 
 of its agency were fully detailed in a former part of the course ; I mean exposure to 
 cold. You will recollect my teUing you that the number of deaths in London from 
 apoplexy and palsy in the month of January, 1795, which was a bitterly cold month, 
 very much exceeded the number in the month of January, 1790, which was a 
 remarkably mild month. The cold operates in two ways, in the production of apo- 
 plexy. In the first place it drives the blood from the surface, and accumulates it m 
 the large vessels of the interior of the body, and so increases the stress upon the 
 cerebral arteries. And in the second place, the cold has a great influence in causing 
 or aggravating affections of the chest ; and the return of the venous blood from the 
 head is impeded, in the manner just now explained, by fits of coughing and ob- 
 structed respiration. 
 
 This influence of external cold, and probably certain barometric conditions also ot 
 
 2c
 
 326 DISEASES OF THE BRAIN. 
 
 the atmosphere, hcip to explain, what I am sure I have several times had experience 
 of, namely, the epidemic prevalence, now and then, of apoplectic seizures. 
 
 There is an alleged exciting cause of cerebral hemorrhage, which I think it the 
 more necessary to consider, because I believe that very erroneous notions prevail 
 about it, even among pathologists of eminence. I allude to the imputed dependence 
 of cerebral hemorrhage upon hypertrophy 9f the left ventricle of the heart. It has 
 been supposed that the powerful contractions of a ventricle thus morbidly strong mav 
 drive forwards the blood with such unusual force, as to strain and burst the cerebral 
 arteries. Dr. Hope, in his very complete work upon Diseases of the Heart, uses 
 these words : — " Instances of apoplexy supervening upon hypertrophy have been so 
 frequently noticed, that the relation of the two, as cause and effect, is one of the 
 best established doctrines of modern pathology." Similar opinions are entertained 
 by the most distinguished of the French writers on this subject ; Andral, Bouillaud, 
 Cruveilhier. I think they are all wrong : or that at least they state their proposition 
 much too broadly and generally. ' 
 
 I fully admit, no less from my own observation than upon the testimony of others, 
 the frequent coincidence of hemorrhage of the brain and hypertrophy of the left 
 ventricle of the heart ; but I distrust the reasoning which would always connect 
 these events with each other as cause and effect. They may sometimes have that 
 relation : but I have long thought that in most cases, if not in all, the coincidence is 
 capable of being explained upon other and more satisfactory principles. 
 
 In the first place, hypertrophy of the left ventricle of the heart is very frequently, 
 far more frequentlj'- than not, accompanied by other structural changes of that organ : 
 changes which imply some impediment to the circulation : changes which involve 
 or influence its right chambers also. In fact, disease of the right heart is not very 
 often seen, without disease of the left; and one of the commonest forms of alteration 
 to which the left side is Hable, is hypertrophy of its ventricle. Now I have already 
 pointed out to you the connection which sometimes subsists between cerebral hemor- 
 rhage and such disease of the heart as obstructs the ready and regular descent of 
 the blood from the head through the veins. Many of the cases of apoplexy occurring 
 in persons who have previously had cardiac hypertrophy are, I really believe, cases 
 of this kind. The brain affection is dependent, in part, upon disease of the heart, 
 but not upon the preternatural strength of its left ventricle. The heart acts morbidly 
 upon the brain through the veins, and not through the arteries. 
 
 But there is another reason for the coincidence ; and here the arteries are con- 
 cerned. 
 
 No one can doubt that the momentum, with which the blood reaches the cerebral 
 arteries, in healthy persons, under violent bodily exercise or mental excitement, must 
 often exceed the momentum produced by a hypertrophic heart in the cerebral arteries 
 of persons who are tranquil and at rest. But apoplectic seizures are frequent under 
 the latter circumstance, infrequent under the former. We must look, therefore, foi 
 something more than the mere hypertrophy to explain the coincidence. Now (sup- 
 posing the absence of any check to the flow of blood from the head through the 
 veins) that something is to be found in disease of the arterial system. 
 
 When the arteries of the brain are ossified, or changed, and rendered brittle in the 
 way I yesterday described, the coimnencement of the aorta also is found, in a great 
 majority of cases, to be the seat of similar alterations ; and, often, to be sensibly 
 dilated. Now the mere albuminous deposit beneath its inner tunic must seriously 
 impair the elasticity of the vessel; and in this way the free passage of the blood 
 out of the heart will be impeded. Dilatation of the aorta at that part will produce 
 the same hindrance more certainly and in a greater measure. Still more effectually 
 and obviously will any contraction of the outlet prove an impediment. It is in con- 
 sequence of these mechanical obstacles to the free exit of the blood from the left 
 ventricle, that the walls of that chamber, urged to more vigorous contraction, become 
 thicker and more powerful. The hypertrophy is the natural compensation for the 
 morbid state of the aorta; without it the heart would much sooner become unable to 
 propel its contents at all : and the hypertrophy does not often, I fancy, become greater 
 than is needful for its purpose. The strength of the left ventricle, therefore, in such
 
 APOPLEXY. 327 
 
 cases, is not a true measure of the force with which the blood is driven into the 
 distant arteries. Q,uite the contrary. It is a measure of the difficulty with which 
 the blood is circulated through the primary branches, and therefore through the 
 entire system of the arteries. It indicates the diminished force with which the 
 blood is likely to reach the cerebral vessels. And in point of fact, you will find 
 in many cases of hypertrophy of the left ventricle — I do not say in all, but certainly 
 in very many — you will find the pulse at the wrist to be disproportionately small and 
 feeble. So that, in these cases, instead of regarding the cerebral hemorrhage as the 
 effect of the hypertrophy, (acknowledging, as I do, the frequent coexistence of these 
 morbid conditions,) I have been accustomed to look upon the apoplexy and the hy- 
 pertrophy as concomitant effects of the same cause; viz., of disease pervading the 
 arterial tree. The hypertrophy of the left ventricle is the effect of the diseased con- 
 dition of the aorta at its mouth ; the cerebral hemorrhage is the effect of the same 
 diseased condition of the arteries in the brain. When you find each of these lesions, 
 and nothing to retard the venous current, you may, I believe, safely apply this ex 
 planaiion of the occurrence of apoplexy. 
 
 Having again referred to the frequent existence of disease in the cerebral arteries 
 as a predisposing cause of hemorrhage Avithin the brain, I will just point out, before 
 1 leave this part of the subject, the light which that fact throws upon the circum- 
 .-^lauce than sanguineous apoplexy is so peculiarly a disease of advanced hfe. Earthy 
 concretions in the coats of the arteries are so frequent in the later periods of existence, 
 that they are met with, according to Bichat, in seven individuals out of ten of those 
 who die beyond the age of sixty ; and Dr. Baillie considered ossification to be much 
 more common in old persons than a healthy state of the arteries. 
 
 In the account which I have endeavoured to give you of the symptoms of apo- 
 plexy, of the different modes in which the attack may commence, and of the various 
 morbid appearances discovered within the cranium in the fatal cases, I have already 
 embodied almost all that can be stated, with any confidence, respecting the special 
 diagnosis and the prognosis of the disease. The one of these follows the other : the 
 exact diagnosis being known, the prognosis is seldom difficult. By the diagnosis, 
 however, I do not now mean simply the recognition of the disease as a case of apo- 
 plexy : of that general diagnosis, of the means of distinguishing the coma of apo- 
 plexy from the coma caused by opium or alcohol, I told you all that I know in a 
 former lecture. But I use the term diagnosis now in a stricter sense, and in reference 
 to the distinctions that exist between one case of apoplexy and another; and I say, 
 that in proportion to the accuracy with which we may be capable of determining the 
 precise condition of the contents of the skull, will be the facility of predicting the 
 issue of the complaint. Let me remind you, then, that when a patient suddenly 
 becomes apoplectic, we cannot tell whether there be effusion of blood, or effusion of 
 serum, or no effusion at all within the cranium : and therefore the diagnosis must be 
 precarious and uncertain. If, after the use of suitable remedies, the coma persists for 
 many hours, the prognosis becomes worse. In those cases which begin with pain 
 of head, faintness, and nausea, and which pass on to coma, the prognosis is posi- 
 tively bad ; for the diagnosis is easy, and we are tolerably certain that a blood-vessel 
 has given way, and that a large quantity of blood has ploughed up the substance of 
 the brain. In the paralytic cases also, if coma supervenes, the prognosis is gloomy ; 
 but frequently coma does not supervene, and then our prognosis, so far as life is con- 
 cerned, may be pronounced favourable. 
 
 Among the symiHoms that belong to the apoplectic condition itself, there are some 
 which experience has selected as being most especially of evil omen ; and it is well 
 worth your while to remark that these discouraging signs relate, almost all of them, 
 to the automatic functions of the cranio-spinal axis. The open, fixed, unwinking 
 eye; the explosive flapping of the cheeks in expiration ; the inability to swallow; 
 the slow, sighing, interrupted breathing; the loosening of the sphincter muscles oi 
 the bladder and anus ; these are fearful, and too often fatal symptoms, and they all 
 depend upon the excito-motory portion of the nervous system. Perhaps the profuse 
 sweat that so often attends the process of dissolution may be referred to the same 
 source ; the whole tone of the various tissues being lost or relaxed. I would not say
 
 328 DISEASES OF THE BRAIN. 
 
 that no one of these symptoms is ever recovered from : but I may say that of twenty 
 patients in whom such phenomena occur, nineteen will die. 
 
 Now symptoms of this kind may be expected to arise, if there be hemorrhafre in 
 or near the medulla oblongata; or if there be mischief so extensive in the brain 
 as to cause pressure upon the medulla oblongata. We should reason out the 
 hkelihood that such symptoms would be of bad augury. But the fact that they are 
 so was ascertained long before the theory which accounts for them was devised. 
 The fact is independent of the theory, and for that reason helps wonderfully to 
 confirm it. 
 
 The older writers entertained some very false notions in respect to the distinction 
 between sanguineous and serous apoplexy. They laid it down that apoplexy result- 
 ing from extravasation of blood within the cranium was denoted by flushing of the 
 face, and strength of the pulse ; and that it was a disease of persons in the vigour of 
 life: while apoplexy resulting from the effusion of serum was marked by paleness 
 of the countenance, and weakness of the pulse ; and occurred in the old and the 
 infirm : and they directed their practice according to this distinction. After what has 
 already been said, I need not tell you that this classification of apoplexies could not 
 have been founded upon the actual observation of disease : and that our treatment, 
 now-a-days, is not regulated by any such erroneous theory. 
 
 Nevertheless, I do not mean altogether to praise the modern practice in apoplexy ; 
 for it is often one of mere routine. Practitioners are too apt, in this as in other 
 instances, to be guided in their choice of remedies by the name of the disease, and 
 to treat all cases of apoplexy alike. I remember being much amused by the per- 
 plexity which a friend of mine once told me he had felt on being summoned by 
 letter many miles into the country to see a gentleman who had been struck with 
 apoplexy. As he posted down he earnestly revolved in his mind what he might be 
 able to advise when he should reach the house of sickness. He felt confident that 
 the patient must already have been copiously bled; cupped, or leeched ; blistered ; 
 and thoroughly dosed with calomel, senna, and croton oil. Mustard poultices had 
 doubtless been applied to his legs. My friend was distressed to think that while 
 much would be expected, nothing would be left for him to do worthy of so long a 
 journey, and so heavy an expense to his client. A clyster of turpentine might yet, 
 perhaps, be an untried expedient. His Qogitations were cut short, however, and his 
 cares relieved, by an express which met him half-way on the road, to announce that 
 the patient was dead. Now this is the routine of which I speak: most proper in 
 many cases ; unnecessar}' in others ; pernicious in some. There are persons who 
 seem to think that they have not done their patient justice if any part of this active 
 intermeddling has been omitted. Others reijard deplt'tion as being worse than use- 
 less, and trust entirely to stimulants and cordials. These are still more dangerous 
 routinicrs than the others: but they are fewer in number. 
 
 Our practice would indeed be much easier than it is, if we could thus make one 
 plan fit all cases which are nominally the same. But I need not now tell you that 
 disease alike in name — aye, and alike in their essential nature — are ofttn widely 
 difTorent in their circumstances. I formerly explained to you that certain symptoms 
 tell us what the disease is ; but that we are often obliged to look to other symptoms ; 
 which ma)'- inform us what we are to do. I know of no rule so likely to guide you 
 aright as that laid down generally by Cullen, of obviating the tendency to death. 
 You must examine and judge to which of the several modes of dying there may be 
 any obvious approach. If tjie tendency be, as in cases of apoplexy it mostly is, to 
 death by coma, then blood-letting and the evacuating plan will generally be requi- 
 site. If, on the other hand, the tendency be to death by syncope, you must with- 
 hold the lancet, and even have recourse to stimulating and restorative measures. The 
 question is of the last importance ; involving often (as Celsus taught) the alternative 
 of life and death : "sanguinis detractio vel occidit, vel liberat." Now the distinction 
 between these modes of dying is to be made by attending to the state, not so much 
 of the nervous, as of the sanguiferous system. Insensibilitj'' and unconsciousness 
 are common both to syncope and to coma: and cases which fall under the ''lass of
 
 APOPLEXY. 329 
 
 apoplexies, and which we cannot separate from that class, are sometimes really more 
 hke cases of concussion than any thing else ; the shock having been of internaj 
 instead of external origin. If the pulse be full, or hard, or thrilling (sometimes it 
 feels like a tense vibrating rope), or if there be obvious external signs of plethora of 
 the head, you must abstract blood. You are not to refrain from bleeding the patient 
 because he is pale, if his pulse warrants it ; nor may you omit taking blood if the 
 head and face be turgid, although the pulse be small ; for that smallness may depend 
 upon organic disease of the heart. 
 
 On the contrary, if his skin is pale and cold, and his pulse feeble and flickering, 
 you would probably ensure your patient's death, or determine the accession of palsy, 
 if you withdrew from the failing heart and blood-vessels a portion of their natural 
 stimulus. I can only invite your attention to these broad features of distinction. 
 Being once taught to look for and attend to them, your own judgment must instruct 
 you as to what may be needful in particular cases. To this, as to most other dis- 
 eases, the remark of Boerhaave is strictly applicable, who declares that he knows 
 of nothing which can be called a remecly, " quin solo tempestivo usu tale fiat." 
 
 Having made up your mind as to the general indications of treatment, you will 
 pursue them steadily in detail. If the patient to whom you are summoned be stupid 
 and drowsy rather than faint, and his pulse and appearance warrant the conclusion 
 01 plethora capitis, the first thing to be done is to place him in a semi-recumbent 
 position, with his head raised ; to loosen any tight parts of his dress, especially his 
 neckcloth and shirt-collar, and whatever might press upon the neck; and then as 
 quickly as possible to bleed him from the arm. We know that in some cases the 
 apoplectic slate occurs, when as yet no injury has been done to the brain ; no effu- 
 sion, no laceration of its texture ; and we may hope, by timely and vigorous mea- 
 sures, to prevent these terrible evils. We never can be sure that there is blood 
 exlravasated in such cases, and we must act, in the first instance, upon the presump- 
 tion that there is not. We are especially encouraged to take away a considerable 
 quantity of blood by venesection when we perceive external signs that the vessels of 
 the head are full; redness and turgescence of the face, throbbing and prominence 
 of the temporal arteries, distension of the superficial veins of the neck and forehead. 
 Our object is to take off the strain upon the internal vessels by bleeding in such a 
 manner and to such an amount as shall produce a decided effect upon the general 
 circulation. Sometimes the good consequence of the bleeding is very marked indeed, 
 so that no doubt of its propriety can be entertained ; the patient being so insensible 
 as not to feel the puncture of the lancet, and yet emerging from his coma while the 
 blood is still flowing. It is seldom, however, that we can expect such manifest and 
 immediate melioration as this. 
 
 After one siifficient bleeding from the arm, the vessels of the head may be further 
 relieved by cupping the nape of the neck, or the temples ; and venesection may be 
 repeated if the condition of the pulse, and the symptoms generally, should require 
 its repetition. It is seldomer, however, in cases of apoplexy than in cases of acute 
 inflammation, that a second or third recourse to the lancet becomes advisable: un- 
 less, indeed, the first blood-letting has been mismanaged. Enough blood must be 
 taken, in the first instance, to produce some evident effect; and therefore no precise 
 rules can be laid down respecting the absolute quantity to be drawn ; nor can we 
 make any sure estimate beforehand as to the whole amount of blood which it may 
 be necessary to remove. 
 
 Even if we could be certain that a blood-vessel had given way, and that blood 
 Avas already poured out upon the brain, there are good reasons why (no adverse cir- 
 cumstances withstanding) we ought to bleed our patient largely, and at once. I 
 will enumerate briefly the benefits we seek to obtain by the abstraction of blood in 
 such cases. 
 
 1. The effusion from the ruptured artery may be slowly going on. Ble.ding 
 irom a vein, so as to make a sensible impression on the general circulation, will 
 diminish the stress upon the cerebral arteries, and so tend to put a stop to the he 
 morrhage. Both of these two objects are of primary importance. 
 
 2. By early and free bleeding we lessen the hazard of inflammation «upervt>nmg 
 
 2c2
 
 330 DISEASES OF THE BRAIN. 
 
 upon the mechanical injury done to the brain by the sudden tearing and contusior- 
 of its texture by thc'effused blood ; and 
 
 3. We thereby bring the system into the most favourable condition for the rapid 
 absorption of the extravasated blood, and for expediting the patient's recovery from 
 those symptoms which depend upon the presence of the clot in the brain. 
 
 But although, in that form of disease which we are now considering, bleeding is 
 our sheet-anchor, it may be carried too far, or repeated too often. We must not lose 
 sight of the fact that many of these patients are old, and will not survive undue deple- 
 tion ; and that if they survive at all, they will need all the strength that we dare 
 suffer them to retain for carrj'ing on the vital actions, when the chief instrument of 
 the most important of the animal functions is so greatly damaged : nor of the fact 
 that if there be blood extravasated, we cannot touch it, except indirectly, by the 
 abstraction of more blood from the arm : nor of the fact that a patient may be bled 
 into convulsions, and fatal syncope. In short, after the first free bleeding, you must 
 be guided by the special circumstances of the case, and particularly by the pulse. 
 The woman at present in the Middlesex Hospital, with paralysis of the limbs on one 
 side, and of the face on the other, attributes her palsy (erroneously most likely) to 
 her having been cupped. She had had a blow some weeks before, and suffered 
 headache from that time. At length she was cupped, from the neighbourhood of 
 the head ; and the next morning she was paralytic. This might have been an acci- 
 dental coincidence. But I remember being sent for, a few years ago, to see a patient 
 at Greenwich, who had alreadj' three physicians about him, and was apparently in 
 danger of apoplexy, of which he had for some time experienced distinct warnings. 
 The three physicians had agreed that he ought to be cupped from the back of the 
 neck; to which I assented; and while blood was being rapidly extracted in that 
 manner, he became all at once hemiplegic. Similar cases have been noticed by 
 other persons. Therefore we are not to bleed without measure or discretion. 
 
 The pulse may be small, and the arterial action feeble, while yet the veins are 
 turgid, and the capillaries of the head and face loaded with blood. Changes may 
 have occurred in the heart, such as to obstruct the stream which it is its healthy 
 office to transmit. These are cases to which the local abstraction of blood from the 
 head, by leeches and cupping-glasses, is pecuharly adapted. 
 
 Again, the whole state of the patient may approximate more or less nearly to the 
 state of syncope ; the pulse being weak, the aspect pinched and bloodless, and the 
 skin cool. In this condition, no good, but the contrary, is to be expected from blood- 
 letting of any kind. You will do better to apply warmth, cautiously, to the surface, 
 and cautiously to administer what are called diffusible stimuli, of which the prepa- 
 rations of ammonia afford the most eligible forms. Five grains of the sesquicarbo- 
 nate or half a drachm of sal volatile, mixed with camphor julep, are ordinary doses. 
 Stand by till the first stunning effect of the internal shock passes off; and careluily 
 watch meanwhile for symptoms of reaction. 
 
 In more ambicuous cases, when you scarcely can tell which way the baLuice 
 inclines, I would advise you to wait the effect of the next remedies I have to men- 
 tion, viz., purgatives, about giving which you need not entertain the same doubt and 
 hesitation. 
 
 Purgative medicines are of signal service in apoplexy. They empty the intes- 
 tines, whicJi are oftentimes loaded, and which, by distending the abdomen, have 
 occasioned, perhaps, undue pressure against the diaphragm, embarrassed the breath- 
 ing, and through it the cerebral circulation. Another very important purpose of 
 hard purtring, which I have frequently pointed out before, is the producing of copi- 
 ous watrry discharges from the bowels, whereby the blood-vessels are drained, and 
 the tendency of blood to the head especially relieved. If the patient can still swal- 
 low, you may give him half a scruple of calomel, and follow it up by a black dose. 
 Il the power of deglutition be lost, the croton oil becomes a most valuable remedy. 
 Dr. Abercrombie suggests that it may be conveniently introduced into the stomach, 
 suspended m thick gruel or mucilage, by means of an elastic gum tube. But really 
 this is not necessary. If two or three drops of the oil be put upon the tongue, as far 
 back as is possible, it will produce its speciiic effect ver}'' readily and v/ell But we
 
 APOPLEXY. 33 1 
 
 are not to wait for the operation of aperients given by the mouth. Strong purgative 
 and stimulating enemata must be thrown into the rectum: half an ounce or six 
 drachms of turpentine susperfded, by the help of the yolk of an egg, in gruel or 
 >^arm water. We very often witness decided signs of amendment upon the free 
 operation of a purgative. I may mention one instance of tliis while it is fresh in xny 
 recollection. I was asked, a few evenings ago, by a medical friend, to see an old 
 general, a patient of his. I found him in bed, comatose, though capable of being 
 roused when loudly spoken to : but he j^resently fell off again into stupor. His respi- 
 ration was peculiar. For a minute or two he would breathe, snoring strongly: then 
 the breathing would cease altogether for half a minute or thereabouts : and then the 
 stertorous respiration recommenced : and so on alternately. 
 
 He had been found by his servant on the floor, nearly insensible, in the morning, 
 having either fallen out of, or upon rising from, his bed. He had very properly 
 been cupped ; and calomel and aperient medicine had been given : but the coma 
 had been growing more profound all the afternoon. His bowels had been but scantily 
 moved ; and the feces and urine were passed as he lay. His extremities were 
 coldish. The pulse was neither full nor strong. 
 
 I learned that for four or five years he had had some very significant warnings ; 
 and within that period had suffered one or two slight apoplectic seizures, which had 
 left him \\'iih impaired mind and memory. 
 
 I recommended bhsters behind the ears, and two drops of croton oil, with two 
 drachms of castor oil, in a draught. The next morning I expected to hear that he 
 was dead; but I found him quite conscious, speaking somewhat inarticulately, witk 
 the right side of his face chopfallen and inexpressive. There seemed no particular 
 weakness of the corresponding extremities. The oils had been followed by copious 
 evacuations from the bowels. The day afterwards he was sitting up, and so well 
 that I took my leave. 
 
 In combination with blood-letting and purgatives, cold lotions to the head are often 
 found useful in this disease, especially if its surface is hot. I need not trouble you 
 by rehearsing the modes in which the application of this remedy may be managed. 
 Blisters near or upon the head, are also frequently of service, after due abstraction 
 of blood, in rousing the patient from his state of coma. 
 
 Formerly, at the suggestion, I fancy, of Dr. Fothergill, it was much the fashion 
 to give an emetic in the outset of the treatment of apoplexy. But this also is a 
 ticklish remedy, capable of doing good or harm according as it is well or ill timed. 
 If there be already extravasation of blood, or even plethora capitis, the act of vomiting 
 will be likely to increase the existing mischief, and to enhance the danger. On the 
 other hand it may rouse and rally the nervous power when the patient is pale, and 
 cold, and faint. Yet this can never be regarded as a legitimate purpose of emetics 
 in apoplexy. They can safely be recommended in those cases only in which the 
 coma may appear to depend, wholly or in part, upon a loaded stomach. Hence the 
 propriety of giving an emetic will deserve consideration whenever an attack of apo- 
 plexy follows close upon a heavy meal. 
 
 When the immediate danger has passed by, and parslysis remains, we are not to 
 be over-busy. If the palsy is to get gradually well, it must be by virtue of time, 
 and the resources of nature. To young and strong persons I should, under such 
 circumstances, give small and repeated doses of mercury : and in all cases I should 
 prescribe aperient medicines, so as to keep the bowels freely open twice or thrice a 
 du}- ; enjoin perfect quiet ; and put the patient upon ver_y short commons. Diuretics 
 are also very proper when the urine is not plentiful without them. 
 
 1: ou will often have to contend against the ignorance and impatience of the sick, 
 or of their friends, on these occasions. Thoy think that ivcakness is to be remedied 
 by sircagthcning food ; by naeat and drink, and tonic medicines ; or if they are not 
 so foolish as this, they will want to be electrified, or lo be put into a warm bath. 
 Certainly in the earher states of the palsy that remains a'ter apoplexy, none of those 
 measures ought to be permitted. If, after some time, when all febrile action has 
 ceased, the palsy seems stationary, it may be warrantable and right to attempt to 
 stimulate the torpid nerves, and to accelerate the acquirement of power by the mino
 
 332 SPINAL HEMORRHAGE. 
 
 over the muscular contractions ; but when any means for attaining these objects are 
 employed at all, they must be used with the utmost caution ; for they are much 
 more likely to stimulate the vascular system, and so to do harm : or even to n^new 
 the apoplectic attack. Electricity, and strychnia, are the remedies most relied upon". 
 In cases of long-standing palsy, it may also, no doubt, be proper to try to awaken, 
 by stimulating frictions, the dormant powers of the muscles, which by protracted 
 inaction becomes forgetful, as it were, rather than incapable, of their natural otfice : 
 and in these old cases we sometimes are able to benefit our patient's condition by the 
 cautious exhibition of some of the preparations of iron. 
 
 I 
 
 LECTURE XXXI. 
 
 Spinal Hemorrhage. Paraplegia. Facial Palsy and Facial Ansesthesia ; their 
 Symptoms, Prognosis, and Treatment. Other Forms of Local Paralysis, and 
 Local Anxsthesia. 
 
 I HAVE done with apoplexy as it respects the brain ; which is the same thing as to 
 say that I have done with apoplexy. You will find the same term applied, indeed, 
 to effusions of blood in other organs of the body ; but this use of the word is a per- 
 version of language. Apoplexy, as I have frequently observed before, is the abolition 
 of the functions proper to the brain; of sensation, voluntary motion, and thought. 
 In short, it is coma, coming on under certain circumstances. 
 
 I shall not speak therefore of spinal apoplexy (though that would be less improper 
 than pulmonary apoplexy, or hepatic apoplexy), but of spinal hemorrhage. Of 
 this I really have little to say, except that it is well known occasionally to occur ; and 
 that the symptoms to which it gives rise are by no means peculiar or distinctive. 
 They consist of pain in some part of the spine ; compulsions ; palsy ; that is, they 
 are the very same symptoms which inflammation, softening, mechanical injury, and 
 other disorders of the same part may produce. Spinal hemorrhage is much more 
 rare than cerebral hemorrhage. Dr. Abercrombie had met with only one case of it. 
 He gives the heads of seven others which have been recorded by different authors. 
 Dr. Bright has never seen it: but he publishes the particulars of one case, which 
 were communicated to him by Dr. Stroud. 
 
 I will read you one or two short examples of spinal hemorrhage, as specimens. 
 A girl, fourteen 3'ears old, was attacked with headache, /)f/m in the back, and a ten- 
 dency to sickness in the erect posture. At the end of a week the pain in the back 
 became suddenly and very greatly aggravated ; and this was followed by general 
 convulsions, which proved fatal in five or six hours. The spinal canal was found 
 filled with extravasated blood, in the lumbar region, where she had felt the pain. The 
 brain and all the other viscera were sound. The case is detailed by JVIr. Chevalier 
 in the third volume of the Medico-Chirurgical Transactions. 
 
 Take one more instance from OUivier, whose work on the spinal marrow you may 
 read hereafter, when you have leisure, with advantage. 
 
 A. gentleman, aged sixty-one, had just arrived in Paris after a long journey, when 
 he was seized with pain of the back, all the way down from the cervical vertebrce 
 \o the sacrum. In the course of a few hours he became paraplegic, and was unable 
 to retain his urine or feces. He then sent for a physician, and died while talking to 
 liim A very extensive extravasation of blood was found in the spinal canal, beneath 
 the membranes of the cord. The lower part of the canal was filled with a bloody 
 mass, in which the substance of the cord could not be distinguished. Above the 
 ih'rd dorsal vertebrae the cord was entire, but of a deep-red colour, and very soft. 
 
 The suddenness of the symptoms may lead you to suspect the true nature of 
 these cases ; but I cannot pretend to point out any other feature by which they may 
 be distinguisnea from other morbid conditions of the spine, already spoken of. T 
 show vou one prejiaration ; of which, however, I do not know the history.
 
 PARAPLEGIA. 333 
 
 I have nothing to add, to what I have already said, respecting that species of palsy 
 which is called" hemiplegia : and I have only a very few further observations to 
 make in regard to paraplegia. 
 
 The cause of this kind of palsy is sometimes obvious ; sometimes most obscure. 
 If we find, in the spinal canal, blood effused, softening of the substance of the cord, 
 traces of inflammation of its investing membranes, tumours pressing upon it, pressure 
 from disease or displacement of the bones, we have a sufficient explanation of the 
 paralysis of those parts of the body, the nerves of which come from the spinal 
 marrow at or below the place of the disease. There are three preparations on the 
 table of tumours that pressed upon the cord ; scrofulous tumours I believe they are • 
 each of the three persons from whose bodies they were respectively taken was more 
 or less completely paraplegic. 
 
 But in very many cases we detect no alteration that seems adequate to explain the 
 paraplegia. The palsy creeps on slowly and insidiously, without any particular pain, 
 or violent symptoms : there is no tenderness or bending of the vertebras. The 
 weakness commences mostly in the legs, which appear to the patient heavier than 
 usual, and of which the healthy sensations are often perverted. The toes tingle, or 
 are numb : he experiences a feehng in them as if a number of ants were crawling 
 on the skin. This is so common a circumstance as to have given a name to the 
 symptom, formication. The patient straddles as he walks. His legs are lifted 
 awkwardly, the toes being often the last part to quit the ground : they are then flung 
 obhquely forwards and outwards, and the feet flap doAvn heavily and uncertainly at 
 every step. By degrees the weakness of the lower limbs increases : the palsy 
 creeps upwards, affects the bladder and rectum, at length invades the arms, and 
 ultimately the patient dies : yet very faint traces of disease, or no traces at all, may 
 be visible upon inspecting the brain and spinal cord. The commonest morbid con- 
 dition is softening of some portion of the cord ; and this is also the condition which 
 is the most liable to be overlooked. 
 
 Very recently I had a patient with these symptoms in the Middlesex Hospital. 
 He went out contrarily to my wishes ; he was discharged, in fact, by mistake : he 
 took refuge in St. Bartholomew's, where he died after a few days. I have been 
 informed that serum was found beneath the arachnoid, and that the whole brain had 
 a wasted appearance ; but nothing satisfactory was made out. The palsy had by 
 slow degrees ascended from his legs to his arms ; he had had no head symptoms 
 beyond some occasional confusion and vague uneasy feelings there. At this 
 present time a patient in a similar condition comes to the hospital every Thursday, 
 dragged by a friend in a hand-chair. He looks very well in the face, but is help- 
 less below. 
 
 It is in these cases that you may expect to witness the very remarkable pheno- 
 mena which I mentioned before as evincing the separate existence of a " true spmal 
 marrow," distinct from the brain and its prolongations into the spinal canal, endowed 
 whh special and peculiar properties, and performing functions that are independent 
 of sensation, of consciousness, and of the will. If you pinch or tickle the surface of 
 the paralytic members, or apply a hot spoon to the sole of one foot, the limbs will, 
 in many cases, start up and move strongly, not only without any voluntary effort on 
 the part of the patient, but in spite of him; or even (in those instances in which 
 there is anaesthesia as well as palsy) without his knowing it. The legs often spring 
 up of their oivn accord as it seems ; but, no doubt, the apparendy spontaneous 
 movement is frequently an excited movement, and takes place in obedience to the 
 lavv that governs the automatic motions of the body. Some impression, made first 
 upon the peripheral extremities of afferent nerves, runs through the nervous arc of 
 communication, and exhibits its uUimate effect at the extremities of the corresponding 
 efferent motor nerves. We can imagine many such accidental and unsuspected 
 sources of excitement ; a casual touch, the varying contact of the bed-clothes, the 
 bite of a flea, for aught I know to the contrary, may suffice. Even the passage of 
 faeces or of flatus along the lower bowel, or of urine through the urinary passages, 
 may be enough (as we are taught by unquestionable, facts) to produce these move
 
 334 PARAPLEGIA. 
 
 ments. They are more readily excited, cssteris paribus, in proportion as tlie inter- 
 fering- influence of the will is more completely cut off. 
 
 I knew a gentleman, who had retired from the medical profession, and who, 
 though not paraplegic, laboured, I believe, under some morbid condition of the spine. 
 He had been, in early life, a hard drinker, and had suffered dehrium tremens. Every 
 night, sometimes more than once or twice, the trunk of his body, and all his limbs, 
 became for a while fixed and stiff, from rigidity of the muscles. A few days before 
 his death, he told me this curious fact. Whenever he scraped his shoes on thf. 
 scraper at the door, his leg flew up, with a spasmodic suddenness from the iron, not- 
 withstanding his endeavour to prevent it. He died suddenly. I believe he was 
 found dead in his bed. 
 
 In some cases of paraplegia involuntary retractions of the palsied limbs can be 
 excited ; in some cases they cannot. When the influence of the cerebrum is quite 
 excluded by the operation of disease affecting the spinal cord itself, then is the sus- 
 ceptibility of excited movements the most lively. But the increased susceptibility 
 Avhich has this inverse relation to the voluntary power, is limited to that portion of 
 the body, the nervous arcs belonging to which lie beyond the seat of the disease ; 
 more distant, I mean, from the brain. Hence it follows that we may determine, 
 approximately, the place of the disease, by the test of these reflex actions. The 
 mischief may be situated, or may extend, so low down, that there are no unin- 
 terrupted nervous arcs below it. Supposing it to lie as low as, or to reach, the com- 
 mencement of the Cauda equina, we should have no involuntary movements. 
 Conversely, when no involuntary movements can be excited, the spinal disease is, 
 at least, as low as the upper lumbar vertebrae. Thus, I say, we have another mode, 
 in addition to those pointed out in a former lecture, of determining, in a given 
 case of spinal palsy, whereabouts, or to what extent, the cord is implicated in the 
 disease. 
 
 We do not so often observe these reflex movements in cases of hemiplegia ; 
 apparently for this reason, that in hemiplegia the sensorial influence is not, usually, 
 so completely shut out as it is apt to be in paraplegia. Yet I have seen some of 
 these phenomena in several hemiplegic patients. One of them, whose right hand 
 and arm were quite passive under the strongest efforts of his will to stir them, took 
 notice himself, as did his nurse, that whenever he yawned and stretched himself the 
 lingers of the palsied hand participated in the action, and were thoroughly extended : 
 and I could, by tickling the sole of his foot, excite some starting of the leg, long 
 before any power of voluntary movement returned. 
 
 Emolion has sometimes the same singular effect upon limbs and muscles over 
 which volition has no dominion whatever. An artist with whom I am acquainted, 
 and whose arm was almost completely powerless after a recent attack of paralysis, 
 do that no effort of his will sufficed to raise it from his side — was one day startled, 
 as he Avas hobbling across a road, by the unexpected approach of a carriage. He 
 noticed, with wonder, that during his endeavours to get out of the way, the palsied 
 arm was' suddenly jerked up above his head. But he could not again lift it there 
 after the fright was over. 
 
 Paraplegia has been ascribed to some primary morbid condition of the nerves 
 which belong to the spinal cord. That the functions of the efferent, or motor, nerves 
 may be impaired, and even arrested, by exposure to cold, and by other injurious 
 mfluences, is both possible and probable. But a diseased or disordered state c/ the 
 afferent nerves has been assigned as a cause of the palsy. This is less clearly con- 
 ceivable. Coexisting disease of the kidneys, and coexisting enteritis, have been 
 thought suflicient to produce and keep up a paralytic condition of the lower limbs. 
 Tne extremities of certain incident nerves being affected, a morbid impression is 
 transmitted to the cord, suspensive of its central function. The efforts even of voli- 
 tion, which come from the brain, are no longer successful. Such is the theory. I 
 <lo not say it is an erroneous theory ; but I am bound to tell you that I think it 
 un proven. Mv own experience has furnished me with no facts which go to 
 support it. 
 
 Do not forget the imponant fact that, in many, nay, in most cases of paraplegia,
 
 PARAPLEGIA. 335 
 
 the urine at length becomes ropy, alkaline, and stinking ; and that the bladder, after 
 ieath, presents appearances such as chronic inflammation might produce; rough- 
 ness and redness of its inner surface, and thickening of its coats. What may be the 
 order and relation of these changes, I confess I do not know : whether the quality 
 of the urine is first altered, and then the bladder suffers from the perpetual contact 
 of this unnatural secretion ; or whether the bladder becomes diseased in consequence 
 of the palsy, and pours forth unhealthy mucus, whereby the quality of the urine is 
 afTected; has not, I believe, been clearly ascertained. The minute particulars of 
 such cases require more careful investigation than they have hitherto received. In 
 support of the latter proposition I have heard the following facts affirmed. The 
 urine voided being alkaline, the bladder was washed out by the injection and with- 
 drawal of warm water. Then the next portions of the urine that descended from the 
 kidneys were immediately removed and tested, and found to be acid. So also, after 
 death, the urine has proved to be alkaline and mucous in the bladder, acid in the 
 pelvis of the kidney. But in other instances of paraplegia, the urine is said to have 
 been secreted alkaline. Disease, in these last cases, may perhaps have been propa- 
 gated from the bladder, backwards. Or the disorganization of the bladder, and the 
 alkaline quahty of the urine, may both have been common results of the interruption 
 of the nervous influence. I would suggest to you to inquire, whenever opportunities 
 occur, at what period of the spinal disease or injury the urine began to be secreted 
 alkalescent. 
 
 We have reason to believe that the defect in some of these cases of paraplegia is 
 merely functional : independent, I mean, of any such change in the nervous matter 
 as is cognizable by our senses. It may be brought on by various causes : by cold ; 
 by intemperance in drinking ; by excessive sexual intercourse : or, still more surely, 
 by self-abuse. I have had the last cause assigned to me voluntarily by patients 
 themselves. In such cases we may presume that the loss of function is confined to the 
 spinal marrow. But there is another way in which paraplegia may be accounted 
 i"or, although its physical cause is very liable to be overlooked. It may result from 
 serous eflusion into the spinal canal ; which efllision may have originated there, or, 
 what seems sometimes to be more probable, may have been poured out within the 
 cranium., and descended by the force of gravity to the lower part of the cavity of 
 the spine. Dr. Baillie read a paper on this subject before the College of Physi- 
 cians : it is contained in the sixth volume of the Medical Transactions. He was 
 not the first person to whom this mode of explaining certain obscure cases of para- 
 plegia suggested itself; but he was the first I beheve who published upon it. This 
 eflusion may very readily be overlooked. Commonly the brain is examined first ; 
 and no great attention is paid to the escape of fluid from the vertebral canal. It 
 would be better to lay open the spinal cavity first, at its lowest part, and to puncture 
 the iheca, and then to observe what quantity of fluid runs out when the body is 
 placed upright. I'here shoidd be a certain quantity : but if much serum so escaped, 
 we might conclude that it had existed in hurtful abundance during life, and had 
 caused the paraplegia. In most of these obscure cases you may trace some head 
 symptoms ; giddiness, transient confusion of thought, loss of memory ; and it really will 
 be worth your while to make the examination in the way I have pointed out, when- 
 ever you have occasion to inspect the body of a patient who has died paraplegic. 
 
 I regret very much that I had not the opportunity of doing this in the case of the 
 man whom I had been for some time watching in the hospital. 
 
 Cases, such as I have now been describing, are by no means uncommon. They 
 are usually slow and tedious; and you will be called upon to administer to their 
 relief. 1 need not repeat the caution which I have several times given, in respect to 
 the condition of the bladder; you must take care that it does not become over dis- 
 tended with urine ; and you must enjoin strict attention on the part of the nurse as 
 to keeping the patient clean and dry. Friction along the course of the spine ; blis- 
 ters to the loins or sacrum, frequently repeated ; issues; and electricity: all these 
 means you will generally have opportunity enough for trying, and for regretting 
 their mutility. In such cases it may sometimes be warrantable and proper to employ 
 strj'chnia ; a poison which mainly affects the spinal cord, causing, when given jn h
 
 336 FACIAL PALSY. 
 
 sufficient dose, tetanic spasnas of the limbs, with very little o no affection ol the cen 
 soriuni. I have heard of some striking instances of recovery from paraplegia uudei 
 the exhibition of this drug. I wish I could tell you that I had ever seen such. Let 
 me caption you against its indiscriminate use ; or rather its abuse. No good can 
 reasonably be expected from it, but much harm, unless the cord be free from orsjanic 
 disease. Even then I would not advise you to begin with a stronger dose of strych- 
 nia, or of the sulphate of strychnia, than the twelfth part of a grain every six hours : 
 this may be gradually and cautiously increased, until it gives rise to tvviichings of the 
 hmbs, or to some other obvious effect. The twitching is usually confined to the 
 palsied limbs. This shows that it results from the agency of the remedy upon the 
 excito-motory system, or true spinal marrow ; of which the reflex function is always 
 more readily excited when the sensorium has lost its customary controlling power. 
 When this symptom occurs, you had better go on with the same dose ; it would be 
 unsafe to increase it : and the progress of the case will soon inform you whether 
 any benefit is likely to accrue from a continuance of the medicine. The out-patient 
 now attending has taken the strychnia. It made the palsied hmbs start and extend 
 themselves ; but no permanent power has been gained. 
 
 There is one other drug which I should recormnend you to try in such cases, viz.; 
 the tincture of cantharides. It certainly has sometimes a very beneficial effect 
 Generally, w'hen it does good, it acts as a diuretic ; and Dr. Seymour has thrown 
 out a suggestion that it is most likely to be useful in those cases of serous effusion 
 into the spinal cavity, of spinal dropsy, which I just now described. He record- 
 mends the tincture as a good diuretic in several forms of dropsy : and supposes that 
 it benefits paraplegia by tending to produce absorption of the serum effused \v:thin 
 the vertebral canal. 
 
 Moreover, there is another principle upon which this medicine may be sometimes 
 advisable. Cantharides are well known to have a pecuhar effect upon the bladder; 
 which effect is doubtless produced through the corresponding part of the spinal 
 cord. If, by means of the Spanish fly, we can excite, though but from time to time, 
 the function of that part, we may obviate, in a great degree, the distressing conse- 
 quences of incontinence of urine, arising from paralysis of the sphincter vesicsc. 
 Dr. Marshall Hall relates a very interesting fact, bearing directly upon this point. 
 A young lady had a tumour within the tenth and eleventh dorsal vertebrce. It 
 gradually, but completely, severed the spinal marrow, and induced perfect para- 
 plegia. The bladder lost its power of retention. But on giving a dose of the 
 tmcture of cantharides, the power of retaining the urine was always restoredybr the 
 time. That power would cease, and again be restored, on suspending and repeating 
 the medicine. 
 
 Dr. Hall remarks that the cantharides obviously acted through the segment of the 
 excito-motory system left below the division of the spinal marrow. 
 
 The tincture may be given in half-drachm doses. 
 
 The forms of paralysis that have hitherto been noticed are forms oi partial para- 
 lysis. y\ hen the palsy is still more limited, although the epithet partial would be 
 equally applicable, the term local palsy is more commonly used. There is one of 
 these local palsies which is exceeding interesting, and of much importance : I mean 
 palsy as it affects, exclusively, one side of the visage : facial palsy. It is sometimes 
 called, not very correctly, paralysis of the portio dura of the seventh nerve. The 
 most common kind of facial palsy is indeed paralysis of the muscles supplied by 
 that nerve. But the word paralysis is misused when it is intended to express any 
 other loss of function than that of the faculty of motion in muscular pans. It is 
 incorrect to speak, as some authors do, of palsy of the kidney ; it is equally inexact 
 to speak of palsy of a nerve. 
 
 I say that facial palsy, and facial anassthesia (for the two should be considered 
 •ogether), are very interesting affections, because they elucidate, in the human 
 subject, some of the most curious speculations of modern physiology : and they are 
 important affections for you to study and understand, inasmuch as, though always 
 ilislressful and alarming to the patient and his friends, and sometimes, indeed, in-
 
 FACIAL PALSY. 337 
 
 dicative of extreme danger, they often are merely inconvenient and disfiffurino-, and 
 bespeak no peril at all. 
 
 Let us first consider that affection in which the majority of the muscles on one 
 side of the face alone are palsied. I have already briefly touched upon this form 
 of palsy when it constitutes a part of hemiphlegia. But it is of more consequence 
 ■to attend to it when it occurs without any similar afl^ection of the limbs. If the arm, 
 or leg, or both, are paralyzed at the same time with one side of the face, we know 
 that the whole results from disease in the brain, or in the upper end of the spinal 
 cord. But it is not necessarily so when the face alone is palsied ; and it is often of 
 great moment to the comfort and the safety of the patient, that we should be able to 
 tell whether the palsy does imply disease within the skull, or not. 
 
 The appearance presented by patients affected with facial palsy is peculiar, and 
 very striking. From one half of the countenance all power of expression is o-one ; 
 the features are blank, still, and unmeaning. The other half retains its natural 
 cast, except that, in some cases, the angle of the mouth on that side seems drawn 
 a little awry. This is apt to be mistaken for proof of a spasmodic condition of 
 that part; but it is owing simply, as I stated before, to the want of the usual 
 balance or counterpoise from the corresponding muscular fibres of the palsied 
 side. The patient cannot laugh, or weep, or frown, or express any feeling or 
 emotion with one side of his face, while the features of the other may be in full play. 
 One half of the aspect is that of a sleeping, or of a dead person : the other half is 
 alive and merry. Tha incoJigruity would be ludicrously droll, were it not so 
 frightful also, and distressing. To the vulgar, who do not comprehend the pos- 
 sible extent of the misfortune, the whimsical appearance of such a patient is 
 always a matter of mirth and laughter. On the other hand, his friends and rela- 
 tions imagine that he has had a fit, and are in great alarm for his life. In th^ 
 majority of these cases there is not, however, any real danofer of that kind to be 
 apprehended; a circumstance which, of itself, would render the exact diagnosis 
 of the complaint peculiarly interesting. In general there is no deficiency of sen- 
 sation. And, vice versa, we sometimes have loss of sensibility in the same parts, 
 without any diminution of the power of motion. The best way, I believe, to 
 place the phenomena of these curious affections plainly be tore you, will be by 
 examples. 
 
 A housemaid, Jane Smith by name, twenty-eight years old, became one of my 
 out-patients at the Middlesex Hospital, with the following symptoms. She had lost 
 all power of moving the right side of her face. When she endeavoured to raise 
 her eyebrows, the right side of the forehead remained smooth, and the left was 
 wrinkled. When she attempted to close her eyes, the right eye was but partially 
 covered, the eyeball rolling upwards, and carrying the cornea within the curtain 
 of the upper lid, which descended a little to meet it. When she tried to snuff in 
 air through the nose, not being able to keep the right nostril stiff and open, its sides 
 came together, and no air passed up on that side. ""When she smiled, the right side^ 
 of the face remained perfectly still, like a mask : and it wore at all times a vacant 
 and inanimate character. When she was told to perform the action of blowing, her 
 right cheek was puffed out like a loose bag, and the breath issued, whether she 
 would or no, at the right angle of her mouth. The same thing happened with hep 
 food and drink ; she could not prevent their escaping at the right corner of her 
 mouth : nor could she convey morsels of food from the'right to the" left jaw, without 
 the aid of her hand applied externally in support of the paralyzed cheek. The 
 masseter and temporal muscles, however, acted as strondy on the one side as on the 
 other; she could chew perfectly well on the palsied side, and the sensation of the 
 palsied parts remained perfect ; and there was no paralysis of any other part of th'« 
 body. 
 
 All these phenomena are invariably met with in all complete cases of tnis Kmd. 
 r will contrast them with the phenomena presented by another of my patients 
 who was. in the hospital, and whose name was Ann Church. I give their names, 
 that I may the more readily distinguish the one from the other. AVhen this 
 *-oman. Church, applied for admission, she complained of intense pain, witb 
 22 2d
 
 338 FACIAL PALSY. 
 
 some swelling in the right temple, and extending thence generally over the right 
 side of the face and head. It was soon discovered, however, that although she 
 complained of most severe pain in these parts, they had entirely lost their ordinary 
 sensibility to external impressions. She felt nothing when her forehead, or cheek, 
 or nose, or chin, was touched on that side. In short, there was complete wixs- 
 thesia of the right half of the face; just as in Smith's case there was complete 
 pahy. The insensibility was very exactly limited to the right half, and termi- 
 nated ahruptly at the middle line. It was remarkably evident in a part in respect 
 to which the bj'standers could scarcely be deceived, even if there had been any 
 reason (which there was not) for distrusting the patient's own statement. The 
 surface of the ej'eball is proverbially sensitive, even to sHght impressions. But 
 you might place your finger upon this woman's right eye, or you might brush it 
 with a feather, without giving her the smallest pain, or producing any sensation at 
 all: whereas, on the left side, the lightest touch caused involuntary shrinking, 
 and closure of the eyelids, and. a gush of tears. She declared also that she had 
 no feeling in the right half of her mouth ; she neither tasted sapid substances, nor 
 was she at all conscious, from any sensation produced by them, that they were 
 placed there. Her lips on the same side, were equally destitute of sensibility ; 
 so that when she drank, having no perception of the contact of the cup with her lips 
 beyond their middle point, she felt as if she Avere drinking from a vessel with a 
 broken rim. This is a circumstance which all persons who are thus affected are 
 much struck with : and it almost always forms a part of their voluntary account 
 of themselves. 
 
 Besides this defect of sensibihty, the power of contracting the masseter and tem- 
 poral muscles on the right side was entirely abolished in this patient. You may 
 deceive yourselves on this point, if yon do not investigate it carefully, and with 
 certain precautions. At least I have known persons doubt, because, having directed 
 the patient to open and shut his mouth, they hav^e confounded the movement of the 
 w^hole jaw with the action of the masseter muscle. But if you tell the patient first 
 to close his mouth, and then to perform the action of grinding with his teeth, 
 placing your fingers at the same time on the corresponding muscles on each side, 
 the difference, when it exists, will be very striking. In the woman of whom I 
 speak, no swelling of the masseter or temporal muscle on the affected side took place 
 when she forcibly closed her jaw^s. There was no other paralysis. 
 
 Now wf cannot separate the physiology from the pathology of such affections as 
 these. Nor ought we. The morbid conditions of which the two cases just de- 
 scribed furnish samples, illustrate in a very beautiful manner the modern doctrine 
 respecting the special uses of particular nerves. In the first of the two cases the 
 palsy resulted from suppression of the function of the hard portion of the seventh 
 pair of cerebral nerves ; and the anteslhesia, in the last of the cases, depended upon 
 suspension of the function of the fifth pair. You know the experiments performed 
 upon living animals have proved that the division, by the scalpel, of the portio dura, 
 before it spreads out into that remarkable nervous net-^vork on the side of the face, 
 paralyzes all the muscles the combined play of which gives varietj' and significant 
 expression to the countenance ; and that, on the other hand, the division of the fifth 
 nerve deprives the same parts of their sensibility. In these two cases, and in such 
 as these, for they are by no means infrequent, a similar set of experiments upon the 
 same nerves, in "the hi/man living body, is performed before our eyes by the agency 
 of the disease, or accident; and the result justifies most completely those conclusions 
 which had been deduced in the first instance, from contrived observations made upon 
 the lower animals. 
 
 There is one point in the history of these cases upon which I must dwell a mo- 
 ment longer; for it is a most interesting point. That the condition of the temporal 
 and masseter muscles should be reversed in two patients so oppositely situated, was 
 no more than might have been expected. But in each these muscles were affected 
 in a manner the very contrary of that which the general circumstances of the case 
 •vould, a priori, have prepared us to anticipate. Where the superficial muscles 
 were paralyzed, and the principal movements of the face suspended, there the mas-
 
 FACIAL PALSY. 339 
 
 seter and temporal muscles were in full power and action ; and where the loss of 
 st'usation was the predominant phenomenon, and the ordinary motion and expression 
 of the countenance remained, there these muscles were in a slate of complete palsy. 
 A few years only ago, this difference and apparent inconsistency would have been 
 quite inexplicable. The progress of modern science has removed the difficulty, by 
 establishing a general agreement between the functions of different nerves, and cer- 
 lain observed peculiarities in their anatomical relations and arrangements. 
 
 Suffer me to remind you (for I know that these interesting points of physiology 
 must have already been taught you) that the nerves which proceed from the spinal 
 column on each side are connected with it by two fascicuh of nervous fibrils — two 
 roots, as they are metaphorically called — of unequal size ; that when the larger of 
 these, which is situated posteriorly, and is furnished with a ganglion, is divided in a 
 living animal, the parts to which the nerve is distributed lose the faculty of sensa- 
 tion, while the power of voluntary motion remains unimpaired ; and that when the 
 smaller and anterior, which has no ganglion, is alone cut, the same parts are instantly 
 palsied, but retain their sensibility. In other words, the posterior fascicuh minister 
 to the faculty of sensation, the anterior to that of motion. 
 
 Now the fifth pair of nerves was observed to have a similar origin ; to be com- 
 posed, that is to say, of two fasciculi or roots, one larger than the other, and invested 
 with a ganglion ; the other smaller, and having no ganglion. It was natural to infer 
 that the function of these roots would be analogous to those of the corresponding 
 portions of the spinal nerves ; that the ganglionic fasciculus would relate to sensa- 
 tion, and the other to motion. And such is found to be the case ; and the arrange- 
 ment here is very curious. The smaller portion of the fifth nerve is exclusively 
 expended upon a very few muscles ; viz., the masseter, the temporal, two pterygoid 
 muscles, the circumflexus palati, and the tensor tympani. The action of the first 
 two of these, of the masseter, and temporal muscles, is obvious to common observa- 
 tion; and therefore their condition is noticed in such cases as I have related. 
 Again, these very same muscles have been shown, by careful dissection, to receive 
 no nervous branches from the seventh nerve, which is a motor nerve, and which 
 ramifies so abundantly upon the superficial muscles of the face- 
 It was to be expected, therefore, that any diseased state confined to the portio dura 
 of the seventh nerve, would leave the temporal and masseter muscles fully effective: 
 and that disease involving the fifth nerve, but leaving the seventh untouched, would 
 destroy, not only the general sensibihty of the face on that side, but also the power 
 of contracting these particular muscles. And this was thoroughly exemplified in the 
 two cases that I have detailed. The girl Smith had total palsy of the superficial 
 muscles ; but sensation, and the action of the deeper-seated muscles, continued per- 
 fect: while in the woman Church there were default of sensibility, and paralysis of 
 the temporal and masseter muscles : but the movements of the superficial muscles 
 were unimpeded. 
 
 Total interruption of the function of the portio dura will paralyze these superficial 
 muscles of the face : and such interruption may be occasioned either by sudden 
 injury done to the trunk of the nerve ; or by disease affecting its proper structure ; 
 or by pressure, the consequence of disease in the parts contiguous to it. And it is 
 of great importance to observe that the morbid condition which causes the interrup- 
 tion may be situated in any part of the course of the trunk of the nerve : while it is 
 yet within the cranium ; or during its passage through the petrous portion of the 
 temporal bone ; or after it emerges upon the face, through the stylo-mastoid foramen, 
 to be ultimately spread in meshes over the cheek and temple. The nerve is often 
 compressed or hurt while still within the skull ; but in most cases of this kind other 
 portions also of the nervous matter are involved in the mischief, and other sets of 
 voluntary muscles testify this by their immobility or their irregular action. This is 
 sometimes the case when facial palsy occurs as a part of hemiplegia. In many 
 instances, however, of hemiplegia, there is but slight distortion of the countenance, a 
 mere hanging of the cheek, with no paralysis of the orbicularis muscle of the eye» 
 In these cases, it has been suggested to me by my colleague. Dr. Todd, that the 
 ♦seventh nerve is probably not affected at all, but the motor branch of the fifth nerve
 
 340 FACIAL PALSY. 
 
 only. When ihe facial muscles alone are paralyzed, it happens in a great majority 
 of instances that the nervous function is interrupted in that part of the portio dura 
 which Hes incased in the bone, or in the more exposed part which issues in front of 
 the ear : and hence it arises that this particular form of palsy is, in general, unat- 
 tended with any danger to life. 
 
 The physical cause of this remarkable disfigurement, and the true explanation of 
 its prevailing immunity from danger, were first pointed out by Sir Charles Bell: 
 but both the existence of the malady as a distinct form of disease, and its compara- 
 tive hannlessness of character, had been observed and described some years previ- 
 ously : although the reason neither of the one nor of the other was at that time 
 understood. Dr. Powell had narrated, in the fifth ^volume of the Transactions of 
 the College of Physicians, three marked instances of this form of local palsy; and 
 had noticed at the same time its apparent independence of any apoplectic tendency, 
 or cerebral disease. 
 
 The exciting causes of the complaint are various. Sometimes it is the conse- 
 quence of mechanical violence, by which it is plain that the nerve has been lace- 
 rated, or otherwise injured. Sir Charles Bell, to whom we are indebted for much 
 information on the subject, mentions several examples of this kind. In one a man 
 was shot by a pistol-ball, which entered the ear and tore the portio dura across at its 
 root. In another, the patient was gored by an ox ; the horn of the animal entered 
 beneath the angle of the jaw, and came out in front of the ear, tearing the nerve 
 across. In a third, the nerve was divided by a surgeon's scalpel, in an operation 
 for the removal of a tumour which lay above and around its course. In all these 
 cases the injury was external and obvious. In a fourth the palsy followed a blow 
 on the ear which caused hemorrhage from that part : here probably the nerve was 
 hurt in its passage through the bone. Some time ago, a man was brought into the 
 Middlesex Hospital who had fallen from a height, upon his head. The muscles of 
 the left side of the face were paralyzed. He died in a few days ; and examination 
 of the head showed a fracture in the base of the skull, passing through the petrous 
 portion of the temporal bone, and rending the seventh nerve at its entrance into the 
 meatus auditorius internus. In the year 1832 I had a patient (Richard Hills) in the 
 hospital with the same kind of paralysis, which seemed, in him, to have been occa- 
 sioned by a mere shock or jar. He was a coachman, and one day, when he was 
 ofThis box, his horses started away, and he ran to their heads to stop them, but was 
 thrown down in the attempt, striking his hip and elbow. He received no blow on 
 the head at all. Three hours afterwards he found that he could not spit properly. 
 The affection is not unfrequently discovered by that circumstance. He could not 
 avoid spitting on his clothes on one side ; and he could not whistle. Another cir- 
 cumstance worthy of notice took place in this man, which often, though not always, 
 happens in these cases, and which I did not mention before. He remained for about 
 two months in the hospital ; and regained, during that time in some degree, the 
 power of exercising the affected muscles ; but he still was unable to bring the ri^ht 
 eyelids together. The eye itself was unharmed. After he was made an out-patient 
 he resumed his functions on the coach-box ; and his eye, permanently half-open and 
 unprotected, was more exposed to cold and to currents of wind than it had been 
 when he was an in-patient. Moreover, he got drunk ; and he soon presented him- 
 self again with universal redness and inflammation of the conjunctiva. Sometimes 
 the inflammation in such cases produces opacity of the cornea and a total loss of 
 vision. This is one of the worst consequences of facial palsy. Fortunately it is 
 only an occasional consequence : and it will occur or not, according to the quantity 
 of motion which remains to the eyelids, and the degree of exposure to the ordinary 
 causes of inflammation. 
 
 Sometimes the palsy depends upon manifest external disease ; sometimes upon 
 disease which is hidden, and probably internal, in the bony canal. Sir C. Bell 
 describes an instance in which it accompanied the disorder called the mumps. Dr. 
 Maiden, of Worcester, witnessed another in which a fixed, hard, indolent tumour 
 had formed between the ramus of the lower jaw and the mastoid process of iho 
 temporal bone. As this tumour gradually subsided, the palsy disappeared. In pnc]»
 
 FACIAL PALSY. 341 
 
 of Dr. Powell's three cases the affection was apparently caused by exposure of the 
 side of the head for some time to a stream of cold air. A medical acquaintance of 
 mine residing in London, had a patient at Greenwich, whom he visited daily. It 
 was cold weather ; and on one occasion, as lie was returning in the cabin of a steam- 
 boat, he was sensibly incommoded by a keen east wind, which blew through an open 
 window directly upon his ear. The next day he presented himself to me with that 
 side of his face fixed in the manner I have been describing. Exactly the same 
 mishap befell a Scottish physician while travelling to London by a coach ; and sent 
 him in great alarm to Sir C Bell. Some years ago a marked example of facial palsy 
 occurred in one of my hospital patients ; it appeared to be owing to his having been 
 constantly in the streets for some days without shoes or stockings, during a cold thaw. 
 It may be presumed that in these instances some swelling was produced in the soft 
 parts around the nerve, compressing it where it lies within the unyielding bone. 
 Exposure to cold in this way is the commonest of all the exciting causes of the com- 
 plaint, and cases thus arising are more obedient to treatment than most others. Pro- 
 bably some of you saw a female patient who came under my care in the hospital in 
 May last (1838), in Avhom facial palsy had existed on one side for eighteen years. 
 When about three years old she had the measles ; and a scrofulous tumour formed 
 behind the ear, and broke ; and after some time, a portion of carious bone came 
 away. Then the wound healed (of which deep traces are still visible) ; and the 
 peculiarity of her features was observed. There are still other cases in which we 
 fail to discover any direct explanation of the paralysis, either in the history of the 
 patient, or in his physical condition. In the girl Smith, whose symptoms I stated 
 in detail as an example of the appearances uniformly present, the malady came 
 on without any obvious cause, and it resisted all the means employed for its 
 removal. 
 
 That the greater number of cases of this kind are free from serious peril, is a fact 
 of great practical importance. It enables us to quiet the alarm of the patient and of 
 his family: and it regulates in many instances the treatment; rendering it less 
 severe tjian it might and ought to be, if the palsy were really the harbinger of apo- 
 plexy. At the same time you should not be ignorant that a similar limitation of 
 paralysis to the particular muscles supplied by the portio dura is sometimes (tnough 
 rarely) observed, when the disease has a more inward origin ; when it affects and 
 involves the brain itself. The following case caused me much anxiety, for the sub- 
 ject of it was a personal friend of mine. — I was summoned to his house in the 
 autumn of 1820, and found him with complete palsy of the left side of the face. It 
 had existed a day or two. I shall not describe the appearances and symptoms that 
 resulted from the paralysis ; for they were precisely the same as were presented by 
 the girl Smith ; and they are always, and necessarily, very much alike. But though 
 the palsy was strictly limited to this set of muscles, there were other symptoms pre- 
 sent which indicated that the interruption of the functions of the portio dura was 
 connected with some morbid condition within the cranium : nausea and vomiting, 
 twitchings of the muscles of the other side of the face, great drowsiness, and a slow 
 pulse, 48 only in the minute. He lurched also, and staggered as he walked ; but 
 he distinguished this from the reeling of vertigo, and denied the latter sensation 
 altogether. He was deaf too, on the affected side. 
 
 His previous history did not tend to diminish the fears which his actual state 
 excited. 
 
 In the preceding February he had been attacked, rather suddenly, with intense 
 pain just above the right eyebrow, and became extremely drowsy. Being desirous, 
 on account of these feelings, to excuse himself from a dinner engagement, he found 
 that he was unable to write a proper note : he could not remember how he ought to 
 express himself. 
 
 All these symptoms soon passed off; after the operation, I beheve, of an emetic. 
 But he had another attack of the same kind in the subsequent May : the same 
 severe pain over the right brow, wiih great drowsiness and confusion of mind. Ho 
 could rot recollect the first line of the ^Eneid. He wished a friend to look at the 
 signatures of some letters that had arrived : and though he knew the root, he could 
 
 3d3
 
 342 FACIAL PALSY. 
 
 1 
 
 rot tell how the word he wished to use was formed ; whether it was sionition, or 
 sig-nation, or signature. The digestive organs on this occasion were made the object 
 of treatment, and he soon got well. 
 
 There was another instructive part of his history ; and therefore I mention it. 
 Before these attacks he was in the habit of eating and drinking freely ; and his 
 power of digestion was supposed to be enormous. After the attack in May he 
 commenced a strict course of temperance. He drank no wine till three or four 
 days before the occurrence of the facial palsy: he had then taken it again, and had 
 about four glasses daily ; and on one of the days he drank two glasses of champagne. 
 
 It was of some moment to this gentleman, not only that he should recover, but 
 that he should recover quickly. He had been appointed by government to a mission 
 to Ceylon, and all his equipment was already on board a vessel, which would sail in 
 a fortnight. 
 
 Cupping behind the ears, Mistering, purgatives, and small doses of calom.el con- 
 tinued till the gums were slightly sore, removed the paralysis, and all the other 
 symptoms, in about ten days. He went to Ceylon, and performed his mission so 
 ably that after his return the government appointed him to one of far greater import- 
 ance in India, where he now is. He has remained perfectly well ; and possesses 
 one of the clearest and strongest intellects that I am acquainted with. 
 
 I must trouble j^ou with one more case, to complete the history of this disease : a 
 case in which the cause of the facial palsy was situated within the cranium and 
 proved fatal, and became visible after death. 
 
 Samuel Dobey, a tailor, fifty-seven years old, was admitted under my care into the 
 hospital, in February, 1833, with complete palsy of the muscles supplied by the 
 portio dura on the right side ; and of no others. There were symptoms enough, 
 however, to show that some serious mischief was going on within the skull. He 
 suffered intense headache, more on the left than the right side ; was dizzy and stag- 
 gering ; and could not get to the ward without being led. 
 
 The palsy had come on about ten days before, in the night. He found when he came 
 down stairs the next morning that he could not spit as usual, and his friends observed 
 the unnatural state of his features. He had had no fit, nor loss of consciousness ; 
 but he thought his memory was failing. At the time when the paralj-sis was first 
 noticed, he had some numbness and tingling of the right arm, extending to the last 
 two fingers. He was quite deaf in the right ear. This is a point deserving attention 
 in such cases. The deafness, when it occurs, marks an affection of both the por- 
 tions of the seventh nerve ; and therefore indicates the probability of an internal 
 cause. 
 
 The whole progress of this case was very interesting; but I must confine myself 
 to those circumstances which bear upon our present topic. He lived about a month 
 after his admission, and during that interval he suffered great pain in the head, 
 was delirious at times, and at other times in a state of coma : at one period he 
 suddenly presented the ordinary symptoms of apoplexy, from which he partly 
 recovered. 
 
 I found a cancerous tumour occupying the right hemisphere of the brain ; at its 
 under part was an apoplectic clot, as big as a hazel-nut. I found, also, a very satis- 
 factory explanation of the deafness and of the facial palsy which had been noticed 
 during his hfetimiC. The portio dura and the portio mollis, where they emerge as 
 distinct cords from the medulla oblongata on the right side, were adherent to each 
 other. The portio dura was both harder and larger than the corresponding nerve 
 on the opposite side, while the portio mollis was wasted and diffluent. The same 
 change was traced up to their entrance into the petrous portion of the temporal bone. 
 Immediately over the medulla oblongata, and in a vertical line above the point of 
 emergence of the seventh pair of nerves, a nipple-like portion of brain projected 
 downwards, and had apparently communicated pressure to these nerves ; and this 
 projection from the lower surface of the brain seemed to have been produced by the 
 general pressure resulting from the growth of the tumour. 
 
 The remarks which I have been applying {o palsy of these parts hold true also m 
 respect to their loss of sensibility. The anaesthesia may or may not portend danger
 
 LOCAL ANAESTHESIA. 343 
 
 to life, according as the interruption of nervous function on which it depends is 
 situated more or less near to the origin of the fifth pair of nerves in the brain. The 
 patient, Church, whose case I have several times referred to in this lecture, left the 
 hospital with the sensibihty of her face nearly as perfect as ever. The treatment 
 consisted in local blood-letting and counter-irritation. She had erysipelas of the 
 head while in the hospital, and was in some danger from that complaint, which was 
 attended with a good deal of fever and delirium. With the exception of the delirium, 
 which belonged no doubt to the erysipelas, there was no reason to suspect any affec- 
 tion of her brain. 
 
 I have incidentally adverted to the plan of treatment to be pursued in these cases 
 of facial palsy. When the complaint is recent, and has an obvious cause, the appro- 
 j)riate remedies will readily suggest themselves. When, for example, it fias come 
 on after exposure to a current of cold air, or after a blow, or any circumstance hkely 
 to give rise to inflammation, you must treat the case as you would treat inflammation ; 
 bearing always in mind that a sniall amount of disorganization, a little thickeninsf or 
 induration of the parts around the nerve, may render the deformity and the incon- 
 venience permanent . If there be inflammatory fever, bleed from the arm : if there 
 be not, take blood from the neighbourhood of the affected nerve by cupping: apply 
 fomentations ; or, what is better in these cases, conduct the steam of hot water against 
 and into the ear : and administer mercury so as just to touch the gums. I should 
 always take this latter precaution, lest any effusion of lymph should cause abidino- 
 pressure on the nerve. If ' the palsy gives way before the gums become tender, the 
 mercury need not be pressed further. 
 
 Where there is any ground to suspect that the brain is implicated, the treatment 
 just described must be pursued with greater diligence, and with such modifications 
 as the nature of the case may require. If there be evidence of chronic disease m 
 the petrous portion of the temporal bone, such as tenderness of the mastoid process, 
 deafness, a protracted discharge from the ear, and an imperfect state of the membrana 
 tympani, we can scarcely expect much good from very active treatment. We must 
 then have recourse to counter-irritation, and such other measures as I spoke of when 
 the subject of otitis was briefly considered. 
 
 The examples which are met with, of local palsy and local ancesthesia, are 
 numberless ; but those which I have mentioned are the most common and the most 
 important. They are always deserving of attention ; but more so when any sus- 
 picion arises that they may be connected with cerebral disease. Sometimes they 
 evidently have no such connection. In the month of November, 1834, a coachman 
 became my patient in the hospital, with incomplete paralysis affecting some of the 
 muscles of the right leg alone, with numbness of the foot. He could both stand and 
 walk ; but on advancing that leg, his foot flapped suddenly down, and he could not 
 deliberately direct and plant it, like the other. His general health was quite good ; 
 he had no headache, nor giddiness, nor palsy of any other part. But a month ago 
 he had been sitting with the right leg thrown over the opposite knee ; and he con- 
 tinued in that position until the foot felt numb and tingling, and was (what is called) 
 asleep ; and it had remained in the same condition from that time. After some 
 general treatment (cupping and purgatives) before he came to the hospital — treat- 
 ment which was quite proper in the way of precaution, but which was probably, in 
 truth, unnecessary — I had his leg electrified; and in about ten Jays the sensation 
 and the power of the limb were almost restored. Mr. Shaw mentions a somewhat 
 similar case, in which anaesthesia of the hand was produced by strong pressure made 
 upon the wrist. 
 
 There are some very curious facts connected with anresthcsia, showing that thi. 
 voluntary exercise of the muscles is regulated in some measure by the sensations of 
 the limb that is employed. The sense of resistance prompts to such contraction of 
 the muscles as is required to balance that resistance ; reminding the will (so to speakj 
 of the necessity that exists for its perpetual and vigilant operation. Continued 
 volition is essential to the continuance of the muscular tension. Thus Dr. Yellol-y 
 descrioes a woman who had no power of feeling in her hand and fingers, althouglt 
 the power of moving them, and of grasping any objects, was entire. This woman
 
 344 REMARKABLE CASES. 
 
 found that she could carry glasses or plates in that haiid very well and safely, if she 
 continued to look at and attend to them : but if her eyes were turned another way, 
 as she did not feel what she held, she was very apt to drop it. Dr. Ley met with 
 just such another case. A woman had defective sensibility on one side of the body : 
 she could hold her child in the arm of that side so long as her attention was directed 
 to it ; but if surrounding objects diverted her from taking notice of the state of her 
 arm, the flexor muscles soon began to slacken, and the child was in danger of falling. 
 All this is exceedingly curious. 
 
 Andral has recorded a most singular example of local anfesthesia, which preceded 
 an attack of apoplexy. The patient lost, from lime to time, all sensation in certain 
 isolated parts of the skin upon the thorax ; there were five or six of these insensible 
 spots, each about the size of a five-franc piece. You might pinch the skin in these 
 places without producing the slightest feeling in the patient. In all other parts the 
 sensibility was perfect and lively. 
 
 There are other cases also on record, more remarkable still; in which the patients 
 have lost both the power of motion and the faculty of sensation in almost every part 
 of the body, and yet have survived for a considerable time. Thus one person 
 (whose case is related in the Bulletin des Scieiiccs Medicales for January, 1S28,) 
 became first amaurotic, then deaf, and then by degrees lost all power of sensation 
 and motion except in the tongue and in the muscles of deglutition and respiration. 
 His speech and intellects were unimpaired. It was accidentally discovered that a 
 small patch on the right cheek retained its sensibility ; and by tracing letters on ihia 
 sensible spot, his wife and children were enabled to interchange ideas with him. He 
 died at length, and his body was not examined. 
 
 I shall finish what 1 have to say on this head, by relating a case of the same kind, 
 which occurred under Dr. Abercrombie's notice ; and which we are sure therefore 
 would be observed with care, and recorded with fidehty. 
 
 A servant girl, about 20 yeai-s old, sprained her back in lifting some heavy article 
 of furniture. She felt no great inconvenience at the time ; but some liule while 
 after, weakness of the legs came on, and gradually increased to complete paraplegia. 
 After an interval, the affection extended to her arms, and she then had not a vestige 
 of motion of any of the parts below the head, except a very slight movement of one 
 of the fingers : but the internal functions were all perfect, and her speech was 
 distinct, except that in speaking she was sometimes seized with spasmodic twitches 
 of the lips and lower jaw. She lived in that state, without any change of the 
 symptoms, and her general health continuing good, for about twenty years. In the 
 morning she was taken out of bed, and placed in a chair, so contrived as to support 
 her in a sitting posture. Her arms rested on a cross board which passed before her ; 
 and if by any accident one of them slipped from this support, she had no resource 
 but to call for the assistance of another person to replace it. Having been on one 
 occasion left alone for about two hours after one of her arms had thus slipped down, 
 the hand had become extensively oedematous. In the same manner, if her head 
 fell forward upon the thorax, it remained in that position until raised by an atten- 
 dant. Her mind was entire. She died after four days' illness with symptoms of 
 low typhus fever. You may suppose that Dr. Abercrombie looked with the greatest 
 interest for the cause of these most remarkable symptoms. " I examined the body 
 v.'ith the utm.ost care, (says he,) along with Dr. Pitcairn, who had been in the habit 
 of seeing her for several 3'ears ; and we could not discover any disease either in the 
 brain or in the spinal cord." 
 
 It is much to be regretted that when this case was under observation, the excito- 
 inotory functions were not understood, nor attended to. 
 
 I shall next proceed to consider those diseases (and there are several of them) 
 which are marked by definite symptoms, which consist essentially in some disturb- 
 ance or disorder of the nervous system, but which are not accounted for by any 
 physical changes that we can appreciate in any part of that system. After some of 
 lliese diseases we do, to be sure, sometimes meet with morbid appearances in the 
 bmin or the spinal marrow : but none that are constant, or uniform.
 
 TETANUS. 345 
 
 LECTURE XXXII. 
 
 Tetanus. Its Symptoms and Varieties. Causes. Diagnosis. Pathology 
 Treatment : Opium ; Blood-letting ; the Warm Bath ; the Cold Bath. 
 
 In those diseases of the nervous system which, have hitherto engaged our attention, 
 the function of voluntary motion, when it has been affected at all, has mostly suffered 
 in the way of diminution, or suspension ; the power of moving has been impaired, 
 or lost ; there has been complete or incomplete palsy. Sometimes, indeed, convul- 
 sion, or an irregular and involuntary action of the muscles, has also occurred. But, 
 distinct from the paralytic affections, there is a class of spasmodic diseases, of which 
 it is the main and leading feature, that the function of voluntary motion is (not mor- 
 bidly heightened, as in the preternatural strength of a madman ; nor lowered, as in 
 palsy; hut) perverted : performed in an irregular and unnatural manner. 
 
 There are two sorts of spasm. One of these is marked by a long-continued con- 
 traction of the affected muscles, not rapidly akernating with relaxation : the relaxa- 
 "tion taking place slowly, after some time : and then, perhaps, the contraction, after 
 another interval, coming on again. This is called tonic spasm ; and, by Cullen, 
 spastic rigidity. A very familiar example of it is the common cramp of the leg. In 
 the other form of spasm, the contractions of the affected muscles take place repeat- 
 edly, forcibly, and in quick succession; and the relaxation is, of course, as sudden 
 and frequent. This has been named clonic spasm. We find illustrations of it in 
 convulsions. 
 
 Sometimes the two are mixed together in the same disease ; certain muscles under- 
 going convulsions or clonic spasm, and certain other muscles being affected with 
 rigidity or tonic spasm. But it is convenient to keep the distinction in mind. 
 
 We recognize these disorders by the unnatural conditions of the muscles ; but you 
 will please remember that the fault lies in the nervous system. 
 
 With regard to spasmodic diseases generally, I may say that some of them con- 
 stitute the most appalling and fatal maladies to which the human body is liable ; and 
 some of them, though frightful to look upon, and productive of extreme distress to 
 patients and to their friends, are trivial in their consequences, and scarcely ever 
 attended with any peril to life. 
 
 I propose first of all to consider one of the most formidable and worst of these 
 spasmodic diseases, viz., tetanus ; of which tonic spasm is essentially chamcteristic. 
 Its name is derived from rstVu, to stretch. 
 
 In respect to all those diseases concerning the exact pathology of which w'e are 
 ignorant, and which we identify b}'' the group of symptoms they present, rather than 
 by any organic changes of structure in any part of the body, the most convenient 
 mode of proceeding will be, first to describe the distinctive symptoms. 
 
 Tetanus, then, is characterized by an involuntary, long-continued, violent, and 
 painful contraction — in one word, by cramp of the voluntary muscles of various 
 parts, or of nearly the whole body. 
 
 There is no difficulty in recognizing the disease Avhen it is fully formed. But it 
 is of much importance to be aware of the marks of its approach, and of its earhest 
 symptoms ; in respect to the treatment to be then adopted. 
 
 In general, the muscles that seem to be the earliest affected are those of the neck, 
 jaws, and throat. The patient feels a difficulty and uneasiness in bending or turning 
 his head; and supposes that he has got what is called a stiff neck. He finds also 
 that he is unable to open his mouth with the customary facility. At length the jaws 
 close : sometimes gradually, but with great firmness ; sometimes (it is said) suddenly, 
 and with a snap. In four cases, perhaps, out of five, the disease begins in this way, 
 with trismus or locked jaiv ; so that this last is the vulgar name for the complaint. 
 Along with this symptom, or very soon after it, the muscles concerned in swallowing 
 become affected ; and in a short time there comes on, what is often the most distress- 
 ing part of the disorder, an acute pain at the lower part of the sternum, piercing
 
 346 TETANUS. 
 
 thiougli to the back. This depends, it can scarcely be doubted, upon cramp of the 
 diaphragm. The pain is subject to aggravation in paroxysms ; and each paroxysm 
 of pain is attended with increased contraction of the other parts also that are impli- 
 cated. The spasm extends to the muscles of the trunk; to the large muscles of the 
 extremities ; the muscles of the face; and last of all, in general, to the muscles of 
 the tongue, and of the hands and fingers, which often remain movable at the wall 
 of the patient, after all the other voluntary muscles of the body have become fixed ; 
 and frequently the muscles of the wrists and hands escape altogether. 
 
 With respect to all the muscles involved, from the time when they are first 
 afltcted to the time when the disease is relieved, or the patient dies, they continue in 
 a state of contraction, and are swelled and hard in their centres. The jaw, for in- 
 stance, can never be completely opened ; and the muscles of the abdomen are so 
 rigid as to make it as hard as a board. But, besides this, they are all subject to 
 aggravations or exacerbations of the spasm, which occur perhaps every ten minutes, 
 or quarter of an hour, and last for two or three minutes at a time ; and then the 
 muscles fall back into the minor degree of contraction in which they were prior to 
 the exacerbation. In a very few instances only has a perfect remission of the spasm 
 been observed. The exacerbations usually begin by an increase of the pain fell at 
 the sternum. Sometimes there is no obvious exciting cause of their occurrence ; 
 but frequently it is evident that they are brought on by exertions of the body ; even 
 by slight movements, such as belong to a change of posture, to the attempt at swal- 
 lowing, or speaking. As the disease advances, these paroxysms of aggravation 
 become more frequent, and a rapid increase in the frequency of their recurrence is 
 one of the most unequivocal signs that the case is severe and dangerous. The more 
 speedil}^ the intervals between the paroxysms shorten, the worse. 
 
 It is a curious thing, that the spasm is observed to give way, sometimes at least, 
 and the muscles to be relaxed, during sleep. To be sure, in the severer cases, the 
 patient is seldom able to sleep ; and it may be that in the less violent instances, the 
 spasm abates or ceases, and the exhausted sufferer sinks into repose, in consequence 
 of this abatement. However, a similar phenomenon occurs in at least another of 
 these spasmodic diseases, as we shall see hereafter. Mr. iNIayo had a boy afflicted 
 with tetanus, in the Middlesex Hospital. On visiting him one day, he found him 
 asleep, and remarked that he lay perfectly relaxed. The abdominal muscles w^ere 
 soft and yielding, and had not the least tension. The boy was awakened, and at the 
 instant the full tension of the muscles returned. Not being further disturbed, he fell 
 asleep again in a few minutes, when the muscles again slackened ; and again, upon 
 his being a second time aroused, resumed the state of spasm. 
 
 In most cases the strong muscles of the back are the most affected, and they 
 overcome those on the anterior part of the body ; so that sometimes the patient 
 during the paroxysm rests only upon his head and his heels, while his body is 
 raised into the shape of an arch. This form of the complaint is called opisthotonos, 
 a bending backwards. The sterno-mastoid muscles of the neck have been so 
 stretched and misplaced as to become powerful extensors of the head. In a few 
 instances the body is bent forwards, so that the head and knees are in contact, and 
 the patient is rolled together like a ball. This is called emproslhotonos. In the 
 only example of emprosthotonos which I ever saw, these two conditions alternated 
 with one another. The patient was a girl in Edinburgh, under the care of a friend 
 of mine, who took me to see her. It was a case of hysteria rather than of tetanus ; 
 but all at once she would be drawn into a position such, that the top of her head, 
 and her feet, were alone supported on the bed, while her body was bent backwards, 
 like a bow ; then, after a time, with equal suddenness, the opposite posture was as- 
 sumed, her forehead and knees being brought together. Still more rarely the body 
 is bent to one side. This is pleurosthotonos, or tetanus lateralis ; and this I 
 never saw. Sometimes, again, in the height of the spasm, the antagonist muscles 
 counteract each other exactly ; and the head and trunk are rigidly extended ; and 
 ine term tetanus is by some writers confined to this form of the disease. It is called 
 trismus when the jaw only is affected. 
 
 It is well to know that thfise varieties occur, and may be looked for ; but in all of
 
 TETiiNUS. 347 
 
 them — trismus, opisthotonos, emprosthotonos, or pleurosthotonos — it is the same dis- 
 ease ; and the j rognosis is not altered, any more than the diagnosis, by the variety 
 that happens. 
 
 » During the fit of exacerbation, the aspect of the sufferer is often frightful. The 
 forehead is corrugated and the brow knit, the orbicularis muscle of the eye rigid, 
 the eyeball motionless and staring, the nostril spread, the corners of the mouth are 
 drawn back, the set teeth exposed, and all the features fixed in a ghastly grin — the 
 true rlsus sardouicus. The tongue is apt to get between the teeth, and to be 
 severely bitten. 
 
 All the contractions are attended with intense pain. You may form some notion 
 of the severity of this pain, if you have ever been troubled by spasm of the gas- 
 trocnemius, or cramp of the leg, and if you can bring your mind to conceive that 
 the same sensation which you then felt in the calf, involves nearly all the voluntary 
 muscles of the body. The pain is worst during the exacerbations, and that which 
 is experienced at the sternum is commonly the most complained of. Even to this, 
 however, there are occasional, though very rare, exceptions. Sir Gilbert Blane has 
 described a case of tetanus, which ran the usual course, and terminated fatally, yet 
 the patient suffered no pain : the sensation excited by the violent muscular con- 
 tractions was a sort of tinghng, of rather a pleasurable kind. 
 
 So violent are the contractions sometimes, that the teeth have been broken by 
 them. There is one case related in which the thigh-bones were fractured by the 
 forcible action of the femoral muscles ; and another in which the psoas muscles were 
 found, after death, to have been torn across. Dr. Latham tells me that he once saw 
 one of the recti muscles, in front of the abdomen, thus rent asunder. 
 
 With all this disturbance of the muscular system, there is commonly very little 
 derangement of the oiher functions of the body. The disorder is almost always 
 attended with obstinate costiveness ; partly, perhaps, from the spasmodic closure 
 of the anus, partly, perhaps, in some cases, from the medicines that are given. 
 When stools are obtained, they are usually very offensive and unnatural. There is 
 no fever. The pulse and respiration are quickened, and a sweat frequently breaks 
 out during the exacerbations, from the pain and anxiety then experienced; but ihis 
 is not the case during the intervals between the paroxysms. In the last stages of the 
 fatal cases, the pulse becomes quick and feeble, and the sweat is cold, as in other 
 instances of approaching dissolution. 
 
 What is still more worthy of observation is that the mental functions are un- 
 affected. There is seldom any delirium, or coma, or disturbance of the intellect. 
 These symptoms only appear (if they appear at all) when other indications of the 
 failure of the powers of life come on. 
 
 The mode of death in this disease seems to be of a mixed nature. Partly it 
 appears to result from apncca ; the thorax being held as in a vice by the spasm of 
 the muscles, and the breathing for a time suspended, or much embarrassed: partly, 
 and cliiefly, it occurs from asthenia: the power of the heart flags and is exhausted 
 by the continuance of the suffering, by the fatigue and expenditure consequent 
 upon the muscular action, and by the patient's inability, in many cases, to take suf- 
 ficient nourishment. When death happens suddenly as it sometimes does, in a 
 paroxysm, it is owing, in all probability, to spasm of the respiratory muscles, and 
 perhaps of those of the glottis among the rest. 
 
 Most cnses of tetanus may be traced to one of two causes : which are, exposure 
 to cold, especially to sudden alternations of temperature, and hodiJij injuries. In 
 many instances both these causes co-operate in producing the disease. When it 
 supervenes upon some bodily hurt, it is called traumatic tetanus; when it arises 
 spontaneously, or after exposure to cold, it is held to be idiopathic. In this country, 
 and 1 believe in every other, the traumatic variety of the disease is much more common 
 than the spontaneous. But in what manner soever it may originate, tetanus is far 
 more frequent in hot than in temperate climates and seasons. In this case, however, 
 as in so many others, the heat appears to act as a predisposing cause only ; the 
 exciting cause, in addition to the wound in the traumatic species, being the appli- 
 cation of cold (particularly, according to Hennen, of cold air in motion) after tiie
 
 348 TETANUS. 
 
 heat or during the prevalence of hot weather. Thus it is stated that after the battle of 
 Muskau, in the midst of great heats, very few of the French troops were affected 
 with tetanus ; whereas those who were wounded in the battle of Dresden, when the 
 weather was cold and wet, just after a very hot season, were decimated by that 
 complaint ; which did not spare even those who underwent immediate amputation. 
 
 Idiopathic tetanus is extremely rare in this country. Dr. Gregory, of Edinburgh, 
 used to mention in his lectures the case seen and treated by himself, of a man who, 
 having fallen asleep in moist grass, awoke with a stiff neck, which afterwards went 
 on into regular tetanus. A good example of well-marked tetanus, arising from ex- 
 posure to cold, is narrated in the Edinburgh Medical and Surgical Journal, by Dr. 
 Hall, of Berwick. 
 
 The history of that species of tetanus which occurs in connection with wounds 
 and injuries, presents nothing constant or uniform. The disease is liable to follow 
 hurts of any parts of the body, and of every kind, degree, and extent; from a slight 
 cut or scratch, to a compound fracture, or a severe surgical operation. It comes on 
 also in various stages and conditions of the injury. Sir James M'Grigor tells us (in 
 the sixth volume of the Medico-Chirurgical Transaciions) that in the Peninsular 
 war the complaint supervened " in every description, and in every stage of wounds, 
 from the slightest to the most formidable : the healthy and the sloughing; the incised 
 and the lacerated ; the most simple and the most complicated." Sometimes, how- 
 ever, the discharge from the wound has been observed to be remarkably diminished 
 or suppressed, at the coming on of the tetanic symptoms ; and sometimes the wound 
 has healed completely before the commencement of the attack of tetanus. To show 
 you how very trivial the injury may be, how various in kind and in place, I may 
 mention a few instances that have been collected, in illustration of the manner in 
 which this terrible disorder may originate. It has been known to arise from the 
 sticking of a fish-bone in the fauces ; from a slight wound of the ear by a musket- 
 shot ; from the mere stroke of a whip-lash under the eye, although the skin was not 
 broken ; from cutting a corn ; from a bite on the finger by a tame sparrow ; from the 
 blow of a stick on the neck and on the hand ; from a seton in the chest ; from the 
 extraction of a tooth ; from the injection of a hydrocele ; from the operation of 
 cupping. 
 
 Nevertheless there are some sorts of injury, and some parts of the body, more fre- 
 quently than others concerned in the pathogeny of tetanus. The disorder more often 
 supervenes upon injuries of the extremities, than of the trunk, head or neck ; and 
 upon wounds made by puncture, than upon most other hurts. Penetrating wounds 
 in the sole of the foot, such as are not seldom inflicted by treading upon a nail or a 
 splinter; and laceration, or other violence done to the muscles that constitute the ball 
 of the thumb, are very apt to be followed by tetanic spasm. Some have supposed 
 jhat the disease has some special connection with injuries of tendinous parts; but 
 diere can be no doubt that it is essentially a malady of the nervous tissue. 
 
 The tetanic symptoms occur at no fixed period after the reception of the injur}'. 
 Professor Robinson, of Edinburgh, was once at table, when a negro servant lacerated 
 nis thumb by the fracture of a china dish. He was seized with convulsions almost 
 mstantly, and died with tetanic symptoms in a quarter of an hour. Such a rapid 
 progress as this is, however, quite out of the usual course of the disease : probably 
 fright had something to do with it. Hennen, in his work on Military Surgery, 
 states that terror is frequently the immediate antecedent of the attack. In general, 
 tne tetanus supervenes between the fourth and the fourteenth day after the infliction 
 of the injury : some time in the second week is the most common period of all. In 
 the Peninsular war it did not commence later than the twenty-second day. In some 
 rare instances its accession is still longer deferred. "Of the nature of the changes 
 that take place in the interval (justly remarks Dr. Alison) we have no informniion 
 wnatever." The longer, however, that the disease delays its assault in these t';iu 
 matic cases, after the reception of the local injury, the milder, in general, do(> it 
 prove, and the more room is there for hoping that it will end favourably. 
 
 When the disorder arises from exposure to cold and damp, it comes on much
 
 TETANUS. 349 
 
 earlier; often in a few hours. If, for example, the exposure takes place during the 
 night, the complaint may begin to declare itself the next morning. 
 
 Although tetanus may be excited by a wound, independently of any exposure to 
 cold, or by cold without any injury, there is good reason for thinking that, in many 
 instances, one of these causes alone would fail to produce it, while both together call 
 it into action. 
 
 After the disease has set in, its rate of progress is various. Almost all writers 
 divide it into acute and chronic tetanus. But the difference is merely in the degree 
 of severity. When the spasms come on suddenly, recur often from the beginning, 
 and increase in frequency and violence, the chance of recovery is but small. The 
 patient, in thete cases, sometimes dies on the second, and generally before the fifth 
 day. If he li /es to the ninth day of the disease, his prospect is somewhat better, and 
 the spasmodic symptoms may gradually abate and disappear. Some, however, have 
 died as late as the sixteenth, the twentieth, and even the thirty-fifth day : but this 
 last is very rare. 
 
 The idiopathic tetanus, or that which is produced by cold, although it commences 
 earlier, is more generally of a chronic character than the traumatic : that is to say, 
 the spasmodic contractions take place more slowly, and the paroxysms do not increase 
 in violence, and in rapidity of recurrence, as they are apt to do in the symptomatic 
 variety : and accordingly this form of the malady is much oftener, I dare not say 
 cured, but recovered from, than the other. 
 
 With respect to the diagnosis of tetanus, there is only one point in which it is at 
 all ambiguous or important. There is no other disease that is likely to be confounded 
 with it, except, perhaps, that extraordinary disease, hysteria, which sometime?: 
 mimics its phenomena. I have already alluded to one example of this kind that I 
 myself saw. But there is a form of poisoning that may easily be mistaken for teta- 
 nus. The symptoms produced by a poisonous dose of strychnia, or its salts, or the 
 vegetables from which it is procured, are the symptoms of tetanus. And as this 
 drug is now readily obtained, and its noxious qualities are well known, it is not un- 
 likely to be made an instrument of suicide, or of murder. It is necessary, therefore, 
 that you should be acquainted with the effects of this poison, which constitutes the 
 active principle of the nux vomica, the fama S'' Ignatii, and the ifpus tieute. Dr. 
 Christison has excellently well described these effects as they are observable in 
 brutes ; and I have once, by accident, had an opportunity of witnessing them in the 
 human body. I shall not be wandering from our present subject, if I enumerate the 
 symptoms to be expected from a large dose of strychnia, especially as I have lately 
 been advising you to make trial of it as a remedy in certain forms of disease. Dr. 
 Christison, who had made experiments with it upon animals, tells us that the crea- 
 ture " becomes agitated, and trembles, and is then seized with stiffness and starting 
 of the limbs. These symptoms increase, until at length it is attacked with a fit of 
 general spasm, in which the head is bent back, and the spine stiffened, the limbs 
 extended and rigid, and the respiration checked by the fixing of the chest. The fit 
 is then succeeded by an interval of calm, during which the senses are quite entire, 
 or unnaturally acute. But another paroxysm soon sets in, and then another and 
 another, till at length a fit takes place more violent than any before it, and the ani- 
 mal perishes suffocated." 
 
 Some time ago I had occasion to prescribe the strychnia for two patients in the 
 Middlesex Hospital, both of whom had paraplegia. I directed one grain to be inti- 
 mately mixed with crumb of bread, so that it might be divided into twelve pills: 
 and one of these pills, or one-twelfth of a grain of strychnia, was to be taken by 
 each patient every six hours. Unluckily, through mistake or negligence of the per- 
 son who was at that time the dispenser, a grain of the poison was administered at 
 once to each patient. It was given about seven in the evening. At half-past seven 
 It began to produce its characteristic effect upon one of the patients. He was sud 
 denly seized with tetanic spasms ; his legs were separated widely from each other, 
 and rigidly extended : and his head and trunk bent backwards. He was, in fact, 
 in a state of opisthotonos. His abdomen was quite hard, and his limbs were stiff', 
 even when the violence of the paroxysms abated. He cried out with the pain at 
 
 2b
 
 350 TETANUS. 
 
 the coming on of these spasms. Any attempt at movement, even the touchmg him 
 by another person, brought them on. This is just what happens in the disease 
 The opening of a door, a sudden current of air, the smallest bodily effort, the act of 
 swallowing, nay, even the imagination of these influences, will be sufficient to renew 
 the spasmodic tightening of the affected muscles. My patient spoke of a particular 
 sense of constriction all over the abdomen, as if it were drawn in. His intellect was 
 quite unaffected. He had two extremely violent attacks of the kind 1 have been 
 describing, in which he thought he should have died : and to say the truth I was 
 myself horribly afraid of the same catastrophe. Afterwards, from half-past eight 
 o'clock to between eleven and twelve, he had several slighter and shorter fits. He 
 was left weak and exhausted by them : but he soon recovered. I may as well tell 
 you that his paraplegia was not a whit benefited by this violent action of the 
 remedy. 
 
 You may suppose that when I found one of my patients in this alarming state, I 
 became very anxious to ascertain the condition of the other, who had taken the same 
 C|uantity of the strychnia, and lay in another ward. He told me that he had been 
 for a short period very dizzy, and had trembled all over ; and at the time when I 
 saw him, he had a weight or uneasy sensation at the nape of his neck, which drew 
 his head backwards ; and he experienced some difficulty in opening his mouth, and 
 in articulating his words. But he thought these symptoms were diminishing rather 
 than increasing. He was perspiring profusely. It is stated by Dr. Chrislison, that 
 if the spasms do not come on Avithin two hours after the poison was swallowed, the 
 patient is safe. It was more than two hours since tliis patient had taken the strych- 
 nia. I gave him a full dose of purgative medicine, which acted as an emetic: and, 
 after he had vomited, the unpleasant sensations about his head and neck left him. 
 
 I scarcely knew what to do with the other patient, in whom the spasms had com- 
 menced. There is nothing satisfactorily made out, that I know of, concerning the 
 mode of treating such cases. Of course, if one saw the patient early, and knew 
 what he had swallowed, the first thing to be done would be to procure its evacuation 
 from the stomach. But here it had had full time to get into the circulation : and no 
 emetic could have withdrawn that part of it at least, which had already found its 
 way into the blood-vessels. When I reached him, though the spasms were strong, 
 they were less violent than they had been, and their violence seemed upon the wane : 
 but they were brought en by any, almost the slightest, muscular effort, or change of 
 position. I hoped therefore that the most dangerous period was passing off (and so 
 it turned out), and I was fearful of doing harm by exciting those movements of the 
 body which accompany the act of vomiting. I recollected, too, that another patient 
 in the hospital, under the care of one of my colleagues, had once been attacked with 
 opisthotonos after taking half a grain of strychnia ; and that brandy and water had 
 been given to him ; and that he got well from that time, without having another 
 paroxysm. So I gave my patient some brandy and water ; and he seemed the better 
 for it : but whether or no it contributed much to his recovery I cannot be sure. 
 
 Now how are we to tell, when we meet with such symptoms as these, whether 
 they are the result of disease, or of poisoning? The symptoms are the symptoms 
 of tetanus ; I know of no means of distinguishing them from the symptoms of 
 tetanus caused by exposure to cold, or supervening upon a wound. Dr. Christison 
 has suggested that the cases of fatal poisoning by strichnia that are quickly fatal, are 
 fatal in a shorter time than the disease ever is. But if the case related by Professor 
 Robinson, in which the negro was dead in fifteen minutes, is to be regarded as a 
 genuine instance of tetanus, this distinction, drawn from the rapidity with which the 
 poison kills, will scarcely hold. Again, persons who have taken an over-dose of 
 strychnia sometimes survive the tetanic symptoms, but die afterwards from the irritant 
 efft'Cts of the poison upon the mucous membrane of the alimentary canal. This we 
 do not observe in the disease. In suspicious or questionable cases, we must look 
 into the history of the 'patient ; inquire whether he were likely to wish to destroy 
 himself; what he last swallowed, and when it was taken; whether he has lately 
 been exposed to the injurious influence of cold, especially to a stream of cold air 
 *bile he was perspiring; and whether he has recently received any bodily hurt.
 
 TETANUS. 351 
 
 By a careful investigation of all the circumstances, we shall generally be enabled tr 
 decide the true nature of the case ; but it is clearly necessary that our eyes should 
 be open to the possibility of a case of poisoning, by some of the preparations of 
 strychnia, being palmed upon us for a case of natural disease. 
 
 The pathology of tetanus is undoubtedly obscure : but not more so, I conceive, 
 than that of those nervous diseases in general which produce violent symptoms, and 
 even death itself, without leaving any traces of their operation inscribed upon the 
 dead materials of the body. Nay, it is not so obscure as several others. I think we 
 may fairly come to the conclusion that the symptoms result from irritation of the 
 spinal cord, or of its afferent nerves ; and that the bruin is not involved in the 
 disease. The French (at least some of the most modern writers on tetanus) hold 
 that it is always an inflammatory complaint ; and that it consists essentially in inflam- 
 mation of the spinal marrow : and some of them have sought to remedy it by enor- 
 mous blood-lettings; from fourteen to fifteen pounds of blood being taken in the 
 course of a few days by one practitioner; and another bleeding his patient eight 
 times, and applying 792 leeches along the course of the spine, and to the epigas- 
 trium. But this do'ctrine of inflammation being at the bottom of every case of tetanus 
 is contradicted by the plainest facts ; and the practice founded upon it has been 
 pushed to a most extravagant and absurd extent. Numberless instances occur of 
 inflammation of the spinal cord and its membranes without any tetanus ; and equally 
 numerous examples of tetanus have been met with, when no Unnatural appearance 
 at all could be discovered within the vertebral canal. I say we must content our- 
 selves with referring the phenomena of the disease to irritation, direct or indirect, 
 of the spinal cord ; or its nervous appendages ; and I am quite proof against all 
 sneers against the alleged vagueness of that term. 
 
 If you irritate, mechanically, by means of a pair of forceps, the exposed spinal 
 cord of a recently decapitated animal, a turtle, for example, you produce spasmodic 
 contraction of the hmbs.. What difficulty is there in supposing that some mechanical 
 irritation existing within the spinal canal of a living man may have a similar effect ? 
 It may be, and probably is, sometimes, the mechanical irritation caused by the altered 
 state of the blood-vessels under inflammation ; for we sometimes find traces of such 
 inflammation in the spinal marrow after death by tetanus. 
 
 Again, if you irritate, by pinching, one of the spinal nerves of a turtle whose 
 head has just been cut off'— if you thus irritate one of these nerves in any part of 
 its course, what happens? why the muscles of the hmbs contract spasmodically; 
 those on the side to which that nerve belongs becomes rigid, and those on the other 
 side also. That property of the cord comes into play which I have so often men- 
 tioned : a property which it possesses independently of the brain ; which it evinces 
 when all communication with the brain is cut off"; a property, therefore, which may 
 be manifested without any exercise of volition, and even in spite of efforts made by 
 the will to restrain its manifestation : I mean, of course, the property whereby it is 
 capable of receiving impressions through the medium of its afferent nerves, from 
 parts at a distance, and of originating motion in the muscles of the trunk and limbs 
 through the medium of its efferent nerves. By the courtesy of Dr. Marsha.l Hall 
 I have been afforded the opportunity of witnessing, in the headless turtle, the phe- 
 nomena that I have been describing to you. Surely they throw a broad light upon 
 the pathology of tetanus, and of sundry other affections. We infer from them, most 
 legitimately as it seems to me, that the tonic spasm which characterizes the disease 
 we are considering may be caused by a diseased state of the spinal marrow itself; 
 or by a morbid condition of the nerves that belong to it. In the latter case, irritation 
 is set up at the free extremity, or somewhere in the course, of incident nerves ; along 
 these nerves an influence is conducted to the cranio-spinal axis, in which a process 
 or change takes place, whereby an answering influence is reflected to the muscles 
 along the motor nerves, and the whole circle of action and reaction is run through 
 with the suddenness and swiftness of lightning, or of thought. You cannot expect 
 that visible marks of the irritating cause should, in all cases, be left upon the body 
 any more than you could discern the pinch made by the forceps after they wer«i 
 withdrawn.
 
 352 TETANUS. 
 
 When, in the experiments to which I have referred, Dr. Hall plucked or com- 
 pressed one of the denuded spinal nerves, spasmodic motions were excited in the 
 muscles of both sides ; and above, as well as below, the junction of that nerve with 
 the cord. This shows that the change (whatever it be) that is wrought in the cord 
 by impressions made upon one of its afferent nerves, is not necessarily confined to 
 the corresponding segment of the cord ; but may be instantly communicated, in both 
 directions, throughout its entire course : the whole of this centre of the excito-motory 
 system, respondmg to the influence conveyed by a single nerve, as completely as a 
 tight string vibrates from end to end, when struck at any one point. We frequently, 
 indeed, find that the excited motions are more limited ; but it is important to mark 
 this ready consent of the whole cord, under sufficient excitement. 
 
 Dr. Hall has given certain distinguished epithets to tetanus, according to the sup- 
 posed source and locality of the irritation. When the irritating cause operates 
 directly upon the spinal cord itself, he calls the disease cm/?7'c tetanus: when it 
 resides in some part of the body distant from the spinal cord, he calls the disease 
 eccentric tetanus. These are good and intelligible names ; and I shall take leave to 
 adopt them. 
 
 Observe now how well this explanation meets the facts of the case. We some- 
 times find the spinal cord or its membranes inflamed, when there has been teianic 
 spasm. We then refcr the spasm to the centric irritation. But in a far greater 
 number of cases we can detect no marks whatever of disease in the spinal canal, 
 while we know that an irritating cause has been applied to parts at a distance. 
 Often we have evidence which is visible, that a nerve has been injured, torn across 
 perhaps, or half torn, or compressed in some way or other; just as we might com- 
 press a nerve, with a pair of forceps, in a decapitated turtle. That experiment 
 shows us that very slight irritation may be enough lo produce the spasmodic action ; 
 and we find that slight injuries, as well as severe, will bring on the disease, when, 
 by the operation of certain injurious agencies, the frame has been predisposed, and 
 rendered morbidly susceptible. There is no part of the trunk or limbs which is not 
 supplied with nerves from the spinal cord ; and we find that injuries of various parts, 
 or of almost any part, in an individual predisposed to take on the disordered action, 
 may produce it. The exciting cause may be a wound irritating a particular nerve ; 
 it may be exposure to cold, acting upon the extremities of various nerves that pro- 
 ceed from the surface : it may be a bundle of worms, irritating the nerves spread 
 upon the mucous tissue of the alimentary canal ; for I omitted to state before that 
 some writers, especially MM. Laurent and Lombard, have maintained that tetanus 
 is almost always, even when it supervenes after wounds, the result of the presence 
 of worms in the digestive organs. They have founded this opinion upon the fact, 
 that-worms have been very frequently indeed discovered in the stomach or intestines 
 of persons dead of this disorder. I think this a point well worth attending to. It is 
 objected that worms infest the human body without causing tetanus : but the very 
 same thing may be said of the operation of cold ; and of external injuries. Any of 
 f.hcse may probably excite the disorder, when the body is preternaturally susceptible 
 of it. The real mystery lies in this predisposition. We have reason to suppose 
 that a high atmospheric temperature, continued for some time, is one predisposing 
 rause ; but how it operates, or what is that state of system in which the increased 
 susceptibility consists, these are points concerning which we are really in the darlc 
 
 The disease is common enough in brutes : and it is frequently eccentric in them ; 
 brought on by injuries, mostly of the extremities. Locked-jaw is well known in the 
 nosology of farriers. It is not uncommon in the horse after castration. I remember 
 a mare belonging to my father dying of that disease a few days after foaling. It 
 o'tcn results, in these animals, from a prick in the foot by a nail in shoeing. Dr. 
 Parry noticed eccentric tetanus in lambs. "I have often seen lambs," says he, 
 •' whose ears, for the purpose of marking them, have been bored with a red-hot iron 
 too near the root, so rigid all over with tetanus, alternating with convulsions, thai 
 '.heir bodies would project in a right line with their hind legs, when one held them 
 f^ut horizontally bj"- the hind feet." Dr. Mason Good tells us that parrots abo are
 
 TETANUS. - 353 
 
 frequently affected with trismus : a calamity which, supposing the bird to be within 
 ear-shot, it would be difficult to commiserate. 
 
 We are not advancing any wild theory, then, respecting the controverted patho- 
 log}' of this disease, when we lay down the following propositions : that it is essen- 
 tially a disorder of the excito-motory apparatus ; that it results from irritation of a 
 peculiar kind, affectincr that part of the nervous system ; that the irritating cause 
 rnay be centric, — within the spinal canal itself; and that it may also be, and often is 
 eccentric, — situated at the extremity, or somewhere in the course, of one or more of 
 the afferent spinal nerves : and that a certain predisposition of the body is for the 
 most part necessary, to render it susceptible of the disease under the operation of 
 the exciting irritation. 
 
 At one time it was supposed that the physical cause of the disease was detected, 
 in the presence of more or fewer thin scales of bony matter, lying in or upon the 
 arachnoid of the cord. I have myself seen these after death preceded by tetanic 
 symptoms. But tetanus often happens and proves fatal without them : and they are 
 often rnet with when there has been no tetanus. If, therefore, there be any connec- 
 tion between these thin plates of ossification and the occurrence of tetanus (which 
 may well be questioned), it must be of this kind ; that the scales of bony matter 
 predispose the spinal cord, somehow, to be affected by the exciting causes of the 
 disease. 
 
 The doctrines recently propounded by Dr. Marshall Hall, of which the import- 
 ance becomes daily more apparent, and by which his name will be enduringly con- 
 nected with the physiology of the nervous system, receive a strong confirmation from 
 the phenomena of tetanus. They furnish a key to many })roblems which had pre- 
 viously perplexed the pathologist; and they do this simply by distinguishing the 
 proper functions of the two distinct nervous centres ; the brain and the spinal cord. 
 But the practical application of these new views is yet in its infancy. 
 
 The treatment of tetanus is a mortifying subject. The disease is and has always 
 been a lamentably fatal one. Hippocrates says, fTtt rpco^aTt. cnm^oi iTivyevowrioi, 
 ewvaai^Lov, tetanus supervening on a wound, is mortal: and the aphorism holds true, 
 with very few exceptions, in the present day. Almost all the acute and severe trau- 
 matic cases are fatal. Hennen declares that he never saw a case of "acute symp- 
 tomatic tetanus" recover. Dr. Dickson found all curative measures followed by 
 "unqualified disappointment." Mr. Morgan uses these words; "I have never yet 
 seen or heard of an instance of recovery from acute tetanus." Another of Hippo- 
 crates' aphorisms is oxouot. vno -ti-COA'ov aXiaxwfat, tx tsaaa^aiv ^^fpjjffti' artoXXvvtM, they 
 who are seized with tetanus, die within four days ; but he adds, fjv Ss ■fowraj Sia^vyuctc 
 iytsii ywovtat; if they get over this period they recover. And to this Ave can only 
 add now, that those who survive the first few days, and ultimately get well, recover 
 in a variety of different ways, and under various modes of treatment. But as to the 
 mode of treatment which is to be preferred, or even as to the real efficacy of any 
 mode, thi-^re is much room for doubt. Under every plan of management a vast 
 majority die. 
 
 Let us briefly pass in review the principal remedies that have been tried, and 
 inquire what degree of success has followed their employment. 
 
 One drug from which much benefit has been hoped for, is opium. In some spas- 
 modic disorders it is of unquestionable service. Very lartje doses of it have been 
 given and borne in tetanus; and some have recovered under its use, and more have 
 died. 
 
 It is well known that pain fclifies the nervous system against the peculiar influ- 
 ence of narcotic substances. We need not, therefore, be surprised that opium, admi- 
 nistered in enormous quantities, in this painful disease, has had but little efl^-ct. I 
 was, assured by a physician, with whom I formed an acquaintance in Edinburgh 
 some years ago, and who is known, I find, to a student now present, that his own 
 wife, while labouring under a tetanic affection, swallowed, in twenty successive days, 
 upwards of 40,000 drops of laudanum, which is at the rate of more than four ounces 
 a day ; in all, more than two imperial quarts. The lady recovered. A case is 
 recorded in the second volume of the Medico-Chinirgical Transactions, in which 
 23 2 E 2
 
 354 TETANUS. 
 
 an ounce of solid opium was taken, in divided doses, every day, for t\venty4wo 
 days. This appears a more astounding instance than the former ; but I am not sure 
 that it was so ; for, in this complaint, solid opium does not always dissolve in the 
 stomach. I have heard the late Mr. Abernethy say that he had found enough un- 
 dissolved pills of opium in the stomach after death, to poison a dozen healthy per- 
 sons. This fact should teach you, if you resolve on trying opium at all, to exhibit 
 it in a liquid form ; laudanum, or a solution of the acetate or of the muriate of mor- 
 phia. And wath the internal administration of opium, it would be well, perhaps, to 
 combine its external use ; to apply a broad strip of opiate plaster along the whole 
 length of the spinal column. 
 
 It is sometimes a difficult matter to introduce medicine by the mouth, so strong is 
 the spasmodic contraction of the muscles that close the jaws. You cannot get the 
 mouth open. Some persons set to work to heave it open, by levers ; and it has been 
 proposed, and I believe practised, to break off or extract a tooth or two, to make a 
 passage for the introduction of medicine and of nourishment; but 1 hope you will 
 never be guilty of such clumsy barbarity as this. Food, and physic, may be carried 
 into the fauces and into the stomach by means of a flexible tube : and this may be 
 inserted through the nostril ; or through the mouth, by passing it between the jaws, 
 behind the back teeth, where there is always an aperture that will admit a tube suffi- 
 ciently large. 
 
 After all, in respect to the cures that have been ascribed to the opiate treatment, 
 they have all (so far as I know) occurred in cases of the milder or more chronic 
 tetanus ; and mostly in the idiopathic form of the disease ; and this circumstance 
 makes it a question whether they were cures at all : whether they w^ere not simply 
 recoveries. 
 
 Dr. William Budd (in the paper already referred to) challenges the propriety, on 
 phj-siological principles, of giving any opium in this disease. He says, " It has been 
 ascertained that the effect of that drug is to excite, and not to quiet, the motor func- 
 tion of the spinal cord : indeed, it is well known that the motor acts of the cord may 
 be rendered much more active and powerful, by giving, before decapitation, opium 
 to animals that are to be subjects of experiment." He considers " these objections, 
 furnished by theory, to be motives sufficient for the future exclusion of opium from 
 the treatment of tetanus." 
 
 I had long been aware that the effect of opium upon frogs was to produce tetanic 
 spasms. But in no case of poisoning by opium in the human subject (and I have 
 seen a great many) have I ever witnessed any approach to tetanus: and I much 
 question the safety of arguing, in such matters, from what we know to happen in the 
 mferior animals, to what we suppose would happen in man. 
 
 The failure, however, of opium in the severer forms of the malady, and its equi- 
 vocal utility in any, taken together with these theoretical objections, prevent my 
 recommending opium as a remedy for tetanus. 
 
 What is the result of experience in regard to blood-letting in tetanus ? I am afraid 
 that as a curative agent, it has very little power over the disease. Yet it may be, 
 and probably is, of considerable use, as an auxiliary to other measures. When the 
 disorder bears any aspect of inflammation — when, for instance, fever is lighted up, 
 and pain is felt along the course of the spine, or when the approach of the spasm is 
 marked by the supervention or the increase of pain in the wound — then our chance 
 of doing good by venesection is the greatest. Some of the cases that happened in 
 the Peninsular war, were decidedly benefited by blood-letting practised under such 
 circumstances. I need scarcely say that though the bleeding, when adopted, should 
 be enrly, free, and full, so as to produce some sensible impression upon the system, 
 yet we must always use this remedy with caution. The tendency of the disease is 
 to exhaust the power of the heart ; and if by one over-bleeding we bring that organ 
 10 a stand-still, it may refuse to begin agiin. 
 
 In a complaint whic'^ depends so much on irritation, and so often on manifest 
 .rritation of external parts, we look naturally to the icarm bath for help. And ii 
 hcLs been fairly tried : and some persons have found it useful ; and others have
 
 TETANUS. 355 
 
 found it useless, doing neither good nor harm : and some have condemned it as actu- 
 ally hurtful. 
 
 The cold bath has been extolled as a much more powerful agent than the warm , 
 and so, doubtless, it is. But it is more potent for harm as well as for good. For 
 example : a tetanic patient, in St. Thomas's Hospital, was plunged into a cold bath, 
 at his own request. "All the symptoms disappeared (says Mr. Morgan) in a moment ; 
 and he was almost immediately taken out of the bath : but he was taken out life- 
 less." Sir James M'Grigor says that, during the campaign of Spain, "the warm 
 bath gave only a momentary relief; and the cold bnth was worse ihan useless." 
 
 However, the application of cold water to the surface has, in many recorded 
 instances, been of at least temporary benefit and comfort : and, in the West Indies, 
 where the disease is common, the cold effusion still continues, I believe, to be tho 
 most favourite expedient. After it, the patient is rubbed dry, put to bed, and has 
 laudanum administered. I have again to observe, of this remedy also, that it is 
 chiefly serviceable in the idiopathic form of tetanus. It has been tried upon animals. 
 Dr. Parry says that it was quite unavailing in the case of certain lambs that had the 
 disease. In a note, which I made at the time, of Mr. Abernethy's lecture on teta- 
 nus, I find the following statement. "The effect of cold in diminishing excessive 
 muscular action was strikingly shown in the case of a horse belonging to Professor 
 Coleman, which had tetanus. The animal was slung, and carried out of the stable, 
 and laid on the snow, which was then on the ground : and he was covered over with 
 snow also. A horse affected with tetanus is a curious sight. His legs straddle, and 
 become stiff'; his ears are pricked up ; and his tail sticks out. In this case, on the 
 application of the snow, his ears sunk, his tail became pliant, and the rigidity of his 
 muscles was removed. He was again taken into the stable, and the spasms returned." 
 Mr, Abernethy said, that were he himself the subject of tetanus, he would desire to 
 have the cold effusion tried. If you are wiUing to assay the same remedy, do not 
 plunge your patient into a cold bath, but take him out of his bed on an extended 
 sheet, pour cold water over his body, wipe him dry, and place him in another dry 
 bed. This will often, for a time at least, diminish the spasmodic action; and the 
 patient will sometimes sleep comfortably after it. 
 
 Dr. Todd has suggested to me the application of ice to the spine ; a measure 
 which he has found eminently beneficial in convulsions. This mode of employing 
 cold as a remedy in tetanus seems well worthy of trial. It would have the "advan- 
 tage of not inflicting any shock which might excite or disturb the reflex function of 
 the cord, through its incident nerves. 
 
 LECTURE XXXIII. 
 
 Treatment of Tetanus, continued. PFine; Mercury; Purgatives; Digitalis; 
 Tobacco ; Musk; Frussic Acid; Belladonna; Carbonate of Iron; Oil of Tur- 
 pentine; Strychnia; Surgical Expedients ; General Bales. Hydrophobia. 
 
 In the last lecture we' considered the symptoms, the nature, the causes, and to a 
 certain extent the treatment, of that terrible malady, tetanus. There is good reason 
 for believing that it is essentially a disorder of the excito-motory apparatus; that it 
 is caused by irritation of a peculiar kind, affecting that part of the nervous system, 
 and producing tonic spasm of the voluntary muscles ; that the irritating cause may 
 be centric, situated within the spinal canal, and applied directly to the cord; o'r 
 eccentric, situated out of the spinal canal, applied to some part of one or more of its 
 aff"erent nerves directly, and thus influencing indirectly the cord itself, and througn 
 it the reflex motor nerves : and that a certain ill-understood state of the system" s 
 necessary, a certain aptitude to take on the disease, before the exciting ^ause caa 
 be efficient; and that one circumstance which has been ascertained to tend to
 
 356 TETANUS. 
 
 the production of such an aptitude, is a long-continued high temperature of tne 
 atmosphere. 
 
 I mentioned several remedies and plans of treatment which have been fairly tried, 
 and mostly tried in vain, for the removal of this disease. The severe cases, and 
 especially the severe traumatic cases, almost all prove fatal ; the less severe cases, 
 those in which the paroxysms are less violent and less frequent, and which run on 
 for several days, sometimes terminate in health : whether in consequence of the 
 measures employed, or whether in spite of them, it is not easy to say. The idio- 
 pathic cases, as they are called, those which appear to be produced by exposure to 
 cold and wet, are usually the least severe, and the more hopeful. The remedies 
 that have been tried, and which were mentioned in the last lecture, are opium ; 
 blood-letting; the warm-bath; the cold-bath. I showed you that, under each of these 
 remedies, a great number of patients died, and some recovered ; and that the reco« 
 verics had been almost exclusively among those patients in whom the disease ap- 
 peared originally in its milder form. So that whether the complaint was actually 
 cured in any of these cases, whether, i. e., any single patient recovered, or recovered 
 sooner, from using any of these remedies, who would have died, or in whom 
 the disease would have been protracted if he had not used them, is a matter of 
 uncertainty. 
 
 The celebrated American physician. Dr. Rush, regarding the disease as essentially 
 a disease of debility, and looking probably at its common tendency to death by 
 asthenia, wrote a paper to recommend the employment of bark, and wine, and 
 spirits, in full doses. It is curious enough, but quite in agreement with what has 
 been already stated of opium, that how much wine soever may be swallowed by the 
 patient, nothing hke intoxication is produced by it. The system resists the ordinary 
 influence of the alcohol. In one instance related by Dr. Currie, the disease lasted 
 six weeks, and in that space of time the patient drank 1 10 bottles of port wine. The 
 same author mentions a remarkable case, in which a horse, which was attacked by 
 tetanus, and happened to be a great favourite with its master, was treated with wine, 
 and got well, after swallowing more port wine than he was worth. Whenever this 
 plan has appeared to do good, it has been in the more chronic variety of the 
 complaint. 
 
 Mercury, you may be sure, has not been left untried. It is said that the system 
 is slow in submitting to its influence, in this malady. The specific effect of mercury 
 upon the gums is not, however, so strongly resisted as that of wine or opium upon 
 the nerves. Nor can we be surprised at this, when we consider that in tetanus the 
 functions of organic life are, comparatively, but little involved. It is clear that there 
 is not time for any effectual exhibition of mercury in those severe cases that are early 
 fatal. In its more chronic form the disorder has been known to yield upon the mouth 
 becoming affected. This happened, if I mistake not, in Mr. Mayo's patient, men- 
 tioned in the last lecture. Tetanus has sometimes, however, commenced while the 
 patient Avas in a state of salivation. Dr. Wells has recorded three instances of that 
 kind. The experience of the military surgeons who were in Spain, is, upon the 
 whole, agamst the reputed efficacy of mercury. We must take care not to conclude 
 too hastily, that because a patient uses a certain remedy and recovers, he recovers 
 through the operation of that remedy : any more than we should conclude, if he 
 recovered during a general election, that the election had cured him. Yet this 
 absurd and unsafe mode of reasoning is for ever employed in respect to disease, by 
 the public ; and too often, I fear, by ourselves. 
 
 Purgatives have been much given in tetanus ; and often with manifest advantage : 
 I mean in the less severe cases. But very large doses are commonly required to 
 procure evacuations from the bowels. Whether the torpor of the intestines be always 
 the effect of the disease, or whether it may not sometimes be, in part at least, a con- 
 sequence of the opium that is given, I am not sure. When they do act, very unna- 
 tural motions are frequently produced. Mr. Abernethy tells us of a hospital patient 
 of his who recovered under the use of purgatives ; they were long before they had 
 any effect, and when they did at last operate, such foetid stuff" came from him that 
 no one who could crawl out of the ward would remain in it. He says also that the
 
 TETANUS. 
 
 nurses, in other cases, have reported the stools to be more -ike sloughs than feces. 
 Enormous quantities of drastic purgatives have been given. You may read an 
 instance of this in the second volume of the Medico-Chirurgical Transactions. It 
 is related by Mr. Harkness. There is a still more extraordinary case detailed by Dr. 
 Briggs, in the fifth volume of the Edinburgh Medical and Surgical Journal. In 
 little more than 48 hours, the patient in that case took 210 grains of scammony, 89 
 of gamboge, 80 of calomel, an ounce and four scruples of jalap, and 2i pints of 
 what we call black dose, the infusion and tincture of senna : and all this without 
 either sickness or griping ; but, on the contrary, with the most decided benefit. In 
 the first week of his disease, the patient swallowed — of calomel, 2-80 grains ; scam- 
 mony, 2G0; gamboge, 110; jalap, 3 ounces and 10 grains; infusion of senna, 5f 
 pints. And altogether in the first 25 days — of calomel, 320 grains ; scammony, 
 340 ; gamboge, 126 ; jalap, 5 ounces and 71 drachms ; infusion of senna, lOf pints; 
 besides an ounce and a half and 35 grains of the colocynth pill. I mention all this 
 to show what the system will bear, under the bondage of the disease ; not as an en. 
 couragement to you to prescribe such doses. 
 
 It is certainly proper and necessary to clear out the bowels, and to endeavour to 
 correct unhealthy secretions ; yet numerous evacuations, the act of going to stool 
 often repeated, should be avoided. Under such obstinacy of the bowels, the croton 
 oil would perhaps be the most eligible purgative. 
 
 Foxglove and tobacco are two medicines, or rather poisons, which have been 
 used ; both, probably, upon the same principle. Their effects, when full doses have 
 been given, are much alike : sickness, faintness, feebleness and fluttering of the pulse, 
 coldness of the surface, with that slack and passive state of the muscles which 
 belongs to syncope. But if we consider that the influence of these substances upon 
 the involuntary muscles, especially upon the heart, is more certain and decided than 
 upon the muscles of voluntary motion, which are the muscles involved in the tetanic 
 spasm, and if we take also into account the strong disposition observable in tetanus 
 towards death by asthenia, we shall scarcely be prepared to expect any good, but 
 the contrary, from digitahs, or tobacco ; especially in the latter periods, when, so far 
 from obviating the tendency to death, they would seem to co-operate with the disease 
 in extinguishing life. However, if the result of experience were clearly in their 
 favour, we should not be warranted, by mere theoretical views, in withholding these 
 drugs. The army surgeons, some of them, have fancied digitalis useful. Sir James 
 M'Grigor mentions a case in which it caused a relaxation of the spasn^s ; but the 
 man died afterwards, apparently from the effects of the remedy. And t-'iis is just 
 what I find with digitalis. When given in large doses (and small ones here must 
 be useless) it becomes unmanageable. Certainly we have no such accounts of its 
 salutary power as would induce me to give it with much expectation of success, or 
 to give it at all. 
 
 The tobacco is not given by the mouth, but thrown up into the rectum : either 
 the smoke of its burning leaves, or (what is probably as efficacious, and I should 
 think more uniform and less unsafe) an infusion of them in water. Mr. Curling, 
 after analyzing a large number of cases of tetanus, thinks tobacco the best remedy 
 we at present possess. Mr. Travers is of the same opinion. However, I should 
 recommend great caution in the use of this ticklish remedy. You ought to know 
 that, when injected in other emergencies, in strangulated hernia, for example, mortal 
 syncope has followed such enemata. 
 
 Musk, in large doses, has been strongly recommended by a Frenchman, Fornier- 
 Pescay, who has written on this disease. He gave ten or twenty grains, at intervals - 
 so that a drachm, or even two drachms, were taken in the course of the day ; and 
 he declares that he found it more efficacious than any thing else that he had tried. 
 
 Prussic acid and belladonna are said, by Dr. Elliotson, to have been freely pre 
 scribed, and to have failed; whether in his own hands, or in those of others, I do 
 not know. 
 
 There is another remedy which the same physician has employed : and employed 
 not without success : the carbonate of iron. Reflecting, he tells us, upon the good 
 eflTect of this medicine in another complaint which has some points o^ analogy witn
 
 358 TETANUS. 
 
 tetanus, viz., chorea, of which I shall soon speak, and considering how miserahty 
 narcotics had failed, he determined to give the carbonate of iron a fair trial upon the 
 first opportunity. He has published some account of its effects in tetanus, in ihe 
 Medico-Chirurgical Transactions. In the first case in which he used it, the tetanus 
 supervened upon a compound dislocation of the great toe. The method in Avhich 
 the remedy was administered was this. The carbonate was made into an electuary 
 by niixing it with twice its weight of treacle. The electuary thus made was well 
 stirred in beef-tea just as the patient was about to drink it. He took this every two 
 hours, as much as he could swallow : and he got well. The next case is described 
 as being a very severe one ; it resulted from a contusion of the thumb. Dr. EUiotson 
 says that he never saw a case, ivhich did well, that was more severe. This patient 
 also took the carbonate of iron, as much as could be got down ; and that was about 
 two pounds a day. He had injections twice daily, to keep the bowels unloaded ; and 
 the iron is described as having come away in large red lumps, in shape like horse 
 dung. This man recovered. In a third case, where a chilblain above the heel was 
 the exciting cause, the boy died within twenty-hours of the time when the remedy 
 was first prescribed. To produce its effects upon the system (Dr. EUiotson observes, 
 very truly), iron must be given ybr a few days: nay, he holds that months some- 
 times elapse before it has any effect. So that if it really be useful in tetanus, we 
 cannot expect much good from it in the more acute cases : and these are the cases 
 for which we want a remedy. 
 
 Oil of turpentine is one of the many substances that have been praised as useful 
 in tetanus. Now, bearing in mind its power (which I shall hereafter describe, 
 but which you must at present take for granted) as a worm-killer, and also the 
 frequency with which worms are met with in the stomach and bowels after death 
 bj"- tetanus, this is one of the drugs which I should employ as a purgative, taking 
 my chance of whatever good might possibly arise from its specific or anthelmintic 
 qualities. It may be given in such cases either by the mouth, or in an enema, or at 
 both ends together: but it must be given in large doses, not less than an ounce at a 
 time ; and it may be mixed with an equal quantity of castor oil. The one oil dis- 
 solves or becomes incorporated in the other. 
 
 Sfrychnia has been suggested as a remedy for severe tetanus ; not in infinitesimal 
 doses, as Hahnemann would, I suppose, prescribe it, but in sufficient quantity to 
 produce a sensible effect. The principle upon which this has been recommended 
 }s the same with that on which the nitrate of silver ointment is applied to the in- 
 flamed conjunctiva in purulent ophthalmia. We know that strychnia acts upon the 
 fpinal cord, affecting apparently those parts and those functions of the cord which 
 are affected in tetanus : and in so fatal a malady, it would be justifiable, I conceive, 
 to give the strychnia, in the hope that it might occasion a morbid action which would 
 supersede the morbid action of the disease, and yet be less perilous and more 
 manageable than it. But it would be right to try such a remedy as this in the first 
 instance, in corpore vili ; upon one of the lower animals. This, were it successful, 
 would be a cure, according to the Hahnemannic doctrine — similia similibus curaii' 
 fur — a doctrine much older, however, than Hahnemann. But the opposite maxim, 
 contraria contrariis has been suggested. Mr. Morgan proposes to give such poi- 
 sons as are knoAvn to cause paralysis, with the view of countervailing the undue 
 action of the muscles in tetanus. He produces artificial tetanus by inserting a 
 poison brought from Java, called "chatic," into a wound, and then relieves the 
 tetanic symptoms by a North American poison, the ticunas. Professor Sewell of 
 the Veterinary College, has tried this principle in one case at least, where the tetanus 
 was the result, not of any poison, but of disease. Not having had an opportunity 
 of getting the particulars of this case from Mr. Sewell himself, I give you Mr. 
 Mayo's account of it. " A horse, suffering from a severe attack of tetanus and 
 locked-jaw, the mouth being too firmly closed to admit the introduction of either food 
 or medicine, was inoculated on the fleshy part of the shoulder with an arrow-point 
 coated with wourali poison. In ten minutes apparent death was produced. Arti- 
 ficial respiration was immediately conimenced, and kept up about four hours, when 
 reanimation took place. The animal rose up, apparently perfectly recovered, and
 
 TETANUS. 359 
 
 eagerly partook of corn and hay. He was unluckily too abundantly supplied with 
 food during the night. The consequence was over-distension of the stomach, of 
 which the animal died the following day, without, however, having the slightest re- 
 currence of tetanic symptoms." I had fancied that the death had resuhed from some 
 injurious effect upon the lungs, produced by the artificial breathing. But I have 
 little doubt that Mr. Mayo derived his statement from Mr. Sewell himself. The 
 experiment deserves to be carefully repeated. 
 
 I have but httle to say concerning what may be called the surgical treatment of trau- 
 matic tetanus. It was a natural thing, the source of the irritation being supposed 
 to be the wound, to expect relief from amputation of the limb. But that will not 
 arrest the morbid action after it has once been fairly established. Dr. EUiotson says he 
 has searched scores of books, and found only one case in which the hmb and the 
 disease were lopped away together. However, Mr. Blizard Curling, in his Essay 
 on Tttanus, refers to seven instances of recovery, after the injured part had been 
 amputated. Yet he states that "it is almost impossible to ascertain with certainty 
 how far the amputation, in these cases, was of service. I beheve I cannot offer you 
 better advice on this subject than may be gathered from the concluding remarks of 
 a very distinguished and philosophical surgeon, in his lectures on this disease. I 
 allude to the late Mr. Abernethy, whose pupil I had the good fortune to be. He 
 said, " The state of the part injured is not the sole cause of tetanus. In cases of 
 tetanus I have often amputated injured fingers; and though I did not thereby save 
 my patients, yet I think that the symptoms were mitigated after such amputations. 
 In such cases, then, I would not amputate any considerable member; nor even a 
 small one, unless I thought that, from the injury sustained, it would prove useless to 
 its possessor, even though the case should terminate favourably." 
 
 The tourniquet has been applied to the hurt limb ; but not, so far as I know, with 
 any good effect. The most promising expedient which surgery offers is the divi- 
 sion of the principal nerve proceeding to, or rather from, the seat of the injury. 
 This, supposing the nerve to be known and accessible, is less formidable, less severe, 
 less hazardous, less maiming, and, if we may judge from past experience, more 
 effectual, too, than amputation of the part. Dr. Murray has recorded (in the 
 eleventh volume of the Medical Gazette), a very interesting case, in which the 
 operation Avas followed by most decided and instant relief. The patient was a young 
 midshipman who, having trodden on a rusty nail, which pierced the sole of his left 
 foot, had kept watch the same night upon deck, the weather being very cold. The 
 disease began the next day, and the symptoms ran high. It was a case, therefore, 
 of severe or acute tetanus. Without loss of time, the posterior tibial nerve was divided. 
 The limb was previously cold, and, as the patient said, dead, and he had httle power 
 of moving it. He could not articulate distinctly, on account of the closed state of 
 his jaws. The nerve was cut through by one stroke of the scalpel : and "immedi- 
 ately (says Dr. Murray) he opened his mouth with an exclamation ; and on looking 
 at his countenance I was astonished at tlie striking improvement in it. I asked him 
 how he felt, and he said he was already much better, and that his leg had come to 
 life again." Some stiffliess of the jaws and neck remained for a day or two ; but 
 he soon recovered. Dr. Murray rel'ers to another case, mentioned by Baron Larrey, 
 in which division of the nerve had a similar result. 
 
 Probably, to be successful, the operation must be early ; before the morbid con- 
 dition peculiar to the disorder has had time to root itself in the nervous system. 
 
 Although, in the present state of our knowledge, there is no one remedy or 
 plan on which we can rely for the cure of this fearful malady, we may with 
 much confidence lay down certain general rules, the observance of which will secure 
 to the patient the best chance of a favourable result. 
 
 Since any, the smallest movement, or impression made upon the surface, or upon 
 the senses, will bring on the severer degrees of spasm, it is of primary importance 
 to protect the patient against these sources of trouble, so sure to aggravate his suf- 
 ferings, and so likely to augment his danger. Hence if blood-letting should be 
 thought advisable, it should be done early, sufficiently, and once for all. There 
 should be no repetition of venesection, or of cupping, or of leeches, unless the cu-
 
 'i60 HYDROPHOBIA. 
 
 cumstances and progress of the case plainly demand them. The same remark 
 applies to the frequent use of purgatives. The bowels should be well cleared in the 
 outset, and then let alone. The patient should lie in a darkened room ; from which 
 noise also should, as much as possible, be excluded. He should not be surrounded 
 by a multitude of friends or attendants. He should be enjoined to speak, to move, 
 to swallow as seldom as he can. In the severe traumatic cases, the nerve, in mv 
 judgment, should be promptly divided. And in all cases, there being no special 
 indications to the contrary, I should be more inchned to administer wine in large 
 doses, and nutriment, than any particular drug. If the tendency to mortal asthenia 
 can be staved off, the disturbance of the excito-motory apparatus may, perchance, 
 subside or pass away. 
 
 There is a form of this complaint called trismus nascentium. As the name im- 
 plies, it occurs in newly-born children. It is very frequent and very fatal in the 
 West Indies ; coming on usually in the second week after birth. Hence it-iias been 
 called " the ninth-day disease." Another of its names in the British settlements 
 there, is " the jaw-fall ;" from the circumstance that shortly before death the lower 
 jaw, which had previously been firmly pressed against the upper, drops on the 
 breast. It has been said that a fourth of' the infant negroes in Jamaica used to die 
 of this disorder. Some persons refer it to the irritation produced by the retention 
 of the meconium in the intestines ; others to irritation from the wound made by 
 dividing the navel-string. A dose of purgative medicine appears to be the most 
 hopeful remedy. The complaint is common, I am told, in ill-ventilated lying-in 
 hospitals. Pure air must, therefore, be desirable as an adjuvant. 
 
 Tetanic symptoms sotnetimes occur (but I should think very rarely) in ague. Or 
 paroxysms of tetanus return at regular intervals, and terminate by profuse perspira- 
 tion : the patient being well during the intermissions. When such phenomena 
 arise, the treatment proper in severe forms of ague must be adopted : what that treat- 
 ment is, I shall in no long time be able, I hope, to lay before you. 
 
 Again, tetanus is occasionally a symptom in hysteria; and then the treatment 
 applicable to hysteria must be had recourse to ; especially encmata of oil of turpen- 
 tine, or the same medicine given by the mouth ; and the cold affusion. 
 
 If the disease of which I have been speaking be dangerous, and very often fatal, 
 in spite of all remedial measures, that which I propose to bring next under your 
 attention is still more appaUing ; for I believe that hitherto it has been uniformly 
 mortal. I know not that any one has ever been rescued by art, or saved by the 
 efforts of nature, from Hydrophobia, after that frightful disease has once declared 
 itself by its characteristic symptoms. The nature of those symptoms, and the 
 absence of all definite or constant traces of organic change in the dead body, suffi- 
 ciently mark the disease as belonging essentially to the nervous system, and as being 
 essentially a spasmodic disease also. 
 
 What are the symptoms stated in broad outline ? These. Excessive nervous 
 irritability and apprehension; spasmodic contractions of the muscles of the fauces, 
 excited by various external influences, and especially by the sight or sound of liquids, 
 and by attempts to swallow them ; and extreme difficulty, amounting sometimes to 
 impossibility, of drinking. 
 
 'Vhh is one of the diseases which are produced by animal poisons ; and its course 
 will be most conveniently traced if we include in our description of it the very first 
 step towards its production, — the application of the specific poison to the body. A 
 man is bitten by a dog. After a time the symptoms proper to hydrophobia come 
 on. After another interval the man is dead. Before we advert to the many very 
 interesting points of inquiry which arise out of the contemplation of this malady, let 
 •is follow the tragedy from its commencement to its closing scene. 
 
 A person is bitten, then, by a mad dog. Does the existence of rabies in the ani- 
 mal modify in any way the injury thus inflicted? No; the wound that is made 
 behaves just the same, to all appearance, as it would have behaved if the dog had 
 not been rabid; and it gradually heals. After an uncertain interval — which lies, 
 for the most part, between six weeks and eighteen months, and which ha.- l.'et-n
 
 HYDROPHOBIA. 361 
 
 called the period of incubation — the following symptoms begin to be noticeable. 
 The patient experiences pain, or some uneasy or unnatural sensation, in the situa- 
 tion of the bite. If it has healed up, the cicatrix tingles, or aches, or feels cold, or 
 stiff, or numb : sometimes it becomes visibly red, swelled, or livid ; on one occasion 
 a papular eruption took place around it; sometimes it opens afresh, and discharges 
 a peculiar ichor. The pain or uneasiness extends from the sore or scar towards the 
 central parts of the body : i. e., if the bite has been inflicted on a limb, the morbid 
 sensations extend towards the trunk. All this gives fearful notice of what is about 
 to happen. This period is called the period of recrudescence. I believe it seldom 
 fails to occur, although it sometimes is not noticed ; the attention of the patient, and 
 of his medical advisers, being absorbed by the horrible sequel. Very soon after this 
 renewal of local irritation — within a few hours, perhaps, but certainly within a very- 
 few days, during which the patient feels uncomfortable and ill — the specific consti- 
 tutional symptoms begin : he is hurried and irritable ; speaks of pain and stiffness, 
 perhaps, about his neck and throat : unexpectedly he finds himself unable to swal- 
 low fluids, and every attempt to do so brings on a paroxysm of choking and sobbing, 
 of a very distressful kind to behold ; and this continues for two or three days, till the 
 patient dies exhausted, in the way of asthenia. 
 
 I have seen only two examples of this terrific malady ; one in St. Bartholomew's 
 Hospital, in the year 1826 ; one much more recently in the Middlesex Hospital. 
 As they constitute the whole of my personal experience in the matter, I shall relate 
 these cases. 
 
 The first occurred in a coachman, the back of whose right hand had been struck, 
 ten weeks previously, by the teeth of a terrier dog; but, as both the patient and his 
 fellow-servants declared, there was no wound made, no blood drawn, no breach or 
 lifting of the skin ; but merely an indentation, showing where the animal's teeth had 
 pressed. He was brought to the hospital on a Tuesday. On the preceding Thurs- 
 day his hand had become painful, and swelled a little. On Friday the pain ex- 
 tended into the arm, and became more severe. His wife stated that he had been in 
 the habit of sponging his head and body every morning with cold water, but that, 
 on this morning, he refrained from doing so, on account of some feeling of spasra 
 about the throat. His own remark on this was, that " he could not think how he 
 could be so silly." 
 
 On Saturday the extent and the severity of the pain had still further increased. 
 On this and the preceding night he got no sleep. He felt ill and drowsy on the 
 Sunday, but drove the carriage to Kensington Gardens : he was, however, obliged 
 to hold both whip and reins in his left hand. The pain extended to the shoulder. 
 He was then bled. A slop-basin full of blood was taken, with much relief to the 
 pain ; and purgative medicine was given, which operated well. 
 
 The next day he complained of " feeling very ill all over," and he told his medi- 
 cal attendant that he could not take his draughts, because of the spasm in his throat. 
 That gentleman (Mr. Macdonald), concealing his own suspicions as to the true 
 nature of the disease, said, "Oh, you don't like the taste of your phj^sic! drink 
 some water." But he declared he had the same difficulty with water. The next 
 day he came to the hospital. When there, water was brought and placed before 
 him in a basin, for the alleged purpose of allowing him to wash his hands. It did 
 not seem to disturb him, nor to excite any particular attention. Water was then 
 offered him to drink, which he took, and carried to his mouth, but drew his head 
 from it with a convulsive- shudder. After this, on the same morning, he was much 
 questioned by several persons about the supposed cause of his iUness ; and water 
 was again brought him, which agitated him, and he became exceedingly distressed 
 and unquiet, complaining of the air which blew upon him. 
 
 I first saw him myself soon after this. He was then, to all outward appearance, 
 wt'l! ; lying on his back, without spasm, without anxiety ; his face somewhat 
 flushed. He said he had a little headache, but no pain in the arm. His pulse 
 was i:3"2, full, and strong; his tongue moist, and shghlly furred. He appeared to 
 be a very quiet, good-tempered man ; and smiled generally when he was spoken to. 
 
 I was naturally much interested by this case, and at nine in the evening I visited 
 
 2f
 
 362 HYDROPHOBIA. 
 
 1 
 
 the patieni again. Ht; was composed and tranquil. Gruel was mentioned, and 
 then he sighed two or three times deeply ; then sat up, and, after a moment's look 
 of serious terror, took half a spoonful of the gruel in a hurried gasping manner; 
 and said he would not take more at a time, lest the sensalion should come on. He 
 was desired to drink the last portion of the gruel from the basin. He accordingly 
 seized it with a hurry, carried, it to his mouth with an air of determination, and 
 then a violent choking spasm of the muscles about the throat ensued, the stemo- 
 mastoidei starting strongly forwards. Most of the gruel was spilled over his chin ; 
 and he observed that he had been too much in a hurry, or he should have managed it. 
 
 The treatment consisted in full doses of opium, repeated at frequent intervals. On 
 this visit to him I noticed, that while attempting to take some of the gruel with a 
 spoon, he seemed inclined to doze as he sat. Otherwise there were no signs of his 
 being overwhelmed, or even sensibly affected by the opium, unless indeed his gene- 
 ral quietness was the consequence of it. He was quite rational and calm, except 
 when attempting to take fluids. 
 
 On the Wednesday, at noon, he was in nearly the same state, but said he was 
 better. In the course of the night some morsels of ice had been given him : with 
 considerable effort he swallowed two or three of these ; the third or fourth caused 
 so much spasm, however, that he was obliged to throw it out of his mouth : but so 
 great was his resolution that he seized it again, and, by a strong exertion, succeeded 
 in swallowing it. He complained now that his mouth was and had been clammy ; 
 and he champed much, and spat out a good deal of tough mucus. At his own 
 request, and ("as he said) that he might injure no one, a strait-waistcoat was brought, 
 which he assisted in putting on. But he was perfectly tranquil then. 
 
 I now had an opportunity of seeing him take some arrow-root. He sat up in bed 
 to eat it ; and before attempting to do so, he made hurried inspirations, and sobbings 
 precisely resembling those which occur when one wades gradually into cold water. 
 He swallowed small quantities of arrow-root eight or nine times, with hurry and 
 difficulty, and with sighs that succeeded each other rapidly. He said that he felt 
 the upper part of his throat narrower than it should be. He continued to take 
 laudanum mixed with sugar and bread into a kind of pulp. 
 
 By the evening of that day the disease had not made much further progress. He 
 again sat up and tried to eat some thinnish gruel. While taking the basin into his 
 hand, he drew back his head to a distance from it, apparently involuntarily. He 
 took one half-spoonful with effort and distress, then sighed deeply and rapidly, or 
 rather his breathing consisted of a succession of sighs at short intervals : he gave up 
 the basin, and sank back on his pillow still sighing. In the course of that night he 
 ceased to take the laudanum ; he could no longer attempt it. The next day ne was 
 still composed, though more easily irritated ; and it was found that he had lost the 
 power of moving the left arm. His pulse was 140, and much weaker than before, 
 and his mental powers Avere failing. He gradually sank, and died in the evening, 
 having repeated the Lord's Prayer an hour previously. During the last hours of 
 life he had been moaning, and tossing from side to side : his bowels were purged ; 
 fluid stools ran from him, and distressed him greatly. His lower extremities first 
 became cold, and the coldness extended by degrees up to his chest. He hawked up 
 in the course of the day a considerable quantity of ropy mucus, and much frothy 
 saliva came from his mouth towards the close. As his wife was wiping this away, 
 his teeth, whether by convulsive accident or otherwise, came in contact with her 
 finger, and drew blood. The part was cut out ; and no bad consequence followed 
 that I know of. 
 
 The examination of his body threw no satisfactory light ujwn the essential nature 
 of the disease. Blood and serous fluid escaped on the removal of the calvarium. 
 The vessels of the membranes were full, and the brain itself was mottled somewhat 
 by Its vascularity. There were a few spots of ccchymosis on the heart. The back 
 part of the tongue was very vascular. The stomach presented the most notable 
 appearance. There was a quantity of brownish-coloured mucus on its inner surface, 
 and the mucous membrane had disappeared from a space about four inches in 
 diameter at its left and larger end. That space alone was diaphanous ; its edges
 
 HYDROPHOBIA. 363 
 
 sloped inwards ; and a segment of this thin place looked exactly like a piece oi china. 
 On a white ground, there were inosculating vessels, some of them blue, and some 
 of them of a coffee-coloured brown. I conclude that this appearance was produced 
 by the action of the gastric juice after death. 
 
 This was in some respects a remarkable case. It was remarkable for its duration. 
 Dr. Bardsley, in the article on Hydrophobia in the Cyclopxdia of Practical Medicine, 
 states that the patients " invariably go on from bad to worse, and finally die before 
 the sixth day." Now if we reckon that stage of the complaint here referred to by 
 Dr. Bardsley to have begun on the morning of Friday, when he was obliged, to omit 
 his sponging because of the spasm about his throat, this patient did not die till the 
 middle of the seventh day. In fact it was a very protracted case, and the symp- 
 toms were less violent than usual. Whether this was owing to the opium he took 
 or not, it would be difficult to determine. 
 
 In the second of the two cases which it has been my lot to witness, the charac- 
 teristic symptoms of hydrophobia were more faintly pronounced than is usual. 
 
 On my arrival at the Middlesex Hospital, on Thursday, the 5th of October, 1837, 
 I was told that a patient had been admitted (under one of my colleagues) labouring 
 probably under hydrophobia. He had applied at the hospital in the middle of the 
 night ; but was then sent away, after receiving some aperient pills, with assurances 
 that he was only feverish and nervous. On his reapplication in the morning, he had 
 been admitted. 
 
 I found him in the ward : a man twenty-five years old, of dark complexion and 
 hair. He expressed his conviction that he was afiiicted with hydrophobia ; and said 
 he was prepared for his fate. I observed that every now and then he suddenly 
 sighed in a very pecuhar manner ; just as I had seen the former patient sigh. This 
 would happen sometimes in the middle of a sentence, while he was speaking. He 
 told us that he had been bitten by a dog in the latter end of July ; the dog was swim- 
 ming, and like to drown, in a canal, and upon his reaching over to lift him out of the 
 water, the animal seized upon his hand. After dragging the dog out, he beat him 
 for his ingratitude ; and then the dog ran off, and was pursued by a mob of boys, 
 who had previously been pelting him as a mad dog. There was a scar on the 
 middle finger of the right hand ; the nail of that finger had (he said) been torn 
 through, and each of the two adjacent fingers had been more slightly bitten. His 
 pulse was 84 ; but varied in frequency at short intervals. 
 
 He acknowledged that after receiving the bite he was uneasy as to its possible 
 effects, and read books about hydrophobia at the time : but he affirmed that he had 
 afterwards ceased entirely to think about it. He had persuaded himself that the 
 dog could not be mad, from its being in the water. On Tuesday, if not earlier, he" 
 had been uncomfortable and restless ; and on Wednesday he found he could not 
 swallow liquids. On one of these days he experienced a slight pricking sensation, 
 without any redness or tenderness, in the site of the scar ; his right arm and leg 
 seemed to himself hotter than the opposite limbs ; and the arm, though not tender, 
 felt raw, and he could not bear the light contact of his clothes upon it. Fie became 
 feverish also. From time to time a slight expression of terror passed across his 
 features, and then he made a sudden, deep, sighing inspiration : at other times his 
 breathing and appearance were perfectly natural. It was said that when some 
 water was brought him he drew himself back from it with horror. He talked a 
 good deal. 
 
 I saw him eat rice, made pulpy with milk. He took it without looking at the 
 spoon, from which he averted his eyes, and ate several mouthfuls, in a gulping man- 
 ner, and with evident effort. His bowels had been purged by the pills, and he 
 declared that the noise of the water in the water-closet had distressed him. The 
 sound of some water poured from one vessel into another by the pa-tient in the next 
 bed, had also agitated him. So did the contact of my cold hand on his arm ; and 
 currents of air, even the breath of any one speaking to him ; so that he insisted on 
 conversing with the apothecary in such a position that the chin of each was upon 
 the other's shoulder. But there was no actual or apparent spasm. 
 
 At this time he affirmed that the presence of company cheered him, and did hnu
 
 364 HYDROPHOBIA. 
 
 I 
 
 good ; and beg-ged that he might not be removed into a separate room. And he 
 wished for some amusing book that he might read. 
 
 In the evening I again went to see him. He did not seem worse, thoutrh he 
 said "his symptoms were increasing." He had taken a dose of musk and'some 
 morphia. 
 
 The next day I found the hospital in some confusion. Between eleven and twelve 
 o'clock in the preceding night some of the officers of the hospital had gone to his 
 bed, while he was apparently asleep, and certainly very quiet. They asked him if 
 he would like some water. This seems to have greatly excited him ; and imme- 
 diately after their departure he rushed out of bed, (terrified he said,) became furious 
 and unmanageable, and was never again tranquil till he died, about the same time 
 next night. He was now put into a room by himself; and, taking advantage of the 
 momentary absence of the nurse, he bolted himself in alone : and he declared he 
 would admit no person but her. The door was at length forced, and a strait- 
 waistcoat was put upon him. He then became quieter in his manner ; begged that 
 no unnecessary violence might be used ; asked to be poisoned ; spat at some of the 
 bj'standers, and reproached them, talking rapidly and wildly like an insane person ; 
 yet loudly and angrily imposing silence on every one who addressed him. He said 
 he could not bear to hear any one speak; that he did not like my bass voice. Then 
 he would sneer at the students, and say they showed bravery enough now he was 
 confined : " Was it right for 3'oung gentlemen of education to stand there gazing 
 with curiosity on a dying man ?" asked for bread soaked in water, and when it was 
 held towards him, snatched it in his mouth in a savage manner ; spoke of his " poi- 
 soned tooth," and talked perpetually. He took a fancy to one of the students, and 
 begged that he might remain with him. 
 
 About this time he vomited some yellow fluid, and thought he felt the better for 
 it, and asked for an emetic ; and some tartarized antimony was exhibited. He was 
 now pale, and his lips were Hvid ; but none of the distinctive spasmodic attacks 
 occurred : indeed water was not at this time suffered to be brought near him. This 
 circumstance it was, this absence of the peculiar spasmodic paroxysms which char- 
 acterize hydrophobia, that induced several medical men of much sagacity and expe- 
 rience to doubt, and even with some positiveness to deny, that the patient was suffering 
 under that disease at all. The}'' supposed him to be hysterical, half-crazj'', or on the 
 brink of delirium tremens. But though slightly expressed, the symptoms were 
 unlike anything I had ever witnessed, except in the previous instance. And the 
 closing scene was quite distinctive. 
 
 It appeared, and he spoke of it as a thing which distressed him, that when he was 
 most excited, his urine passed involuntar}'. 
 
 In the ev^ening I found his father with him. He had recognized him, and kissed 
 his mother-in-law ; but soon began to rave, and to be apparently occupied with 
 absent persons. He was pale and weak, and lay with his head over the side of the 
 bed, spitting continually upon the floor, which was thus made quite wet. He wished 
 to have his hands at liberty that he might " clear his mouth." He was soliloquizing 
 when I went into the room in this way: "Monsters — monsters — see that monster, 
 Susan — take her away." (It appeared that he was now speaking of a young woman 
 who had had a child by him.) "I thought they would do much for science, but 
 never sujiposed they would inflict such agony as this ;" and so on. 
 
 A little later Mr. Arnott visited him. He had then no pulse at the wrist. The 
 waistcoat was removed. He sat up, and used some water, brought to wash his 
 hands, without apparent distress. Soon after he sank back exhausted ; and expired. 
 
 His father corroborated what the patient had said of the dog ; and told us his son 
 was clever, and better educated than many of his rank (he wai a tailor), but always 
 exceedingly nervous. 
 
 The bodj' was examined the next day. Its posterior and undermost surface was 
 very livid. The blood everywhere quite fluid. The veins of the spinal cord, on its 
 posterior part, were turgid; not at all so on the anterior. The substance of the cord 
 was quite natural. There was some fluid in the theca. The brain appeared to me 
 in every pari, quite sound and healthy.
 
 HYDROPHOBIA. 365 
 
 The head and face, which had been hanging over the table while the spinal canal 
 was opened from behind, were deeply purple as though universally bruised. This 
 colour diminished rapidly after the corpse was placed supine, and the head raised 
 somewhat above the level of the body. The papilte at the back part of the tongue 
 were greatly exaggerated, and looked like large vesicles. The cartilage of the 
 epiglottis, at its lower part, was red. At about the middle portion of the oesophagus 
 there was an appearance as if the cuticle was abraded. The mucous membrane of 
 the stomach was soft, and red here and there, with a dotted injection resembling 
 ecchymosis, especially on its rugae. The air-passages were apparently heakhy. 
 
 Generally, the disease, when it has once set in, and shown the peculiar hydro- 
 phobic symptoms, runs a short and fierce course. The nervous irritability becomes 
 extreme. The peculiar paroxysms of choking spasm, and sobbing, are excited, not 
 only by attempts to swallow liquids, but by the very sight or sound of them. Dr. 
 Elliotson mentions a boy who was thrown into a state of violent agitation by hearing 
 a dresser who sat up with him make water. The passage of a gust of wind across 
 his face, the waving of a polished surface, as of a mirror, before his eyes, the crawl- 
 ing of an insect over his skin, is often sufficient to excite great irritation, and the 
 peculiar strangling sensation about the fauces, in a hydrophobic patient. These 
 circumstances were but little observable in the men whose cases I have related. The 
 first of them indeed was remarkably calm and tranquil under the disease. In general 
 the patient is dreadfully irritable, and apprehensive and suspicious ; and in most 
 cases there is a degree of mania or delirium mixed up with the irritability ; the suf- 
 ferer is very garrulous and excited. In this respect there is a marked difference 
 between hydrophobia and tetanus. In the latter disorder the mental facukies are 
 clear, and the patients serene, and what is called heart-whole, to the last. The two 
 diseases differ in another striking particular: the spasm in the one case is tonic, in 
 the other clonic. In tetanus, again, there is no thirst, and seldom any accumulation 
 of tough and stringy mucus in the fauces and about the angles of the mouth ; in 
 hydrophobia both these symptoms are always, J believe, present. So probably is 
 vomiting; but vomiting in tetanus is rare. The nervous irritability in hydrophobia 
 is doubtless a part of the disease, and is very seldom absent even now-a-days. Some- 
 time ago it might perhaps have been plausibly attributed to the treatment adopted. 
 I allude to that period in which it was believed that these miserable persons had both 
 the power, and the inclination, to impart the disease to others by biting them ; and 
 when, under pretence of shortening his sufferings, but really, I am afraid, with the 
 cowardly view of protecting themselves, his friends were accustomed to smother the 
 unhappy patient between two feather-beds, or to open a vein, and to leave him to 
 bleed to death. Any person suspecting what was the matter, and foreseeing such a 
 termination to his disease, might well be nervous and irritable. But now that this 
 barbarous practice has been exploded, and the dread of being smothered does not 
 occur to the mind of the patient, he is still found to be exquisitely frritable and timo- 
 rous. The foam and sticky mucus that gather in the throat and mouth, these patients 
 make great efforts, by spitting and blowing, to get rid of; and the sounds tl.cy thus 
 produce have been exaggerated by ignorance and credulity into the barking and 
 loaming of a dog. In the same way the paraplegia which sometimes takes place, 
 rendering the patient unable to stand upright, has been misconstrued into a desire on 
 his part to go on all fours like a dog. The pulse, though it may be strong and hard 
 at the outset, becomes, in a short time, frequent and feeble, and the general strength 
 declines with great rapidity. Death occasionally takes place within twenty-four 
 hours after the commencement of the specific symptoms. Most commonly of all it 
 happens on the second or third day ; now and then it is postponed to the fifth day , 
 and in still rarer instances, of which my first case Avas one, death does not occur till 
 the seventh, or eighth, or nin-th day. In most cases the paroxysms becoming more 
 violent and frequent, exhaust the patient ; but in a few instances the symptoms un- 
 dergo a marked alteration before death. The paroxysms cease, the nervous irritabi- 
 Uty disappears, the patient is able to eat and drink, and converse with ease ; thoso 
 Sights and sounds which so annoyed and distressed hira before, no longer cause him 
 
 2f2
 
 366 HYDROPHOBIA. 
 
 any disquiet. In this state he often sinks into a sleep, and suddenly wakes from it 
 to die : sometimes his existence is put an end to by a sudden and violent convulsion. 
 
 It is needless for me to go into a minute account of the morbid appearances that 
 l^ave been met with in persons dead of hydrophobia. They are various, uncertain, 
 unsatisfactory. In some bodies the most careful examination has discovered nolhinc 
 amiss. In others, vascularity of the brain, or of the spinal cord, has been noticed. 
 And in not a few instances the mucous membrane of the fauces, ossophagus, and 
 stomach — or of the larynx and trachea — or of both these tracts — has been found red, 
 and covered with adhesive mucus. But we must take care not to attribute undue 
 importance to these last appearances — not to conclude that they have been the cause 
 of the symptoms, when, in truth, they may have been the effect of the disease. That 
 we should find the parts in the throat red and congested is what we might naturally 
 expect, when we consider the violent straining spasmodic action of these parts for 
 some time before death. The morbid anatomy of this disease throws but little hght 
 upon its nature, or upon its proper treatment. 
 
 There are many very interesting questions connected with hydrophobia. I will 
 state the principal of these as shortly as I can. 
 
 1. You will be surprised when I tell you that some persons have made it a ques- 
 tion whether there is any such disease at all. I have known such. The late Sir 
 Isaac Pennington, who was Regius Professor of Physic at Cambridge, had never 
 seen a case of hydrophobia, and nothing could persuade him that any one else had 
 seen any thing more than a nervous complaint produced by the alarmed imagination 
 of the patient, who, having been bitten by a dog reputed to be mad, and having the 
 fear of feather beds before his eyes, was frightened into a belief that he had hydro- 
 phobia, and ultimately scared out of his very existence. Now if you meet with such 
 incredulous persons, and think it worth your while to argue the point with them, you 
 may object to their unbehef, the improbability that so many persons who have been 
 bitten by mad dogs should have suffered so precisely the same train of symptoms, 
 and at last have died, from the mere force of a morbid imagination. You may urge 
 them with the fact that many of these persons have been under no apprehension at 
 all until the disease has seized upon them ; that many also have been men of na- 
 turally strong and firm minds, not at all hkely to be frightened into beheving that 
 they were seriously ill unless they really were so, and still less likely to be terrified 
 into their graves. And if this has no weight Avith such reasoners, you may bring 
 forward the conclusive facts that the disease has befallen infants and idiots, who had 
 never heard or understood a word about mad dogs or hydrophobia, and in whom the 
 imagination could have had no power in calling forth the complaint. And if they 
 are proof against this, you must give them up : I can suggest nothing more. 
 
 2. Allow that the disease exists as a real, and not merely imaginary disease, and 
 also that it is caused by the bite of a rabid animal : this important question arises — 
 has it any other cause ? 
 
 Setting aside that quibbhng apphcation of the term hydrophobia, which some 
 writers have chosen to make, to diseases in which, from some painful affection of 
 the throat, the patients have been unwilling to attempt to swallow fluids, there are 
 cases recorded, exactly resembling hydrophobia in their symptoms, and occurrincr 
 in persons who were never known to have been bitten by, or even to have been in 
 the presence of, a rabid animal. The celebrated and accurate Pinel has given the 
 history of such a case. There is another by Savirotte, in the Journal des Savans 
 (August, 1757). Now it is just possible that this disease may sometimes develop 
 itself in the human body without any contagion having been applied : and it is also 
 possible, and much more probable, in my judgment, that the poison may have been 
 applied without the person's being aware of it. We shall see, by and by, some very 
 possible ways in which that might happen. All that we need concern ourselves with 
 practically, is this — that in 999 cases out of 1000 the disease in the human body is 
 uerived from a rabid animal. If it ever be spontaneous, we cannot reckon upon 
 meeting with such a case : indeed, many medical men pass through life without 
 witnessing the disorder at all.
 
 HYDROPHOBIA. 367 
 
 3. Granting, then, that the disease in man is the result of an animal poison, the 
 next question is, from what animals may he receive the infection ? 
 
 We are sure that the disease, by the inoculation of which hydrophobia may be 
 produced in man, is common in the dog, and that it has been communicated to the 
 human animal by the fox also, the wolf, the jackal, and the cat. Mr. Youatt says 
 that the sahva of the badger, the horse, the human being, has undoubtedly produced 
 rabies, and some affirm that it has been propagated even by the hen and the duck. 
 The same author mentions a case in which a groom became affected with hydro- 
 phobia through a scratch which he received from the tooth of a horse that was 
 labouring under the disease. All animals, even fowls, are susceptible of the disorder 
 when bitten by the rabid dog. Of course it is an important question to have resolved, 
 whether the saliva of all these is capable of conveying the malady. The case just 
 now mentioned on Mr. Youatt's authority would seem to settle the question as 
 respects the horse ; but as horses, cows, turkeys, &c., do not generally bite, we have 
 not many opportunities of supplying a positive answer to the general question : there 
 can be no doubt about the cat, the fox, the wolf, and the jackal. 
 
 The late Duke of Richmond died abroad of hydrophobia, communicated, it was 
 though., by a tame fox. In the 13th volume of the Medico-Chirurgical Transac- 
 tions, an account is given by Mr. Hewitt, of several cases of fatal hydrophobia from 
 the bite of a wild and rabid jackal. Many examples are on record of the produc- 
 tion of the disease by the bites of mad cats and wolves. 
 
 The first case which I have spoken of, as having been seen by myself, would seem 
 to prove, if all the facts were correctly stated at the time, that the saliva of the dog 
 may be sufficient to produce the disease, when it is merely applied to the unbroken 
 skin. It was affirmed by various persons that the teeth of the terrier did not break 
 the cuticle. But we must take care not to draw a hasty general inference from a 
 single case. Mr. Youatt, who has seen more of the disease probably both in man 
 and in other animals, than any person alive, does not think that the saliva of a rabid 
 animal can communicate the disorder through the unbroken cuticle : he believes that 
 there must be some abrasion or breach of surface. He holds, however, that it may 
 be communicated by mere contact with the mucous membranes. 
 
 Of its harmlessness on the sound integument he offers this presumption — that his 
 own hands have many times, with perfect impunity, been covered with the sahva 
 cf the mad dog. He mentions some singular instances in Avhich the disease had 
 been transmitted by contact of the saliva with the mucous membranes. " A man 
 had endeavoured to untie with his teeth a knot that had been firmly drawn in a 
 cord. Eight weeks afterwards he perished, undeniably rabid. It was then recol- 
 lected that with this cord a mad dog had been confined. A woman was attacked 
 by a rabid dog, and escaped with the laceration of her gown. In the act of mend- 
 ing it she thoughtlessly pressed down the seam with her teeth. She died." If 
 these cases be authentic, they are conclusive of this question ; unless, indeed, the 
 hps of those who perished happened to have been chapped or abraded. But Mr. 
 Youatt's own opinion is, that the virus cannot be received on a mucous surface 
 without imminent danger. 
 
 The disease is said to have been caused by the scratch of a cat. But as we know 
 that cats as well as dogs frequently apply their paws to their mouths, especially 
 when the latter part is uneasy, (as it clearly is in mad dogs,) this fact, of the produc- 
 tion of the disease by a scratch, if thoroughly made out, would not prove that the 
 disease can be introduced into the system m any other way than by means of the 
 slaver.
 
 368 HYDROPHOBIA. 
 
 LECTURE XXXIV. 
 
 Hydrophobia, concluded. Various Queslions considered respcctins; the Disease as 
 if appears in the Human Subject, and respecting Rabies in the Hog. Pathology 
 of the Disorder. Treatment. Preventive Measures. 
 
 After giving you some account of the phenomena of hydrophobia, or rabies 
 canina, I began to notice, in the last lecture, the chief of the interesting questions 
 which naturally present themselves to the minds of most men, and especially of 
 medical men, in respect to that shocking disorder. 
 
 In the first place, there is such a disorder. It appears, too, secondly, from state- 
 ments made upon credible authority, that the same group and succession of symp- 
 toms as characterize the disease when it is produced by the bite of a rabid animal, 
 have been observed to occur in persons who were never known to have been bitten. 
 In my own opinion it is more probable that these persons had been exposed to the 
 virus without being aware of it, than that the disease was spontaneously engendered 
 in their bodies. 1 would make the same remark with regard to an instance which 
 is said to have happened of hydrophobia in a lad who had been bitten five weeks 
 before by a healthy dog : the dog remaining well at the time of his seizure and 
 death. Mr. Youatt holds, indeed, that however the disease originated, it never 
 occurs now, not even in the dog, except as a consequence of the application of the 
 specific contagion. It is certain, in the third place, that (besides the dog) the wolf, 
 the fox, the jackal, and the cat, have communicated the disorder to the human ani- 
 mal. Mr. Youatt affirms, that the saliva of the badger, of the horse, and of the human 
 being, has caused rabies ; and I mentioned, on his authority, a case in which a groom 
 contracted the disease through a scratch which he received while administering a 
 ball to a rabid horse. But 1 feel much less certain about these latter animals. Re 
 specting the dog, the fox, the wolf, the jackal, the cat, there can be no question. 
 The result of certain experiments made at the Veterinary School, at Alfort, is opposed 
 to Mr. Youatt's statement. Professor Dupuy made wounds in cows and sheep, and 
 rubbed upon these wounds sponges which had been chewed by rabid animals of the 
 same species: yet he never succeeded in communicating the disorder in this way; 
 but when he used a sponge that had been mumbled by a mad dog, then the disease 
 occurred in the sheep and cows. 
 
 It is still more interesting to inquire, whether the saliva of a human being, labour- 
 ing under hydrophobia, is capable of inoculating another human being with the same 
 complaint? Mr. Youatt says yes : that the disease has undoubtedly been so pro- 
 duced. If this be so, the fact will teach us — not to desert or neglect these unhappy 
 patients, still less to murder them by smothering — but to minister to their wants with 
 certain precautions: so as not to suffer their saliva to come in contact with any sore 
 or abraded surface; nor, if it can be avoided, with any mucous surface. On the 
 other hand, all carefuhiess of that kind will be unnecessary^ if the disease cannot he 
 propagated by the human saliva. Certainly many experimenters have tried in vain 
 {0 inoculate dogs with the spittle of a hydrophobic n)an ; but there is one authentic 
 experiment on record, which makes it too probable that the disease, though it may 
 not be communirft/fc/ often, or easily, is yet communit'«/)/e. The experiment is said 
 to have been made by MM. Magendie and Breschet, at the Hotel-Dieu, and to have 
 been witnessed by a great number of medical men and students. Two healthy dogs 
 were inoculated, on the 18th of June, 181;3, with the saliva of a patient, named Surlu, 
 who died of hydrophobia the same day in that hospital. One of these dogs became 
 mad on the '27th of the following month. They caused this dog to bite others, 
 which, in their turn, became rabid also : and in this way they propagated the mala- 
 dy, among do2s, during the whole summer. Now this is a very striking fact, yet it 
 uught not to be considered conclusive : for it is possible that the dog might have 
 erne mad at that time, whether he had been so inoculated, or not. It may have 
 been a mere coincidence. We want repetitions of such experiments to settle the
 
 HYDROPHOBIA. 369 
 
 point : nevertheless, we have enough in this one experiment to make u;? use all 
 necessary caution when engaged in attending upon a hydrophobic patient. 
 
 I just touched upon the question, whether the saliva of a rabid dog could produce 
 the disease if it fell upon the sound skin? The first of the two cases which I related 
 as having been witnessed by mysel-f, would appear to give an affirmative answer to 
 this question. Mr. Youatt thinks the disease would not follow such an application 
 of the virus ; but that it cannot be received upon even the unbroken surface of a 
 mucous membrane without the greatest danger. Horses are said to have died mad 
 after eating straw upon which rabid pigs had died. Portal was assured that two 
 dogs, which had licked the mouth of another dog that was rabid, were attacked with 
 rabies seven or eight days afterwards. Mr. Oilman, of Highgate, in a little pam- 
 phlet on Hydrophobia, quotes an instance from Dr. Perceval, in which a mad dog 
 licked the face of a sleeping man, near his mouth, and the man died of hydrophobia, 
 although the strictest search failed to discover the smallest scratch or abrasion on 
 any part of his skin. 
 
 At the very close of the lecture I observed, that even should it be clearly proved 
 that hydrophobia has ever resulted from the scratch of a rabid animal's daws — the 
 claws of a cat, for example — we are not to set it down as a sure thing that the dis- 
 ease can be introduced into the system independently of the saliva of the diseased 
 animal. As we know that dogs and cats are in the habit of putting their paws to 
 their mouths when they feel uneasy there, we may readily understand how the poi- 
 sonous saHva may be introduced by a mere scratch with the creature's nails. Mr. 
 Youatt believes that the sahva only is capable of conveying the disease. 
 
 4. Supposing the virus to have been inserted into the part bitten, what becomes 
 of it ? Is it immediately taken into the system, and does it, like the poison of small- 
 pox, in some mysterious way, multiply and diffuse itself in the body, until the dis- 
 ease explodes? Or does it remain imprisoned in the wound, or in the cicatrix, for 
 a time ? This is an important practical question. For if the poison lurks for some 
 weeks in the place where it was originally deposited, we mirrht successfully remove 
 it at any time between the infliction of the bite and the period of recrudescence. 
 Now, the facts that at this period of recrudescence the wound or scar is re-inflamed 
 often, and almost always becomes the seat of some fresh morbid phenomena, pain, 
 swelling, numbness and the like, spreading towards the trunk — and that, soon after 
 this, the peculiar paroxysmal symptoms begin — these facts are strong in favour of 
 the belief that the poison does lie inert in the place of the original hurt, for some 
 time. Dr. Bardsley states that the recrudescent pains seem always to follow the 
 course of the nerves, and do certainly never inflame or irritate the lymphatic glands 
 in the vicinity, though passing in a parallel course towards the trunk. He affirms 
 the entire absence of any fact contrary to this observation in the works of the nume- 
 rous authors who have written on the subject. I mention this statement because it 
 certainly is not correct. Mr. Mayo says, " in one case which I witnessed and exa- 
 mined after death, the inner part of the cicatrix was bloodshot ; and a gland in the 
 axilla had swelled at the coming on of the hydrophobic symptoms." And I find 
 among my notes of Mr. Abernethy's lectures, another striking case, still more to the 
 point. " A very intelhgent boy had been bitten by a dog in the finger: he was 
 brought into St. Bartholomew's Hospital. Caustic had been liberally used, affecting 
 the sinewy parts, and producing a terrible sore : yet the boy was recovering him- 
 self, and the sore was healing. One day as Mr. Abernethy was going round tlie 
 hospital, he saw and spoke to the boy, who said he thought himself getting well, 
 but that he had that day an odd sennation in his fingers, stretching upwards into his 
 hand and arm. Going up the arm, Mr. Abernethy saw two red lines, like inflamed 
 absorbents : they doubtless were so. He affected to make light of the matter, ordered 
 a poultice, and recommended the boy to take some medicine. Early the next morn- 
 ing Mr. Abernethy visited the ward, pretending he had some other patient thoni 
 whom he wished particularly to see : and when going out again, he asked the boy, 
 in a careless tone, how he was. He said that he had lost the pain, but that he wau' 
 very unwell, and had not slept all night. Mr. Abernethy felt his pulse, told him hi; 
 was a little feverish, as might be expected, and asked him if he were not thiritv, 
 24
 
 370 HYDROPHOUIA. 
 
 and would like some toast and water. The boy said he was thirsty, and that he 
 should like some drink; when, however, the cup was brought, he pushed ic from 
 him : he could not drink. In forty-eight hours he was dead." 
 
 Facts, such as these, would lead to the conclusion that, in cases in which ex- 
 cision had not been performed in the first instance, the scar or the sore might be cut 
 out with propriety at any time before the period of recrudescence : and if the case 
 happened to be my own, I would have done this even at that period, the moment 
 any new sensation manifested itself in the seat of the injury. Mr. Mayo, on the 
 same grounds, advocates the removal of the cicatrix, even although the hydrophobic 
 symptoms may have appeared. I do not mean to sajr that the facts now referred to, 
 show with any certainty that the poison remains in the place where it was first de- 
 posited, until the phenomena of recrudescence take place : but they afford some 
 presumption in favour of that notion ; and in such a disease as hydrophol|ia, we are 
 bound to act upon the very lowest presumption that affords a chance for our patient's 
 hfe. The poison may be absorbed into the general system at the period of recru- 
 descence, although no affection of the absorbing vessels or glands should be mani 
 fest : through the veins, namely. 
 
 Considermg the matter philosophically, we might be inclined to suppose that the 
 poison was silently maturing its force in the general sj'stem during the period of in- 
 cubation, just as the poisons of small-pox and of measles are presumed to do. But 
 looking at it practically, I should recommend, under tlie circumstances already 
 stated, the excision of the cicatrix. 
 
 5. Another important question is this. Is a man who has been bitten b}' a mad 
 dog, and in whose case no precautions have been taken, a doomed man ? will he be 
 sure to have the disease, and therefore to die of it ? By no fneans. But few, upon 
 the whole, of those which are so bitten, become affected with the hydrophobia. 
 
 It is curious that different species of animals appear to bo susceptible of hydro- 
 phobia in different degrees. Thus, according to Mr. Youatt, two dogs out of three, 
 bitten by one that is rabid, become rabid. The majority of horses inoculated with 
 the virus, perish. Cattle have a better chance : perhaps because in them the skin 
 is looser and less easily penetrated. A full half (he thinks) of those that were 
 seized by a mad dog, would escape. With sheep the bite is still less dangerous. 
 He Reckons that not more than one in three would be affected. The tooth, perhaps, 
 has been wiped clean in its passage through the wool. The human being is least of 
 all in danger. John Hunter states that he knew an instance in which, of twenty- 
 one persons bitten, one alone fell a victim to hydrophobia. Dr. Hamilton estimates 
 the proportion to be one in twenty-five. But I fear these computations are much 
 too low. In 1780, a mad dog, in the neighbourhood of Senlis, took his course 
 within a small circle, and bit fifteen persons before he was killed: three of these 
 died of hydrophobia. The slaver of a rabid wolf would seem to be highly virulent 
 and effective. These beasts fly always, I believe, at a naked part. Hence, probably, 
 the fatality of their bites. The following statement applies exclusively to the wolf. 
 In December, 1774, twenty persons were bitten in the neighbourhood of Troyes ; 
 nine of them died. Of seventeen persons similarly bitten in 1784, near Brive, ten 
 died rabid. In May, 1817, twenty-three persons were bitten and fourteen perished. 
 Four died out of eleven that were bitten near Dijon : and eighteen of twenty-four 
 bitten near Rochelle. At Bar-sur-Ornain, nineteen were bitten, of whom twelve 
 died of hydrophobia within two months. Here we have one hundred and fourteen 
 persons bitten by rabid wolves, and among them no less than sixty-seven victims ; 
 considerably more than one-half. There is no doubt, however, that the majority of 
 persons who are bitten by a mad dog escape the disease. This may partly be 
 owing to an inherent inaptitude for accepting it. We see some persons who, though 
 often in the way of it, do not contract syphilis ; there are others upon whom the 
 contagion of small-pox has no influence. This difference exists, apparently, even 
 among dogs. There was once a dog, at Charenton, that did not become rabid after 
 being bitten by a rabid dog; and it was so managed that, at different times, he was 
 bitten by thirty different mad dogs ; but he outlived it all. Much will depend also 
 upon the circumstances and manner in which the bite is inflicted. Ifitbemade
 
 HYDROPHOBIA. 371 
 
 throigli clothes, and especially through thick woollen garments, or through leather, 
 the saii-va may be wiped clean away from the tooth before it reaches the flesh. In 
 the fifth volume of the Edinburgh Medical and Surgical Journal, there is a case 
 described by Mr. Oldknow, of Nottingham, in which a man was bitten in three dif- 
 ferent places by the same dog ; viz., in the scrotum, the thigh, and the left hand ; 
 the bite on the hand was the last. Now it seems not improbable that but for this 
 last bite, on a naked part, he might have escaped. At least it was a remarkable 
 circumstance that the phenomena of recrudescence occurred only in the hand and 
 arm. The dog is supposed to have closed his mouth after inflicting the first two 
 bites ; and thus to have charged his teeth afresh with the poisonous saliva. 
 
 It is this frequent immunity from the disease in persons who have been bitten, 
 that has tended to confer reputation upon so many vaunted methods of prevention. 
 Ignorant persons, and knavish persons, have not failed to take advantage of this. 
 They announce that they are in possession of some secret remedy which will prevent 
 the virus from operating; they persuade the friends of those who die that the 
 remedy was not rightly employed, or not resorted to sufficiently early : and they 
 persuade those who escape that they escape by virtue of the preventive remedy. 
 If the plunder they reap from the foolish and the frightened was all, this would 
 be of less consequence : but unfortunately the hope of security without under- 
 going a painful operation, leads many to neglect the only sure mode of obtaining 
 safety. 
 
 Mr. Youatt is of opinion that the power of the virus ceases with the life of the 
 animal. He states, that in many dissections of the dog, the saliva, in spite of all 
 care, must have come in abundant contact with his hands, and they were not always 
 sound. I should strongly recommend you not to act upon this opinion : but to use 
 the same precautions, in dissecting a rabid animal, as you would use if you were 
 persuaded that the disease might be communicated with equal certainty before and 
 after the death of the animal. 
 
 6. A still more anxious inquiry next arises. Whoever has been bitten bj'' a 
 rabid or a suspected animal, must be considered, and will generally consider himself 
 as being in more or less danger of hydrophobia. This dread is not entirely removed, 
 even by the adoption of the best means of prevention. Now, how long does this 
 state of hazard continue ? When is the peril fairly over ? After what period may 
 the person who has received the injury lay aside all apprehension of the disease ? 
 To this inquiry no satisfactory reply can be given. In a vast majority of instances, 
 indeed, the disorder has broken out ivithin tivo months from the infliction of the bite. 
 But the exceptions to this rule are too numerous to permit us to put firm trust in 
 the immunity afforded by that interval. Cases are recorded in which five, six, 
 eleven, nineteen months have intervened, between the insertion of the poison and 
 the eruption of the consequent malady. Nay, in one instance, three j'^ears are said 
 to have elapsed, and in another the enormous period of twelve years. In these 
 cases one cannot help supposing that some unsuspected re-inoculation, some fresh 
 application of the peculiar virus, must have taken place. If not, then we must con- 
 clude that the poison really hes imprisoned in the part ; and only becomes destructive 
 when, under certain obscure conditions, and at indefinite periods, it is set afloat in the 
 circulating blood. 
 
 It is interesting to know that the same uncertainty of access has been noticed 
 among infected dogs. On the night of the 8th of June, 1791, the man in charge of 
 Lord Fitzwilliam's kennel was much disturbed by the hounds fighting; and got up 
 several times to quiet them. On each occasion he found the same dog quarrelling ; 
 at last, therefore, he shut that dog up by himself, and then there was no further dis- 
 turbance. On the third day afterwards, the quarrelsome hound became unequivocally 
 rabid ; and on the fifth day he died. The whole pack were thereupon separately 
 confined and watched. Six of the dogs became subsequently mad ; and at the 
 following widely different intervals from the 8th of June, viz., 23 days, 56, 67, 88, 
 155, and 183 days. 
 
 There are some considerations respecting this disease which relate both to tho 
 biter and the bitten ; the canine and the human being. And there are some which
 
 372 HYDROPHOBIA. 
 
 relate exclusively to the dog, yet concerning which, we, as medical philosophers, 
 ought not to be ignorant. I shall advert to a few of these. 
 
 One question I have already glanced at, viz., whether the disease mav be pro- 
 duced by a heahhy, though angry dog or cat. I referred to one instance in which 
 this was supposed to have been the case ; and I repeat that I should be more inclined 
 to think, unless we had other examples of the same kind, that the person had been 
 inoculated in some way that he was not aware of. But I have heard INIr. Youatt 
 describe cases in which there had been no symptoms of rabies observed in the doer 
 at the time the injury was inflicted, though soon afterwards the animal became 
 decidedly rabid. It is much to be regretted that the dog is so often destroyed. When 
 a person has been bitten by a dog or cat suspected to be rabid, the beast ought by 
 no means to be killed, but to be secured, and kept under surveillance, and suffered, 
 if it shall so happen, to die of the disease. If he does not die, in other words, if he 
 is really not rabid, that will soon appear; and the mind of the patient will then be 
 relieved from a very painful state of suspense and uncertaintj^ which might other- 
 wise have haunted him for months or years. If the dog dies mad, the injured person 
 will be no worse off than if the animal had been killed in the first instance : nay, 
 in one respect, he will be better off, inasmuch as certainty of evil is preferable to 
 perpetual and uneasy doubt. " Give a dog a bad name (says the proverb), and hang 
 him :" and it is literally so with the imputation of madness. A poor wretch of a 
 dog is perhaps ill, or weary, or cross, or he may have been worried already by mis- 
 chievous boys : the cry of mad dog is raised ; and then he can expect no mercy. 
 There are gross errors prevalent with regard to the signs of madness in the dog. 
 If a dog be seen in a fit in the street, some person charitably offers a conjecture thai 
 perhaps he may be mad ; the next person has no doubt of it ; and then, woe to that 
 dog ! But Mr. Youatt assures us that the rabid dog never has fits : that the exist- 
 ence of epilepsy is a clear proof that there is no rabies. Again, it is a verj' common 
 belief that a rabid dog, like a hydrophobic man, will shun water; and if he takes 
 to a river, that is thought to be conclusive evidence that he is not mad. But the 
 truth is, that the disease, in the quadruped, cannot be called hydrophobia : there is 
 no dread of water, but an unquenchable thirst ; no spasm attending the effort to 
 swallow, but sometimes in dogs an inability to swallow, from paralysis of the muscles 
 about the jaws and throat. They will stand and lap, lapping, without getting any 
 of the liquid down. They fly eagerly to the water ; and Mr. Youatt states that all 
 other quadrupeds, with, perhaps, an occasional exception in the horse, drink with 
 ease, and with an increased avidity. This erroneus impression is not confined to the 
 vulgar. In the case which I have more than once alluded to, and which is men- 
 tioned in Hufeland's Journal, of a lad who died of hydrophobia after having been 
 bitten by a dog that had not been, and was not then, mad, one circumstance stated in 
 evidence of the animal's freedom from rabies is, that he drank without difficulty a 
 large quantity of water. 
 
 There is another superstitious opinion not at all uncommon, viz., that healthy dogs 
 recognize one that is mad, and fear him, and run away from his presence, in conse- 
 quence of some mysterious and wonderful instinct, warning them of danger. This 
 is quite unfounded. Equally mistaken are the notions that the mad dog exhales a 
 peculiar and offensive smell, and that he may be known by his running with his tail 
 between his legs ; except, as Mr. Youatt says, when, wearj' and exhausted, he is 
 seeking his home. 
 
 It will not be out of place to state what are, the symptoms of rabies as observed in 
 the dog, and as described by Mr. Youatt. 
 
 The earliest* symptoms of madness in the dog (he says), are sullenness, fidgeti- 
 ness, continual shifting of posture, a steadfast gaze expressive of suspicion, an ear- 
 nest hcking of some part, on which a scar may generallj^ be found. If the ear be 
 the affected part, the dog is incessantly and violently scratching it. If it be the foot, 
 he gnaws it till the integuments are destroyed. 
 
 Occasional vomiting and a depraved appetite are very early noticeable. The dog 
 will pick up and swallow bits of thread or silk from the carpet, hair, or straw, even 
 Hung: and frequently he will lap his own urine, and devour his own excrement.
 
 HYDROPHOBIA. 373 
 
 Then the animal becomes irascible ; flies fiercely at strangers ; is impatient of cor- 
 rection ; seizes the whip or stick ; quarrels with his own companions ; eagerly hunts 
 and worries the cats ; demolislies his bed ; and if chained up, makes violent efforts 
 to escape, tearing his kennel to pieces with his teeth. If he be at large he usually 
 attacks only those dogs that come in his way ; but if he be naturally ferocious he 
 will dilisently and perseveringly seek his enemy. . According to Mr. Youatt, the 
 disease is principally propagated by the fighting dog in towns ; and by the cur or 
 lurcher in the country : by those dogs, therefore, which minister to the vices of the 
 lower classes in town and country respectively. He maintains that if a well- 
 enforced quarantine could be established, and every dog in the kingdom confined 
 separately for seven months, the disease might be extirpated. This opinion is founded 
 of course upon the behef that rabies never originates at present, any more than 
 small-pox does, spontaneously ; but is always propagated by the specific virus. And 
 it is corroborated by the fact that rabies and hydrophobia are unknown in some 
 countries. I fancy that South America is, or was, a stranger to it. It appears to 
 have been imported into Jamacia, after that island had enjoyed an immunity from 
 the disease for at least fifty years previously ; and Dr. Heineken states that curs of 
 the most wretched description abound in the island of Madeira ; that they are 
 afflicted with almost every disease, tormented by flies, and heat, and thirst, and 
 famine, yet no rabid dog was ever seen there. On the contrary, 1666 deaths from 
 hydrophobia in the human subject, are stated to have occurred in Prussia in the 
 space of ten years. 
 
 Very early in the disease, as it appears in the dog, the expression of countenance 
 IS remarkably changed ; the eyes ghsten, and there is slight strabismus. Twitch- 
 mgs of the face come on. About the second day a considerable discharge of saliva 
 commences ; but this does not continue more than ten or twelve hours, and is suc- 
 ceeded by insatiable thirst : the dog is incessantly drinking, or attempting to drink : 
 he plunges his muzzle into the water. When the flow of saliva has ceased he ap- 
 pears to be annoyed by some viscid matter in his fauces ; and in the most eager and 
 extraordinary manner he works with his paws at the corners of his mouth, to get rid 
 of it: and while thus employed he frequently loses his balance and rolls over. 
 
 A loss of power over the voluntary muscles is next observed. It begins with the 
 lower jaw, which hangs down, and the mouth is partially open; but by a sudden 
 effort the dog can sometimes close it, though occasionally the paralysis is complete. 
 The tongue is afl^ected in a less degree. The dog is able to use it in the act of lap- 
 ping: but the mouth is not sufficiently closed to retain the water. Therefore, while 
 he hangs over the fluid, eagerly lapping for several minutes, it is very little or not 
 at all diminished. The paralj'sis often attacks the loins and extremities also. The 
 animal staggers about, and frequently falls. Previously to this he is in almost inces- 
 sant action. Mr. Youatt fancies that the dog is subject to what we call spectral illu- 
 sions. He says he starts up and gazes eagerly at some real or imaginary object. 
 He appears to be tracing the path of something floating around him, or he fixes his 
 eye intently upon some spot in the wall, and suddenly plunges at it ; then his eyes 
 close, and his head droops. 
 
 Frequently, with kis head erect, the dog utters a short and very peculiar howl; 
 or if he barks, it is in a hoarse inward sound, altogether dissimilar from his usual 
 tone, and generally terminating with this characteristic howl. Respiration is always 
 afl^ected : often the breathing is very laborious ; and the inspiration is attended with 
 a very singular grating, choking noise. On the fourth, fifth, or sixth day of the dis- 
 ease, he dies: occasionally in slight convulsions, but oftener without a struggle. 
 
 Mr. Youatt gives a detailed account of the appearances met with after death \u 
 the carcases of these rabid dogs. They are not very constant or distinctive. The 
 most curious and uniform consist in the presence of unnatural ingesta in the stomach . 
 straw, hay, hair, horse-dung, earth. Sometimes the stomach is perfectly distended 
 with these substances; and when it contains none of them, there is a fluid of the 
 deepest chocolate colour mixed with olive ; or still darker, like coffee : and when 
 neither the unnatural ingesta nor the dark fluid appear, it will be found, Mr. Youatt 
 
 2o
 
 374 HYDROPHOBIA. 
 
 says, upon carefal inquiry, that the dog has vomited much hair, hay, straw, or the 
 like. 
 
 In 1837, a few daj^s after the case of hydrophobia occurred in the Middlesex Hos- 
 pital, I saw the carcass of a dog, that had died rabid, examined by Mr. Ainslie at his 
 and Mr. Youatt's Infirmary. The most remarka-ble morbid appearances were in the 
 stomach, Avhich contained some bits of straw and stick, and a considerable quantity 
 of a dark fluid like thin treacle. In various parts of the stomach there were spots 
 almost black, of a considerable size ; apparently produced by dark blood partly exlra- 
 vasated beneath, and partly incorporated with, the mucous membrane. 
 
 I believe that Mr. Youatt's opinion, already mentioned, of the cause of rabies ir. 
 dogs, and in all creatures — viz., that it always results from the introduction of a spe 
 cific virus into the system — I believe this opinion is not commonly entertained. 
 Most people think that the disease is generated, de novo, in the dog at least ; and 
 causes have been assigned for it which certainly are not the true or the sole causes. 
 Thus hydrophobia in the dog has been ascribed to extreme heat of the weather. It 
 is thought by many to be particularly likely to occur in the dog-daj's ; and to be, as 
 Mr. Mayo observes, "a sort of dog-lunacy, having the same relation to Sirius that 
 insanity has to the moon : which, indeed, in another sense, is probably true." Many 
 cautions are annually put forth, about that period, for muzzling dogs, and so on: 
 verj' good and proper advice, but, if those who have noted the statistics of the dis- 
 ease majr be depended upon, it would be as appropriate at one period of the 3'ear as 
 at another. Rabies occurs nearly as often in the spring, in the autumn, and even in 
 winter, as it does in summer. M. Trolliet, wiio has written an interesting essay on 
 rabies, states that January, which is the coldest, and August, which is the hottest 
 month in the year, are the very months which furnish the fewest examples of the 
 disease. The disorder has often been ascribed to want of water in hot weather, and 
 sometimes to want of food. But M]M. Dupuytren, Breschet, and Magendie, have 
 caused both dogs and cats to perish with hunger and thirst, without producino- the 
 smallest approach to a state of rabies. At the Veterinary School at Alfort, three 
 dogs were subjected to some very cruel but decisive experiments. It was during 
 the heat of summer, and they were all chained in the full blaze of the sun. To one 
 salted meat was given ; to the second water only ; and to the third neither food nor 
 drink. They all died; but none of them became rabid. Nor does the supposition 
 that the disorder has some connection with the period of sexual heat in these ani- 
 mals appear to have any better foundation. 
 
 If you are desirous of knowing what my own opinion on this matter is, I must 
 say that I think Mr. Youatt's doctrine by far the most probable one ; that rabies 
 never occurs except from inoculation of the specific virus. It has never been proved, 
 and indeed it would scarcely be susceptible of proof, that the disease ever breaks out 
 spontaneously ; large tracts of country are totally free from it ; and in nineteen cases 
 out of twenty, perhaps, we trace the bite or the fray in which the inoculation has 
 been efTected. 
 
 If I were asked to define the seat of this terrible disease, I should place it, without 
 hesitation, in that division of the nervous system which comprises the excito-motory 
 apparatus ; the true spinal marrow, with its appendages of afferent and efferent 
 nerves. Nay, I should go further, and say that it is the uppei^oart of this appara- 
 tus, of which the functions are primarily and chiefly deranged : that the poison acts 
 mainly upon the nervous arcs which pertain to the throat, and with which the eighth 
 pair of nerves in particular is connected. There is nothing singular in this locahza- 
 tion of the influence of a specific poison. The ergot of rye affects principally those 
 arcs which belong to the uterus ; cantharides, those which govern the muscular 
 fibres of the bladder. It is true that the mental functions are remarkably modified, 
 and that paralysis of the lower extremities occurs, in most instances of the disease. 
 But neither of these phenomena is constant ; and they simply illustrate, when they 
 do happen, the facility with which any morbid state of the spinal cord may propa- 
 Stite its influence in either direction. Whether, in hydrophobia, the essential change 
 Be centiic or eccentric, cannot be determined with any thing like certainty : but it 
 ysems tc me to be most probable that the sensibility of the afferent nerves of th&
 
 HYDROPHOBIA. 375 
 
 fauces, of the skin, and of the air-passages, is altered or morbidly exalted , vvhencs^, 
 upon the application of the exciting stimulus, the peculiar sighing dyspncea, and the 
 strangling dysphagia, are produced by a reflected influence through the central axis 
 upon the muscles concerned in these actions. But, as I said before, the pathology 
 of the excito-molory apparatus is as yet in its new birth. 
 
 What can I say of the treatment in hydrophobia, or in rabies ? There is no well 
 authenticated case on record, that I am aware of, in which a hydrophobic person has 
 recovered. As it has been, so it is still, larpoj iarai 9amroj. The physician that cures 
 is death. There can be no ground therefore for the recommendation of any espe- 
 cial drug, or form of medicine, nor even for any general plan of treatment, after the 
 peculiar sj'mptoms of the disease have once set in. 
 
 Of course those powerful remedial agencies that are in common use among medi- 
 cal men, have been fairly tried ; copious blood-letting, mercury, opium, arsenic, 
 sugar of lead, oil of turpentine, the cold affusion even : and not only those, but the 
 strong poisons that are sometimes, but not so generally, employed for other diseases: 
 belladonna, stramonium, prussic acid,,white hellebore, strychnia, cantharides, the 
 nitrous oxide gas : and no end of less gigantic remedies ; such as alkalies, and espe- 
 cially ammonia, carbonate of iron, electricity and galvanism, tobacco-juice and the 
 guaco (which was introduced into this country a few years ago with high encomi- 
 ums for its power over the disease), the mineral acids, violent exercise : and if we 
 take into account the substances administered to the brute also, we may increase 
 this list by the alisma plantago, Scutellaria, box, and rue, all of which, at one *ime 
 or another, have been vaunted as successful remedies, veratrum sabadilla, and cicu- 
 nas poison. 
 
 The difficulty of swallowing fluids, and in some cases of swallowing at all, is a 
 serious obstacle to the fair trial of almost every form of internal remedy. It has 
 been proposed to introduce powerful medicines into the rectum, in clysters ; but to 
 this also the patients have been found to make great resistance. The injection of 
 medicines into the veins has been tried. Magendie hoped that he had discovered a 
 cure, in first largely bleeding the patient, and then injecting his veins with a corres- 
 ponding quantity of warm water : but it has always happened with this, and with, 
 other promising experiments, that just as the patient seemed to be about to recover, 
 he has died. The nervous irritability has in one instance or two been much calmed 
 by the injection of a solution of a salt of morphia into the veins. In a case treated 
 by Professor Todd the symptoms appeared to be greatly mitigated for a time, by 
 applying ice to the cervical portion of the spine, and to the fauces. 
 
 Mr. Mayo has suggested bronchotomy : upon this ground (to use his own words), 
 "that the principal character of the disease, and the rapid exhaustion which attends 
 it, appear to depend in great part upon the fits of spasm and closure of the glottis, 
 brought on, not merely by the attempt, or the idea of drinking, but by any sudden 
 impression upon the senses. Now it is clear (he adds) that as far as the distressing 
 feelings in the throat consist in a sense of suffocation, they would be put an end to 
 or relieved by the establishment of a free opening in the windpipe." Dr. Marshall 
 Hall would use, in combination with tracheotomj^, the hydrocyanic acid. Now I 
 should be sorrj' to say any thing to damp your reasonable hope of benefit from any 
 experiment ; but I am bound to confess to you that I should not expect the smallest 
 advantage from tracheotomy in this disease. The mode of death offers no encour- 
 agement to its use. There may be spasm of the glottis, but I doubt it. At any rate 
 the patients do not die of suffocation. The death is not death by apnoea, but by 
 asthenia. We see persons labouring grievously for their breath for hours together, 
 who yet survive, and are presently themselves again ; persons, for instance, who are 
 affected with severe spasmodic asthma. I have seen a man sitting up in bed a whole 
 night long, inspiring with such difficulty that, if I had not been aware of his having 
 scores of times, been as bad before, I should not have thought lie could exist five 
 minutes longer. Now we have nothing of this dyspnoea in hydrophobia : and, as I 
 said already, I am sorry, and diffident too, when I difler from great authorities on 
 
 Practical points, but I see no hope of cure, nor even of sufficient benefit to counter- 
 dance the inconvenience and hazard of the operation from the perform.mce of
 
 376 HYDROPHOBIA. 
 
 bronchotomy. The principle is that of suffering the parts gradually to recover 
 themselves, and of allowing the patient in the meanwhile to breathe through another 
 channel. The principle is excellent (as I shall show you by and by), where there is 
 a permanent obstacle to the admission of air to the lungs through the larynx ; but ia 
 hydrophobia there is no such permanent obstacle to surmount. Though )'Our patient 
 in laryngitis should be at the point of death, yet open his wind-pipe, and he breathes 
 again and is safe ; but it is not at all uncommon for a hydrophobic patient to lose his 
 spasms, to swallow well, and to breathe easily, yet he does not recover. This amend- 
 ment is the prelude of death, the last flicker of the expiring lamp. Since I lectured 
 upon this subject last year. Dr. Latham has told me the following circumstance 
 respecting a patient whom he treated for hydrophobia, in the Middlesex Hospital. 
 He went one day to the ward, fully expecting to hear that the patient was dead. But 
 he found him sitting up in his bed, quite calm, and free from spasm : and he had 
 just drunk a larije jug of porter. "Lawk, sir (said a nurse who sat by), what a 
 wonderful cure !" The man himself seemed surprised at the change. But he had 
 no pulse; his surface was cold as marble. In half an hour, he sank back, and 
 expired. Furthermore the experiment in question has been tried, and it has been 
 tried by its proposer, Mr. Mayo, upon the dog, without affording, as Mr. Youatt 
 assures us, the slightest rehef. In the matter of cure, surgery, I fear, is as impotent 
 as physic. 
 
 Not so, however, in the matter of prevention : this is the most important part of 
 the practice. The early and complete excision of the bitten part is the only measure 
 in which we can put anj' confidence: and even here we are met with a source of 
 fallacy. In the majority of cases no hydrophobia would ensue, though nothing at 
 all were done to the wound. How can we know, then, that the disease is ever pre- 
 vented by its excision ? No doubt many persons go through the pain of the operation 
 needlessly. But in no given case can we be sure of this. They get at any rate relief 
 from the most harassing suspense, with which they would probably have been tortured 
 for months. And if a large number of bitten persons, who had suffered the wound 
 to heal as it would, could be compared with an equal number who had had the bitten 
 part cut out, hydrophobia would be found a frequent consequence of the bite in the 
 first class — a very rare consequence of it in the second. Mr. Youatt, who trusts to 
 caustic, and who has himself been bitten seven times, and is yet alive and well, tells 
 us that he has operated, with the caustic, on more than four hundred persons, aU 
 bitten by dogs, respecting the nature of whose disease there could be no question ; 
 and that he has not lost a case. One man died of fright, but not one of hydrophobia. 
 Moreover, a surgeon of St. George's Hospital told him that ten times that number 
 had undergone the operation of excision there, after being bitten by dogs (all of 
 which might not, however, have been rabid), and that it was not known that any one 
 had been lost. Mr. Youatt, I say, trusts to caustic ; and the caustic he uses is the 
 nitrate of silver. But I advise you to trust to nothing but the knife, if the situation 
 of the bite will allow you to employ it effectually. If the injury be so deep or 
 extensive, or so situated, that you cannot remove the whole surface of the wound, 
 cut away what you can ; then wash the wound thoroughly, and for some hours 
 together, by means of a stream of warm water, which may be poured from a tea- 
 kettle ; place an exhausted cupping-glass from time to time over the exposed wound; 
 and finally apply to every point of it a pencil of lunar caustic. If you cannot get 
 the solid caustic in contact with every part, you had better make use of some liquid 
 escharotic : the nitric acid, for example. In my own case — and what I should choose 
 for myself I should advise for another — if I had received a bite from a decidedly 
 rabid animal upon my arm or leg, and the bite was of such a kind that the whole 
 wound could not be excised, my reason would teach me to desire, and I hope I 
 jhould have fortitude enough to endure, amputation of the limb, above the place of 
 the injury. 
 
 But if the wound is of such a size, and in such a part, that it can be excised, what 
 IS the proper way of cutting it out? Were I to give you any opinion, as from 
 myself, upon that point, you might think, perhaps, that I was stepping beyond my 
 proper province. I shall, therefore, again retail to you the advice of my old master.
 
 HYDROPHOBIA. ^71 
 
 Mr. Abernethy. The cell (he says) into which a penetrating tooth has gone, must 
 be cut out. Let a skewer be shaped, as nearly as may be, into the form of the tooth, 
 and then be placed in the cavity formed by the tooth ; and next let the skewer, and 
 the whole cell containing it, be removed by an elliptical incision. We may examine 
 the removed cell, to see if every portion with which the tooth might have come in 
 contact has been taken away : the cell may even be filled with quicksilver, to see if a 
 globule will escape. The efficient performance of the excision does not depend upon 
 the extent, but upon the accuracy, of the operation." Mr. Aberneihy was of opinion 
 that when once the poison had been imbibed into the system, nothing ever had done 
 good, and nothing, probably, ever would. I should be sorry to be so absolutely 
 despairing in respect to a disorder from which dissection after death discloses no 
 reason why the patient might not recover. He used to add, that as bleeding had 
 been much extolled, had he hydrophobia he wfiuld allow a surgeon to bleed him, 
 even to death. Like Seneca he would be willing to have his veins opened, though 
 his disease might not permit him to indulge at the same time, like Seneca, in the 
 luxury of a warm bath. 
 
 I say early excision is the only sure preventive ; but let me repeat that it will, in 
 all suspicious cases, be advisable, if, for any reason, the operation has been omitted 
 in the first instance, to cut out the wound, or the cicatrix, within the first two months, 
 or at any time before the symptoms of recrudescence have appeared. One would 
 do it, though with less hope, as soon as possible ufter they had appeared ; but I do 
 not expect to hear of excision being successful then in stopping the disease. Dr. 
 Bright has recorded a case in which the arm was amputated upon the supervention 
 of tingUng, and other symptoms, in the hand, in which the patient had been bitten 
 some time before ; but the amputation did not save him. 
 
 It has been proposed to fill the wound with ink, and then to wash it until every 
 trace of the ink is gone; in this way, it is conceived, the complete ablution of the 
 poison also will be ensured. With a timid or an obstinate patient, who would not 
 submit to the knife or the caustic, some such expedient ought to be diligently tried ; 
 but it would be better to try it after the excision, or after the application of the escha- 
 rotic substance. It is impossible to take superfluous pains to obviate so fearful a 
 disease as hydrophobia. 
 
 It has been recommended, after the wound has been excised or cauterized, that it 
 should be prevented from healing, and made to discharge for a long time, by means 
 of irritating applications. This may be advisable when thorough excision, or com- 
 plete cauterization, cannot be effected ; but I should think it quite useless as auxihary 
 to those expedients, and only likely to keep up, or to produce, a hurtful irritability 
 of the system. 
 
 I should perhaps have mentioned before, a theory, and a plan of preventive treat- 
 ment, which made a great figure in all the journals, foreign and domestic, a (o\v yeaisi 
 ago. It was pretended by a Russian physician. Dr. Marochetti, that some time be- 
 tween the third and the ninth day after a person has been inoculated with the hydro- 
 phobic poison, by the bite of a rabid dog, small pustules appear on or about the 
 frasnum of the tongue, containing a small quantity of sanious fluid, of a yellow or 
 greenish colour. Pustules of the same kind were declared to exist also under the 
 tongues of the mad dogs themselves. Now Dr. Marochetti pretended further, that 
 if, from the very time of the bite, you gave the patient large doses of the decoction 
 of broom tops, and looked out for the eruption of these pustules, which seldom lasted 
 more than twenty-four hours, you might infallibly prevent the disease by opening 
 and emptying the pustules, and then cauterizing them with a red-hot iron ; and after- 
 wards causing the patient to gargle his mouth with that same decoction of broom. 
 He held that the poison was deposited there for a short time, and then re-absorbed 
 into the sj^stem ; and he proposed to prevent such re-absorption. This was a very 
 pretty theory ; and took mightily in the medical world. But it has turned out a sort 
 of hoax. I do not mean a wilful hoax on the part of Dr. Marochetti ; for I have no 
 doubt that he contrived to hoax himself. These pustules have been looked for again 
 and again ; but they have never been discovered in Englishmen affected with hydro- 
 phobia ; nor in Enghsh mad dogs. The truth seems to be that the mucous foDicles 
 
 2g2
 
 378 HYDROPHOBIA. 
 
 of the mouth, geneially, and those at the base of the tongue, and those beneath the 
 tongue, in particular, are commonly enlarged and exaggerated in the dog, and in the 
 human animal, labouring under the disease ; and these enlarged and altered follicles 
 were regarded by the Russian phj'sician as a specific eruption, which furnished the 
 virus and pabulum of the complaint. 
 
 As almost every drug that has ever been included in any Pharmacopoeia has been 
 administered with the hope of checkinp^ the disease, so a great number of medicines 
 and measures have been praised as preventives. Some people have great fuith in 
 sea bathing; and they go to the coast to be ducked and half drowned every day for 
 six weeks : and if they escape hydrophobia they conclude that the immersion in the 
 salt water has saved them. Some of the specifics, as you may suppose, are great 
 secrets ; and they who possess them — Avhether they beheve in them or not is another 
 matter — sell them at no cheap rate to those who, having been bitten by the dog, are 
 weak enough to be bitten again by the quack. The composition of several of them 
 has transpired ; and they are found to consist either of ingredients the most insigni- 
 ficant and worthless, or of poisons of which the inefficacy had already been ascer- 
 tained. The celebrated pii' is antili/ssus, which was introduced by no less a person 
 than Dr. Mead, into the London Pharmacopoeia, was a mixture of ash-coloured 
 liverwort and black pepper. The Ormskirk medicine, long famous, and scarcely 
 obsolete yet in the north of England, was made up of bole armeniac, alum, chalk, 
 elecampane, and oil of aniseed. The Tonqidn medicine was composed of cinnabai 
 and musk : and the Tanjore pills Avere a combination of mercury and arsenic. Even 
 now scarce a year elapses but some correspondent of the newspapers, whose philan- 
 thropy is more conspicuous than his judgment or his knowledge, recommends a new 
 and infallible preventive. I confess to you that 1 have not the slightest faith in any 
 one of them ; but as I have a great respect for Air. Youatt, and as he is not fjidtc so 
 sceptical as I am on this point, and as patients or their friends will insist upon the 
 adoption of protective measures sometimes, when the local means of prevention 
 have been omitted or imperfect, I will tell you what he (Mr. Youatt) has -done in 
 respect to these prophylactic drugs. 
 
 In the first place he never succeeded in curing the disease in the dog with any 
 thing that he had ever tried. 
 
 In the way of prophylaxis, he experimented with a great number of substances. 
 He thought that the box-wood, which is the basis of some celebrated preventive 
 drinks in Hertfordshire and Kent, had some efl^ect. He tried the alisma plantfigo, the 
 boasted elRcacy of which had been strictlj^ inquired into by the magistracy of Toula, 
 and the receipt purchased by the Russian government at an immense price. But 
 he had no success with it. He then put the belladonna to the test, beginning with 
 two grains, and increasing the dose to a scruple twice every day, and continuing this 
 for six weeks : and he says he is confident that he saved several dogs ; but he lost 
 almost as many. They all became debihtated and most rapidly emaciated. 
 
 Then, in the year 1820, his attention was directed to the Scutellaria lateriflora, 
 which Dr. Spalding, an American physician, had found highly successful as a pre- 
 ventive of rabies: and upon trial of it, he soon was brought to regard it as really 
 valuable : and (not to tire you with a detail of his proceedings in the interim) he at 
 length combined it with belladonna: "and the result" (I here quote his own lan- 
 guage) "has been a medicine which I cannot, dare not, call a specific; for it has 
 failed : but the use of which, in the cases of doubt and fear to which I have alluded, 
 1 would most earnestly recommend." He relates two experiments, which seem to 
 have made a great impression upon his mind. They are as follows : — 
 
 " Three pieces of tape were thoroughly moistened with the saliva of a rabid dog, 
 and inserted as rowels in the polls of three other dogs. To two the Scutellaria and 
 belladonna were given : the third, a fox-hound bitch, was abandoned to her fate. On 
 the 2;Jth aay after the inoculation she became rabid." The others, at the time this 
 was written, i. c, some months afterwards, were living and well. 
 
 He afterwards took the same two dogs, and a third. He moistened two pieces of 
 tape with the saliva of a rabid dog, and inserted them in the polls of one of the old 
 dogs, and of the third dog. Another piece of tape, dragged repeatedly through the
 
 EPILEPSY. B^ 
 
 mouth of tho same rabid dog twenty-four hours after its death, was inserted m the 
 poll of the second of the old dogs. This dog and the new one were suffered lo lake 
 i.heir chance. To the other old dog the medicine was given. In the fourth week 
 the new dog died undeniably rabid. The other two survived. 
 
 I repeat that I have no faith in these preventives. But sometimes some of them 
 piust be tried ; and I would prefer those which are thus sanctioned b}'' Mr. Youatt's 
 good opinion to any others. 
 
 And with respect to the established disease, I think that if I were tho unhappy 
 subject of it, I should wish to be put into a hot air bath, and thoroughly sweated, 
 and to lake opiates ; not so much in the hope of recovering as with a view to the 
 euthanasia. But with all respect to those gendemen who advocate that practice, no 
 one, if I could help it, should make a hole in my wind-pipe. 
 
 LECTURE XXXV. 
 
 Epilepsy. Its symptoms and varieties; duration and recurrence of the parox- 
 ysms ; periods of life at which they commence ; warnings. Effects of the 
 paroxysms, immediate and ultimate. Pathology. Anatomical characters. 
 Causes. 
 
 The great functions of which the brain is the material instrument, are sensation, 
 thought, and voluntary motion. The influence of the will is a cerebral influence : 
 it reaches and acts upon the muscles through the interposition of the spinal cord. 
 Motions that are involuntary belong more exclusively to the system of the true 
 spinal marrow. Yet cerebral changes, morbid states of the brain, may excite 
 them. . 
 
 I have shown you that all these functions are liable, under disease, to be sepa- 
 rately affected, and each in various ways and degrees. The number of combina- 
 tions capable of arising out of disordered conditions of two, or three, or all of these 
 functions, is very great. Yet the symptoms proper to the nervous system do arrange 
 themselves into groups sufficiently detinite and constant to allow of our giving them 
 distinctive names, and making them separate objects of inquiry. 
 
 At the same lime, as might indeed be expected, these several groups have strong 
 resemblances to each other. They are obviously of the same family : " facies non 
 omnibus una, nee diversa tamen ; quahs debet esse sororum." Occasionally the 
 features are so near alike, that we find it somewhat puzzling to determine with 
 which of the sisters we are conversing ; but usually there is some mark or oilier by 
 which the individual may be identified. 
 
 Of these essentially nervous diseases, there are several in which the most promi- 
 nent and obvious of the phenomena relate to the muscular system ; irregular, violent, 
 and involuntary contractions occurring of muscles which, in the healthy state of the 
 body, are subject to the control of the will. I have spoken of two very frightful dis- 
 orders belonging to this head: — oi^ tetanus, namely, in which the muscles of volun- 
 tary motion present the most striking changes, being affected with tonic spasm ; 
 while the sensibility undergoes no other alteration than what is a consequence of 
 that spasm, pain I mean in the muscles themselves ; and the intellectual functions 
 continue undisturbed : — and of hydrophobia, in which the natural sensibility suffers 
 much, and the mental functions some derangement ; yet still the characteristic fea- 
 tures of the malady depend upon the irregular and uncontrollable action of muscles 
 usually obedient to volition. 
 
 The disease which I am next to consider is scarcely less terrible to witness, when 
 It occurs in its severer forms, than tetanus or hydrophobia ; but it is not attended 
 with the same urgent and immediate peril to life. Yet it is, upon the whole, pro- 
 ductive of even more distress and misery; and is liable to terminate in worse than 
 death. You will understand that I am alluding to Epilepsy: a disease not paiotul
 
 ^80 EPILEPSY. 
 
 probably in itself ; seldom immediately fatal ; often recovered from altogether : yet 
 apt, in many cases, to end in fatuity or insanity ; and carrying perpetual anxiety 
 and dismay into those families which it has once visited. 
 
 The leading symptoms of epilepsy are, a temporary suspension of consciousness, 
 with clonic spasm ; recurring at intervals. 
 
 It is impossible to frame a perfect dcfinilion of epilepsy ; nay, so various are its 
 forms, so numerous its modifications, that no general descriptmi even of it can be 
 given. It will be necessary for me therefore here (as it has been stated before) to 
 describe first the most ordinary type of the disease, as a standard ; and then 
 *.o note the several variations from that standard which are known to occur in 
 practice. 
 
 A man, then, in the apparent enjoyment of perfect health, shall suddenly utter a 
 loud cry, and fall instantly to the ground, senseless and convulsed. He strains 
 and struggles violently. His breathing is embarrassed or suspended ; his face 
 turgid and livid : he foams at the mouth ; a choking sound is heard in his wind- 
 pipe ; he appears to be at the point of death by apncea. But presently, and by 
 degrees, these alarming phenomena diminish, and at length cease ; the patient is 
 left exhausted, heavy, stupid, comatose : but his life is no longer threatened. And 
 in a short time he is once more, to all appearance, perfectly well. The same train 
 of morbid phenomena recur, however, again and again, at different, and mostly 
 at irregular intervals. — This is a brief description of the most ordinary form of 
 epilepsy. 
 
 The suddenness of the attack is remarkable : in an instant, when it is least ex- 
 pected by himself or by those around him, in the middle of a sentence, or of a ges- 
 ture, the change takes place ; and the iniserable sufferer is stretched foaming, strug- 
 gling, and insensible upon the earth. This fearful suddenness is expressed in the 
 name of the disease, ln'a»;4''a, a seizure, an abrupt invasion. The ancients, among 
 whom the complaint was well known, superstitiously ascribed it to the malice of 
 demons, or to the anger of their offended deities. If a person Avas seized with epi- 
 lepsy in the forum, it was considered an ill omen, and the meeting was at once 
 dissolved, and all public business suspended for that day. Hence the disease was 
 called morbus comiticdis. 3Iorbus qui sputatur was another of its names, because 
 those present were accustomed to spit upon the epileptic man, or into their own 
 bosoms ; either to express their abomination, or to avert the evil omen from them- 
 selves. In this country its common designation is the falling sickness : or, more 
 vaguely Jits. The cry which is frequently, though by no means always, uttered, is 
 generally a piercing and terrifying scream. Women have often been thrown into 
 hj'-gierics upon hearing it. It is said to have caused pregnant females to miscarry. 
 Even the lower animals appear to be sometimes startled and alarmed by a note so 
 harsh and unnatural. Dr. Cheyne informs us that, upon one occasion, "a parrot, 
 himself no mean performer in discords, dropt from his perch seemingly frightened 
 to death by the appalling sound." The muscular convulsions are strong, irregular, 
 and often universal. In most of the fits of which I have happened to see the com- 
 mencement, the first effect of the spasm has been a twisting of the neck, the chin 
 being raised, and brought round by a succession of jerks, towards one shoulder: and 
 one side of the body is, usually, more strongly agitated than the other. The 
 features are always greatly distorted. The brows are knit ; the eyes sometimes 
 quiver and roll about, sometimes are fixed and staring, sometimes are turned up 
 beneath the lids, so that the cornea cannot be seen, and the white sclerotica alone is 
 visible ; the mouth is twisted awry ; the tongue thrust between the teeth, and caught 
 by the violent closure of the jaws, is bitten, often severely ; and the foam which 
 •ssues from the mouth is reddened by blood. The hands are firmly clenched, and 
 the thumbs bent inwards upon the palms : the arms are thrown about, striking the 
 chest of the patient with great force, or bruising themselves against surrounding 
 objects, or inflicting hard knocks upon the friends and neighbours who have has- 
 tened to the patient's assistance. It frequently happens that the urine and excie- 
 ment are expelled during the violence of the spasm : and seminal emission some- 
 f'mes takes place. The spasmodic contraction of the muscles is occasionally so
 
 EPILEPSY. 381 
 
 powerful as to dislocate the bones to which they are attached : the joints of the 
 jaw, and of the shoulder, have been thus put out ; and the teeth are sometimes frac- 
 tured. 
 
 When the convulsive paroxysm is over, the patient falls into a deep sleep. You 
 might imagine that he slept from exhaustion, hke a man Avorn out by great fatigue; 
 but there is something more than this ; the patient passes into a state of incomplete 
 coma, or rather the insensibility continues after the convulsions have ceased. When 
 he wakes he is often confused and incoherent for a time ; by degrees, however, he 
 resumes his ordinary appearance and condition : but he remembers nothing of what 
 passed during the fit. 
 
 You may suppose that so much irregular contraction of the muscles of voluntary 
 motion is not likely to occur without some derangement or modification of the func- 
 tions of the circulation. The breathing is irregular, gasping, or arrested. The heart 
 palpitates violently against the ribs during the paroxysm ; the pulse becomes fre- 
 quent and feeble ; and sometimes it ceases to be tangible at the wrist during the 
 height of the fit, and begins to be felt again as the spasms subside. The turgescence 
 of the face indicates obstruction of the venous circulation ; the cheeks and lips 
 become purplish and livid, and the veins of the neck and forehead are visibly dis- 
 tended. 
 
 This, then, is one form, the most severe and the most common as well as the best 
 marked form, in which an epileptic attack occurs. 
 
 But there is a large class of cases, in which the symptoms are much more mild. 
 There is very shght and transient, or even no convulsion at all ; no turgescence of 
 the face ; no foaming at the mouth ; no cry ; but a sudden suspension of conscious- 
 ness, a short period of insensibility, a fixed gaze, a totter perhaps, a look of confu- 
 sion ; but the patient does not fall. This is momentary ; consciousness presently 
 returns ; the patient resumes the action in which he had been previously engaged, 
 and is not always aware that it has been interrupted. Sometimes, with this tempo- 
 rary abeyance of the mental functions, there is some shght evidence of convulsion or 
 involuntary action ; the fingers of one hand, or less commonly of both, are moved 
 irregularly, and without any object ; or the eyes roll or are turned upwards : or the 
 muscles of the face are twitched. Sometimes the patient is himself aware of what 
 has been his condition, but shows some cunning in endeavouring to conceal it. 
 
 This slighter attack is called by the French, petit mal; while the severer form is 
 named grand mal. The former is spoken of also as epileptic vertigo, and distin- 
 guished by that appellation from the epileptic fit. 
 
 Of afl^ections so different in degree, and in some respects so dissimilar in kind, 
 you may be disposed to ask whether they really constitute the same disease. That 
 they are essentially of the same stamp, we have this evidence ; that both forms of 
 attack occur in the same individuals. Sometimes a patient will suffer many recur- 
 rences of the epileptic vertigo, and at length will become affected with violent epi- 
 leptic fits. Or the two forms will intermingle, sometimes the milder happening, 
 sometimes the severer. In such cases we cannot doubt that the attacks are the same 
 in nature, though different in form and degree. And when (as sometimes happens) 
 we meet with the slighter disease alone, we cannot refuse to assign to it the charac- 
 ter and the name of epilepsy. 
 
 Between the two extremes there are many links of gradation. Sometimes the 
 sufferer sinks or slides down quietly, and without noise ; is pale, is not convulsed at 
 all, but insensible ; much like one in a state of syncope. After recovering, he 
 remains sick, languid and confused, during the remainder of the day. 
 
 You will ])erceive, from what I have now said, the difficulty of giving any single 
 description of epilepsy, which will include all its varieties. It is of course still more 
 difficult to offer a strict definition of the disease. CuUen defines it to be " musculo- 
 rum convulsio, cum sopore." Dr. Copland furnishes a larger and more compre- 
 hensive definition : " Sudden loss of sensation and consciousness, with spasmodic 
 contraction of the voluntary muscles, quickly passing into violent convulsive distor- 
 tions, attended and followed by sopor, recurring in paroxysms often more or less 
 regular."
 
 382 EPILEPSY. 
 
 But almost every one of these circumstances may, in its turn, be wanting. There 
 may be no convulsion ; there may even be very slight and transient interruption of 
 consciousness ; there may be no subsequent coma or sopor ; there may be no recur 
 rence of the attack. 
 
 Yet I trust that you now have obtained some general notion of what is meant by 
 an epileptic seizure. And I go on to inquire into several most important points con- 
 nected with the paroxysms. 
 
 In the first place they vary considerably in duration. Sometimes, as T have 
 already staled, the seizure is slight, and does not occupy more than a moment or 
 two of time. But even the severer attacks are often over in a few minutes. They 
 seldom continue longer than half an hour, and probably the average duration may 
 safely be laid at between five and ten minutes. Attacks that are spread over three 
 or four or more hours, generally consist of a succession of paroxysms, with indistinct 
 intervals of comatose exhaustion. In the long-continued fits, or in the protracted suc- 
 cession of fits, the patient often dies. 
 
 The periods at which the paroxysms return are also extremely variable. Occa- 
 sionally the patient dies in the first paroxysm ; occasionally, though he recovers 
 from it, he never has another. Both of these occurrences are rare. Rather more 
 frequently the fits recur at very long intervals ; at the distance, I mean, of many 
 years. Most commonly of all, they revisit the sufferer at irregular periods of a few 
 months or weeks : sometimes they are repeated at intervals of a few days : some- 
 times every day or every night : and not very unfrequently they take place many 
 times in the twenty-four hours. This extreme frequency of repetition belongs prin- 
 cipally to the slighter imperfect seizure, the petit mal. Sometimes the fits observe 
 a strictly regular period of return ; but, for the most part, they are quite uncertain 
 and ij-regular. 
 
 The time of life at which the fits commence, and the circumstances attending 
 their commencement, are deserving of notice. They not uncommonl)^ begin in 
 infancy. Those fits of convulsion to which young children are subject during the 
 first dentition, and which sometimes appear to depend upon the irritation of teeth- 
 ing, and sometimes upon manifest disorder of stomach and bowels — these fits are 
 not distinguishable in their phenomena from genuine epdepsy ; and we must reckon 
 them as instances of epilepsy. It has been remarked by some one, that if a'ou can 
 trace the early histor)'' of an adult epileptic, you will almost always find that he or 
 she suffered infantile convulsions. 
 
 [This is true. Epileptics, it will very generally be found, were affected with repeated 
 attacks of convulsions during the period of infancy. In many subjects, however, we have 
 known the disease to commence immediately subsequent to puberty, or even late in life. 
 In the majority of these latter cases the disease appeared to be the result of a life of intem- 
 perance. — C] 
 
 To what extent this is true I do not know, but I recommend it to you as a point 
 worth attending to in your future opportunities of observation. 
 
 The epileptic attack may come on, for the first time, at any age. According to 
 Dr. Bright (whose account of the disease, though short, is particularly perspicuous), 
 the most common periods are about the age of seven or eight years, probably about 
 the time of the second dentition ; and from fourteen to sixteen, shortly before the age of 
 puberty. And the disease (he says) is very apt to occur for a few years subsequently 
 to this. But sometimes the first fit has taken place between the ages of thirty and 
 forty ; in not a few cases after sixty ; and occasionally quite in the decline of life. 
 
 Dr. Bright offers a little piece of theory in respect to the periods at which epi- 
 lepsy is apt to begin. It is a reasonable piece of theor}% and serves to tie the alleged 
 facts to one's memory, even if it be not yet proved to be true. Doubtless in many 
 cases the circumstances that determine the first attack are quite accidental. But 
 setting aside these casualties, he says " there are leading periods in the evolution of 
 the frame, and peculiar circumstances connected with certain periods, which may 
 well be considered as influential in the production of the disease. In infancy the 
 nervous system is delicate, and easily acted upon by various causes of irritation. 
 Then follows the trying period of teething. In a few years the second dentition
 
 EPILEPSY. 383 
 
 occurs. In a few years later, all the great changes connected with the age of pu- 
 bert3^ To this follow the excesses and exposures of manhood ; and after the lapse 
 of years, the vigour of the system fails, and many causes act to derange the nice 
 balance of the constitution; the bowels often become sluggish; changes more or 
 less serious take place in the structure of the arterial and venous system ; and many 
 causes, organic or functional, which had before been unable to exert an influence oa 
 the vigorous frame, acquire power from its relative weakness." 
 
 The first accession of the disease takes place more commonly before than after 
 puberty. Of sixty-six epileptic women, in whom the outset of that disease and the 
 first period of menstruation were carefully noted, thirty-eight had epileptic fits before, 
 and twenty-eight not till after that period. 
 
 The attacks are very apt to come on during the night ; in the commencement of 
 the disease, they frequently are confined to 'he night. They are said chiefly to 
 occur at the moment when the patient is sinking into sleep, or awaking from sleep. 
 How far this is true I cannot tell. When the disease is yielding, the fits often 
 happen in the night only; so that after they have, for a certain period, taken place 
 in the day-time, or during the day and night, indiscriminately, it is reckoned a good 
 prognostic sign if they begin to restrict themselves to the night. Som.e patients, 
 under these circumstances, suppose that the physician has particular remedies that 
 will make the fits happen in the night rather than in the day ; and they ask for these 
 r^edies. 
 
 Sometimes each paroxysm arrives unannounced and unexpected ; sometimes dis- 
 tinct ivurnings of its approach are given. The latter is less frequent than the former. 
 Georget affirms that the premonitory symptoms do not occur more than four or five 
 times in a hundred cases. I am sure that this is much understated. When warning 
 symptoms do happen, they are sometimes spread over a considerable period ; several 
 hours, or a whole day ; sometimes they last just long enough to enable the patient to 
 remove from a situation in which a fall would be attended with unusual danger: to 
 dismount from horseback, to lie down in a boat, to get away from the fireplace, from 
 the edge of a precipice, from the vicinity of water, to assume the horizontal position 
 of his own free will and in his own manner, or to give notice to those about him of 
 what is going to befall him. In some cases the warning is too short and sudden even 
 for this. The kind of notice that he receives is very variable indeed. Often it 
 consists in some unnatural state of the mind, the feelings, the temper ; the patient is 
 fidgety, irritable, low-spirited, timid, sullen ; or, on the other hand, he feels unusually 
 strong, and hearty, and cheerful. Sometimes there is a notable change in some one 
 or more of the natural functions, or of the bodily sensations ; the patient loses his 
 appetite, or his appetite becomes voracious ; a great flow of urine takes place ; ho 
 smells an ill smell, is aware of a strange taste, hears extraordinary noises, or seesr 
 spectral illusions ; not mere specks floating before him — muscce vohtantes — but dis- 
 tinct forms of persons and things. This is not very common, but it certainly happens. 
 The late Dr. Gregory, of Edinburgh, was assured by a patient of undoubted veracity, 
 that always, when he had a fit of epilepsy approaching, he fancied that he saw a 
 httle old woman in a red cloak, who came up to him, and struck him a blow on the 
 head, and then he immediately lost all recollection, and fell down. 
 
 Headache, giddiness, dim or dazzled vision, are all of them common symptoms 
 among those which have been observed to be precursory of epilepsy. Sometimes 
 there are circumstances which are obvious to a bystander : a flushing of the face, 
 or lividity : difficult articulation ; vomiting. Of twenty-one epileptics treated in the 
 hospital at Wilna, by Joseph Frank, vomiting announced the paroxysm in seven. 
 Som.e of the uneasy feelings are apt to come on and continue even for several days 
 previously to the attack ; restlessness in particular, disturbed sleep, distressf'ul 
 dreams, a peculiar and sudden coldness of the extremities. An internal working 
 is a phrase often used by such persons to express a sensation which is probably in 
 describable. 
 
 But the most curious precursory symptom of all, if we except the spectral illu 
 sions, is what is called the epileptic aura. This is a sensation which is likened by 
 different patients to different things ; to a stream of water or cold air, to th*^ tmkiing
 
 364 EPILEPSY. 
 
 of water, to the creeping of a spider. The sensation proceeds commonly from some 
 distant part of the body. — from one of the extremities, from a thumb or linger, or 
 to some spot on the trunk, — and runs along the skin towards the head : occasion- 
 ally it gets no further than the pit of the stomach: as soon as it reaches the head, 
 or stops at the epigastrium, or elsewhere, the patient's consciousness forsakes him, 
 and the paroxysm declares itself. 
 
 There seems to be some analogy between this epileptic aura and the well-known 
 sensation, to be spoken of hereafter, of a ball rising from the stomach to the throat, 
 and constituting the globus hystericus ; except that in cases of epilepsy the sensation 
 commonly begins in an extremity, and not in the stomach : and the fit comes on 
 when it reaches the head and not the throat. Sometimes, I think, these two sensa- 
 tions are blended. 
 
 In some instances, spasms of the muscles of the part whence the aura proceeds 
 »re observed to take place prior to the more general state of spasm. 
 
 This aura is certainly a very curious phenomenon. It has been thought to depend 
 upon some change propagated along the nerve upwards to the brain, and to be some 
 times connected with some injury done to, or some morbid impression made upon, 
 an afferent nerve. I think that this explanation may apply to some cases. 
 
 Dr. John Thomson, of Edinburgh, used to state in his lectures, that h-e. had known 
 epilepsy to begin with an aura proceeding from an old cicatrix in the side. In a 
 patient of my own, who was subject to epilepsy, the warning sensation commenctd 
 in one of his thumbs, which presently after began to be twisted inwards ; but by 
 tying his handkerchief tightly round the thumb, he could prevent the fit. Dr. Sey- 
 mour mentions the case of an epileptic boy, who had learned to protect himself 
 against a threatened paroxysm, by biting his tongue. 
 
 In other cases the aura probably originates in some change w'ithin the head, and 
 is analogous to the numbness or tingling that is often felt in some part of the body or 
 extremities immediately before an attack of palsy or apoplexy. There is no real 
 inconsistency in this twofold explanation : the source of the aura may be centric or 
 eccentric ; so also may the exciting cause of the paroxysm ; as, in due time, I shall 
 explain to you. 
 
 A knowledge of these warning circumstances is clearly of importance, always as 
 far as respects the comparative security of the patient during the attack ; sometimes 
 as afibrding us the opportunity of slaving off the fit altogether. And it is necessary 
 to remark, that they sometimes give, as it were, a false alarm; they occur, and yet, 
 although no measures of prevention are taken, no paroxysm follows. 
 
 The phenomena that succeed the paroxysm are also of great interest and moment. 
 
 I have already apprised you that the convulsions generally terminate before the 
 insensibility is over: the patient draws, perhaps, two or three deep sighs, and ceases 
 to struggle. Some few persons are quite themselves again in a few moments ; some 
 appear to recover consciousness, and then fall into a deep and prolonged slumber; 
 but many do not regain their consciousness at all upon the cessation of the convul- 
 sions, remaining in a state of profound stupor, from which, however, they can gene- 
 rally be roused for a time. This state of coma (for it is nothing else) has been 
 known to last a week. After the patient emerges from it, he is sometimes merely 
 languid and inert: sometimes he is like a person stunned, or in a state approaching 
 to idiocy, which gradually clears up ; sometimes he is furiously delirious for a short 
 time: not unfrequenlly there is a degree of partial paralysis, which also usually 
 soon goes off", though it occasionally is permanent ; the eyes are fixed, or he squints, 
 or the pupils are dilated, or he drags a leg, or he falters in speech. Most commonly 
 he speaks of headache, or discomfort of some kind. 
 
 It is very seldom that the patients have any recollection whatever of what has 
 passed during the fit. Many of them are not aware that they have had a fit: and 
 those who do know it, discover the fact by finding themselves wet or dirty ; by the 
 injuries they have received during the convulsions ; by the soreness of the bitten 
 longue ; by the bruises of their limbs ; or by the confused or painful sensations 
 which they subsequently experience, and which they have learned to associate with 
 me conviction that a fit lias happened, by having been informed on previous occasions
 
 EPILEPSY. 385 
 
 when they felt the same sensations, that they had suffered a paroxysm of insensi- 
 biUiy and convulsions. 
 
 Upon the whole, it is seldom that any permanent ill effect can be noticed as 
 having been left behind it by any one single fit ; but, alas ! this cannot often be said 
 of I heir repetition. 
 
 Doubtless a single paroxysm does often leave the patient in a worse condition than 
 that in which it found him ; but this does not become perceptible to an ordinary ob- 
 server, until after the alteration has been rendered apparent by repeated fits, and 
 repeated small additions to the permanent injury. The friends of the patient 
 remark that his memory is enfeebled in proportion to the number of his attacks ; 
 that his mental power and intelligence decline. His features even assume, by 
 degrees, a peculiar character; and too often he sinks into hopeless fatuity, or con- 
 firmed imbecility or insanity. It is this tendency which renders epilepsy so sad 
 anu fearful a disease. 
 
 Foville affirms, that the intellectual degeneration is more constant, and comes on 
 more early, in persons who are principally afflicted with the epileptic vertigo, the 
 petit mal, the imperfect seizure, than in persons in whom the grand mat, the vio- 
 lent and decided paroxysm, takes place. Dr. Copland, on the other hand, is of 
 opinion, that " the more severe the fits, the more is that result to be dreaded. This 
 is a point which can only be settled by statistical facts. And as we all have the 
 opportunity of collecting some such facts, and of adding them to the general stock, 
 I mention this, and some other points that are still uncertain or disputed, as worth 
 bearing in mind. More, probably, depends upon the repetition of the fits, than 
 upon their precise nature or severity. Cases do occur in which epileptic persons 
 preserve their faculties to a good old age; but those who are early epileptic do 
 not often attain old age ; and ivhcnever the disease comes on, if it repeats itself 
 frequently, it is much more often than not followed by impairment of the mind, 
 or by some apoplectic or paralytic affection, which implies and accompanies the 
 mental change. You will sometimes hear the cases of Julius Ccesar, of Ma- 
 homet, and of Bonaparte quoted, as examples of high intellectual power, existing 
 and remaining in spite of epilepsy : — and it is allowable, perhaps, to make use of 
 such cases for comforting the friends of epileptic persons : or for giving the 
 advantage of sustained hope to the patient himself. But, in truth, these cases 
 are not worth much. Napoleon is said, I know not upon what authority how- 
 ever, to have suffered something like epilepsy during sexual intercourse. This is 
 not very uncommon in persons subject to that disease. And, with respect to Julius 
 Caesar, we learn from Suetonius, that it was only in the latter part of his life that 
 he laboured under epileps}^ ; and that he had two attacks while engaged in business. 
 
 Having now described the phenomena of epilepsy ; the periods of life at which 
 it is most apt to commence ; its varieties ; and its tendency and termination : let 
 us next inquire what is known respecting the real seat and nature of this strange and 
 melancholy complaint. 
 
 The functions that are affected are clearly the functions of the brain. Sensation, 
 thought, and motion regulated by the will, are the natural functions of that organ. 
 The temporary abeyance of sensibility, thought, and volition, and violent and ir- 
 regular action of the muscles which are thus withdrawn from the empire of the 
 will, constitute a paroxysm of epilepsy. We have, in this malady, another illus- 
 tration of the fact, that when the controlling influence of the sensorium is suspended, 
 the peculiar functions of the spinal marrow are exercised, not only in a disorderly, 
 but also in an unusually energetic manner. That the brain and the spinal marrow, 
 though physiologically distinct, are )'et intimately connected with, and dependent 
 upon, each other, a thousand familiar facts assure us : and there are good reasons 
 for believing that the change, whatever it is, w'hich is the immediate precursor and 
 cause of the epileptic fit, may sometimes originate in the spinal cord, and thence 
 extend to the brain ; and sometimes originate in the brain, and communicate itself 
 to the spinal cord. Dr, Marshall Hall's doctrine, that all convulsive diseases are 
 diseases of the spinal marrow, cannot be properly applied to this convulsive disease 
 25 2h
 
 (i86 EPILEPSY. 
 
 of epilepsy. It is true that the spinal cord is concerned whenever there is convul- 
 sion ; but it is concerned in every voluntarij movement also, through the inslru- 
 mentalit}' of the brain itself; and it ma}' be, and often is, irregularly influenced by 
 a disordered and unnatural state of the brain. Tetanus may fairly be regarded as 
 1 disease of the cord and its proper appendages. The spasms arise and reach their 
 height, while the powers of thought and sensation are undisturbed, and while vo- 
 lition remains, although the morbid condition of the cord renders it inefTectual. In 
 epilepsy, these cerebral functions are always implicated. There is always a loss of 
 consciousness : and in epileptic vertigo, the petit mal, there is frequently a suspen- 
 sion of consciousness only, icithout any convulsion at all. The brain, therefore, 
 . we must consider to be essentially concerned in this disorder. 
 
 What the precise state of the nervous matter may be, which determines the loss 
 of consciousness and the spasms, we can only conjecture. A derangement in the 
 relation between the arterial and venous circulation within the head ; a temporary 
 pressure somehow arising ; a determination of blood towards the head ; a diminu- 
 tion of the natura^ ''uantity of blood sent thither from the heart ; all these have 
 been assigned as possible causes of the paroxysms. Plausible reasons might be 
 given in favour of the operation of each of them ; but the speculation is more 
 curious than useful. We have not yet penetrated the mystery of these remarkable 
 phenomena, and it will be more profitable to turn to another question, which 
 admits of a somewhat more definite answer, viz. : what is the morbid anatomy of 
 epilepsy ? 
 
 Suppose that a person who has had epileptic fits, but in whom they have not been 
 followed by any durable affection of the intellectual or locomotive functions, dies of 
 some other malady ; and you may have the opportunity of minutely examining the 
 condition of the nervous system. Ofien you will find nothing at all which can throw 
 any light upon the occurrence of the epileptic paroxysms ; no appreciable alteration 
 whatever in any part either of the brain or of the spinal cord. In other cases you 
 may discover some organic disease within the head : a scrofulous tubercle, a spicu- 
 lum of bone projecting from the skull. Have you then detected the cause of the 
 disease I All that can be said is, that the piece of bone or the tubercle was 
 probably a predisposing cause of that derangement of the nervous substance which 
 determined the parox)^sms ; the derangement itself, if, indeed, it was of such a 
 nature as to be cognizable by our senses, has gone, with the symptoms ; the tuber- 
 cle or bone having in the meantime remained, without any sign which could betray 
 its presence. 
 
 M. Foville, whose testimony in this matter is entitled to much weight, affirms 
 that ifi persons who have been subject to epilepsy, uncomplicated as yet with any 
 permanent disorder of the intelleci, or of the faculty of voluntary motion, and who 
 have died in the Jit, constant alterations are observable within the head; viz., a 
 strong injection of the vessels of the encephalon. The membranes, the brain, and 
 the cerebellum, are gorged, he asserts, with Hvid blood. But he goes on to say that 
 thi i is to je ascribed to the mode of death : that we see the same appearances in 
 persons who have died by hanging, or any form of apnoea ; that they are not pecu- 
 liar to epileps}', and do not explain the attack, but only point out the way in which 
 it has been fatal. 
 
 It is, I fancy, a very common notion, both that such congestion does take place, 
 and that it is the cause of the paroxysm : and it may be worth while shortly to state 
 the reasons which are opposed to the conclusion, that the congestion (granting for 
 the moment that it does happen) is a sufficient explanation of the attack. 
 
 In the first place it is not easy to conceive that the congestion could so suddenly 
 arise and subside again, as it must sometimes do, if it be the immediate determining 
 cause of the fit : within the space of a single minute, for example. 
 
 And in the second place, the signs of external congestion and plethora, by which 
 signs we measure the amount of the internal, are most marked just when the symp- 
 toms of the paroxysm begin to subside and disappear. So that we cannot, I think, 
 look upon the congestion as the cause of the convulsive symptoms. 
 
 Ijet us go a step further, and inquire into the state of the encephalon in those
 
 EPILEPSY. • 387 
 
 persons who, having suffered epilepsy, had, before death arrived, been affected 
 with some permanent impairment of the mental functions, or (what often goes 
 along with such impairment) with some degree or other of muscular paralysis or 
 debility. 
 
 The most common alterations met with in the brain in such cases are the 
 following. 
 
 Induration of the white matter of the brain, which presents a dull appearance ; 
 sometimes, besides the hardening, a general injection of the white matter ; and in 
 the majority of cases a marked dilatation of the blood-vessels. In some instances tbe 
 consistence of the white matter is diminished ; it is soft and flabby ; but there is the 
 same dilatation of the blood-vessels. These changes pervade the whole of the white 
 matter in every part of the brain. At the same time the gray matter is found irre- 
 gular on its surface, marbled or of a rosy colour in its substance, and sometimeo 
 altered in consistence. And in many cases the membranes are found to be adherent 
 in some parts to the convolutions with which they he in contact. 
 
 Such are the results of the experience of careful observers in respect to the 
 morbid anatomy of epilepsy; of Morgagni, of Foville, and of MM. Bouchet and 
 Casauvielh. The changes last described are such as are produced by chronic inflam- 
 mation of the brain and its membranes. They are the consequences (I imagine) of 
 repeated paroxysms of epilepsy ; they are the very same as are frequently met 
 with in cases of insanity complicated with paralysis, and they elucidate, therefore, 
 the connection of these affections ; but they certainly teach us little or nothing of 
 that actual condition of the nervous mass upon which the epileptic paroxysms de- 
 pend. And, in truth, to expect to find in the brain the traces of convulsions that 
 have passed away, would be as unreasonable as to expect to find the traces of former 
 voluntary movements. 
 
 Of those organic changes which may be regarded as strong predisposing causes 
 of the paroxysms, my own experience accords with that of Dr. Bright ; who states, 
 that they are more frequently such as affect the surface, than the deeper-seated parts 
 of the brain : tumours external to the cerebral matter ; alterations in the bones of 
 the skull ; or in the membranes that envelop the organ. Various altered states of 
 the spinal marrow have also been recorded. 
 
 But besides the morbid appearances that are sometimes only visible in the nervous 
 centres themselves, there are others, which it is of great importance to attend to, situ- 
 ated in other parts of the body, and at a distance from those centres : diseased states 
 of the liver; biliary concretion; granular kidneys; renal calculi; stones in the 
 bladder ; worms in the alimentary canal ; diseases of the uterus ; and of various 
 oiher parts. And these morbid conditions have often, no doubt, an intimate connec- 
 tion with the epileptic paroxysms. Accordingly, some authors make almost as many 
 varieties of epilepsy as there are organs of the body ; they specify the cerebral, the 
 spinal, the cardiac, hepatic, gastric, intestinal, nephritic, genital, uterine, and so on. 
 It will be sufficient, however, to consider two species only ; that, namely, in which 
 the disease originates in the nervous centres themselves, and especially in the brain; 
 and that in which it originates in some other part. Most persons who have written 
 on epilepsy make this distinction, although they employ different terms to express it. 
 Cerebral and occasional ; primary and secondary; idiopathic and sympathetic ; cen- 
 tric and eccentric. The last two terms are the best. But let us clearly understand 
 them. The disease may, in one sense, be considered eccentric, even when it is situ- 
 ated in the brain ; eccentric, i. e., in respect to the true spinal marrow. But I ap[)ly 
 the epithet centric to epilepsy when its cause lies in either of the two great nervous 
 centres; the brain, or the cranio-spinal axis. The distinction itself we shall find to 
 be an important one, both as regards the prognosis and the treatment. But I must 
 first say a few words respecting the causes and the diagnosis of epilepsy. 
 
 There is no doubt that a tendency to epileptic disease is frequently hereditary. 
 It may be derived from parent to child ; or it may skip over a generation or two, and 
 appear in the grandchild or great-grandchild; or it may be traceable only in the col 
 lateral branches of the ancestors. This is just what takes place in other hereditary
 
 388 EPILEPSY. 
 
 maladies. You may often notice also that other forms of nervous disorder prevail in 
 the same families. 
 
 MM. Bouchet and Casauvielh found that among 110 instances of epilepsy, 31 
 were hereditary. Of 321 persons afflicted with epileptic insanity, and seen by 
 Esquirol, 105 were descended from insane or epileptic parent^. 
 
 Again, a tendency to epilepsy is very often found to go along with an tinnatttra' 
 form of the head, which is pinched up hke a sugar-loaf; or misshapen and unsym 
 metrical, one-half being unlike the other ; or oddly configurated in some way ot 
 other. Epilepsy is no uncommon attendant of chronic hydrocephalus. 
 
 And thirdly, the scrofulous diathesis is a strong predisposing cause of epilepsy 
 Dr. Cheyne even holds that epilepsy is as certain a manifestation of the strumou:; 
 disposition, as tubercular consumption, or psoas abscess. Now of the two predis- 
 posing circumstances last mentioned, it may be observed, that they commonly 
 merge in that which preceded them : the strumous diathesis, and a particular con • 
 formation of the he^d, are both very likely to descend from parents to their progeny 
 
 Whether the sex has any influence in determining a predisposition to epilepsy, it 
 a question that remains to be settled. Foville thinks it is most common in females . 
 Dr. EUiotson in males. I have certainly seen more epileptic boys and men, than 
 girls and women. But the casual experience of a single observer is not enough tc 
 determine the point. We want numerical statements on a large scale. At the close 
 of the year IS 13 there were 102 male epileptics in the Bicetre ; 289 female cases in 
 the Salpetriere Jos. Frank observed that of 75 patients, 40 were females. 
 
 LECTURE XXXVI. 
 
 Epilepsy, continued. Recapitulation. Exciting causes. Simidafed epilepsy. 
 Diagnosis. Prognosis. Treatment: during the Jit ^ during the intervals } 
 during the warnings. 
 
 At our last meeting I began to speak of epilepsy. Let me rapidly retrace the 
 ground we then passed over. 
 
 An epileptic seizure may be very severe ; or very slight. The very severe attack* 
 are characterized by a sudden cry, immediate loss of consciousness, general and vio 
 lent convulsions, and subsequent coma or heavy sleep. The very slight attacks 
 consist in a momentary abeyance of the mental faculties, sometimes with and some- 
 times without shght and partial convulsion. The extreme forms of epilepsy we 
 judge to differ only in degree, inasmuch as they both attack the same persons at 
 difftirent times ; or the one form conducts to the other. Betweep these the gradations 
 are innumerable. We call the extremes the ejnhpticfit, and the epileptic vertigo ; 
 the French name them the grand mcd and the petit mul. 
 
 These fits may last from a few seconds to half an hour. Paroxysms apparently 
 longer than this commonly consist of a succession of fits. The average duration is 
 from five to ten minutes. 
 
 The fits recur at variable intervals ; which are sometimes periodic, mostly irregular. 
 There may be many in a single day : there may be only one for many years. They 
 are commonly more severe in proportion as they are less frequent. 
 
 The epileptic seizures sometimes begin in early infancy : another period at which 
 they often commence is about the age of seven or eight : another period at fourteen 
 or sixteen, or for some few years after that age. They more frequently begin before 
 puberty than after it. Sometimes the first fit takes place in the middle period of 
 life : sometimes even in declining age. They often occur in the night, espe- 
 cially in the outset and the dechne of the disease ; usually when the patient if 
 between asleep and awake ; i. e., at the commencement or the termination of his 
 slumber. 
 
 In the majority, perhaps, of cases, the fit is unexpected, and preceded by no
 
 EPILEPSY. 389 
 
 warning. But in other instances there is some alteration perceptible by the patient 
 himself, or by his friends, sjiving notice of its approach ; some change in the temper, 
 feeHngs, appearance ; some disturbance of the senses ; ocular spectra ; or what is 
 called the epileptic aura, a creeping sensation arising in some part of the surface, 
 generally of the extremities, and gliding towards the head. Some of these warnings 
 precede the paroxysm by a day or two, or by a few hours ; some by two or three 
 seconds only. Sometimes the blow is threatened by their appearance, but it does 
 not fall. 
 
 The fit is almost always, in its severer forms, attended and followed by coma ; 
 sometimes, after the coma, by temporary confusion of mind ; deafness ; slight para- 
 jysis ; delirium ; inarticulate speech. There is seldom any appreciable permanent 
 'damage effected by a single fit. 
 
 A repetition of the fits leads, in a large majority of instances, first, to a defect of 
 the memory, and of the general intelligence ; and at length to a peculiar expression 
 of countenance, to decided imbecihty of mind, to complete fatuity ; and with this 
 there is often associated some paralysis or muscular debihty. 
 
 The convulsions take place, necessarily, through the medium of the spinal cord 
 and nerves — just as voluntary movements do; but the suspension of sensation, 
 thought, and volition (which suspension is seldom absent, while the irregular mus- 
 cular action often is wanting) shows that the brain is essentially involved in the 
 disease. 
 
 Accidental organic lesions are sometimes (and sometimes only) found in the ence- 
 phalon, or in the spinal cord, of persons who have suffered epilepsy uncomplicated 
 with any permanent mental or paralytic affection ; tubercles, for example, or bony 
 groyvths from the interior of the skull : but as these are constant, while the paroxysms 
 are occasional, and as in the intervals they give no signal of their presence, we can 
 only regard them as being probably predisposing causes of the seizures. 
 
 When the epilepsy has been complicated with permanent alienation of mind, or 
 with some degree of paralysis, evidence of chronic inflammation of the brain and 
 its membranes is generally discovered. This has been the consequence of the 
 repetition of the paroxysms. This explains the frequent connection of fatuity and 
 palsy with epilepsy of long standing. 
 
 The diseased condition which excites the paroxysms may be situated in the nervous 
 centres themselves, or in some other part of the body. In the one case we call the 
 disorder centric, or idiopathic ; in the other, eccentric, or sympathetic. We cannot 
 always be sure with which species of the disease, the centric, or the eccentric, we 
 have to deal : but the distinction, when it can be made, is of considerable importance, 
 in respect to the prognosis, and in respect to the management of the case. 
 
 The predisposition to this fearful complaint is often hereditary. Malformation, or 
 defect of symmetry in the two sides of the head, is a frequent predisposing cause. 
 So, pre-eminently, is the scrofulous diathesis. And these two, viz., the scrofulous 
 diathesis, and a peculiar conformation of the head, are both liable and hkely to be 
 propagated from parents to children. But the predisposition is found to be here 
 ditary, even when the shape and structure of the body is, to all appearance, quite 
 perfect and natural ; and when no outward indication of the strumous diathesis if 
 perceptible. 
 
 [The following statistics are presented by M. Leiiret, in an interesting paper on Epilepsy 
 in the Archives Ge.ntrales for May, 1843. Among 106 epileptics, in 24, or nearly one-fourth, 
 the disease commenced between the tenth and fourteenth years of their age ; in 18, or nearly 
 one-sixth, between the fifteenth and nineteenth years, and in 16, between the fourteenth and 
 twcnty-fonrth years. Thus 58 patients, or more than one-half, were first attacked between 
 their fourteenth and twenty-fourth years, Of the whole number of cases, in six only vvas it 
 ascertained that the disease existed in one or other parent, and in but eight was it found that 
 one of the parents had died of any disease of the brain, namely, tliree of insanity, two of 
 apoplexy, one of paralysis, one of siucide, and one of meningo-cephalitis. Of the 106 patients, 
 thirty had been drunkards, twenty-four masturbaters, and fifteen addicted to women. In 
 fifteen cases, the actual or presumed cause of the first attack of epilepsy was ascribed ti 
 terror; in twelve to onanism ; in six to drunkenness ; in two to anger; in two to distress ; ib 
 two to fa'ls : in one to libertinage, S(c. Thirty cf the patients hal an attack \fry r-guiai'v 
 
 2h3
 
 390 EPILEPSY. 
 
 once a fortnigh; ; 17 suffered attacks once a month; 13 once a week; 9 every three or foui 
 daj's ; 4 almos-; every day; 2 every day; 1 every two months; 3 every three months; and 
 24 at very irre^lar intervals. In 35, the attacks took place in the night especially ; in 29, 
 they were as frequent in the day as in the night; in 12, they frequently opcurred in th*e day ; 
 in 8, they occurred during the day only; in S, during the night only; in 3, in the morning 
 only; in 3 others generally in the morning; and in 4, in the evening only. — C] 
 
 At the very close of the lecture I informed you that it is an unsettled question 
 — and it is not a question of very great importance — whether the disease is more 
 common in females or males : whether the sex has any thing to do with the pre- 
 disposition. 
 
 There are certain vices which are justly considered as influential in aggravating 
 and even in creating a disposition to epilepsy; debauchery of all kinds; the ha- 
 bitual indulgence in intoxicating liquors ; and, above all, the most powerful predis- 
 posing cause of any, not congenital, is masturbation — a vice which it is painful and 
 difficult even to allude to in this manner, and still more difficult to make the subject 
 of inquiry with a patient. But there is too much reason to be certain that many 
 cases of epilepsy owe their origin to this wretched and degrading habit : and more 
 than one or two patients have voluntarily confessed to me their conviction that they 
 had thus brought upon themselves epileptic paroxj^sms for which they sought my 
 advice. 
 
 Among the exciting causes of epilepsy, fright is conspicuous. And any strong 
 mental emotion is apt to produce the fit in a person who is already subject to the 
 disease. This fac* alone would be enough, I conceive, to forbid our ascribing the 
 paroxysms exclusi\ely to an affection of the spinal cord. Bodily pain ; manifest and 
 {Treat disturbance of almost any of the principal functions of the body, may act also 
 as exciting causes. Sometimes the cause is obvious ; sometimes it is quite inscru- 
 table. If the attack occurs every night. Dr. Bright thinks it may be attributed to 
 the "congestion" of sleep : if it takes place at monthly intervals in women, we may 
 " often trace it to nervous irritation in sympathy with the uterus : and when long 
 periods h^ve intervened we may usually trace each distant paroxysm to the repe- 
 tition of some excess, or to a neglected state of the bowels." In these latter cases 
 the epilepsy is of the sympathetic or eccentric kind ; the irritation being seated in 
 some part at a distance from the nervous masses in the stomach, or intestines, oi 
 uterus. Now I would suggest the expediency of observing what muscles or sets 
 of muscles are Jirst affected by the spasm in such cases, and in what part the 
 warning aura (if there be any) arises : because by accurately noting these parti- 
 culars, we may, perhaps, be led to a knowledge of the part or organ in which the 
 irritation operates ; and if we know the seat of the irritation, we shall be more likely 
 to know its nature and its cure. 
 
 [M. Lamonthe relates, in the Journ. de Med. de JBourdeattx, a case in which the ejjilepsy 
 was caused by a foreign body in the ear, and ceased upon its removal. The patient was a 
 man thirty years of age, in whose external meatus a pebble had been accidentally introduced. 
 He at first experienced only a slight diminution of hearing ; afterwards suppuration 
 occurred, and finally epileptic attacks supervened ; from which he had suffered for two years 
 before he consulted M. Lamothe. This gentleman, being informed of the probable existence 
 of a foreign body in the ear, made an examination, and detecting it, by proper means, sue 
 ceeded in removing from the meatus a rough pebble of nearly a triangular shape, and from 
 that period the patient had no more attacks of epilepsy. In the same Journal, another case 
 of the same kind is related by M. Roussilhe. — C] 
 
 Among the exciting causes of epileptic fits are also enumerated — and I beheve, 
 from what I have myself noticed, with great justice — the repulsion of eruptions, and 
 especially of eruptions about the head, when proper artificial evacuations are not 
 obtained at the same time ; the cessation of habitual discharges ; and, on the other 
 hand, profuse and unusual discharges. Hemorrhage certainly will often bring oa 
 convulsions and a state of insensibility exactly like certain forms of epilepsy. Per- 
 sons who are bled till they actually faint, are often at the same time convulsed. 
 And animals that are killed by loss of blood are always afTected, with convulsions 
 before they expire. 
 
 There is yet another very singular occasional cause of epilepsy that deserves to
 
 EPILEPSY. ' 391 
 
 be mentioned, viz., the sight of a person in a fit of that disease. This has been 
 noticed over and over again. Not only will a patient who has already suffered such 
 attacks, often fall into one upon seeing another so afTecled ; but people will even 
 sometimes do so who have never before shown any symptom of epilepsy. In this 
 way the disease will now and then run through a boarding-school: or through a 
 ward in an hospital. There is a very good example of this recorded in the 11th 
 volume of the Medical Gazette, by Dr. Hardy, of Bath. A strong, healthy young 
 man was hired to take care of an older patient, who sufTered frequent and exceed- 
 ingly violent paroxysms of epilepsy. He remained with the patient night and day ; 
 and at the end of seven weeks became himself epileptic in a very high degree. An 
 acquaintance of his, of equally robust make, but some years older, occasionally 
 visited the parties. In a fortnight from his first visit he also was seized with simi- 
 larly violent attacks. Dr. Hardy quotes the following short case, also, from Baglivi : 
 — " Vidimus, anno IGOO, in Dalmatia juvenum gravissimis correptum convulsionibus, 
 propterea quod inspexerat solummodo ahum juvenem dum epilepsia humi contor- 
 quebatur." 
 
 [M. iNIeyer has recently given an account of a mimber of the pupils in a female school that 
 were attacked with epilepsy, in consequence of seeing one of their number under the influ- 
 ence of the disease. Most of the subjects were approaching the period of puberty ; whilst 
 they were all of a highly excitable temperament. — C] 
 
 Dr. Cullen, w'ho, as well as many others, had noticed the same things, starts the 
 question whether this mode of propagation of the disease be imputable to dread and 
 horror; or the mere force of imitation, which is often so strong, in health as well as 
 in disease : and he decide* in favour of the force af imitation. In fact there are 
 many other signs equally horrifying with that of a person in convulsions ; yet there 
 is no spectacle of horror so efficacious in producing a fit of epilepsy in others, as that 
 of a person suffering under epilepsy. 
 
 This principle of imitation holds good in many of the spasmodic diseases: and 
 in sume of them, especially in hysteria, its influence is more remarkably seen than 
 in epilepsy : I shall therefore have to recur to it again. There is one very curious 
 fact, however, which relates to epilepsy in particular. You are aware that this 
 disease is often feigned, by impostors. Now I believe it is ascertained, beyond the 
 possibility of doubt, that fits and actions which were at first, in these pretenders, 
 strictly voluntary, have at length become involuntary and uncontrollable, and have 
 passed into paroxysms of real epilepsy. The rogue is caught in his own trap. 
 
 And the mention of these impostors leads me to consider the diagnosis of epilepsy. 
 First, how are we to distinguish the feigned disease from the true ? Secondly, are 
 there any other real diseases which may be mistaken for epilepsy, or for which 
 epilepsy may be mistaken? 
 
 In the number o{ feigned diseases epilepsy is one of the most common. Soldiers 
 and sailors pretend to have epileptic fits, in the hope of obtaining their discharge 
 from the service. Cases of simulated epilepsy occur also continually in our streets 
 among mendicants and impostors, who think to excite the compassion and pecuniary 
 charity of the credulous ; and are even sometimes actuated I believe by a desire to 
 obtain admission into hospitals, where they five tolerably well, and quite idly. It is 
 easy enough, they think, to throw their legs and arms about, and to grin ; and many 
 of them get up a capital show of foaming at the mouth, by placing a bit of soap 
 between the gums and cheek. The means of detecting these vagabonds are of 
 some importance to us all ; and it is more particularly necessary that they shoul(# 
 be well known to those who are likely to join the medical department of our fleets 
 or armies. 
 
 It is of course desirable, in questionable cases, to witness a fit. But pretenderf 
 are not very willing to perform when they know that a medical man is looking on 
 You may sometimes convict them, in the absence of the fits; as cross-examination, 
 A cheat will seldom be consistent in the account which he gives of his fits ; as lo 
 whether they are regular or irregular ; and as to the times and places in which he 
 has sufllered them. An impostor chooses such situations for his exhibition as are 
 most suitable to his own purposes ; a crowded street, or a well-frequented public
 
 392 EPILEPSY. 
 
 walk. True epileptics almost always select retired places to take exercise in ; espe- 
 cially if they have any warning or expectation of the approach of a paroxysm. You 
 will find also that the impostor is not attacked at his own home ; but always fixes 
 upon some spot in which he is not only sure to be seen by others, but in which he 
 is not likely to sustain any injury by tumbhng down. True epileptics are often 
 seriously hurt by their falls ; feigned ones generally come ofT without much bodily 
 damage. However, if the fits are alleged to be frequent, and if also they are reorular, 
 you may soon expect one, and must make a point of being present : and then you 
 will seldom fail to remove or to verify your suspicions. In the first place the mus- 
 cular power of epileptics is far beyond what is natural. It will sometimes take four 
 or five stout men to hold a weak emaciated lad, in a fit of epilepsy. Of course no 
 impostor can command more than his natural strength. In the second place a real 
 epileptic fit, if it lasts long, is seldom violent ; whereas impostors, for obvious reasons, 
 make their fits both long and violent. You may often get much information from 
 the state of the eyes, which usually in true epilepsy are partly open, with the eye- 
 ball visibly rolling and distorted. In feigned epilepsy the actor almost always prefers 
 to shut his eyes completely. Sometimes, if he be closely w^atched, and no suspicion 
 is expressed, he will be seen to open his eyes occasionally, to ascertain the effect of 
 his exhibition upon the bj^standers. In real epilepsy, too, the pupils are often con 
 siderably dilated, and do not contract when stimulated by light. This is a very sure 
 criterion ; for no impostor can prevent his iris from acting on exposure to vivid fight. 
 The pulse, in true epilepsy, is not only frequent but often irregular also ; a circum- 
 stance which can never be imitated. The skin of an epileptic, during the fit, is 
 commonly cold ; but that of an exhibitor is hot, and covered with sweat, obviously 
 the consequence of his violent and voluntary exertions. In this respect, also, it ia 
 scarcel}' possible for him to deceive us. Again, an impostor will not bite his tongue, 
 as epileptics often do ; nor very willingly void (Hke them) his excrements and urine 
 during the fit; indeed, it would not be very easy for him to do so, and at the same 
 time to carry on the necessary pretence of convulsions. Besides, epileptics, during 
 a fit, are quite insensible to external impressions ; and hence the vulgar modes of 
 detection, though harsh and not to be recommended, are often effectual ones ; such 
 as dropping melted sealing-wax upon the patient; putting some gin into his eyes; 
 burning him with a hot poker ; or (what I beheve is more fashionable among beadles 
 and pohce constables, when they have to administer to such patients), the pressing 
 your thumb nail violently under that of the supposed impostor. This causes exqui- 
 site pain, yet inflicts no lasting or serious injury ; and I believe that few pretenders 
 stand out against this expedient. It is astonishing, however, how much torture some 
 of them will bear before they can be brought to confess their imposition. If we 
 speak of having recourse to some of these painful tests in the hearing of the pre- 
 tender, we shall find that the fit will soon come to an end. Dr. Cheyne mentions an 
 instance in which one table was placed upon another, and a soldier, who was sup- 
 posed to be shamming, was laid upon the upper one, while his paroxysm was on 
 him ; and the fear of faUing from such a height soon stopped the convulsions. Mr. 
 Hutchinson relates the case of a sailor who was suspected to be a cheat, in whom 
 the convulsions were instantly removed by blowing some fine Scotch snuff' up his 
 nostrils through a quill. This brought on another kind of fit, viz., a fit of sneezing, 
 which lasted nearly half an hour ; and there was no return of the epilepsy so long 
 as Mr. Hutchinson remained in that ship. He tried the same expedient in cases of 
 real epilepsy, but never could produce any similar efTects, although the patients were 
 not snuff'-takers. There was a beggar in Paris, who often fell into epileptic fits in 
 the streets ; one day some compassionate spectators, fearing that he might injure 
 himself in his struggles, got a truss of straw and placed him upon it : but when he 
 was in the height of his paroxysm, and performing remarkably well, they sat fire to 
 the straw ; and he presently took to his heels. 
 
 There is another ingenious plan, very likely, I should think, to detect an impostor, 
 and yet not calculated, like the one last mentioned, to injure a real sufferer: which 
 s to propose gravely, in his hearing, to pour boiling water upon his legs, and then 
 to proceed actually to pour cold watgr upon them.
 
 EPILEPSY. 393 
 
 « 
 
 Of the real diseases which are apt to be confounded wiih epilepsy, hysteria is the 
 chief. The question whether a given case be one of epilepsy or of hysteria, very 
 often arises. By a careful attention to several circumstances, the discrimination is 
 generally to be made. In the first place the total suspension of consciousness, which 
 is so constant an accompaniment of the epileptic paroxysm, does not take place in 
 the hysterical : in epilepsy there is no globus hystericus, no alternations of laughter 
 and tears ; the solitary cry which ushers in the epileptic attack so frequently, and 
 which is so characteristic, is not heard in hysteria ; not that hysterical girls do not 
 scream, for they often do; but then it is repeatedly and continuously. The heavy 
 comatose sleep that succeeds epilepsy is not common in hysteria. Hysterical patients 
 contrive also to avoid hurting themselves by their contortions : they do not bite 
 their tongues, nor foam at the mouth. Dr. M. Hall tells us that, in epilepsy, there 
 is a forcible closure of the larynx, and expiratory efforts which suffuse the counte- 
 nance, and probably congest the brain with venous blood. In hysteria the respira- 
 tion, on the contrary, is rapid and sobbing. 
 
 Observe that I have been speaking, all along, of what has been sometimes called 
 habitual epilepsy. It is not every attack of convulsions with insensibility which 
 ought to be so named. Such attacks are apt to follow sudden injuries done to the 
 brain ; stunning blows on the head, fractures of the skull, the eruption of blood in 
 anguineous apoplexy, and even overwhelming emotions of the mind. The reten- 
 tion of urea in the unpurified blood, occurring in connection with a peculiar renal 
 disease to be hereafter described, appears to be a frequent cause of similar seizures. 
 With these casual occurrences of epileptiform convulsion I do not here meddle. 
 
 Epilepsy is one of those complaints concerning the probable issue of which the 
 patient, and still more the patient's friends, are sure to make repeated and anxious 
 inquiries. It is seldom that we can pronounce with any confidence a favourable 
 prognosis ; but there are some cases in which the prospect is much worse than in 
 others. 
 
 If we have reason to believe that the disease is centric, and connected with any 
 organic derangement of the nervous centres themselves, the prognosis must be bad. 
 Cseieris paribus it is rendered worse by the coexistence of any sign of scrofulous 
 disease, or of the well-known bodily characteristics of the scrofulous diathesis : it is 
 rendered worse, also, when the disease has happened in the parents or among the 
 more immediate ancestors of the patient ; whenever, in short, there is reason to think 
 the disposition to it is inherited. The prognosis is bad when the complaint occurs 
 in persons who have slanting foreheads and misshapen skulls : and when the epi- 
 leptic physiognomy has become established. The prognosis is always the more 
 unfavourable the longer. the disorder has lasted; the oftener the fits have been 
 repeated ; and the more habitual they have become. And when the memory is 
 permanently enfeebled, or fatuity has come on, or the disease is complicated with 
 any form or degree of paralysis, the case is hopeless ; so far, at least, as a perfect 
 cure is concerned. 
 
 On the other hand, the prognosis is better when the disease is eccentric: i. c, 
 when there is any obvious exciting cause of the paroxysms, manifest in structural 
 or functional disorder of some part of the body other than the nervous matter. And 
 when this eccentric cause is removable — a stone in the bladder, for instance, worms 
 in the intestines — then the prognosis still further improves. On this account the 
 prognosis is better in children than in older persons, for the exciting cause is often 
 clearly eccentric, and likely to be transitory ; the irritation of teething, for example : 
 and besides this, it is staled by many practical writers that even repeated and habitual 
 attacks of epilepsy in children often go off" as the patients grow older ; and especially 
 at the age of puberty. The experience of Heberden, however, was against this. 
 He says that he had known several persons become epileptic at that time ; but that 
 he had never met with one who had then got rid of the disease. He had seen a 
 few who had recovered before, and some after, the age of puberty. Dr. EUiotson 
 mentions a case in which a girl had epilepsy prior to the first period of menstrua- 
 tion : then the fits stopped ; and she remained free from them until in advanced life 
 the catamenia ceased to recur ; and then the epilepsy returned. In all those cases
 
 394 EPILEPSY. 
 
 in which we can assign some evident cause for the fit — such as the use of improper 
 food, uterine irritation, mental emotion, and so on— the prognosis is somewhat better 
 than usual. 
 
 [In the predisposed, one of the most frequent causes by which the paroxysm is brought 
 on, is errors in diet, either in regard to the quality or quantity of the food taken. We have 
 known cases in which the patients remained free from an attack so long as they abstained 
 from a particular article of food, but invariably experienced one on partaking of it. — C] 
 
 " The eccentric epilepsy (says Dr. Hall) is to be viewed as curable, however 
 difficult of cure." And however unfavourable the prognosis may be, there is nothing 
 that can excuse any apathy or neglect on the part of the practitioner. Though few 
 cases of habitual epilepsy admit of a cifre under any treatment, yet there are few 
 which may not be relieved by treatment, so far as regards the frequency or the vio- 
 lence of the fits, or both. 
 
 The treatment of epileps}^ resolves itself into the measures to be adopted during 
 the fit ; and the measures to be adopted during the intervals between the fits. 
 
 In the paroxysm itself we have to provide against the risk of injury from the 
 struggles and contortions of the patient ; and if possible, to mitigate the violence, and 
 to shorten the duration of the fit. The patient should be placed in the centre of a 
 large bed ; his neckcloth, and any ligatures about his person, should be loosened ; 
 his head should be somewhat elevated. When the risk of his hurting himself can- 
 not be avoided in any other way, his limbs should be restrained by the bystanders, 
 or secured in a waistcoat. Some persons have advised that a piece of cork or soft 
 wood should be placed between his teeth, to prevent him from biting his tongue, or 
 breaking his teeth. But it is not easy to manage this expedient cleverly. If the 
 head be visibly congested, and hot, cold wet cloths may be applied to it with pro- 
 priety ; and if, at the same time, the extremities be cold, means of restoring warmth 
 to them should be adopted. 
 
 I do not know whether art can abbreviate the paroxysm. Some years ago the 
 late Barry O'Meara sent a letter to one of the newspapers, saying that he fancied he 
 had seen a popular remedy useful in such cases; that, namely, of cramming salt 
 into the patient's mouth : he thought he had succeeded in bringing the patient about 
 by that expedient. In the epileptic patients that come into hospitals, the physician, 
 not being always on the spot, does not see all, nor even many of the paroxysnis ; but 
 after reading that letter, I desired the nurses to treat all my patients who might ba 
 seized with epilepsy in the wards upon that plan : and on comparing the length of 
 the paroxysms when the salt was used, with their ordinary duration as reported by 
 the friends of the patient, or as previously observed in the hospital during some of 
 the earlier fits, it certainly did seem to curtail the convulsions. Probably it is more 
 calculated to relieve an hysterical than an epileptic fit. In the epileptic fits of chil- 
 dren much benefit often results from immersing them in warm water: particularly 
 if there be any coldness of the extremities. 
 
 It is very much the fashion to bleed persons who are seen in a fit, of whatever 
 kind ; and to bleed them largely. I have already given you my opinion respecting 
 the indiscriminate use of this decided measure in apoplectic attacks. If it be clear, 
 from the phenomena, or from the known history of the patient, that the case is one 
 of epilepsy, bleeding, during the Jit, will seldom be necessary or proper; unless, 
 indeed, the evidence of cerebral plethora is very strongly marked : and even then I 
 would advise you not to do more than take a moderate quantity of blood, by cup- 
 ping, from the neck or temples. The convulsions and the sopor may be expected 
 soon to pass off; as soon, probably, and as completely without, as with, any abstrac- 
 tion of blood. Whereas the difference of the alternative is not trifling, in respect to 
 the condition in which the patient will be left when the fit is over. The injurious 
 efltct of excessive blood-letting upon the system at large, is manifest, sometimes, foi 
 months afterwards. 
 
 During the intervals between the attacks we seek to prevent their recurrence ; 
 and this end is to be attained, when it is attainable at all, by getting rid of the pre- 
 disposition to the disease on the one hand, and by protecting the patient against its 
 exciting causes on the other. Now there are certain kinds and causes of predispo-
 
 EPILEPSY. 395 
 
 silion which we cannot get riJ of; such are the tendency that is inherited; the 
 strumous diathesis; malformation of the head; the presence of some organic lesion 
 in the brain or spinal cord. Vicious and dissolute habits are also di.licult, but not 
 impossible to eradicate. It will be our duty, when such are discovered, to set strongly 
 before the unhappy patient the dreadful end towards which he is hastening ; the 
 certain loss of reason to which, when once the disease has shown itself, the continu- 
 ance of his baneful indulgences will drive him ; and to urge upon him the necessity 
 for a short and sudden turn on his part, if he would expect any aid from medicine. 
 Where no physical cause of the proclivity exists, or can be detected, it is of much 
 importance to ascertain whether there be any deviation from the standard condition 
 of health ; towards general plethora in the one direction, or towards emptiness and 
 asthenia in the other. The first of these unnatural states may be redressed by regi- 
 men and exercise, by abstinence from stimulating food and drink ; by a slender diet 
 also ; and, if need be, by direct depletion. The second, which, perhaps, is the most 
 common of the two, and which often leads (as I have explained before) to local ple- 
 thora, may be removed or lessened by a tonic treatment. The object in both cases 
 is to give stability and firmness to the nervous system ; to diminish that mobility, or 
 readiness to be impressed, which is so strong a characteristic of the class of patients 
 affected with epilepsy, although it may not be very apparent in some "ew individuals 
 among them. It is upon this principle that mineral tonics sometimes do good in 
 epilepsy, and not by any specific virtue which they possess in restraining the fiti. 
 
 It is owing, perhaps, to a neglect of these two somewhat opposite conditions of 
 general plethora and general debility, or to the difficulty which sometimes is met 
 with in distinguishing them, that such a variety of opinions have been expressed 
 concerning the proper treatment of habitual epilepsy. Plethora is to be reduced 
 without causing hurtful debility: tone is to be given without inducing dangerous 
 fullness. It requires some nicety to carry the balance even ; to attain the hoped-for 
 good, and at the same time to avoid the evil that is apt to wait upon it. In very 
 many cases the requisite extent and measure of the tonic plan on the one hand, or 
 of the lowering system on the other, can only be learned by careful trials. But 
 sometimes the indications of treatment are more plain. When the patient is young 
 and strong, and full of blood, and not of a particularly movable temperament; when 
 he has a hard pulse, or any degree of feverishness ; when the disorder has super- 
 A'ened upon the suspension of some customary discharge, so that there is an obvious 
 cause of plethora; and when the disease is in its early stage, and the recurrence of 
 the fits has not yet been established by habit; in any or all of these circumstances it 
 will often be proper to abstract blood from the patient, and it will always be right to 
 purge him actively, and to insist upon an abstinent regimen. When former pa- 
 roxysms have been preceded by signs of fullness of the vessels of the head — by 
 headache, for instance, throbbing of the temporal arteries, distension of the superfi- 
 cial veins, a flushed or loaded countenance — you may sometimes, by a timely use 
 of the lancet or the cupping-glass, avert an attack that was apparently impending. 
 
 On the other hand, if the patient is pale and weak; or unduly susceptible; or if 
 his malady has been fastened upon him through many repetitions of the fit ; you 
 will generally find that any form of active depletion is injurious, and learn to place 
 your best hope in measures which are calculated to invigorate the frame. 
 
 One of the most useful of the particular remedies employed for strengthening the 
 body, is the cold shower-bath. This tends more, perhaps, than any single measure, 
 to give permanent firmness and steadiness to the system. The best test, in all cases, 
 of the tonic and bracing effl'ct of this remedy is the occtn-rence of a pleasant and 
 general glow after each application of it. It is the only safe mode in which the cold 
 bath can be used by an epileptic person. 
 
 You will find, in books, a great many tonic medicines recommended for this dis- 
 ease, which medicines you will have opportunity and ample time for trying. Of the 
 mineral tonics, the salts of silver, zinc, copper, and iron, have been chiefly praised. 
 The nitrate of silver used to be highly thought of; but there is one very serious 
 objection to it which must never be forgotten : viz., that it is apt to produce a perma- 
 nent discoloration of the skin, a frightful lead-colour. There is a footman in ii house
 
 396 EPILEPSY. 
 
 near Cavendish Square who has been thus blackened : and there is a gentleman of 
 property resident at Brighton in the same predicament ; his face looks as if it had 
 been thoroughly and carefully pencilled over with plumbago. A barrister, a frienc. 
 of my own, had a narrow escape from a similar misfortune : in fact his skin haa 
 acquired a just perceptible tinge of gray. Now if the remedy were sure to cure the 
 disease, I am not certain that every one Avould accept of a curs on such terms. It 
 would be proper, even on that supposition, to tell the patient that though he (or, a 
 fortiori, she) would get rid of the epilepsy, there was a likelihood that this unamia- 
 ble complexion might ensue. But the truth is, that in giving this nitrate of silver 
 we run a great risk of obtaining its disfiguring effect, for the sake of a very small 
 chance of curing the epilepsy. I have been assured, by one of his friends, that the 
 Brighton gentleman has carried a dark outside for a quarter of a century at least ; 
 and that he is as subject to epileptic fits now* as ever he was. If the lunar caustic is 
 to do good, it must be given for some time together, and the probability is that it 
 will not do good even then ; and if it be given for some time together, there is great 
 danger of its changing the colour of the skin. For these reasons I never give it 
 myself, and therefore I cannot recommend it to you. If j^ou wish to try it, or if you 
 have a patient who insists on trying it, as some will, you may begin with half a 
 grain in a pill three times a day ; and the dose has sometimes been carried as high 
 as fifteen grains. And it is worth observing that in the larger doses this drug proves 
 purgative. It is possible that its good efTect, when it has any, may be attributable 
 to its operation in that way. 
 
 There is no danger of spoiling the beauty of your patient by administering the 
 oxide or the sulphate of zinc ; or the cuprum ammoniatum. The liquor arsenicalis 
 has been thought useful ; but it requires to be exhibited with great caution. Of all 
 the metallic remedies I should prefer some preparation of iron. I think I have 
 seen much good done by the vinum ferri ; not by any specific agency, however, but 
 by its giving what is called tone to the nervous system, and rendering it less prone 
 to be affected by the slighter exciting causes of the disease. I cannot pretend to 
 weigh the merits of the long list of substances which have been lauded as efficacious 
 in keeping off and curing the disease ; and which, when they have been useful at 
 all, have operated, I conclude, in diminishing the disposition to epilepsy by corro- 
 borating the nervous system. The most renowned of them are valerian, assafetida, 
 wormwo(xl, the misletoe of the oak, the cardamine pratensis, rue, the sedum acre, 
 indigo ; narcotic vegetable preparations, stramonium, belladonna, hemlock, lettuce ; 
 animal substances, musk, castor, ox-gall; and the number might be many times 
 multiplied : and this long array of drugs, all of which have been known, or sup- 
 posed, to accomplish a cure, affords, in truth, one of the strongest evidences of the 
 intractability of the disease under any plan of treatment. There is a shrewd remark 
 of Esquirol's which I believe to be quite true, however difficult it may be to account 
 for the fact, which is, that epileptics are apt to improve for a time under every new 
 plan of treatment. 
 
 Whatever drug you may see reason to prefer (and the patients will have drugs, 
 Mid you must be prepared to ring the changes upon them), there are certain other 
 points in the management of the disease which are of considerable importance. The 
 patient who is subject to epilepsy should live bj^ rule, and be temperate in all things. 
 His diet should be simple, nutritious, but not stimulating : he should renounce all 
 strong liquor, and become, in the new-fangled and vulgar phrase, a tee-totaller. He 
 Ehouid rise early, and take regular exercise in the open air; keeping his head cool, 
 find his extremities warm. He should avoid all menial excitement, and the fatiguing 
 pursuit of what is called pleasure: all probable sources of sudden anger, surprise, 
 alarm, or deep emotion of any kind ; all striving and contention of the intellect. The 
 student, of whatever age and sort, in whom epilepsy has declared itself, should shut 
 his books: the man of business abandon or abridge his professional toil: at least 
 ihej^ must be instructed to abstain habitually in their respective callings, from such 
 applications as would task and strain their powers, whether mental or bodily: and 
 endeavours should be made to engage their thoughts and to interest their minds in 
 <;ss engrossing objects of attention. No minute rules can be laid down on these
 
 EPILEPSY. 397 
 
 points, but, keeping the general indication in view, it will seldom be difficult to foDow 
 it up in practice. 
 
 When the fits appear to have been brought on by a species of moral contagion, or 
 by imitation of the same disease seen in others, care should be taken to exclude as 
 much as possible those objects or trains of thought which produce the mental emotion 
 or the morbid propensity. In these cases, and, indeed, I may say in almost afl cases, 
 it is more rational to expect benefit from such measures as tend to calm the mind 
 and to fortify the nerves, than from this or that substance thrown at random into the 
 stomach. 
 
 There is cause for suspecting that epileptic fits sometimes depend upon a syphi 
 jitic affection of the bones of the ^kull ; I am much mistaken if I have not seen such 
 cases. When that suspicion arises, it will be proper to give mercury a full and fair 
 trial. Such a plan has been followed by success. I should always premise, how- 
 ever, in such cases, the iodide of potassium; the efficacy of which in dispersing 
 syphilitic nodes is no longer doubtful. I am accustomed to recommend a gentle and 
 long-continued course of mercury whenever organic disease of the brain is sus- 
 pected ; the irifluence of that remedy being carefully watched. It will be right and 
 proper also to try the effect of counter-irritation ; of blisters, a seton in the neck, or 
 the tartar-emetic ointment. But I must confess to you that, often as this expedient 
 is employed, I have seldom witnessed any such resuk from it as would encourage 
 me to expect benefit from repeating it in another case. There is one form of counter- 
 irritation which I have never seen put to the test, but which has of late been strongly 
 recommended by a very able and observing physician. Dr. Pritchard ; and of which 
 I have heard very good accounts from a gentleman who had seen it extensively 
 employed in Bristol ; I mean the making a long issue in the head itself, dividing 
 the integuments down to the bone by means of a scalpel in the direction of the 
 sagittal suture, and keeping the incision open and discharging for some time, by 
 means of issue peas. The formation of the issue is said to be not so painful as one 
 might suppose. 
 
 Dr. Gluain, in his edition of Martinet'' s Pathology, relates the following case •■ 
 " Some years ago I saw a boy who was epileptic from infancy, and who, in one of 
 his usual fits, fell over the chff by the sea-side, and received a very severe lacerated 
 wound of the scalp, which healed slowly and with a copious suppuration. While 
 the discharge continued he was free from any epileptic attack ; but as soon as the 
 wound healed, the fits returned as before." 
 
 Twice I have seen similar good effects from the insertion of a seton in the neck. 
 Twenty times that measure has disappointed my hopes. 
 
 When the disease is ascertained or believed to be of the eccentric kind, we must 
 search diligently to find the seat of the distant irritation, in some disturbance of 
 function ; and apply our remedies accordingly. The irritation may be found, as I 
 have already intimated, in almost any organ of the body. Painful or irregular 
 dentition is perhaps one of the commonest of the eccentric sources of epilepsy. 
 Sometimes the attacks are attended with symptoms of disease in the liver ; shght 
 yellowness of the skin, uneasiness and tenderness of the right hypochondrium, and 
 lowness of spirits. In such a case we must rectify that state of the hver, by such 
 means as I shall have to specify hereafter. If the disorder depends on a stone in 
 the bladder, the cure must be committed to the surgeon. I have a patient at present 
 under my occasional inspection, who from time to time has slight fits of epilepsy ; 
 on most occasions he passes about the same time a small calculus by the urethra. 
 I make no doubt that in his case the exciting cause of the epilepsy hes in the 
 kidney. 
 
 You will find that most persons, in respect to such diseases as that which we are 
 now considering, have some favourite or usual mode of treatment ; and if I were 
 called upon to name any single drug, from which, in ordinary cases of epilepsy, I 
 should most hope for relief, I should say it was the oil of turpentine. And I find 
 that other physicians have come to the same conclusion. Dr. Latham the elder was, 
 I believe, the first person who made known its efficacy in this disorder. Foville 
 states that he has seen excellent effects from it. It is highly spoken of by Dr. Per 
 
 2i
 
 S98 EPILEPSY. 
 
 cival, in the Dublin Flospital Reports. It is not to be given in large doses, 3ut in 
 smaller ones, frequently repeated ; from half a drachm to a drachm every six hours. 
 You are aware that it sometimes produces strangury, and therefore the patient must 
 be forewarned of this, or carefully watched. Occasionally turpentine has done (rood 
 in virtue of its anthelmintic properties. I know that a physician of my acquaint- 
 ance cured a case of epilepsy in this way, somewhat to his own surprise. Without 
 having in his mind any notion of worms, he thought it "might be well to pur^e his 
 patient, who had laboured under epilepsj^ for some time, with the oleum terebinthintc. 
 The patient, who is the brother of a person holding at present a high office in this 
 country, was residing two or three miles out of town. In the middle of the night the 
 doctor was summoned to him in a great hurry ; the messenger said he was supposed 
 to be dying. He was only intoxicated, however, by the free dose of turpentine he 
 had swallowed : the next morning he voided into the close stool a large tape-worm ; 
 and he has never had epilepsy since. A nobleman residing in Cambridgeshire was 
 long epileptic ; and he too got rid of his epilepsy and of a worm at the same time. I 
 believe that the cure was effected by turpentine in his case also ; but I am not certain 
 of that. Such cases are remarkably interesting : they show that irritation of the 
 stomach or intestines may be sufficient to cause the fits ; they illustrate excellently 
 well the eccentric form of the disease ; and they deserve to be always borne in mind 
 when we are asked to prescribe for an epileptic patient. A cure from so dreadful a 
 complaint, by such simple means — the cause of his malady, and the certainty of his 
 having got rid of that cause, being both so obvious and intelligible to the patient — 
 ma3^ be enough, sometimes, to make a practitioner's fortune. But I think you will 
 sometimes find the oil of turpentine very useful, even though it expels no worm, and 
 when there is no worm to expel. If the bowels should be costive, the oil of turpen- 
 tine and castor oil, in equal proportions, go exceedingly well together. 
 
 When the patient has a distinct warning of an approaching paroxysm, can any- 
 thing be done to ward it off'? Why, in some cases, b}' interrupting the precursory 
 symptoms, it certainly may be prevented. A pupil of the class informs me that a 
 brother of his, twelve or thirteen years old, has been subject to epileptic fits for two 
 years. They occur in the night, especially if he is waked, even though the awaken- 
 ing cause has no tendency to startle him. He often is dull and drowsy the evening 
 before, and if he is roused from this lethargic state by conversation or amusements, 
 the attack expected that night sometimes does not happen. Another student knows 
 a young girl, in whom the occurrence of very high spirits is always precursory of 
 the paroxysm ; when this extreme vivacity is moderated by those about her, the 
 threatened fit is sometimes averted. I mentioned before an instance in which the 
 aura, proceeding from one of the thumbs, was frequently checked by tying a hgature 
 tightly round the thumb. Other examples of exactly the same kind are on record. 
 Mr. Wardrop cured a case beginning with an aura in one finger, by amputating a 
 joint of the finger. Dr. M. Hall states that the immediate accession of the parox- 
 ysm may sometimes be prevented by dashing cold water on the face, or by exciting 
 the nostiils by snuff". In this manner the disposition to closure of the larynx, and to 
 expiratory efforts, is exchanged for sudden acts of inspiration. Another patient of 
 my own, an old college friend, indeed, who is afflicted with epilepsy, feels convinced 
 that he sometimes staves off a fit by applying smelling salts to his nose : and he 
 always carries a bottle about with him for that purpose : but unfortunately the warn- 
 ing (which consists chiefly in giddiness) is generally so short that he has not time to 
 have recourse to his preventive before ne falls down. It is a question whether the 
 fit may not be obv'iated by a strong mental effort in some cases. I make no doubt 
 that it may, especially in th« imitative form of the disease, which originates in and 
 depends upon mental and moral causes. 
 
 It is scarcely necessary that I should do more than aavert generally to those pre- 
 cautions which every one who is subject to epilepsy ought to observe, and which 
 it is the business of his medical adviser to enforce, both upon the patient himself, 
 »nd upon his friends. His bed should be large ; or if not large, it should be enclosed 
 with some netting or other defence against his falling out of it. If he sleeps in a 
 room by himself, care should be taken that in the winter a proper temperature ib
 
 CHOREA. 399 
 
 kept up, for if in his attacks he gets out of bed and on the floor he may be seriously- 
 injured by the cold. He should not, however, be left alone if it can be helped. 
 Guards should be placed over every grate near which the patient may come. He 
 should avoid ascending and descending stairs as much as he can. He should not 
 ride on horseback ; nor on the outside of a coach ; nor even in a gig ; nor go about 
 especially in solitary places, without an attendant. A patient of Dr. Cheyne's, a 
 young man of twenty, was drowned in his own garden by falling into a little runnel 
 of water, which was not four inches deep. Neither, on the other hand, will it be 
 proper or safe for him to frequent crowded or hot rooms ; or the streets of a popu- 
 lous town, in which the multiplicity and distraction of objects are apt to produce, 
 even in a healthy person who is not accustomed to them, a degree of vertigo and 
 confusion. Dr. Cheyne advises that when the patient's circumstances will admit of 
 his having a constant attendant with him, the latter should be provided with some 
 diffusible stimulus ; a potion, for example, composed of camphor mixture and aether, 
 by swalloAving which the impending paroxysm may sometimes be repelled. 
 
 LECTURE XXXVII. 
 
 Cliorea. Symptoms ; Pathology ; Complications ; Causes ; Treatment. Chronic 
 Chorea. Other Nervous Disorders to which the same name has been applied. 
 
 Another disease of a spasmodic kind, and essentially belonging to the nervous 
 system, is Chorea^St. Vitus's dance. This is far less serious than the complaints 
 which we have recently been considering; but it is a very unpleasant disorder to 
 suffer, and it has several points of analogy with the other nervous and spasmodic 
 ailments. Its prominent symptom is an irregular and involuntary clonic contraction 
 of some of the voluntary muscles, which, however, are not wholly or constantly 
 withdrawn from the government of the will. In tetanus we had a rigid spasm, 
 while the mind was clear and free ; voHtion was unaffected, but the muscles which 
 should have obeyed the effort of the will, were seized upon by some stronger over- 
 ruling power. In epilepsy, with convulsive spasm, there was suspension of the 
 mental functions : a temporary interruption of consciousness, and therefore of volition. 
 But in chorea we have a different state from either of these. There is no loss of 
 consciousness ; no defect of vohtion. The ordinary movements of the body can be 
 performed in some degree, or sometimes, under the direction of the will ; but it 
 would seem as if some other power wantonly interfered to excite them when they 
 are not needed, to render them unsteady and imperfect, to arrest the natural action, 
 and give a new direction to the limbs, and to cause the patient to gesticulate and 
 grimace like a Merry-Andrew. Moreover, these apparently absurd movements do 
 not occur in paroxysms, but continue throughout the day, sometimes for weelfs toge- 
 ther ; but they generally cease during sleep : for the most part, but not always, the 
 agitated limbs are still, while the senses are shut up in slumber. The complaint is 
 not attended withyeyer. 
 
 This disorder was first distinctly described by Sydenham, whose account of it is 
 very graphic and excellent, and has been copied by most subsequent writers. With- 
 out reference, however, to the portrait which he has left us, I will sketch the disease 
 as it has occurred under my own observation. It usually begins with slight twitches 
 of a few musles in the face, or in one of the extremities ; and by degrees the spas- 
 modic action becomes more decided and more general. All the voluntary muscles 
 are liable to be affected by it. Those of the face seldom escape. The features are 
 twisted into all sorts of ridiculous forms ; you might suppose that the patient was 
 what is called pulling a face, or making mouths at you : but there is neither mirth 
 nor mockery in the contortion ; it is a convulsion. It is succeeded by a vacant look, 
 and then it begins afresh. The disease occurs much oftener in young girls than in 
 any other persons. If you ask the patient to put out her tongue, she makes sundry
 
 400 CHOREA. 
 
 attempts to do so before she can accomplish it ; and then the tongue is suddenly- 
 thrust out, and as suddenly withdrawn, and the jaws snap together as if she were 
 resolved that you should have as short a glimpse of it as possible. She writhes and 
 contorts her shoulders. She cannot keep her hand or arm half a minute in the same 
 position. When, at meals, she desires to carry her hand to her mouth, it is arrested 
 midway, and suddenly pulled back again, or pushed off in some other direction ; and 
 it is only after many deviations and fruitless efforts that she succeeds. The lower 
 extremities are equally affected. When the patient intends to sit or stand still, her 
 feet scrape and shuffle on the floor, or one is thrown over the other; and if she en- 
 deavours to walk, her progress is most uncertain ; she halts and drags her leg rather 
 than lifts it up, and advances in a jumping manner by fits and starts. In short, the 
 voluntary muscles are moved in that capricious and fantastic way in which we might 
 fancy they would be moved if some invisible mischievous being, some Puck or Robin 
 Goodfellow, were behind the patient, and prompted the discordant gestures. With 
 all this the articulation is impeded : there is the same perverse interference with 
 some of the muscles concerned in the utterance of the voice. By a strong figure 
 of speech, the disorder has been called " insanity of the muscles." 
 
 Such is a picture of the main symptoms of this strange malady, as they have 
 presented themselves to me ; and such, I venture to say, you will often see in your 
 future practice. You will find, moreover, that the irregular jactitations are usually 
 more marked and general on one side of the body than on the other : and sometimes 
 they are confined to the muscles of one side. Here, therefore, we have a trait of 
 resemblance to epilepsy and to hemiplegia. If you take hold of the only limb which 
 happens to be thus agitated, and keep it still by main force, some other limb or part 
 will take on the convulsive action. The persons who are subject to chorea are 
 always inordinately sensitive, and what is popularly called "nervous." They are 
 easily stirred up by new ideas and sudden feelings, and pass readily, and upon 
 slight occasions, from one mood of mind to another. The mind is affected, as Dr. 
 Cullen remarks, in the same way, and often shows the same varied, desultory, and 
 causeless emotions, as in hysteria. You see the indication of this nervousness in 
 the fact that the fidgety catching of the muscles increases when the patient is spoken 
 to, especially by a stranger — by the physician, for example. The nurses of the 
 hospital constantly tell me that such or such a patient, who has chorea, is much 
 more composed at other times than she is during my visit, when she is surrounded 
 by students, and made the object of their attention. In most cases the jactitations 
 are partly and in some degree under the influence of the will. Sometimes the pa- 
 tient seems to give way to them, indulges in or exaggerates them : at other times 
 she can, by making an effort, control them. Many of the patients, especially such 
 as are old and intelligent enough to understand the directions given them, and to 
 make the trial fairly, can suspend for some seconds the convulsive movements, by 
 taking a deep inspiration, and resting upon it, without expiring, for a little while. 
 Like other spasmodic diseases occurring in movable constitutions, chorea is liable to 
 be propagated also by a species of contagion, or rather of involuntary imitation. 
 These diseases constantly approximate and touch each other in some of their 
 characters. 
 
 Chorea, in this its standard form, is essentially a disease of youth. Sydenham, 
 and Cullen, who closely copies him, state that for the most part it attacks boys 
 and girls, who have not reached the period of puberty ; between the tenth and 
 fourteenth years of their age. These limits are, however, too scanty. It is very 
 common between the eighth and sixteenth years ; it sometime comes on as early 
 as five or six : and now and then it begins in adult life, or in old age. I have 
 already intimated that it is much more frequent in girls than in boys. Dr. Heber- 
 den says the proportion is as 3 to 1. Dr. Elliotson, out of 30 patients, had 22 
 females and 8 males. Of 84 cases reported by Dr. Reeves, of Norwich, 57 were 
 females, and 27 males. Of 72 occurring in Dr. Manson's practice, at Notting- 
 ham, 5J? were females, 19 males. Of 18 cases in the Hampshire County Hos- 
 pital, 12 were girls, and the rest boys. Now taking all these numbers together, 
 we hav? 204 cases, of which there were 144 females and 60 males ; the proper-
 
 CHOREA. 401 
 
 tion 13 as 12 : 5, or a little more than 2:1; and leaving out Dr. Reeves' list — 
 which differs considerably from the others in containing a larger number of males 
 — we have 129 cases, of which 87 were females, and 83 males ; this ratio is as 
 29 : 11 ; or nearly, but not quite, 3 : 1. [In 429 cases referred to by Dufossi 
 and Rufz, 130 occurred in boys and 299 in girls. — C] I have also observed 
 that the disease occurs much more frequently in children having dark hair and eyes, 
 than in those of a light complexion ; and I think I have seen the same remark in 
 some book, but I forget where. 
 
 [According to Mr. W. H. Bell — (Did. des Etudes Mediralcs) Diifosse (ibid.), and Rufz {Ar- 
 chives Generates de Med., iv. 239) — ihe subjects of chorea have chiefly light hair. — C] 
 
 When the disease is strongly marked, or lasts long, there is usually some imbe- 
 cility of mind manifested ; a slight degree of fatuity, and a foolish expression of the 
 features. But this goes off with the other symptoms. The child generally recovers, 
 but the malady is apt to recur, and that more than once. In this respect we may 
 trace a distant resemblance to epilepsy ; if we regard each attack as a long and 
 mild paroxysm, then these paroxysms are liable to repetition. No doubt the du- 
 ration of the disorder is often abbreviated by proper treatment ; there are cures in 
 this disease as well as recoveries. It is a very rare thing for chorea to prove fatal ; 
 and the few fatal cases that have occurred have thrown no light on its pathology. 
 Dr. Elliotson saw a strong girl affected with it die of apoplexy ; but perhaps she 
 would have died of apoplexy whether she had had chorea or no. Chorea offers 
 no protection against the invasion of other diseases. My colleague at the Middle- 
 sex Hospital, Dr. Hawkins, had a fatal case. He found great vascularity of the 
 uterus, earthy concretions in the pancreas, omentum, and mesentery, and tubercles 
 in the lungs. But these conditions had no connection probably with the chorea. 
 In an instance that proved fatal under Dr. Bright's observation, there was consider- 
 able disease in the uterus and its appendages. I am afraid that we shall seek in 
 vain in the dead body to discern the nature of chorea. When we find organic disease 
 accompanying it, we must look upon such organic disease, if it have any connection 
 with the chorea at all, as being a predisposing cause ; as producing or increasing 
 that irritability and mobility of the nervous system which fit it for submitting to the 
 exciting causes of various nervous diseases. 
 
 There is a speculation of some of the French writers respecting the seat and 
 nature of chorea so ingenious, that I cannot refrain from mentioning it. 
 
 It is affirmed by certain modern physiologists, as you may perhaps know, that 
 one of the functions, the principal office indeed, of the cerebellum, is to preside 
 over and regulate the faculty of locomotion ; to keep the muscles in due subordi- 
 nation, as it were, to the will. No voluntary movement, almost, can be executed 
 without the combined and consenting action of many muscles ; it is the business of 
 the cerebellum, they say, to maintain this consent and community of purpose ; to 
 prevent any mutiny of individual muscles, and to make them unanimously co-ope- 
 rate in producing a given movement. How far this doctrine is true I do not intend 
 to inquire: but supposing it well founded, then they very ingeniously assign the 
 cerebellum as the seat of that change, whatever it is, which gives rise to the phe- 
 nomena of chorea. And it is most certain that the irregular movements by which 
 chorea is characterized can neither be considered as the effects of imperfect paraly- 
 sis, as some ha"e slated, nor of convulsion, in the proper sense of that word, as others 
 have asserted ; but rather as consequences of the want of due harmony and agree- 
 ment between the various muscles, which should combine to produce the desired 
 state either of rest or of motion. There is a defect of the requisite association in 
 the actions of the different muscles ; and it is in this sense that chorea has been de 
 nominated insanity of the muscles. There is a certain portion of the brain which 
 ministers to the intellectual functions ; there are certain altered states of that portion, 
 which lead to mental aberration ; the persons so affected form false judgments ; 
 cannot associate their ideas aright. So also there is a certain portion of the ence- 
 phalon which presides over the locomotive functions ; and there are altered states of 
 that portion, which lead to a loss of the due association of muscular contraction)! 
 2e 2i2
 
 402 CHOREA. 
 
 That portion is the ccrebtllum. Such is their theory ; and it is a very plausible and 
 pleasant, but withal an unsatisfying theory. The disorder really belongs, I appre- 
 hend, to the excito-motory department of the nervous system. From some infirm 
 or unnatural state, either of the cord or of the incident nerves that convey impres- 
 sions to it, its reflex function is called into irregular play, and voluntary muscles con- 
 tract independently of volition. Sometimes, at the same instant, the patient ivilla 
 certain definite movements through the instrumentality of the very same muscles. 
 But the authority of the will is impaired, and the automatic motions are proportion- 
 all}^ strong and unruly. The consequence is, that the same muscles, receiving at 
 the same time contradictory orders from these two sources, obey neither mandate 
 completely, but give rise, by their discordant action, to the grotesque and seemingly 
 antic gestures which these patients exhibit. 
 
 But to leave these seductive theories, and return to duller matters of fact. Chorea 
 is a complaint that is seldom attended with any bodily pain. I have in several 
 instances, however, known it to be accompanied by pain in the head ; and in some 
 of them, with pain on that side only of the head which was opposite to the agitated 
 limbs. I mention this as being of some practical importance ; for I have found the 
 disease to become sensibly less severe, and very soon to cease, upon drawing blood 
 by leeches, or cupping, from the painful side of the head. In a greater number of 
 cases, however, no such pain is experienced. Sometimes you wall find that in all 
 respects, excepting the nervousness, and the irregular movements, the patient is in 
 the enjoyment of perfect health. But neither is this very common : generally there 
 is something manifestly wrong in the state of the stomach and bowels, either before 
 or during the complaint ; a capricious appetite, costiveness, a tumid abdomen, offen- 
 sive breath, a foul tongue. 
 
 Chorea is sometimes complicated with other disorders, and above all with hysteria : 
 and no wonder, since they both occur chiefly in persons of the same sex, of the same 
 susceptible temperament, and at nearly the same period of life. It is said also to 
 happen in conjunction with acute rheumatism and rheumatic pericarditis; and with 
 certain affections of the skin. Its coincidence with cutaneous complaints, if not 
 merely accidental, may perhaps be owing to irritation of the peripheral extremities 
 of afferent nerves, by the eruption. Judging from my own experienQg alone, I should 
 not say that the disease was often associated with acute rheumatism. Dr. Copland 
 and Dr. Bright have both, however, noted that connection, and therefore I cannot 
 doubt that it does sometimes exist. I certainly have seen jactitations hke those of 
 chorea in a few instances of rheumatic carditis. Very lately a boy, affeQted with 
 chorea, became my patient in the hospital. We soon detected a strong bellows sound 
 of his heart ; and tracing his history back a little, we found that he had suffered 
 acute articular rheumatism. In a recent volume of the Medico-Chirurgical Trans- 
 actions, there is a paper by Dr. Bright, detailing " cases of spasmodic disease, 
 accompanying aflections of the pericardium." Now we do not perceive any obvious 
 or direct connection between the cardiac disorder and the nervous disorder. There 
 are just two conjectures which occur to me upon the subject,- Rheumatism (as we 
 shall see by and by) is especially a disease of fibrous structures, and it usually affects 
 various fibrous parts at the same time. It is not improbable, therefore, that in the 
 cases in question, some morbid condition of the membranes of the spinal canal may 
 have arisen, simultaneously with the inflammation of the pericardium. Or the car- 
 diac disease may perhaps operate, by some ill-understood influence, upon afferent 
 nerves of the cord, as an eccentric cause of the irregular movements. 
 
 Probably any thing which makes a forcible impression upon the nervous system 
 ma}^ act as an exciting cause of chorea. Strong mental emotion, or a sudden menta 
 shock, is very likely to bring it on in those of a movable constitution who are pre 
 disposed to it. Of its ascertained or alleged exciting causes, fright is beyond al 
 comparison the commonest. It has been known to follow a blow or fall on the head 
 but even in these cases the alarm may have had more to do with the disorder than 
 the blow itself. It sometimes seems to depend upon irritation of the stomach o' 
 Iwwels, by improper diet, by accumulated feces, or by worms ; and it is found to be 
 connectea, m not a few cases, with difficult and painful menstruation. It frequently
 
 CHOREA. 403 
 
 begins about the period of the second dentition : the late Dr. Gregory, of Edinburgh, 
 was in the habit of relating instances of that kind. In one case, the old teeth were 
 remaining while the new ones were appearing by their sides. The old teeth were 
 drawn, and the removal of the chorea were complete. This Dr. M. Hail would 
 justly call eccentric chorea. But even in such cases the state of the gums cannot 
 be regarded as the sole cause of the chorea: there must be the predisposition, as 
 well as the accidental exciting cause ; for the complaint is apt to recur under the 
 agency of some new irritation, and may then be removed by other means. 
 
 [We have not found the disease to be much influenced by the season of the year or con- 
 dition of the atmosphere. Duges, Rufz, Spangenburg, and Blache state that it occurs most 
 frequently in summer. According to the statements of Rochoux, Chervin, and Danste, it is 
 a rare affection in the southern hemisphere. It is not a very frequent disease in Philadel- 
 phia.— C] 
 
 Chorea, such as I have been describing it, may last from a week or two to some 
 months. In those eighty-four cases which I have already mentioned as having been 
 reported by Dr. Reeves, the shortest period of medical treatment was two weeks ; 
 the longest eight months ; and the common average seven weeks. This appears to 
 me a long average. The disorder often terminates — at any rate much more often 
 than epilepsy does — at the period of puberty ; especially upon the first coming on 
 of the menstrual discharge in the female. 
 
 [Chorea, like epilepsy, may be excited by imitation (Andral) ; the fact is, however, denied 
 by Rufz and Blache. — C.] 
 
 I had occasion, in the last lecture, to remark, that when a vast number of different 
 drugs are recommended as specifics in any given disease, we may sometimes infer 
 from that very circumstance that the disease is difficult of cure, and generally in- 
 tractable under all plans of management. But there is another class of diseases 
 which a variety of drugs are supposed capable of curing, — those, namely, which 
 tend to terminate in health, I believe that many cases of chorea — most cases — 
 would at length get well without any aid from physic : I believe also that many of 
 the boasted specifics have been quite innocent of any share in the recovery of the 
 patients to Avhom they were administered ; at the same time I am quite certain that 
 treatment has a great influence over the disease. 
 
 It was Sydenham's practice first to bleed and purge his patients, and then to ad- 
 minister bitters, aromatics, and antispasmodics, with a view of strengthening the 
 nerves. After his time the blood-letting and purgatives fell into disuse, until the 
 publication of Dr. Hamilton's well-known work again brought the latter deservedly 
 into favour. 
 
 The treatment of chorea embraces two definite objects. The first, and chief, is to 
 give stability to the unduly movable nervous centres. The second is to remove 
 or avert whatever may be likely to produce unnatural excitement of their incident 
 nerves. 
 
 Now the complaint is seldom (in its genuine form I may say it is never) dependent 
 upon any organic or inflammatory disease. The instrument is not broken anywhere, 
 but it is slackened, jangling, and out of tune : and (to pursue the metaphor) we 
 often can restore its harmony by bracing it up again. 
 
 I can confidently recommend you to abstract blood locally in those cases in which 
 there is a fixed pain in the head ; but with this exception, blood-letting is neither 
 useful, nor even (in my opinion) justifiable. There is oftener a deficiency than a 
 redundance of red blood in the system. 
 
 I shall not attempt to distract your attention by discussing the various remedies 
 that have been vaunted against chorea; but shall take the hberty of referring )0u to 
 books (to Dr. Copeland's Dictionary, for example) for further information on thai 
 subject, and content myself with teUing you what modes of treatment I have been 
 in the habit of employing, with very satisfactory resuhs. I think, then, setting aside 
 the complication with headache just mentioned, you will be able to deal successfully 
 with most of the cases of chorea which you may have to treat, if you have xi vour
 
 404 CHOREA. 
 
 command purgative medicines, the shower-bath, preparations of iron and of arsenic, 
 and the oil of turpentine. 
 
 It will be right, in all cases, to begin by clearing out the bowels with calomel and 
 jalap, or some active aperient ; and you should persist in the regulated use of purga- 
 tive medicines, if they continue to bring away much fecal matter. You are to be 
 guided less by the amount of the doses than by the effects they produce ; at any 
 rale one fuU evacuation of the bowels should take place every day. But though 
 purgatives are good auxiliaries, we cannot trust to them alone for the cure of the 
 complaint. 
 
 One of the most effectual of the tonic remedies is the cold shower bath. If the 
 patient be of a feeble constitution, the water may at first be used tepid ; by degrees 
 it should be used cold. This remedy should be employed every morning, or every 
 other morning, early, as soon as the patient gets out of bed. Of the best indications 
 of the propriety of its continuance I spoke in the last lecture only ; I need not tire 
 you, therefore, by repeating the observations I then made. 
 
 With this external tonic it will be right to combine some internal one ; and for the 
 most part, the best for the purpose is some preparation of iron. The carbonate of 
 iron is an exceedingly good form, and it may be given in the way recommended by 
 Dr. EUiotson, one of whose pets it is, — namely, mixed with twice its weight of 
 treacle, so as to form an electuary. You may begin with it in half-drachm doses, 
 and presently increase the quantity to a drachm, or a drachm and a half, or two 
 drachms. Much larger quantities indeed have been given, and that for a long time 
 together ; but I am not in the habit of so pushing this drug. Patients do not like to 
 swallow from half an ounce to an ounce of the powder and twice as much treacle 
 three or four times a day ; and some of them cannot get so much down. And I 
 mentioned on a former occasion that the iron is apt to accumulate in the large intes- 
 tines, and to be expelled at last, often with difficulty and pain, in large, hard, red 
 masses, like what is called, I fancy, slag, or the dross of iron ore from a furnace. 
 When one or at most two drachms given three or four times a da}^ make no impres- 
 sion on the disease, you had better (in my humble judgment) change the form of 
 the medicine. Give two or three grains of the sulphate of iron for a dose, or fre- 
 quent draughts of Griffith's mixture (mistura ferri composita), or twenty or thirty 
 minims of the tinctura ferri muriatis. Dr. Bright says he has found the sulphate of 
 zinc answer when the carbonate of iron had failed, and the iron succeed when the 
 zinc had done no good. One most severe case, about which I was consulted, and 
 which had resisted other remedies, got well under the use of the sulphate of zinc ; 
 the dose of which was gradually increased to ten grains, given three times a day. 
 Whenever the medicine was pushed beyond this point it became emetic. Certainly 
 the disease is often very obedient to arsenic ; but, for plain reasons, it is better ta 
 effect a cure, when we can, by less hazardous substances. The gravest case I ever 
 had to treat occurred, not long since, in one of my hospital patients. I tried the carbo- 
 nate of iron in vain. The shower bath so terrified and agitated the girl that I could 
 not persist with it. I then gave her arsenic, under which she improved at first, but 
 it ultimately was very injurious ; her bowels were greatly irritated by it, she became 
 paralytic in her lower extremities, and sank into a typhoid state ; and I really was 
 afraid that I should lose her. But she recovered from this condition, which I could 
 uot but ascribe to the arsenic ; and as soon as I dared venture, I began to give her 
 the muriated tincture of iron, twenty drops at a time, every six hours. Under this 
 treatment she steadily and rapidly improved, and was soon quite well. 
 
 [Recently very decided testimony has been presented by Young, of Pennsylvania, Lindsly, 
 of Washington, Hildbreth, of Ohio, Kirkbride and Professor Wood, of Philadelphia, and 
 Beadle, of New York, in favour of the efficacy of the cimicifuga, or black snake-root, in cases 
 of chorea. It may be given in the dose of half a teaspoonful of the powdered root three 
 *i»nes a day ; or from one to two drachms of the saturated tincture, or a winegiassful of the 
 decoction. The cyanuret of iron, in the dose of three grains three times a day, in the 
 form of a pill, has been strongly recommended by Dr. Zollickoffer, of Maryland. The 
 cyanuret of zinc, in the dose of one-third of a grain, twice a day, gradually increased tc 
 fourteen grains in the twenty-four hours, has recently been highly spoken of by the physi 
 <»&j)S of Berlin and elsewhere. See Condie on Diseases of Children. — C]
 
 CHOREA. 405 
 
 The oil of turpentine also is certainly a valuable medicine in this disease ; whether 
 there be worms at the bottom of it or not. When the bowels are torpid, and the 
 girl is of that age when menstruation may be conjectured to be at hand, its arrival 
 seems sometimes to be accelerated, and great relief to be produced by the turpentine. 
 The best way of exhibiting it in such cases is in combination with an equal quantity 
 of castor oil; two drachms or half an ounce of the mixture may be given every 
 morning, or every other morning, according to its effect upon the bowels ; and when 
 they are very sluggish, or the stools are unnatural, it will often be serviceable to give 
 a couple of grains of calomel also, twice or thrice a week, at bed-time. 
 
 It is scarcely necessary for me to say that due attention must be paid to the diet. 
 This ought to be plain and simple, but at the same time nourishing, and even gene- 
 rous. Exercise, short of that which produces fatigue, in the open air, in fine and 
 dry weather, will also conduce much to the patient's recovery. And all kinds of 
 immoderate emotion should be guarded against : for the contest often seems to lie 
 between the emotional and the voluntary impulses to action. The stillness of the 
 muscles during sleep is in accordance with this behef. 
 
 There is an affection (it scarcely deserves to be spoken of as a disease) which is 
 Bometimes called chorea, of a chronic nature, and resembling the disorder I have just 
 been speaking of, inasmuch as it commonly is met with in nervous persons, and 
 consists in the irregular, unmeaning, and involuntary contraction of certain muscles, 
 especially in the limbs, neck, or face : but differing from it in this, that the same 
 muscles are always affected, and in the same way; that it lasts long, almost always 
 for life, and implies no accompanying derangement of the general health. In its 
 slighter form the irregular movements are ratlaer awkward tricks than spasms : a 
 repeated shake of the head, or knitting of the eyebrows, or corrugation of the integu- 
 ments of the nose, or shrugging of the shoulders — which the person seems hardly 
 conscious of. At other times, however, the motions are more extensive ; a limb 
 starts out, or the head is turned awry ; and the individual who performs these evolu- 
 tions is quite aware that he does so, and vexed and annoyed at the ridiculous figure 
 he makes, but he cannot help performing them ; or if he can prevent it, the necessary 
 effort is worse than the disease. One young man who was subject to this infirmity 
 told a friend that he could stop the movement by a strong exertion of the will ; but 
 that tJutt exertion was extremely painful, and was followed by languor and much 
 discomfort. In some instances 1 make no doubt that the continuance of the affection 
 is the result of a long-established habit. It occurs more frequently in men than in 
 women. I had for a long lime, as an out-patient at the hospital, a girl about seven- 
 teen years old, in all other respects the picture of health, but who was annoyed by 
 an involuntary shake of the head, which took place two or three times in a minute. 
 She received no benefit from medicine. A lad in my own service was affected in a 
 similar manner. He seemed to be giving me, and my friends, from time to time, a 
 famihar nod ; and I was obliged to part with him. Others are subject to twitchings 
 of the face. I am acquainted with one gentleman who is perpetually wrinkling his 
 nose: and he has assured me that he was subject, when young, to an involuntary 
 shake of the head, hke the two persons just mentioned ; but a blister having been 
 once applied to his throat for some disorder in his air-passages, the shaking of the 
 head was thereby rendered painful and difficult, and the movement there ceased : 
 but (as he expressed it) it broke out in his nose, where it triumphs to this day. This 
 chronic chorea, as it has been called, I merely mention to prevent your confounding 
 together two affections which, though they have received the same name, and are in 
 some respects analogous, yet differ in still more points, and those points of more im 
 portance. 1 believe that medicine has no power over any of these tricks. They 
 are distressing and unsightly ; but in no way dangerous. 
 
 The word chorea, which you know signifies a dance — and the trivial term of St. 
 Vitus's dance — are not very appropriate to either of the nioaifications of the nervou:i 
 affection which I have been noticing. In fact that terra was originally apphed, and 
 much more suitably, to another set of symptoms of a most singular kind, concerning
 
 406 CHOREA. 
 
 the real occurrence of which we mifrht well be sceptical, if we had not authentic 
 narratives of many instances of such disorder from different persons of credit, as 
 well in this country as in others. What has happened many times before, may 
 happen again ; and you ought not to be in ignorance of the histories to which I 
 allude. They relate to an affection cliaracterized by movements that cannot be 
 called spasmodic, but are rather owing to an irresistible propensity to muscular action, 
 increased sometimes to a sort of mania by the force of imitation, or by the sound of 
 music. It is the voUliori that, in these cases, is morbid and perverse. You might 
 fancy the patient to be possessed and coerced by an evil spirit, like the Sat.^uom^nfx.si>oi, 
 of the Gospel history. 
 
 Some of the subjects of these extraordinary affections, impelled by a strange unin- 
 telligible necessity, execute measured and regular movements with surprising energy, 
 rapidity, and perseverance. When music is performed in their hearing, the move- 
 ments become an actual dance ; and where crowds are collected together, the dancing 
 mania is apt to spread from person to person by a sort of imitative infection ; real- 
 izing the fable of Orpheus, and giving origin (it may be presumed) to those romantic 
 legends met with in the hterature of most ages and countries, of universal, involun- 
 tary, and unceasing saltation, at the sound of a magic pipe. To these feats the term 
 chorea is apposite enough. Indeed I have seen it somewhere suggested that the 
 phrase chorea Sancti Viti is but a vulgar corruption of chorea Sancii inviti ; and 
 took its rise in the misfortune of some holy person who chanced to be afflicted with 
 one of these unwilling but invincible impulses to caper. The common explanation 
 makes this holy person to have been a certain German saint Weit, to whom a chapel 
 is said (I know not with how much truth) to be dedicated at Ulm, in Suabia. 
 
 Sometimes, instead of dancing on their feet, these patients drum and beat with 
 their hands, either upon their own knees, or upon the objects near them. This 
 variety has received the bombastic title of "malleation." Sometimes they circum- 
 volve with great rapidity ; or they turn their heads repeatedly from side to side with 
 great velocity: this is "rotation." When they are irresistibly impelled to move in 
 a given direction, the term " propulsion" is employed. The very invention of these 
 names attests the reaHty of the disorder. 
 
 You will find one of these singular cases related by Mr. Kinder Wood in the 
 seventh volume of the Medico- CI drurgical Transactions. 
 
 The patient was a young married woman. After having suffered severe pain in 
 one side of her face, she began to be troubled with involuntary movements. They 
 commenced in the eyelids, which were opened and shut with excessive rapidity. 
 Then the muscles of the extremities became affected. The palms of the hands were 
 beat rapidly upon the thighs, and the feet upon the floor. The motions soon ex- 
 tended to the trunk and pelvis. The patient was suddenly half raised from her 
 chair, and instantly reseated. This was repeated as quickly as one action could 
 possibly succeed another. Sometimes she had a propensity to leap upwards, and 
 strike the ceiling with the palm of her hand ; or to touch little spots or holes in the 
 furniture of the room. Or she would dance on one leg, holding the other in her 
 hand. These attacks were accompanied by headache, sickness, and vomiting. At 
 last she took to making steps about the room, regulated b};- an air, or by a series of 
 strokes on the furniture as she passed, her lips moving as if words were articulated, 
 but no sound escaping them. A person, thinking he recognized the tune which she 
 beat on the furniture, began to sing it ; and she danced directly up to him, and con- 
 tinued dancing till he was out of breath. A drum and fife were now procured, and 
 the same air played upon them. She immediately danced up to the drum, and as 
 close to it as possible, till she missed the step, when the motions instantly ceased ; 
 and this was found always to be the case. The motions stopped also when the 
 measure was changed ; or was increased in rapidity beyond her power to keep pace 
 with it. A continued roll on the drum had also the effect of putting an end to her 
 movements. This being discovered, their approach was Avatched ; and by always 
 rolling the drum as soon as they threatened to begin, the chain of association which 
 seemed to constitute the disease was at length broken. The bowels were in an 
 unnatural state during the complaint ; and the menstrual discharge appeared on the
 
 CHOREA. 40"" 
 
 evening' cf the day on which it ceased. One might conceive that the conduct here 
 described was an indication of folly or of insanity ; but Mr. Wood declares that the 
 patient's spirits were good, and her perception and judgment accurate and just ; that 
 during the absence of the paroxysms she went about her household affiiirs as usual ; 
 and that she had a correct knowledge of her situation, and of the advantage she 
 derived from the drum, with an anxious desire to continue its use. She stated " that 
 there always was a tune dwelhng upon her mind, which at times becoming more 
 pressing, irresistibly compelled her to commence the involuntary motions." 
 
 In a lady, whom Dr. Abercrombie saw, the following symptoms, among others, 
 occurred : — After she had been ill with various nervous affections for two years, she 
 began to suffer convulsive action of the muscles of the back, and involuntary twitches 
 of the legs and arms, producing a variety of movements of the whole body very diffi- 
 cult to describe. These were much increased by touching her, especially on any 
 part of her back. This is a symptom quite in conformity with Dr. Hall's doctrine 
 of eccentric irritation. At one time there was difficulty of deglutition, so that attempts 
 to sv/allow produced spasms, resembling those of tetanus. At other times, after lying 
 for a long while quiet, she would in an instant throw her whole body into a kind of 
 convulsive spring, by which she was jerked entirely out of bed : and in the same 
 manner, while sitting or lying on the floor, she would fiing herself into bed, or would 
 .eap, as a fish might do, upon the top of a wardrobe fully five feet high. These are 
 feats that surpass the powers of a person in health : and I say we should hesitate to 
 believe them if they were not related by a physician of such sober judgment and 
 unquestionable veracity as Dr. Abercrombie. He tells us that during the whole of 
 these symptoms her mind continued entire : and the only account she could give of 
 her extravagance was, a secret impulse which she could not resist. 
 
 But after a time motions still more wonderful commenced, affecting the muscles 
 of the upper part of the back and neck, and producing a constant semi-rotatory mo- 
 tion of the head. This sometimes continued without interruption night and day for 
 several weeks together ; and if the head or neck were touched, the motion was 
 increased to a most extraordinary degree of rapidity. These paroxysms were 
 relieved by nothing but cupping on the temples to the amount of ten or twelve 
 ounces, when the affection suddenly ceased, with a general convulsive start of the 
 whole body. She was then immediately well, got up, and was able to walk about 
 in good health for several weeks ; when the same symptoms returned, and required 
 a repetition of the same treatment. All this went on, at intervals, for four years ; 
 the menstruation during that time being irregular and scanty, and the bowels torpid 
 She was pale and bloodless from the frequent bleedings, but not reduced in flesh 
 At last, in the spring of 1829, she had a severe paroxysm of the rotatory motion of 
 the head ; and it was then determined to allow the attack to take its course, and to 
 direct the treatment entirely to the menstruation. Sulphate of iron, and Barbadoes 
 aloes, were prescribed. She went on for three weeks, the convulsive motion of the 
 head continuing without intermission night and day. At length, in the middle of 
 the night, the paroxysm ceased in an instant, with the same kind of convulsive star' 
 of the whole body with which it used to cease after cupping. At the same instant 
 menstruation took place in a more full and healthy manner than it had done for 
 many years. From that time she remained well ; at least up to the period when 
 Dr. Abercrombie wrote the account. 
 
 The alternating rotatory motion of the head is by no means an uncommon feature 
 of these singular cases. It occurred in a patient of Dr. Conolly's ; in whom the 
 menstruation was irregular, and about to cease altogether. It came on in parox)?-sms 
 which were repeated many times a day, and was attended with inordinate loquacity. 
 The head was turned from side to side about eight times in a second, and each 
 paroxysm lasted three or four minutes. The patient got well after being cupped 
 and leeched, and thoroughly purged. I have seen precisely the same thing in a 
 hospital patient. Dr. Crawford met with an instance of involuntary rotation of the 
 head, without pain, but attended with intolerance of light. And there is a striking 
 example of it described in the twenty-third volume of the Edinburgh Medical and 
 Surgical Journal, by Mr. Hunter, of Glasgow, who speaks of it under the name o/
 
 408 CHOREA 
 
 "rotatio or chorea." The motions are said to have been furious and alarming: they 
 were executed with such extreme rapidity, that it was difficult even for the eye to 
 follow them. She appeared, Mr. Hunter says, absolutely to be looking backwards 
 and forwards, and in every direction, at the same moment. This woman had some- 
 times fifty paroxysms of this kind in a day : they greatly exhausted her ; but she 
 was perfectly rational in the intervals. A modification of the same kind of affection 
 took place in a most extraordinary case recorded by Dr. Watt, of Glasgow, in the 
 fifth volume of the Medico-Chirurgical Transactions. His patient was a girl ten 
 years old. First she had headache, accompanied by vomiting, and increased by the 
 slightest deviation of the body from the erect posture, either backwards, or forwards 
 or to one side. These symptoms lasted about a month ; and during that time she 
 lost the power of speech and of walking. At the end of that period she was seized 
 with a propensity to twirl round on her feet, hke a top, with great velocity, always 
 in one direction ; and was pleased when those about her assisted in increasing the 
 rapidity of her movements. After continuing nearly a month, these motions ceased, 
 the headache relumed, and she became unable to move her neck, or support her 
 head. Soon after, she was visited with a new kind of motion ; she would lay her- 
 self across the bed, and turning over like a roller, move rapidly from one end of it 
 to the other. At first the fits of this kind lasted two hours ; but they gradually 
 extended to six or seven hours every day. On being carried into the garden she 
 rolled rapidly from one end of a gravel walk to the other ; and even when laid in 
 the shallow part of a river, though apparently on the point of being drowned, she 
 began to turn round as usual. The rotations were about sixty a minute. She made 
 httle or no use of her arms in revolving. In about another month or six weeks an 
 entirely new set of movements began. She lay upon her back, and, by drawing her 
 head and heels together, bent herself like a bow, and then allowing her head and 
 heels to separate, her buttocks fell with considerable force upon the bed. She 
 repeated these movements ten or twelve times in a minute, first for six hours daily, 
 and at length for fourteen. After another space of about five weeks had elapsed, 
 the most singular freak of all ensued ; she became possessed with a propensity to 
 stand upon her head with her feet perpendicularly upwards. As soon as the feet 
 were elevated in this manner, all muscular exertion seemed to be withheld, and the 
 body fell down as if dead; her knees striking the bed first. This was no sooner 
 done than she instantly mounted up as before ; and continued to do so from twelve 
 to fifteen times in a minute, for fifteen hours a day. After a variety of fruitless 
 treatment, a spontaneous diarrhosa came on, and she recovered. 
 
 The spinning motions observed during a part of this case have been observed in 
 other instances. 
 
 In Magendie's Journal de F/u/sioIogie, the two following singular forms of dis- 
 ease are referred to. A man, after some other symptoms of cerebral disorder, was 
 seized with an irresistible inclination to move forwards, stopping only when ex- 
 hausted. He would sally forth into the streets, and continue walking straight 
 forward until he dropped down from fatigue, and was obliged to be brought home in 
 some conveyance. This man at length died, and several tubercles were found in 
 the anterior hemispheres of his brain. Dr. Laurent of Versailles, exhibited to the 
 Academy of Medicine a young girl, labouring under the exactly opposite necessity. 
 In the attacks of a nervous disease she was irresistibly propelled backwards, and 
 with some rapidity : being unable to avoid obstacles or hollows, she received many 
 falls and bruises in her course. 
 
 I say that histories such as I have been giving vou some samples of, and those 
 mostly in an abridged form, would sound very like romances, if they were met 
 with in the old authors alone, or if they were not attested by unimpeachable au- 
 thority They resemble chorea in this respect, that they are examples of muscular 
 actions performed by persons in possession of consciousness, and performed in 
 spite of themselves. But in most other respects they differ from what we now-a- 
 days mean when we speak of chorea. Perhaps they may rank among hysterical 
 vagaries. It is remarkable that the majority of them occur in young women, in 
 wnom :ne menstrual function is suspended or irregularly performed. Some persons
 
 CHOREA. 409 
 
 may consider them as varieties of insanity. The patients certainly did not feign to 
 be ill, for the feats of strength and agility which many of them enacted were much 
 beyond their natural power and endurance. The truth seems to be, that there are 
 * innumerable modifications of the nervous functions, and that some of them are more 
 common and more capable of being arranged into groups than others ; but that they 
 all offer points of resemblance, like (as I observed before) the different members of 
 a large family, in which the individuals have the same general cast of features, and 
 yet preserve each his particular identity. 
 
 I advert to these odd forms of disease with a view of directing your attention to 
 such of them as may come in your way. We are yet terribly in the dark about 
 morbid affections of the nerves, both organic and functional. Hereafter some medi- 
 cal Newton will arise, and reduce all these apparently compHcated phenomena 
 under one simpler law. At present all that we can do is to collect and, as far as we 
 may, to arrange facts, in the hope that at length some better light will be shed upon 
 the subject. And it must be observed that some of the modern researches into phy- 
 siology do throw a little glimmering of illumination into these dark corners of pa- 
 thology. In certain of M. Magendie's experiments on animals the following curious 
 facts were ascertained : — When a vertical section of the cerebellum of a rabbit was 
 made, leaving one-fourth of the whole adhering to the crus of the right side, and 
 three-fourths to the left, the animal rolled over and over incessantly, turning itself 
 towards the injured side. The same phenomenon occurred upon the division of the 
 crus cerebelli. The animal lived for eight days, and continued during the whole of 
 that time to revolve upon its long axis, unless stopped by coming in contact with 
 some obstacle. How like is this to the symptoms exhibited at one period in the 
 girl whose case is related by Dr. Watt ! Nor is Dr. Watt's case a singular one ; M. 
 Serres has described another much resembling it. A shoemaker, sixty-eight years 
 old, of intemperate habits, after one of his debauches, exhibited a kind of drunken- 
 ness which surprised his friends. Instead of seeing objects turn round him, as a 
 drunken person is apt to do, he thought he was himself turning, and soon began to 
 revolve ; and this lasted till he died ; and when his head was examined, extensive 
 mischief was found in one of the peduncles of his cerebellum. 
 
 Again, M. Magendie noticed that when the upper part of the cerebrum is gently 
 removed in birds and mammalia, they become blind ; but no affection of the locomo- 
 tive powers is produced. No further result is occasioned by the removal of a portion 
 of the gray matter of the corpus striatum : but when the striated part is cut away, 
 the animal immediately darts forward with rapidity, and continues to advance as if 
 impelled by some irresistible force, until stopped by an obstacle ; and even then it 
 retains the attitude of one advancing. The experiment was tried with the same 
 resuk upon various species of animals — dogs, cats, hedgehogs, rabbits. Guinea-pigs, 
 and squirrels. It seems that there are horses that cannot back ; although they make 
 good progress enough in a straightforward direction. Now Magendie says that he 
 has opened the heads of such horses ; and has always found, in the lateral ventricles 
 of their brains, a collection of water, which must have compressed and even disor- 
 ganized the corpora striata. It has further been ascertained, by the same experi- 
 menter and by others, that certain injuries of the cerebellum cause animals to move 
 backwards contrarily to their will. If the tail of the animal so mutilated be pinched, 
 he still persists in his retrograde course. Injuries of the medulla oblongata had the 
 same effect. Pigeons into which he forced a pin through that part, constantly re- 
 ceded for more than a month, and evenjleiv backwards. A section of the medulla 
 oblongata, where it approaches the anterior pyramid, gives rise to a movement in a 
 •circle, like that of a horse in a mill: the animal, in its walk or its flight, bearing 
 round continually to the injured side. Surely we have, in these facts, supplied by 
 experiments on living animals, and by observation of the phenomena of disease in 
 the living human body, some of the materials for a more exact knowledge, both of 
 the physiology and of the pathology of the nervous system, than we have yet 
 reached. M. Magendie supposes that different portions of the encephalon are en 
 dowed with energies which tend to cause motion in various directions ; that in the 
 healthy state these balance each other, and that a prcponderalmg impulse can be 
 
 2 k
 
 410 CHOREA. 
 
 given to any one of these forces by the will ; but that when the equilibrium is: 
 destroyed by disease, the will is not sufficient to counteract the tendencies which are' 
 then brought into play. Mr. Mayo offers a different explanation of the phenomena. 
 He supposes that the injuries inflicted on the nervous matter produce a sensation] 
 analogous to vertigo; and that the animal conceives itself either to be hurried for- 
 ward, and makes an exertion to repel the imaginary force ; or to be moving back 
 ward, or turning round in one direction, and endeavours to correct this by moving ; 
 the corresponding muscles. Whatever may be the true explanation, lihe facts 
 themselves are abundantly curious and interesting, and I recommend them to your 
 attention. 
 
 Some of the affections that I have been describing, fall, perhaps, under th^ cate- 
 gory of those to which the appellation of the leaping ague has been given in some 
 parts of Scotland. There is a class also of convulsive spasmodic affections which 
 resemble epilepsy on the one hand, and chorea on the other, or rather form a hnk of 
 alliance between the two, and which are especially remarkable for this, that they are 
 capable of being propagated by that kind of imitative contagion of which I have 
 several times spoken. This point might be well illustrated by the history of various 
 sects of religious enthusiasts. One or two of those enthusiasts have apparently at 
 first worked themselves up into a state approaching to epilepsy, accompanied even 
 by insensibility sometimes ; and then this state has been communicated by sympathy 
 to the more susceptible of their auditors. I must not, however, go into any further 
 details on this subject ; and perhaps I have prosecuted it too far already. Those 
 among you who are inclined to pursue it further may find some curious accounts of 
 an epidemic which occurred in Lanarkshire, in Sir John Sinclair's Statistical Ac- 
 count of Scotland, under the head of the " Conversions of Cambuslang ;" a:nd in 
 one of the early volumes of the Edinburgh Medical and Surgical Journal. Dr. 
 Robertson has described, in an inaugural dissertation De Chorsed Sancti Viti, a 
 similar epidemic, which occurred in the states of Tennessee and Kentucky, in the 
 western districts of America. This is also referred to in the same volume of the 
 journal. Among other things. Dr. Robertson says, that while extravagant sounds, 
 and actions, and gesticulations, were in the first instance 7vilful, the actors " at length 
 to their own astonishment, and the diversion of many of the spectators, continued to 
 act from necessity the curious character which they had commenced from choice." 
 I will only remark further of such forms of nervous disease, that as they spring often 
 from moral causes, so they admit, in a great degree, of moral remedies. The pranks 
 played by the Scotch enthusiasts were brought to an end by threatening to duck 
 every one who should thereafter be attacked ; and, I believe, a few of them loere 
 horseponded, by way of example. With respect to the solitary instances of per- 
 verted locomotion, our business must be to correct whatever is wrong in the state of 
 the bowels : in women, to amend the disordered uterine functions ; to strengthen and 
 confirm the system generally ; and, in addition to the measures proper to effect these 
 objects, I suspect that the cold sousing would in many cases be found of most 
 material service. 
 
 LECTURE XXXVIII. 
 
 Paralysis Agitans. Mercurial Tremor. Hysteria : Two forms of Hysteric Pa- 
 roxysm; Diagnosis from Epilepsy ; Class of Persons most liable to Hysteria ; 
 Diseases apt to be simulated by Hysterui ; Treatment ; Prevention. 
 
 In the last lecture I spoke of chorea, and of some singular forms of disorder that 
 have sometimes been included under the samtj appellation; and I shall begin the 
 present with a few observations concerning a disease very closely allied to some of 
 those which we were then considering, and yet distinct enough to deserve and require 
 a separate notice. I refer to what has been called the shaking pcdsy — paralysis agi
 
 PARALYSIS AGITANS. 411 
 
 tans. Allusions to this fo/m of diseaiie are to be found in manj- of tli'^, older sys- 
 tematic writers on physic ; but it never was much attended to in this country until 
 Mr. Parkinson published an essay upon it in the year 1817; and a very interesting 
 little pamphlet it is. He defines the disease thus : — "Involuntary tremulous motion, 
 A'ith lessened muscular power, in parts not in action, and even when supported : 
 with a propensity to bend the trunk forwards, and to pass from a walking to a run- 
 ning pace : the senses and intellects being uninjured." The latter symptoms consti- 
 tute the scelotyrbe festinans of Sauvages ; and the former symptoms of the definition 
 are not always attended by the latter. In old persons you may often observe incessant 
 and involuntary nodding and shaking of the head, without any tendency to run for- 
 wards. There is an old woman whom I see regularly sitting in the aisle at church 
 every Sunday ; she walks to her seat slowly and steadily enough, and sufficiently 
 upright ; but her head never ceases to nod, and wag, and tremble in various directions. 
 It may be that she is in the less advanced stage of the malady ; but I have remarked 
 her for three or four or more years, and I see no change. 
 
 Mr. Parkinson's notice was first called to the disease during his professional attend- 
 ance upon a person afl^ected by it. From observation of that case, and of several 
 others that he subsequently met with, his account of the disorder was drawn up. 
 He states that its first approach is insidious, and its progress often so slow and imper- 
 ceptible that the patient cannot recollect precisely when it began. A sense of weak- 
 ness, and a disposition to trembling, fastens on some particular part : sometimes it is 
 the head, but more commonly it is one of the hands or arms. These symptoms 
 gradually become more decided ; and at length the morbid influence is felt in some 
 other part. At a still more advanced period the patient is found to be less strict than 
 usual in preserving an upright posture, even when standing or sitting, but especially 
 when walking. By degrees he finds a difficulty in making the hand obey the dictates 
 of the will when he is engaged in any delicate manipulation — in writing, for exam- 
 ple ; and he is obliged to walk with circumspection and care : his legs are not raised 
 t(» that height, nor with that promptitude which the will directs; so that much 
 attention is necessary to prevent frequent falls. Then, as the malady proceeds, the 
 propensity to lean forwards becomes more strong — the patient is forced to step on 
 the toes and fore-part of the feet, while the upper part of the body is thrown so far 
 forward as to render it difficult to avoid falling on the face : in some cases he is irre- 
 sistibly impelled to take much quicker and shorter steps than common, and thereby 
 to adopt unwillingly a running pace. When once this state has been pointed out, I 
 make no doubt that some of you may recognize it in old persons whom you may 
 have seen walking about. But the disorder does not stop here : the unhappy patient 
 becomes unable to feed himself; or to walk at all without an attendant, who walks 
 backwards before him, and prevents his faUing forwards by the pressure of his 
 hands against the fore part of the patient's shoulders : his powers of speech and 
 deglutition fail; and the saliva dribbles from his mouth ; he can no longer retain his 
 urine or feces ; and at length death closes the miserable scene. 
 
 Mr. Parkinson conjectures that this complaint results from some chronic change 
 of the upper part of the spinal cord, or of the medulla oblongata : but dissections 
 are wanting to support or to refute that conjecture. Some of the patients, whose 
 cases he has given, had been intemperate livers ; hard drinkers ; others had not 
 been guilty of any such excesses : several had suffered a good deal from rheuma- 
 tism, which he thought might have laid the foundation of their lamentable disease. 
 But a more exact pathology of the shaking palsy is still needed. Dr. M. Hall 
 observes that the symptoms have, in several particulars a marked resemblance to the 
 effects observed by M. Serres (and related in his Jlnatomie du Cerveau) of disease 
 of the tuber annulare, or of the tubercula quadrigemina. 
 
 Nor have we any ascertained means of curing this disease ; or rather this state ot 
 decay. Dr. Elliotson indeed says that he succeeded in one instance (of which, how- 
 ever, the particulars are not given), with the carbonate of iron ; but that he had 
 tried the same medicine in vain in several other cases. We must administer to 
 symptoms, and endeavour to set those functions right which may be obviously 
 wrong: to regulate .the bowels, to procure sleep, to nourish and uphold the pa
 
 412 MERCURIAL TREMOR. 
 
 tient without unduly stimulating him; and this is all that I can tell you of the 
 shaking palsy. 
 
 Another analogous disorder, meriting a moment's notice, is that peculiar kind of 
 trembling which is apt to occur in persons who are much exposed to the poisonous 
 lumes of mercury : mercurial tremor it is called ; and popularly, the trembles. It 
 consists of a sort of convulsive agitation of the voluntary muscles, which is most 
 violent whenever efforts are made to move the hmbs by the help of those muscles ; 
 whenever, in fact, volition is brought to bear upon them. It differs, therefore, from 
 the shaking palsy, inasmuch as the tremor ceases when the muscles are supported, 
 or are not called into action. It is also more susceptible of relief by medicine. The 
 last person in whom I have witnessed this curious affection has been twice my patient 
 in the Middlesex Hospital, and has twice got well there. John Chattin, 33 years 
 old, was first admitted in August, 1837. He was led into the room, walking with 
 uncertain steps, his limbs trembling and dancing as though they had been hung upon 
 wires. While sitting on a chair he was comparatively quiet ; you would not have 
 supposed that he ailed any thing ; but as soon as he attempted to rise and to walk, 
 his legs began to shake violently with a rapid, incessant, and irregular motion. He 
 could neither hold them steady, nor direct them with precision. Indeed without sup- 
 port he must have fallen down. His arms were agitated with similar involuntary 
 movements. His tongue was tremulous, and he spoke in a hurried, abrupt, inter 
 rupted, staccato manner, not natural to him. He had no fever. His pulse was (56, 
 and soft ; his skin natural : his bowels costive. He complained of shght nausea. 
 At the end of six weeks he went out w^ell, or with very slight remaining weakness 
 of his knees, and a httle occasional tremor upon unusual exertion. In June, 1S39, 
 he again presented himself, in a similar state of agitation and helplessness. 
 
 This man was a water-gilder ; and had been employed in that business for 18 years. 
 Till somewhat more than a twelvemonth prior to his first appearance at the hospital, 
 he had been free from disease. Then he began to tremble a little ; but for a fortnight 
 before his admission the shaking had become so much worse that he could not go up 
 stairs, nor even walk upon uneven ground. The trembling, when once brought on 
 by efforts to move, did not cease until he sat down, or got one of his fellow- workmen 
 to grasp his limbs tightly. 
 
 This singular disorder is produced by the agency of mercury as a poison upon 
 the body ; and especially by the abforplion of that metal when raised into vapour 
 by heat, and inhaled in breathing. It is accordingly very common among water- 
 gilders. Water-gilding is the gildinc of metals, and of silver in particular, by means 
 of fire. It is called ?ra/e;--gilding ( believe, to distinguish it from other kinds of 
 gilding, called gilding in oil. Thf. silver to be gilded is covered with an amalgam 
 of gold and mercury, and then is placed over a charcoal fire, by which the mercury 
 is raised in fumes and driven oflj and the gold alone is left adhering. To these 
 fumes the workmen are necessarily exposed ; and numbers of them become affected 
 with this tremor, which is not a common result of mercury applied to the system 
 in other ways. The same complaint is frequent among the workmen in the quick- 
 silver mines of Friuli and of Almaden, where the crude ore is purified by the aid of 
 heat. Dr. Bateman relates, in the 8th volume of the Mcdico-Ckinirgicul Traaaac- 
 tions, some cases like that which I have been describing. But the best account of 
 the disorder that I have seen is given by Merat, in an appendix to his book on the 
 Cohque MetaUiqiie. 
 
 The malady comes on sometimes suddenly, more often by degrees. The patient 
 is less sure of his arms than usual: they become tremulous, and at last shake, and, 
 if he continues to pursue his employment, the force of the trembling goes on 
 mcreasing, tin at length it is so general and violent that he can persist no longer. 
 His power of locomotion is impaired ; his mastication, his speech, all his n)anual 
 operations, are interfered with ; he becomes unable to convey food to his moudi, and 
 is obliged to be attended to and fed, like an infant; and by and by, if he does not 
 quit the poisonous atmosphere, graver symptoms supervene — wakefulness, dehrium 
 loss of consciousness. .
 
 MERCURIAL TREMOR. 413 
 
 As the tremor increases, the digestive organs become disordered ; the appetite falls 
 off; nausea is felt, the tongue becomes furred, and gas collects in the intestines. The 
 patients acquire a remarkable brown hue ; and their teeth turn black. The pulse is 
 generally full and slow. 
 
 The time required for the production of these effects varies much in different 
 cases ; from two years to five-and-twenty. Something depends no doubt upon the 
 quantity and intensity of the fumes. Chattin told us that the workmen became ill 
 whenever they had a large job on hand. In both his severe attacks (and very often 
 besides, both in him and his companions) the mercury produced salivation. This 
 was unfrequent in the patients observed by Merat. The duration of the complaint 
 is considerable : it may last two or three months, or longer ; and sometimes it is not 
 completely recovered from at all. Yet it is not a fatal disorder. 
 
 Although the visible affection is of the muscles, the mischievous operation of the 
 poison is really upon the nerves, weakening their natural influence. When the will 
 is directed upon the muscles, they contract unsteadily, and with frequent remissions ; 
 their action is not sustained ; and it is a general observation by all who have written 
 upon the disease, that it is aggravated by all kinds of mental emotion, by alarm, 
 anger, surprise. My patient's shaking was, at first, augmented by the shock of the 
 shower-bath : and always became excessive in thundery weather. So, on the other 
 hand, it has been noticed that whatever tends to stimulate and fortify the nervous 
 power, does temporary good : a glass of wine for example. Chattin informed us 
 that, while the malady was coming on, he could not get up stairs to his work with- 
 out first swallowing half a quartern of gin ; and that he was obliged to drink porter 
 two or three times a day. 
 
 The treatment consists in withdrawing the patient from the injurious atmosphere, 
 and m administering tonics. 
 
 Conium has been recommended by Mr. M'Whinnie. Q,uina has been found 
 useful. But I have most faith in preparations of iron. My patient Chattin mended 
 decidedly and rapidly when he began to take steel. It was not the mere avoidance 
 of the cause of the complaint that produced the improvement, for he had been away 
 from his work for a fortnight before he applied for admission. 
 
 To prevent this effect of mercury, the workmen should be mstructed to avoid, as 
 much as possible, inhahng the poisonous fumes, to ventilate the room thoroughly, 
 and to pay great attention to cleanliness. I believe the furnaces may be so built 
 that the metallic vapour shall not reach the operator. If he cannot avoid being in 
 volved in it, perhaps some sort of respirator might afford protection. 
 
 [A very peculiar form of convulsive disease has recently been described. It is charactei 
 ized by repeated bobbings of the head forward, at first slight and occasional, but becoming, 
 in process of time, so frequent and powerful, as to cause a heaving of the head forwards, 
 towards the knees, succeeded by an immediate return to the upright position, somewhat 
 similar to the attacks of emprosthotonos. In one case, related by J. W. West, these bobbings 
 were repeated at intervals of a few seconds, ten, twenty, or more times, in each attack, which 
 continued from two to three minutes, and recurred twice, thrice or oftener in the day; the 
 filtack occurring whether the patient was sitting or lying. Durnig the attack, the child re- 
 tained his consciousness. The other cases that have been since recorded by Drs. Barton and 
 Bennett, in their general symptoms, differ in no degree from that of Mr. West, with the 
 exception of that of Dr. Bennett, in which the disease was of a more aggravated character. 
 Sir Charles Clarke has seen four cases of the disease, and from the peculiar bobbing of the 
 head, has named it the Salaam Convulsion ; Dr. Locock has seen two cases. One of Sir 
 Charles Clarke's patients recovered perfectly, the other became paralytic and idiotic, and died 
 at the age of seventeen. Mr. West has heard of two other cases — one of the patients lived 
 to the age of seventeen ; the other to nineteen, — both became idiotic. The sex and ages of 
 the patients whose cases are on record, are one female of seven years, and two boys of on© 
 and six years — death did not occur in either ; in the female and one of tlie boys the distase 
 appears to have ceased. 
 
 Of this strange form of convulsions, the pathology is still a subject for future investigation, 
 and until that is ascertained, its treatment must be tentative and experimental. — C] 
 
 I proceed to the subject of hysteria : a subject highly interesting and important, 
 as well as obscure and difficult. I scarcely know how to arrange what " have to say 
 so as to present the disorder to your notice in the most intelligible manner. Hysteria 
 
 2k3
 
 414 HYSTERIA. 
 
 has characters peculiar to itself: but it is apt also to assume the form, and mimic 
 the symptoms, of various other diseases of a much graver nature. If we are not 
 capable of distinguishing the true malady from that which is its double, we shall be 
 constantly committing most serious mistakes in the prognosis, to our own damage 
 and discredit; and in the treatment, to the injury of our patient. I shall hrst 
 attempt to describe to you the phenomena which are peculiar to hysteria; and then 
 to point out the class of persons who are most subject to it; and afterwards I shall 
 briefly advert to the imitative freaks which we are almost daily witnessing in hys- 
 terical consiitutions, and to some other points connected with this extraordinary 
 complaint. 
 
 I need not tell you that the hysterical joaroa:!/*^ '^ almost exclusively confined to 
 women. 
 
 [We have repeatedly seen all the phenomena characteristic of hysteria in the male sub- 
 ject. The fact of their occurrence in males is also stated by Sydenham, Louyr Villermay, 
 Georget, Ferriar, Frotten, Conolly and others. See also the admissions of Dr. Watson to- 
 wards the close of his remarks on the pathology of the disease.-r^C] 
 
 It occurs under a great variety of forms, but they may all be reduced, for conve- 
 nience of description, to two. The first of these has a general resemblance to an 
 epileptic fit. The trunk and limbs of the patient are agitated with strong convulsive 
 movements; she struggles violently, hke a person contending; rises into a sitting 
 posture, and then throws herself back again; forcibly retracts and extends her legs, 
 while her body is twisted from side to side; and so powerful are these muscular 
 contortions tliat it often is all that three or four strong persons can do to restrain a 
 shght girl, and prevent her from injuring herself or others. The head is generally 
 thrown backwards, and the throat projects ; the face is flushed ; the eyehds are 
 closed and tremulous ; the nostrils distended ; the jaws often firmly shut ; but there 
 is no distortion of the countenance : the cheeks are at rest, unless when, as often 
 happens, the patient is uttering screams, or exclamations. If the hands are left at 
 hberty, she will often strike her breast repeatedly and quickly, or carry her fingers 
 to her throat, as if to remove some oppression there ; or she will sometimes tear her 
 hair, or rend her clothes or attempt to bite those about her. With all this her breath- 
 ing is deep, labouring, irregular; and the heart palpitates. After a short time this 
 violent agitation is calmed : but the patient lies panting and trembling, and starthng 
 at the slightest noise or the gentlest touch ; or sometimes she remains motionless 
 during the remissions, with a fixed eye ; till at once the convulsive movements are 
 renewed : and this alternation of spasm and quiet will go on for a space of time that 
 varies considerably in different cases : and the whole attack frequently terminates in 
 an explosion of tears and sobs, and convulsive laughter. 
 
 There is a variety of this form of hysterical paroxysm, in which the patient sud- 
 denly sinks down insensible, and without convulsions : with slow and interrupted 
 breathing, a turgid neck and flushed cheeks; and she recovers from that condition, 
 depressed in spirits, fatigued and crying. 
 
 You will observe that the symptoms I have been enumerating belong to the nerv- 
 ous system ; and indicate great derangement in th^ functions of animal life. In the 
 other of the two forms to which all the various modifications of the attack may be 
 reduced, the principal marks of disturbance are referable to some of the viscera. 
 The patient experiences a sense of uneasiness in some part of the abdomen, fre- 
 •juently towards the left flank ; a ball appears to roll about, and to rise first to the 
 situation of the stomach, and then to the throat, where the patient feels a choking 
 sensation ; the action of swallowing is frequently rej>eated ; the abdomen becomes 
 distended \vith u-ind, loud rumblings and sudden eructations take place ; there 
 is much palpitation of the heart, the patient is sad and sorrowful, and prone to 
 fched tears. 
 
 After the paroxysms, these patients commonly void a large quantity of hmpid, pale 
 anne, looking almost like water; and this sometimes expelled during the fit. 
 
 Such is a brief, and, I am aware, incomplete account of the hysterical pa.oxysm. 
 U sets forth, however, in outline, the two principal varieties of the attack : -xfA yoii
 
 HYSTERIA. 415 
 
 are to observe that the last, the quieter form, is often the prelude to the convulsive ; 
 out it not seldom also occurs alone, and then is as indicative of hysteria, as the petit 
 inal, to which it is somewhat analogous, is of epilepsy. 
 
 And before I go any further, let us again inquire into the circumstances which 
 distinguish the paroxysms of those two diseases, epilepsy and hysteria. I have 
 shortly adverted to these discriminative circumstances before ; but we shall be better 
 able to appreciate them now that the main features of each diseased state have been 
 under our consideration. It is of great importance to be able to render the dianrnosis 
 certain and accurate. It is a dreadful announcement to have to make to a father or 
 a mother that their child is epileptic ; whereas hysteria, though it is sufficiently dis- 
 tressing, is attended, in nine hundred and ninety cases out of a thousand, with no 
 ultimate peril either to mind or body. In some instances the diagnosis is perfectly 
 easy : in others it is dubious and full of anxiety. Whenever you fail to satisfy your- 
 selves completely as to the nature of a given case, you will do well, in legal phrase, 
 to give your patient the benefit of your doubt, and acquit her of epilepsy ; or pro- 
 nounce her guilty of the minor offence of hysteria. 
 
 The points of resemblance, and the points of distinction, belonging to the hys- 
 terical and epileptic paroxysm respectively, have been very clearly summed up by 
 Foville. 
 
 There are two principal forms of each disorder. In each, one of these forms is 
 convulsive, and the other is not. The non-convulsive form of epilepsy relates exclu- 
 sively to the sensorium : it is characterized by vertigo, and by a suspension (how- 
 ever brief and transitory) of the mental powers. The non-convulsive form of hysteria 
 has little apparent connection with the animal functions : its palpable phenomena 
 consist in derangement of the organic functions of the thorax and abdomen. It is 
 the ganglionic portion of the nervous system that seems chiefly disturbed. 
 
 In the epileptic j^^ there is an entire loss of consciousness. The patient, oa 
 emerging from the paroxysm, recollects nothing of what has been going on durino- 
 Its continuance. It is not so in the hysterical fit. The loss of consciousness is very 
 seldom complete ; and it never occurs at the outset of the attack. The patient often 
 is able to repeat (though she may not always choose to confess it) what has been 
 said by the bystanders during the period when she seemed insensible. This is a 
 point of distinction well worth remembering, for more reasons than one. It not only 
 helps the diagnosis when the fact comes out ; but it suggests certain cautions to our- 
 selves. VVe must take care not to say any thing by the bed-side of an hysterical 
 patient which we do not wish her to hear ; and we may take advantage of her appa- 
 rent unconsciousness, and pretend to believe in it, and speak of certain modes of 
 treatment which she will not much approve of, but the very mention of which may 
 serve to bring her out of the fit. 
 
 In the epileptic paroxysm the face is usually livid ; and foam, which is frothy 
 with air, or red with blood, escapes from the patient's mouth. These are symp- 
 toms which we do not see in the fits of hysteria. The convulsive movements even, 
 offer some characteristic shades of distinction. In epilepsy they are often more 
 marked on one side of the body than on the other, and less irregular : the same 
 movements are rapidly repeated: there is a strangling rattle in the breathing: 
 while in hysteria the forcible flexion and extension of the limbs, and the contortions 
 of the trunk, are more sudden, and, as it were, capricious ; the respiration is deep, 
 sighing, mixed with cries, and sobs, and often with laughter. But, perhaps, the con- 
 vulsive motions differ most in the face. The epileptic expression is usually fright- 
 ful ; the eyehds half open, the eyeballs rolling, the mouth drawn to one side, the 
 teeth grinding, the gums exposed by the retraction of the lips, the tongue protruded 
 and bleeding, the complexion leaden : while in hysteria the cheeks are red, but at 
 rest; the eyelids are closed and trembling; if you raise the upper one, you will see 
 the eye fixed, perhaps, but it is bright, and very different from that of the epileptic, 
 which, if it be not rolling, is dull, projecting, and the pupil usually dilated. 
 
 Foville states that when, besides a sudden loss of consciousness with convulsive 
 movements, there are also lividity of the face, and an escape of frothy saliva from 
 between the hps, and the con'ulsions are more pronounced on the one side of the
 
 416 HYSTERIA. 
 
 body than on the other, the disease is epilepsy, and not hysteria : and I think he is 
 right. 
 
 By Dr. Marshall Hall the grand distinction between the two diseases is affirmed 
 to be this : — that in hysteria, much as the larynx may be affected, it is never 
 closed ; in epilepsy, it is closed. Accordingly, in the former we have heaving, 
 sighing, inspiration ; in the latter, violent ineffectual efforts at expiration. In 
 the very outset of the epileptic paroxysm the respiration, I believe, is thus sus- 
 pended. 
 
 The hysterical seizure may be over in a quarter of an hour, or in less time than 
 that ; or it may last many hours, or even several days. 
 
 The hysterical seizure is almost peculiar to women : and it seldom occurs in them 
 except during that period of their lives in which the menstrual function of the uterus 
 is or ought to be in activity. In this country it is most apt to occur between the 
 ages of fifteen and forty ; and in the vast majority of patients who do suffer it, you 
 will find some marked derangement of that particular function. These facts alone 
 afford a strong corroboration of the ancient theory, which ascribed the whole of the 
 phenomena to uterine disorder ; and named the disease accordingly. You will hear 
 or read of disputes as to whether the womb, with its appendages, or the nervous 
 system, is the seat of hysteria. But such disputes are merely verbal, I conceive. 
 No doubt the convulsive movements, and the mental affection, and the unnatural 
 sensations, depend upon some altered condition of the brain and nerves ; but it does 
 not follow that the disease originates in that altered condition. We know that the 
 uterus or the ovaries cannot of themselves determine the muscles to contract; 
 but if they be in an unhealthy state they may act upon the muscles through the 
 inedhan of the nervous system : and such I take to be the fact. How they do so 
 we no more know than we know how the little finger is bent when we resolve to 
 bend it. 
 
 But, say some, we every day meet with diseased conditions of the uterus and 
 ovaries — amenorrhoea, dysmenorrhoea, monorrhagia, even disorganization — without 
 any of these nervous symptoms. True ; and we cannot always fathom the mystery 
 of this. But one thing is certain, that there exists in some persons a much greater 
 readiness to take on the disease, upon the application of the exciting cause, than in 
 others. This predisposition I have had occasion to advert to again and again, since 
 I began to speak of the spasmodic diseases of the nervous system. Such diseases 
 occur in certain individuals only; and in these individuals there pre-exists a pecu- 
 liar condition of the nervous system, "for which," says Dr. Alison, "we have no 
 more precise or definite expression than nervous irritability or mobility; a con- 
 dition which is more common in women and children than in men ; and more com- 
 mon in all persons when in a state of weakness, than when in the full enjoyment 
 of muscular strength ; in women, particularly, more common about the menstrual 
 periods, and immediately after delivery, than at other times ; more common likewise 
 in those in whom the monthly discharge is habitually excessive or altered as in leu- 
 corrhoettt or suddenly suppressed, or more gradually obstructed in the different forms 
 of amenorrhoea, than in others. In this condition of mobility, both sensations and 
 »;motions are intensely felt; and their agency on the body is stronger and more 
 lasting than usual ; continued voluntary efforts of the mind, and steady or sus- 
 tained exertions of the voluntary muscles arc difficult, or impossible; the muscular 
 motions are usually rapid and irregular, and the 'animus, nee sponte, varius et mu- 
 tabilis.' " In persons of this movable temperament, spasmodic complaints are easily 
 excited : and the tendency to their recurrence is increased by each repetition of 
 them. 
 
 Now the persons who suffer hysteria are of this class. They are commonly 
 young women, in whom the process of menstruation is in some way or other dis- 
 ordered ; and who either are naturally of a feeble constitution, or have been debili- 
 tated by disease, or by their habits of hfe. They often are pale ; have cold hands 
 and feet ; are subject to chilblains ; eat but little, and do not fancy meat, which they 
 sometimes absolutely dislike and refuse ; or their taste is depraved and capricious 
 ♦hey will devour wax candles, wafers, chalk, sealing wax, slate pencil, and such 
 
 I
 
 HYSTERIA. 417 
 
 irash. And, what is very curious and cliaracterislic, although they often abstain 
 ahnost entirely from animal food for weeks or months together, and take very little 
 nourishment of any kind, they do not in general emaciate. You might expect that, 
 under such a mode of life, they would waste away : but they continue round, and 
 plump, and smooth. Some of them are even ruddy. 
 
 And belonging to women of this pecuhar constitution there is one other very re- 
 markable character, which it behoves us to make ourselves thoroughly acquainted 
 with. Almost any part of the nervous system, in these persons, is liable, under the 
 influence of slight causes, and even without any obvious cause, to fall into a disor- 
 dered state of action and suffering more or less resembhng that which inflammation 
 or organic disease might excite in the same part. 
 
 This is a most important fact ; because if we erroneously ascribe symptoms which 
 really result from inflammation to mere nervous or hysterical disorder, we may 
 suffer the patient to perish for want of active measures that would have saved her: 
 and on the other hand, if we apply to these nervous, imitative, hysteric complaints, 
 the treatment proper for inflammation, we shall generally, indeed, relieve our pa- 
 tient for the time ; but we shall leave her more prone to the nervous affection than 
 before, and permanently damaged by our mischievous activity. 
 
 [On the subject of the pathology of hysteria the reader is referred to the very judicious 
 paper of Dr. Conolly in the 2d vol. of tlie Cyclopa;dia of Practical Medicine, Philadelphia 
 edition. 562 ct seq. — C] 
 
 I say that almost every kind of serious disease may be mimicked b}'' what we must 
 call hysteria. And your skill will sometimes be severely tasked to determine the 
 true import of the symptoms, and the real nature of the case. 
 
 One of the diseases which is most often copied by hysteria, is inflammation of 
 the pcrilonmm. You will find a patient complaining of acute pain of the abdomen, 
 aggravated by the slightest pressure ; and she shall have, perhaps, a hot skin, a 
 quick pulse, and a furred tongue. When you meet with such symptoms in a 
 young female, in whom there is any derangement or irregularity of the uterine 
 functions, you will do well, before you bleed her to syncope, and cover her abdomen 
 with leeches, to ask yourselves whether all this suffering may not be simply ner- 
 vous. Search into her previous history as narrowly as you can ; if you find that 
 she has had similar attacks before ; if she has been known to suffer hysterical fits ; 
 and if the tenderness is excessive, and, as it were, superficial, felt upon the slightest 
 touch as much as when firmer pressure is made, you may generally spare the blood- 
 letting, purge the patient well, and cause an asafcetida enema to be thrown into the 
 rectum ; and in a {^iw hours you will find that the peritonitis has vanished. 
 
 Among the pains which infest females of the hysteric constitution, and which are 
 apt to be erroneously ascribed to inflammation, stitches and pains in the hypochon- 
 dria are probably the most common. They are oftener complained of in the left 
 hypochondrium than in the right. These things are much more generally under- 
 stood now than they used to be even a few years ago. I cannot tell you how many 
 persons I have seen who had been diligently treated with leeches, and blisters, and 
 blue pill, for supposed chronic inflammation of the liver or spleen, or still more 
 actively depleted lor presumed pleurisy or pericarditis, when no such inflammation 
 existed, and when the treatment, by reducing the strength, tended to rivet that 
 mobility of system which was the chief predisposing cause of the pains. 
 
 You would scarcely suppose that palsy — perfect hemiplegia or paraplegia — could 
 De simulated by hysteria : yet this certainly is the case; and I have seen instances 
 of it even among hospital patients. They are difficult and perplexing cases. The 
 sudden occurrence of the paralysis, witliout any of the other symptoms which 
 commonly mark the real disease, its sudden disappeamnce, and, above all, the 
 supervention of an hysterical paroxysm, will often disclose the true nature of the 
 affection. Hysterical affections referred to the throat are very common. Aphonia, 
 for exami)le : the voice being lost on a sudden, and returning as suddenly. Mock 
 laryngitis. I remember being a.sked by Sir Charles Bell some years ago to see a 
 young woman in the INIiddlesex Hospital under his care. She had recently arrived, 
 27
 
 418 HYSTERIA. 
 
 and was breathing with the stridulous noise peculiar to inflammation of the larynx 
 She had twice before, in the country, had tracheotomy perfornried for similar attacks; 
 and there were the scars of the operations on her neck : but both Sir Charles and 
 myself were satisfied, upon considering all the circumstances of the case, that the 
 difficult inspirations Avere spasmodic and hysterical; and she recovered under the 
 remedies which do good in hysteria. Inability to swallow, dysphagia, is anolhei 
 of the hysterical vagaries relating to the parts about the throat. Dr. Bright has a 
 veiy instructive case of that kind. A patient was sent to Guy's Hospital for stric- 
 ture of the CESophagus. It was stated that the difficulty of deglutition had existed 
 for several weeks, and was increasing. The surgeon under whose care she was 
 admitted was instantly struck by certain circumstances which did not seem to consist 
 very well with the notion that there was organic disease. Her appearance belied it, 
 and her age. But he thought it right to examine the esophagus by means of a 
 probang ; and no sooner was the instrument introduced, than the patient went into 
 an hysterical fit, which was followed immediately by hi'steria in several females in 
 the same ward. The complaint turned out to be nothii g but an hysteric constric- 
 tion, and was soon completely removed. 
 
 Surgeons are familiar with the " hysterical breast." The mamma becomes 
 painful, tender, enlarges somewhat perhaps. The girl fears that a cancer .is breeding. 
 She communicates her alarm to her friends, and a medical man is consulted. If he 
 happens to be timid and inexperienced, he makes matters infinitely worse by apply- 
 ing leeches and fomentations ; by examining the breast at every visit; and by keeping 
 the patient's attention anxiously fixed upon it. Whereas the treatment ought to be 
 directed to the state of the general system ; and the local uneasiness spoken lightly 
 of, or disregarded. 
 
 Among the hysteric affections of the air-passages, there is a pecuhar kind of cough 
 which you ought to be acquainted with. It is loud, harsh, dry, more like a bark 
 than a cough. Sometimes it is incessant, sometimes it occurs in paroxysms which, 
 I verily believe, are more annoying to hear than to suffer. Hysterical afl^ections of 
 the diaphragm again are by no means rare. I had a very obstinate case of that sort 
 in one of my hospital patients. She Avould sit in her bed all day long, uttering 
 every eight or ten seconds a loud and most discordant hiccup. And I remember an 
 out-patient, who presented a picture of perfect health, and who came week after 
 week, to be cured of what I could consider nothing but an hysterical eructation : it 
 was continual and distressing, and prevented her from obtaining any employment as 
 a servant. Hysterical vomiting is also frequent, simulating cancer of the stomach. 
 Nay, hysterical hmnatemesis. A romantic girl was for some months under my care 
 in the hospital with that complaint. She vomited such quantities of dark blood, 
 (which did not coagulate, however,) as I would not have believed if I had not seen 
 them. Day after day there were poifuls of this stuff'; yet she did not lose her flesh, 
 and she menstruated regularly ; and what was very curious, the vomiting was 
 always suspended during the menstrual period, and recurred again as soon as the 
 natural discharge ceased. I said she was romantic; but I should rather have said 
 that she had that peculiar mental constitution which belongs to hysterical females. 
 She used to write me long letters of thanks for my attention, though I was heartily 
 tired of her ; and these were couched in all the fine language of the Minerva press 
 At last I sent her away : just as bad as when she came into the hospital. This 
 was five or six years ago ; and last year she called at my house with a present of 
 some game, and told me that she had got married to a hair-dresser, and was quito 
 recovered. 
 
 There is a kind of sanguineous expectoration belonging to females of this class, 
 and very likely to mislead the unwary. I meet with two or three instances of it 
 every year. The patient excreates daily, or at irregular intervals, a thinnish fluid 
 something like saliva, more or less tinged and streaked with brown or florid blood. 
 A young hand investigates diligendy the source of the bleeding, and puzzles himself 
 to determine whether the case be one of hxmutemesis or of hsemoplysis. Nine times 
 out of ten it is neither the one nor the other. The blood comes from the moutii or 
 ihe fauc('5 

 
 HYSTERIA. 419 
 
 Hysterical affections of the joints are very common. A young girl became my 
 patient in the hospital for some trifling ailment, and after a short time she began to 
 complain of great pain in her knee and hip ; she could not stand upon the Hmb, nor 
 bear to have it moved or touched. I got Sir Charles Bell to see her : he was so 
 satisfied of the nature of the case — so convinced that it was a genuine example of 
 inflammation and ulceration of the hip-joint — that he gave a httle lecture to the pupils 
 who stood round the bed upon the characteristic position in which the patient lay ; 
 and he took her into one of the surgical wards to be under his own care. Some 
 time afterwards I had occasion to go into that ward, and there I found my former 
 patient with her heel drawn tight up against her buttock. It turned out that she 
 had had no serious disease of the hip at all : both it, and the rigid contraction, gave 
 way under measures which could have done no good to an ulcerated joint. I think 
 the first clue to the real nature of her malady was the occurrence of a fit of hysteria. 
 Sir Benjamin Brodie says, that among the higher classes of society, at least four-fifths 
 of the female patients who are commonly supposed to labour under diseases of the 
 joints, labour under hj^steria, and nothing else. 
 
 Another prank belonging to hysteria, and one which it is very necessary that you 
 should be on your guard against, is that of mimicking disease of the bones of the 
 spine. The patient complains of pain and tenderness in her back, and of weakness 
 probably in her lower extremities ; and it is now become notorious that scores of 
 young women have been unnecessarily confined for months or years to a horizontal 
 position, and have had their backs seamed with issues, for supposed disease of the 
 bodies of the vertebrae, who had really nothing the matter with them but hj'steria, 
 and who would probably have soon ceased to complain if, instead of being restricted 
 to that unnatural imprisonment and posture, they had taken a daily gallop on horse- 
 back. 
 
 It is curious enough to notice how the mind is apt to become affected in some of 
 these cases. After the patient has been lying supine for some weeks, she is unable 
 to stand or walk, simply because she thinks she is unable. The instant she makes 
 a fair effort to use her limbs again, she can and does use them. Her condition in at 
 once reversed. Potest quia posse videticr. Mr. Corfe, the present apothecary to 
 the Middlesex Hospital, has no little trouble with patients of this kind ; but he gene- 
 rally succeeds in 7naking them walk, and in convincing them, as well as himself, 
 that they may do so with impunity. Sometimes, though the authority of the doctor 
 may not be efficacious in this respect, some stronger influence prevails. A lady told 
 me not very long ago that an acquaintance of hers, a member of a family of distinc- 
 tion, had been lying I knov/ not how long on her back ; that position having been 
 prescribed to her by some medical man for a presumed disease of the spine. She 
 lost all power of using her legs, but she got quite fat, as, indeed, well she might, for 
 her appetite was remarkably sharp, and she hved chiefly upon chickens ; and the 
 number of chickens she devoured was incredible. She'hved at a little distance from 
 town, and at last Sir Benjamin Brodie was sent for to her. Now Sir Benjamin, to 
 use a vulgar phrase, is up to these cases; and he wished to see her try to walk: 
 but she declared that the attempt to do so would kill her. He was resolute, how- 
 ever, and had her got out of bed : and in a few days' time she was walking about 
 quite well, and very grateful to him for his judicious conduct. A medical man of 
 less name, or of less determination, would probably have failed. Dr. Bright has a 
 good example of a somewhat similar kind ; showing the power of another form of 
 influence. He was asked to see a young lady who had been confined to her bed for 
 nine months. If she attempted to move she was thrown into a paroxysm of agita- 
 tion, and of excruciating agony, affecting more particularly her abdomen. She had 
 almost lost the use of the lower extremities ; and she and her friends seemed to have 
 given up all hope of her restoration. But she presented no appearance of important 
 disease ; her countenance bore no marks of visceral mischief; nor was it possible to 
 discover any proof of organic change. Dr. Bright set the case down in his own 
 mind as one of hysteria. She seemed to have derived relief from some stimulating 
 injection, and from certain pills. As her friends were in moderate circumstances, 
 Dr. Bright talked seriously to the mother, and recommended that simple water should 
 %
 
 420 HYSTERIA. 
 
 be employed for the injection, and that bread pills should be substituted for those the 
 girl had been taking. The mother soon perceived that these means produced the 
 same tranquillizing effects on her daughter which had hitherto been ascribed to the 
 medicine. "My visits," he says, "became less frequent ; I was absent a fortnight 
 on my renewing my visit, no change had taken place. I attempted to get her shifted 
 gently from the bed to the sofa, but it was impossible ; the paroxysm almost over- 
 came her. Once (after having attended altogether about nine months) I called after 
 an absence of nearly a month ; her sister met me at the street-door with a smiling 
 face to tell me that our patient was quite well : and on inquiry, she related how, 
 ihree mornings before, under a deep religious impression, she had completely reco- 
 vered U.11 her powers ; and I found her sitting up, working and amusing herself as 
 if she were completely convalescent from some ordinary illness." 
 
 These are the cases which suit the purposes of miracle mongers. A few years 
 ago all the journals belonging to a certain party in the rehgious world were full of 
 an instance of miraculous cure. The patient was a young woman; her legs had 
 been paralytic, or contracted, I forget which ; some enthusiastic preacher had influ- 
 ence enough with her to make her believe that if on a certain day she prayed for 
 recover}'' with a strong faith, her prayer would be successful, she would recover at 
 once ; and she did so. No one can doubt that it was just such a case as those I have 
 now been mentioning. Many of these pseudo-diseases terminate suddenly under 
 some strong moral emotion. A fall — a fire in the house — any overwhelming terror, 
 will sometimes put an end to them. And where the joints have been the parts 
 affected, several patients have declared that they felt a sensation as if something had 
 snapped or given way in the part, immediately before the sudden recovery took 
 place. 
 
 Some of the shapes assumed by this pathological Proteus are hideous and dis- 
 gusting. Paralysis of the muscular fibres of the bladder, or spasm of its sphincter, 
 sometimes really occurs, sometimes is only aped, in hysteria. It is a common trick 
 with these patients to pretend that they labour under retention of urine; and that, 
 although the bladder is full, they cannot make water. The daily introduction of the 
 catheter by a dresser or apprentice appears to gratify their morbid and prurient feel- 
 ings. Sometimes, no doubt, the difficulty is real ; but it is oftener feigned or exag- 
 gerated. I have again and again known it to disappear upon the patient's being left, 
 without pity, to her own resources. But girls have been known to drink their urine, 
 in order to conceal the fact of their having been obhged and able to void it. The 
 state of mind evinced by many of these hysterical young persons is such as to entitle 
 them to our deepest commiseration. The deceptive appearances displayed in the 
 bodily functions and feelings find their counterpart in the menial. The patients are 
 deceitful, perverse, and obstinate : practising, or attempting to practise, the most 
 aimless and unnatural impositions. They will produce fragments of common gravel, 
 and assert that these were voided with the urine : or they will secrete cinders and 
 stones in the vagina, and pretend to be suffering under some calculous disease. A 
 young woman contrived, in one of our hospitals, to make the surgeons believe that 
 she had stone in the bladder ; and she actually submitted to be placed upon the 
 operating table, and to be tied up in the posture for lithotomy, bei'ore a theatre-full 
 of students ; and then the imposture was detected. Sometimes they simulate sup- 
 pression of urine, and after swallowing what they have passed, vomit it up again, 
 to induce the belief that the secretion has taken place through the new and unnatural 
 channel. 
 
 it is impossible, I say, not to pity the unhappy victims of this wretched disorder, 
 when their morbid propensities drive them to such acts as these. 1 mention them 
 because you must expect to meet with such cases ; and because, while you take care 
 not to express your suspicions prematurely, or on light evidence, you should be 
 upon your guard against the mortification of being deceived, by the false signals 
 held out, into active and ill-directed measures of treatment. 
 
 There is another very common hysterical pain which I ought to have mentioned, 
 VIZ., a pain occupying some one point in the head ; the patient speaks of it as a 
 sensaiion like that which would be caused by driving a nail into the part ; and the
 
 HYSTERIA. 421 
 
 afTection has therefore been called the clavus hysterictis. It is often situated just 
 above one eyebrow ; and it sometimes comes on every day% at the same hour. Now 
 \n these cases it imitates very closely the hemicrania, which constitutes no uncom- 
 mon form of an intermittent, and is called, accordingly, the brow ague. The dis- 
 tinction between the two — whether the affection, I mean, be hysterical or aguish — 
 is not of any great consequence : but in many of the previous examples of hysterical 
 pain mimicking organic or inflammatory disease, the diagnosis is obviously of the 
 greatest moment. 
 
 How, then, is it to be made ? You may, generally, I believe, be led to a right 
 judgment if you look to the several points that I have incidentally touched already. 
 You may guess that the affection is hysterical if the patient be a young unmarried 
 woman : if there be any disorder or irregularity in the uterine functions ; if you can 
 gather any history of former hysterical disease ; and especially if she is subject to 
 Jits of hysteria. The suspicious symptoms may often be traced back, and found to 
 spread themselves over a considerable previous period of time : yet there is no such 
 wasting, or commensurate deterioration of the general health and strength, as might 
 be expected in organic disease. When the complaint simulated is some acute local 
 inflammation, and there is pain increased upon pressing the part, you will find that 
 the pain is aggravated by the gentlest touch ; it is more felt if you brush your hand 
 over the surface, or slightly pinch the integuments, than when firm pressure is made : 
 and you will find also that this exquisite tenderness is not limited to the part com- 
 plained of. Suppose it is the abdomen, the patient will shrink and exclaim if you 
 suddenly put your finger on her neck, or her arm. The suspicion that the disorder 
 is nervous or hysterical will also be corroborated if the symptoms which resemble 
 the symptoms of inflammation arise and subside rapidly, without obvious cause for 
 such fluctuation ; anJ if various organs appear to be attacked in succession. Be- 
 tween the several symptoms that mark real disease there is always (as we learn by 
 experience) a certain congruity and relation ; but in the simulative displays of 
 hysteria the symptoms are apt to be irregular, inconsistent, contradictory. When, 
 after the most careful investigation of the case, you still doubt, it will be right either 
 10 pause, or to treat it upon the most tmfavourable supposition. The consequences 
 of suffering active inflammation to go on unchecked would be far worse than the tem- 
 porary and slight and remedial injary to the system which might result from once 
 applying the remedies of inflammation to a case of mere hysteria. There is another 
 hazard also which you must be aware of, and seek to avoid ; that of overlooking real 
 disease, when it is mixed with, and masked by hysterical symptoms. It is not easy 
 to lay down positive rules of action for all these supposable cases ; but I trust that I 
 have said enough to convince you of the importance of making the diagnosis of 
 nysleric complaints a careful object of your future study. 
 
 I have hitherto spoken of hysteria as if it were exclusively a malady of females. 
 Etymolofrically to apply that teim to the diseases of males would be absurd. But 
 that peculiar modification of the nervous system which is observed in hysteric girls 
 does certainly present itself, though rarely, in young men. I have seen two or three 
 instances of what I could give no other name to than hysteria in males. One of 
 them was in the person of a young surgeon, who had been house-surgeon to the 
 Middlesex Hospital. I believe he applied to not less than a dozen medical men for 
 advice ; and in that batch I happened to have my turn. He had some of the symp- 
 toms that are ascribed to hypochondriasis ; i. e., he was exceedingly attentive to his 
 own sensations, and fancied he had a number of diseases which had no existence 
 but in his own imagination : he showed great unsteadiness and infirmity of purpose; 
 was what is called " very nervous ;" and had occasional bursts of choking, and tears. 
 and laughter, exactly resembling those which we so often witness in the other sex. 
 Many cases of hysteria in the male have been recorded by different writers. The 
 same movable stale of the nervous system, and the same symptoms referable to lAat 
 system, may oxist in both sexes. In females, in nine cases out often, or in a mu^h 
 larger proportion, the exciting cause of the hysteria is connected with the sexual 
 tuuctions ; and that is all that can be meant when it is asserted that, for the female 
 the complaint is not badly named, but has an intimate dependence upon the utenne 
 
 2l
 
 422 HYSTERIA. 
 
 sympathies. At the same time it is quite true that the " uterus is not the only orgar 
 0? which the irritation niaj^ so affect the nervous system as to produce hysteria." 
 
 As in epilepsy, so also in h3'steria, the treatment to be adopted regards, first, the 
 paroxysm itself; secondl}^ the condition of the patient during the absence of the 
 paroxysm. 
 
 One object, during the paroxj'sm, is to prevent the patient from injuring herself, 
 by her hands, or by her teeth, or in her convulsive movements. Her dress should 
 be loosened ; but it may be necessary to confine her hands and arms. The next 
 thing to be aimed at is the putting an end to the fit. Various measures are found 
 more or less useful for that purpose. The patient should be surrounded, as far as 
 that is possible, with cool fresh air. If she is able to swallow, j'ou may sometimes 
 shorten the attack by administering a couple of ounces of the n:iistura assafetida ; oi 
 half a drachm of ether, with fifteen or twentj' minims of laudanum, in camphor julep, 
 or a draught containing a drachm of the ammoniated tincture of valerian. When 
 the patient cannot or will not SAvallow, she may sometimes be brought about by 
 stimulating volatile substances offered to the nostrils. Signal good may also be 
 effected by fetid or stimulant enemata ; the enema assafetida, for example, made by 
 mixing two drachms of assafetida with half a pint of water, by means of the yolk of 
 an es.g ; or the turpentine injection, made in the same manner, and containing half 
 an ounce of turpentine ; or the same quantity of ice-cold water thrown into the rec- 
 tum, or applied to the pudenda, will often bring the fit to a speedy termination. 
 Indeed I believe thq^-e is more virtue in cold water, in hysterical diseases, than in 
 any other single remedy. In the parox5-sm it may be freely and repeatedly sprinkled, 
 or dashed with some force, upon the face and chest. Active purges are beneficial 
 and requisite in almost all these cases. There is coramonl}^ a costive, sometimes an 
 obstinate, and alwa)-s an unnatural, state of the bowels. 
 
 In those long paroxj^sms — if they may be so called — in which some other disease 
 is simulated by hysteria, the cold afflision is a most valuable resource : especially in 
 those forms of the disorder in which a limb is permanently bent, or incapable of 
 motion. In several instances, in which such contraction had existed for a long 
 time, it has yielded, in the Middlesex Hospital, to a few minutes' application of the 
 cold douche. Mr. Corfe, as I stated before, takes much pains with these cases : he 
 pours cold water from a tea-kettle, or any other convenient vessel, in a small stream, 
 from a moderate height, upon the contracted limb. It has been bent up for weeks 
 perhaps ; no power that you are able to exert can extend it ; and any very forcible 
 attempts to straighten it give the patient extreme pain. After the stream of water 
 has been kept up for a short time, the patient complains of it very much ; but Mr. 
 Corfe is inflexible — more so than the culprit limb — he goes on. Presentlj" the limb 
 begins to tremble, the tight state of the muscles is evidently on the point of yield- 
 ing, and in no long time they are entirely relaxed and manageable, and the member 
 becomes as lithe and movable as ever. It often happens that the state of contraction 
 recurs ; but a repetition of the douche has always the same good efltct, and by de- 
 grees the habit is broken, and the patient set free. It requires some determination 
 to put this expedient in practice. The patient looks upon j-ou as a monster of cru- 
 elty : and, in private, the friends will not always allow such " rough" treatment, as 
 they consider it. Sir Charles Clarke, who necessarily sees a great number of these 
 cases — they are more common in the upper than the lower classes of society — is a 
 great advocate of this ducking system. A paper of his upon the subject was read 
 before the College of Physicians a few years ago. He recommends a "sudden and 
 lavish" application of water to the face ; or the immersion of the Avhole body. He 
 describes the class of patients, in whom the hysterical affection which is curable by 
 that method occurs, as being generally females of a pasty complexion, fat, pale, and 
 weak ; or such as evince the ordinary signs of debility, a feeble pulse, cold extremi- 
 ues, and purpleness of parts distant from the centre of circulation. The age of the 
 patients varied from ten to thirty years ; in many of them menstruation was imper- 
 fect, or absent. * 
 
 A medical practitioner whom I met lately at a patient's house, told me he had 
 just come from another patient, upon whom he had seen a surprising cure performed.
 
 HYSTERIA. 423 
 
 A young lady, for many days, had been affected with trismus. She was unable to 
 open her jaws, and therefore could neither speak nor eat. At last Sir C. Clarke 
 was called in to see her. He presently comprehended the nature of her ailment, 
 Had her placed with her head hanging over a tub by the side of the bed : and pro- 
 ceeded to pour pitchers of cold water on her face. Before he had emptied the 
 second the patient began to scream and complain, giving very audible indications 
 that she could open her mouth. I say although these patients get great relief by the 
 treatment, they do not like it ; and if they are convinced that it will be put in force, 
 they will generally contrive not to require it. 
 
 Of all the spasmodic affections, hysteria is that which is most readily propagable 
 by what may be called moral contagion. If, in a large ward, one girl goes off in a 
 fit, half a dozen others perhaps, all who happen to possess the hysteric diathesis, will 
 experience a strong inclination to follow her example. But this chorus, as it were, 
 of hysteria, is much more common in some wards than in others. A stern nurse, or 
 a general order that the cold affusion shall at once be employed in every instance of 
 an hysterical fit, will keep the complaint wonderfully in check: and on the other 
 hand, great sympathy with such patients has a striking effect in encouraging the 
 paroxj'sms. These facts show that the symptoms are, to a certain degree, under the 
 patient's control. The fits are not wholly wilful ; neither are they wholly uncon- 
 querable. 
 
 I have but little to say respecting the medical management of such patients in 
 the intervals between the paroxysms. The objects to be aimed at are, to restore the 
 nervous system to the requisite degree of stability : and to correct the disordered 
 functions of the uterine system. Now much the same plan of treatment is applica- 
 ble to both these objects ; and I spoke of the remedies that are found most beneficial 
 for giving tone and firmness to the system, when I was upon the subject of epilepsy, 
 and other nervous spasmodic ailments. The following points must be kept in view. 
 The regulation of the bowels, which are mostly sluggish, by aloetic aperients ; the 
 exhibition of some form or other of steel ; the steady employment of the shower bath ; 
 regulated exercise, both on foot and on horseback; the avoidance of hot rooms and 
 of late hours, both in respect to going to bed, and to rising from it ; the avoidance 
 also of strong moral emotions, of novel-reading, and of all the other thousand modes 
 of dissipation, mental and bodily, which always accompany, and abate the blessings 
 of, a high state of civilization. Marriage often proves a cure : sometimes it does 
 not. 
 
 The disposition to hysterical disorder may be more easily prevented than cured ; 
 but upon this point medical men are not consulted. Parents do not foresee the 
 misery they are often laying up for their daughters by the unnatural mode of hfe 
 to which they are subjected for the sake of filling them with fashionable accomplish- 
 ments. I cannot close this subject, and this lecture, better than by quoting Sir Ben- 
 jamin Brodie's remarks on the same point, as I find them in a little work recently 
 published by him, and containing many highly valuable observations and instruc- 
 tions in respect to local hysterical affections. 
 
 " You can render (he sa3''s) no more essential service to the more affluent classes 
 of society, than by availing yourselves of every opportunity of explaining to those 
 among them who are parents, how much the ordinar}' system of education tends to 
 engender the disposition to these diseases among their female children. If you 
 would go further, so as to make them understand in what their error consists, what 
 they ought to do, and what the}' ought to leave undone, you need only point out the dif- 
 ference between the plans usually pursued in the bringing up of the two sexes. 
 The boys are sent at an early age to school, where a large portion of their time is 
 passed in taking exercise in the open air; while their sisters are confined to heated 
 rooms, taking little exercise out of doors, and often none at all, except in a car- 
 riage. Then, for the most part, the latter spend much more of their time in actual 
 study than the former. The mind is over-educated at the expense of the physical 
 structure: and after all with little advantage to the mind itself: for who can doubc 
 that the principal object of this part of education ought to be, not so much to fill 
 the mind with knowledge, as to train it to a right exercise of its intellectual and
 
 424 CATALEPSY. 
 
 moral faculties ; or that, other things being the same, this is more easily accom ll 
 plished in those whose animal functions are preserved in a healthy state, than it is 
 in others." 
 
 LECTURE XXXIX. 
 
 Catalepsy. Ecstasy. Neuralgia: Tic Douloureux; Sciatica; Hemicrania 
 
 There are yet some strange forms of nervous disorder which require to be men- 
 tioned ; but upon which I do not intend to (hcell. Catalepsy is one of these ; and 
 what is called ecstasy another. These affections are very rare as well as very W07i- 
 derful : so wonderful and rare, that weak and superstitious persons have referred 
 them to the interposition of supernatural agents in human affairs ; and stronger 
 minded persons, who happen never to have witnessed such diseases, deny their oc- 
 currence as fabulous, or laugh at them as the tricks and cheatings of imposture. 
 They certainly do happen, however ; and they happen mostly in the same class of 
 persons in whom hysterical and nervous complaints of all kinds are most common 
 They often appear to be produced by similar causes with these ; they resemble hys- 
 teria in being seldom attended with any danger to life : their pathology is, if possible, 
 still more obscure than that of hysteria : and if I were to speak of the treatment 
 which would seem to be most suitable for their cure or prevention, I should merely 
 have to repeat what 1 said upon the treatment and prevention of hysteria, in yester- 
 day's lecture. I shall content myself, therefore, with a short description of these 
 Uvo affections, that you may be aware of their characteristic phenomena, and 
 not be taken by surprise in case either of them should occur to you in your 
 practice. 
 
 A fit of catalepsy implies a sudden suspension of thought, of sensibility, and of 
 voluntary motion : the patient remaining, during the paroxysm, in the position in 
 which she (for it is almost always a female) happened to be at the instant of the 
 attack, or in the position in which she may be placed during its continuance ; and 
 all this without any notable affection of the functions of organic life. 
 
 This is certainly a very curious state, and one different from any that we have 
 yet contemplated. We have had the muscles rigidly contracted with tonic spasm, 
 while the powers of the mind, and the sensibility of the body, were unimpaired. 
 ^Ve have had the same muscles shaken with clonic convulsions; both with and 
 without coexistent disorder of the intellectual functions. But here we have a ne'n 
 phenomenon ; the mental faculties are in abeyance, and the sensibility is abohshed, 
 and so also is the function of voluntary motion ; but the limbs are not tied down b} 
 spasm; nor agitated by successive contraction and relaxation of their muscles; noi 
 yet left, like portions of dead matter, passively obedient to the laws of gravity : thej 
 assume any posture, however absurd, however (to all appearance) inconvenieni 
 and fatiguing, and that posture they retain, until some new force from without is ap- 
 plied to them, or until the paroxysm is at an end. The patient so affected, with 
 open staring eyes often, and outstretched limbs, looks like a waxen figure ; or an 
 manimate statue ; or a frozen corpse. Indeed, Hoffman seems to have formed the 
 strange conclusion that, as catalepsy, so far as he knew, occurred most frequently in 
 winter, it must depend on congelation of the nervous fluid. 
 
 'J'liese singular attacks occur in paroxj'sms ; and they have been known to alter- 
 nate with well-marked hysteria; and to take place in connection with insanity. 1 
 have never seen an instance of perfect catalepsy ; which I now regret, as I once had 
 an oii})oriunity of doing so of which I did not avail myself. Dr. Gooch has described 
 a ciise of it, as he witnessed the disease in a patient who suffered puerperal mania. 
 She had long been subject to the common forms of hysteria. This is iUustrative of 
 wnat 1 have often stated respecting the consanguinity of these nervous disorders. It 
 had become necessary to confine this patient in a strait- waistcoat ; she was at- 
 tended by Dr. GJooch and Dr. Sutherland. I will quote Dr. Gooch's account of the
 
 ECSTASY. 425 
 
 cataleptic state ; for it is authentic and modern. He says, " A few days after our 
 first visit we were summoned to observe a reriiarkable change in her symptoms : the 
 attendants said she Avas dying, or in a trance. She was lying in bed, motionless, 
 and apparently senseless. It had been said that the pupils were dilated, and mo- 
 tionless, and some apprehensions of effusion on the brain had been entertained : but 
 on coming to examine them closely, it was found that they readily contracted when 
 the light fell upon them ; her eyes were open, but no rising of the chest, no move- 
 ments of the nostrils, no appearance of respiration, could be seen; the only signs of 
 life were her warmth and pulse ; the latter was, as we had hitherto observed it, weak, 
 and about 120." 
 
 " The trunk of the body was now lifted, so as to form rather an obtuse angle with 
 the Hmbs (a most uncomfortable posture), and there left with nothing to support 
 it ; there she continued sitting while we were asking questions and conversing ; so 
 that many minutes must have passed. One arm was now raised, then the other ; 
 and where they were left, there they remained. It was now a curious sight to see 
 her, silting up in bed, her eyes open, staring hfelesslj^, her arms outstretched, yet 
 without any visible sign of animation. She was very thin and pallid, and looked 
 like a corpse that had been propped up, and had stiffened in this attitude. We now 
 took her out of bed, placed her upright, and endeavoured to rouse her by calhng 
 loudly in her ears ; but in vain. She stood up, but as inanimate as a statue. The 
 slightest push put her off her balance. No exertion was made to regain it. She 
 would have fallen if I had not caught her." 
 
 " She went into this state three several times. The first time it lasted fourteen 
 hours, the second time twelve hours, and the third time nine hours ; with waking 
 intervals of two days after the first fit, and one day after the second. After this the 
 disease resumed the ordinary form of melancholia ; and three months from the time 
 of her delivery she was well enough to resume her domestic duties." 
 
 There is a minor form of this affection described, in which the patient is incapa- 
 ble of moving or speaking, but is conscious of all that goes on around him at the 
 time. I saw a lady last year, who was subject to these attacks of imperfect catalepsy ; 
 which have been whimsically, but very expressively, called also attacks of daymare. 
 From her time of life, her habits, and some other points in the history of the diseasse, 
 I concluded that in her case these seizures of temporary loss of muscular power 
 without loss of consciousness were dependent upon a diseased state of the blood- 
 vessels of the brain. She afterwards consulted Dr. Chambers ; and he told me that 
 he had formed the same opinion of the nature and cause of the symptoms. 
 
 In what is called ecstasy, the state is different. The patient is lost to all external 
 impressions ; but wrapt and absorbed in some object of the imagination. The muscles 
 are sometimes relaxed ; sometimes rigid as in slight tetanus : but the loss of volun- 
 tary power over them is not complete or universal, for these patients often speak in 
 a very earnest manner, or sing. They are, as the term ixataai^ imports, out of the 
 body at the time, wholly engrossed in some high contemplation. This state is not 
 uncommon as forming a part of religious insanity : and sometintres it runs into ordi- 
 nary hysteria. Nervous and susceptible persons are apt to be thrown into these 
 trances under the influence of animal magnetism : and grave authors assure us that 
 the intelligence which then deserts the brain concentrates itself in the epigastrium; 
 or at the tips of the fingers : that people in that state read letters which are placed 
 upon their stomach, or applied to the soles of their feet; answer oracularly, enig- 
 matical questions ; describe exactly their own internal organic diseases ; and even 
 foretell future events. Credat Judccus Appella, Non ego. I take for granted that 
 they who were in the habit of speaking, a few years since, in some of our places of 
 worship, in what they called unknown tongues, were either gross impostors, who 
 deserved to be publicly w'hipped, or persons labouring under this disease, and want- 
 ing physic. Dr. Copland mentions a curious fact in connection with this subject. 
 He says that many of the Italian Improvisator! are in possession of their peculiar 
 faculty only while they are in a state of ecstatic trance ; and that few of them enjoy 
 good health, or consider their gift as otherwise than something morbid. 
 
 I repeat that I can add nothing respecting the pathology or llie managemens of 
 
 ^l2
 
 426 NEURALGIA. 
 
 these diseases, to what I have already said in reference to the whole class to which 
 they belong. 
 
 Leavinfj these nervous disorders, in which the function of voluntary motion is so 
 curiously modified ; and in which there sometimes is no alte^ration of the intellectual 
 faculties, and sometimes very great disturbance, or the complete suspension of them : 
 I would beg to turn your attention to another class of complaints, in which the nerv- 
 ous system is still the part principally interested, but in which the deviation from 
 the natural state is manifested chiefly in the function of sensation ; the powers of 
 thought and of voluntary motion, being scarcely affected, or not affected at all. Com- 
 plaints, I mean, in which the sensibility is perverted, and augmented ; cases of nerv- 
 ous pain. We have considered before that modification of sensation which consists 
 in numbness, or anaesthesia, i. e., in the diminution of the natural sensibility, or its 
 total privation. We have noticed also incidentally many perversions of sensation ; 
 such as giddiness, nausea, faintness, and the hke ; and in the same incidental way 
 the morbid exaltation of the sensibility which is called pain, has come before us, as 
 a symptom of various other diseases ; of inflammation, and of hysteria. But there 
 are diseases which consist of pain, and of nothing else, that we can perceive. They 
 are often attended bj' no inflammation, no detectable change of structure in the pain- 
 ful part, no fever. These affections are included under the general term, neuralgia. 
 Now pain is one of the things which we are oftenest consulted about ; and these 
 neuralgic pains are apt to be excessively severe and troublesome ; and it cannot but 
 be of importance to understand what has been ascertained of their nature, and causes, 
 and capability of cure. 
 
 That pain is owing to some morbid condition, or to some irritation of a particular 
 nerve, we may sometimes know, by finding that it occupies exactly the course, and 
 follows the distribution of that nerve. But when, as often happens, the pain is con- 
 fined to a certain spot, we then conclude it is neuralgic, if and because we can find 
 no other explanation of its existence. 
 
 What increases the difficulty of making out the cause and origin of these nervous 
 pains, is that they may be produced by some source of irritation situated at a dis- 
 tance from the part in which the pain is felt. It may be placed in the brain itself, 
 or in the spinal cord ; or in the trunk of the nerve that supplies the aflected part ; 
 or in one of the branches of the same trunk, which branch is distributed to another 
 part. If you strike the inside of the elbow in a certain way, so that the blow lights 
 upon the ulnar nerve, a peculiar tingling sensation is felt in the little finger ; that is, 
 not in the part struck, but in the sentient extremity of the same nerve ; and the same 
 thing happens continually in disease. There is an excellent paper on this subject, 
 by Sir Benjamin Brodie, published in one of the earlier volumes of the Medical 
 Gazette, in which he has collected numerous and striking illustrations of the pro- 
 duction of nervous pain by irritation situated in a distant part. Thus, to take a case 
 in point ; a man was admitted into St. George's Hospital on account of severe pain 
 on the inner side of his knee. The joint was carefully examined, but no mark of 
 disease could be detected in it. On tracing the hnib upwards, however, an aneurism 
 of the femoral artery, as big as an orange, was discovered in the thigh. This nhe 
 patient thought nothing of; his only concern was the pain in his knee. Sir E. Honr^e 
 performed the usual operation for aneurism: and the moment the ligature was drawn 
 firmly round the artery in the upper part of the thigh, the tumour ceased to pulsate, 
 and the pain in the knee ceased also. This man died four or five days after the 
 operation : and upon inspection of the limb afier his death, the aneurism was found 
 reduced to one-half its former size ; and some branches of the anterior crural nerve, 
 which passed over it, and which musi have been kept on the stretch previously to 
 the operation, were seen to terminate in the part to which the pain had been referred 
 on the inside of the knee. There is just such another case related by Dr. Denmark, 
 in the Medico-CJdrurgical JVansaclions. A sailor was wounded by a musket-ball 
 in the arm. The wound healed ; but the patient remained affected w'ith agonizing 
 pain, beginning in the extremities of the thumb and fingers, except the little fii-ger, 
 and extending up the fore-arm. His sufferings were so great that he willingly sub-
 
 NEURALGIA. 427 
 
 /I 
 milled to have the limb amputated : and the operation gave him complete and imme- 
 diaie relief. AVhen the amputated limb was dissected, a small portion of lead 
 which seemed to have been detached from the ball when it struck against the bone, 
 was found imbedded in the fibres of the median nerve. 
 
 These examples teach us, when we receive complaints of pain in any part, and 
 can discover no cause of pain in the part itself, to look for some possible source ot 
 irritation in the trunk of the nerve, from which the part in question is supplied with 
 nervous librils. 
 
 But the source of irritation may be further back than this : it may depend upon a 
 diseased stale of the spinal marrow, or of the brain. Of this we have had so 
 many examples before us already, that I need not seek for any new illustrations 
 of it. 
 
 Sometimes, again, irritation applied in the course, or at the extremity of one branch 
 of a nerve, will give rise to pain at the extremity of another branch of the same 
 nerve. The sensation appears to be reflected, as il were, along the branch which is 
 not, direcily, the subject of the irritation. Thus hlaments of the phrenic nerve pene- 
 trate the diaphragm and communicate with the ganglia that lie around the cceliac 
 artery; other hlainents are distributed to some of the muscles about the shoulder; 
 and in this way has been explained the well-known fad, that disease or irritation of 
 the liver is very apt to be accompanied with pain in the shoulder. 
 
 Thus also we have pain in the glans penis, from irritation of the bladder, produced 
 by a stone there ; ^ain of the thigh and testicle, from irritation of the kidney : pain 
 in the left arm, from disease of the heart : pain in the feet, from stricture and irrita- 
 tion of the urethra. 
 
 I'here are many pains also, plainly enough connected with irritation of distant 
 parts, although no olher nervous connection can be traced between the parts, except 
 that which is afforded by the nervous centres. In such cases we must suppose that 
 the morbid impression travels to the brain, and then the sensation is referred to the 
 part affected through another nervous channel of communication. Dr. Wollastoa 
 was accustomed to relate the following story of himself. He had eaten some ice- 
 cream after dinner one day ; and his stomach did not seem to be capable of digest- 
 ing it. Some time afterwards, when he had left the dinner table for the drawing 
 room, he found himself rendered lame by a violent pain in one ankle. Suddenly he 
 became sick, the ice-cream was vomited, and instantaneous relief of the pain fol- 
 lowed its ejection from the stomach. " A gentleman (says Sir Benjamin Brodie) 
 awoke in the middle of the night, labouring under a severe pain in one foot. At 
 the same time certain other sensations, to which he was not unaccustomed, indi- 
 cated the existence of an unusual quantity of acid in the stomach. To relieve the 
 latter he swallowed a large dose of alkaline medicine. Immediately on the acid in 
 the stomach having been thus neutralized, the pain in the foot left him." 
 
 I'he lesson that we learn from all these facts is this : that when we can find no 
 explanation of a pain in the very spot in which it is felt, we should look for some 
 condition that may explain it in the trunk of the nerve supplying that part : or in 
 the pans supplied by oilier branches of the same nerve ; or (if we are still unsuc- 
 cessful), we look for other indications of disease in the brain or spinal marrow : and 
 if these be wanting, we should extend our search, and inquire whether there be any 
 intelligible disorder or cause of irritation elsewhere, which, operating through the 
 medium of the nervous centres, may have occasioned the sympathetic pain of which 
 our patient complains. 
 
 I say we should institute this search, because, if it be successful, it may teach us 
 on the one hand, that the cause of the pain is fixed and irremediable ; or, on the 
 other, it may enable us by some simple and obvious expedient to cure the pain. 
 But sometimes we shall be quite disappointed in all this seeking. We shall find 
 nothing either in the living patient, or in the dead body, which throws the smallest 
 light upon the cause of the neuralgia. 
 
 Now with respect to those neuralgic pains, for which we can discover no ade 
 quale cause, either in any diseased structure, or in any morbid action of the blood 
 vessels, there are certair. general facts observable which I wiU mention bcfoie [
 
 428 NEURALGIA. 
 
 specify any particular forms of neuralgia. They occur in all parts of the body ; but 
 they are more frequent about the head than in any other part : and next of all, pro- 
 bably, in the abdomen. In the head, or face, the branches of the fifth pair of nerves 
 are verj' frequently the seat of neuralgia ; and to such pain, in that situation, the 
 name of tic douloureux is generally given. The painful affection called hemicru- 
 nia is another example of neuralgia of the head. Certain forms of angina pectoris, 
 and of gastrodynia, seem to belong to the same class of disorders ; and sciatica — 
 which depends on different causes in different cases — is often rather a neuralgic than 
 a rheumatic pain. I have stated that the pains sometimes follow the track of cer- 
 tain nerves ; but this is not, I think, very common. Inflammation of the nerve, or 
 of its investments, generally causes pain having that property : but the truly nervous 
 pains are much better characterized by the suddenness with which they come on, 
 and the suddenness with which they sometimes go off also; by their intermittence 
 in many cases, and the regularity of the period at which they often, though not 
 always, return ; by the total absence (in most cases) of heat and swelling, and often 
 of tenderness too, when they are external, and of febrile symptoms when they are 
 internal, even although their intensity be extreme ; by their apparent dependence, 
 in numerous instances, upon sudden changes of the weather; by their occurring 
 chiefly in persons of a nervous temperament in whom the health is otherwise disor- 
 dered ; and by their frequently abating under tonic remedies, or what are called spe- 
 cifics, rather than under antiphlogistic treatment. (Alison's Outlines.) There is 
 another circumstance, characteristic of these pains, which has been mentioned by Sir 
 Benjamin Brodie, and I do not know that the same thing has been noticed by other 
 writers. These pains are often suspended by sleep. " A person suffering from tic 
 douloureux in the face may for a time be prevented from falling asleep, but if once 
 asleep, his sleep is likely to be sound and uninterrupted for many hours." He says 
 that though there may be exceptions to this rule, they are comparatively rare. Now 
 this, you will observe, is quite analogous to what takes place in certain spasmodic 
 affections of the muscles also. The jactitations of chorea are almost always sus- 
 pended during sleep. It is the same with the spasmodic wry neck, in which the 
 involuntary contraction of some muscle, commonly the sterno-cleido-masloideus, 
 drags the chin round, and the head awry. Persons affected with that sort of 
 deformity when awake, have their necks flexible enough, I beUeve, while they are 
 sleeping. 
 
 I mentioned just now one character of these neuralgic pains, viz., the total ab- 
 sence in most cases, when they occupy the surface, of heat, redness, swelling, or 
 tenderness ; and I said in most cases, because there are unquestionably exceptions 
 to this. After these pains have been long-continued and intense, they may o-jve 
 rise even to a moderate degree of inflammation of the part; which will become 
 tender to the touch, manifestly vascular, and even swollen a little. " In a gentle- 
 man," mentioned by Sir B. "Brodie, " who suffered for a great length of time what 
 was regarded as a most severe tic douloureux in the face, at first the parts to which 
 the pain was referred retained their natural appearance, but ultimately they be- 
 came swollen, from an effusion of scrum into the cellular texture, and so exqui- 
 sitely tender that they could not bear the slightest touch. In a patient who had 
 laboured for some time under pain in the testicle, depending on a calculus passing 
 down the ureter into the bladder, the testicle became tender and considerably 
 swelled." 
 
 The attacks of neuralgia may recur at intervals of a few seconds onlj' : or they 
 may take place daily, or every other day : or the)'- may be separated by much longer 
 intervals, regular or irregular. Sometimes there is continual pain, but it is wonder- 
 fully exalted and aggravated by fits. It is described as being sharp, sudden, 
 twinging, fike an electric shock in its momentary duration. Sometimes it is at- 
 tended by a feeling of constriction and cramp, although no muscular contraction 
 accompanies it. I suppose that is one reason why such pain is so often spoken of 
 even by medical men, and almost always by the vulgar, as spasm. AVhenever a 
 patient tells me he has spasms here or there, I am obliged to request that he wih 
 explain himself further. I want to know how he construes spasm ; and nine times
 
 TIC DOULOUREUX. 429 
 
 out of ten I find that he intends a sudden and sharpish, and generally a transitory 
 aitack of pain: whereas the term spasm really signifies, and ought to be restricted 
 to, involuntary muscular contractions. When a medical man prints a case in which 
 he states that spasms occurred in suc-h or such a part, it is impossible to tell 
 what he means, unless that term is explained by the context. Pray avoid this 
 inexactness. 
 
 The most common of these neuralgic *pains, as I have said, is that which has been 
 called, xav i^oxf]v, tic douloiireicx, and which is situated in the facial branches of the 
 fifth pair of nerves ; nerves, as you know, of sensation ; and it is usually restricted 
 to one of the three branches that emerge severally to supply the parts in their neigh- 
 bourhood. Sometimes two, sometimes all of them, are implicated. The middle one 
 of these branches, the infra-orbitary, is, I believe, the most commonly affected in the 
 severer forms of the complaint. The torture occasioned by this dreadful malady is 
 sometimes excessive. The sufferers speak of it as anguish that is scarcely endura- 
 ble ; and you see, in their quivering features and restless limbs, that the acute bodily 
 pang is, indeed, hard to bear. 
 
 When the uppermost branch of the trifacial nerve is the seat of the complaint, the 
 pain generally shoots from the spot where the nerve issues through the superciliary 
 hole ; and it involves the parts adjacent, upon which the fibrils of the nerve are dis- 
 tributed ; the forehead, the brow, the upper lid, sometimes the eyeball itself. The 
 eye is usually closed during the paroxysm, and the skin of the forehead on that side 
 corrugated. The neighbouring arteries throb, and a copious gush of tears takes 
 place. In some instances the eye becomes blood-shotten at each attack ; and when 
 the attacks are frequently repeated, this injection of the conjunctiva may become 
 permanent. 
 
 When the pain depends upon a morbid condition, or morbid action, of the middle 
 branch of the nerve, it is sometimes quite sudden in its accession, and sometimes 
 comes on rather more gradually ; being preceded by a tickling or pricking sensation 
 of the cheek, and by twitches of the lower eyelid. These symptoms are shortly 
 followed by pain at the infra-orbitary foramen, spreading in severe flashes (so to 
 speak) over the cheek, affecting the lower eyelid, ala nasi, and upper lip, and often 
 terminating abruptly at the mesial line of the face. Sometimes it extends to Ifte 
 teeth, the antrum, the hard and soft palate, and even to the base of the tongue, and 
 induces spasmodic contractions of the neighbouring muscles. 
 
 When the pain is referable to the inferior or maxillary branch of the fifth pair of 
 nerves, it darts from the mental foramen, radiating to the lips, the alveolary processes, 
 the teeth, the chin, and to the side of the tongue. It often stops exactly at the sym- 
 physis of the chin. Frequently it extends in the other direction to the whole cheek, 
 and to the ear. During the paroxysm the features are liable to be distorted by spas- 
 modic action of the muscles of the face, amounting sometimes to tetanic rigidity, and 
 holding the jaw fixed and immovable. 
 
 The paroxysms of suffering in this frightful disease are apt to be brought on by 
 apparently trivial causes ; by a slight touch, by a current of air blowing upon the 
 face, by a sudden jar or shake of the bed in which the patient is lying, by a knock 
 at the door, or even by directing the patient's attention to his malady by speaking 
 of it, and asking him questions about it. This was remarkably manifest in a patient 
 who came into the hospital under my care for another complaint ; but who had for 
 some time been subject to tic douloureux. The necessary movements of the face in 
 speaking, or eating, are often sufficient to provoke or renew the paroxysm. At the 
 same time firm pressure made upon the painful part frequently gives relief, and 
 causes a sense of numbness to take the place of the previous agony. 
 
 This cruel malady occurs most commonly in persons who exhibit, in other re- 
 spects, the signs of an unsound, or deranged, or debilitated system. It is more apt 
 to fasten upon those who are pale, and asthenic, and upon individuals whose powers 
 have been broken by advancing years. It is not unfrequently attended with some 
 obvious disorder of the digestive organs, and ceases or is mitigated when that disor- 
 der is corrected. Sometimes it is clearly connected with a disposition to rheumatic 
 affections ; coming on in persons who suffer rheumatism in other puts, and even
 
 430 TIC DOULOUREUX. 
 
 alternating with rheumatism in other textures. It is observed to be common among 
 fishermen, and the inhabitants of marshy districts ; and in some of these sufferers it 
 maj- be attributable to their habitual exposure to cold and moisture ; and this nerve, 
 lying superficially, and being unprotected by any artificial covering, is more likely, 
 ]>erhaps, for that reason, to be affected by vicissitudes of temperature ; but in many 
 of these cases the disease seems to be produced by the malaria, which is preA'alent 
 in those situations. The paroxysms are then not only intermittent, but periodical, 
 and they will frequently yield to the remedies which have been ascertained to be 
 specific against ague and its various modifications. Sometimes the facial neuralgia 
 is evidently dependent upon some general state of the system : for it will cease in 
 the face, and fix itself in some other place ; and in this way it may come to occupy 
 several distant parts of the body in succession. There are other cases again in 
 which the disease has a local origin, and results from some diseased bone, or exosto- 
 sis, in the neighbourhood of the painful spot. The late Dr. Pemberton afforded a 
 well-known example of this. He was seized with tic douloureux in the very zenith 
 of his reputation, and when he was in the fullest practice of his profession in this 
 town. It completely ruined him : compelled him to give up business. He ulti- 
 mately died of apoplexy. When his head was examined after death, the os frontia 
 was found to be unusually thick ; and on the falciform process of the dura mater, al 
 a little distance from the crista galli, a small osseous substance was discovered, nearly 
 half an inch long, and almost as broad. Sir Henry Halford has recorded severaJ 
 other instances in which the disease was connected with some morbid condition of 
 the bones of the head or face. 
 
 Now tic douloureux is one of those complaints for the cure of which there exists 
 a number of specific remedies. But what I have been stating of this disease will 
 suffice to convince you that, as it depends upon different causes and different per- 
 sons, it is absurd to expect that any single drug — or even any one plan of treatment 
 — will always remove it. Our first care, in every e.cample of it that comes before 
 lis, must be to investigate all the particulars of the case. We must not be satisfied 
 with learnmg that the complaint is tic douloureux, and then go on prescribing, one 
 after another, the reputed specifics for tic douloureux. It may happen that the ori- 
 gin of the disease is plain, and the remedy obvious. We must endeavour to make 
 out Avhatever is amiss in the system at large, or in the state of particular functions. 
 Very rarely, I believe, tic douloureux is dependent upon a condition of general ple- 
 thora. Mr. John Scott gives the case of a gentleman who suffered severely from it 
 for some time ; at length he had an uttack of apoplexy, and for this last disorder he 
 was copiously bled, and the bleeding seemed to cure the neuralgia. Much more 
 frequently we find evidence of a feeble or a shattered state of the system ; debility 
 and paleness : and then we may expect to do good by the treatment so strongly 
 recommended by Mr. Hutchinson, viz., by giving the carbonate of iron. This 
 remedy has been put largely to the test, since Mr. Hutchinson wrote in commenda- 
 tion of it, by Dr. Elliotson, and subsequently by others. Dr. Elliotson states it as 
 the result of his experience, that, " in all cases of neuralgia, whether exquisite or 
 not^ unaccompanied by inflammation, or evident existing cause, iron is the best 
 remedy." I have already explained the manner of administering the carbonate of 
 iron, the quantity in which it may be given, and the limits within which I should be 
 inclined to restrict the doses. Sir Benjamin Brodie thinks it probable that the car- 
 bonate of iron proves beneficial by its mechanical operation on the internal surface 
 of the intestines : but I should rather ascribe its good effect to the well-known pro- 
 perty of preparations of iron, to give firmness to the nervous system ; apparently by 
 increasing the quantity of red blood that circulates in it. However, it is of the utmost 
 consequence that the state of the digestive organs should be attended to. Mr. Aber- 
 nethy used to relate, in his lectures, many instances of tic which he had been suc- 
 cessful in curing by measures which were solely directed to the improvement of the 
 stomach and bowels. He had a notion, that in patients who suffer under this disor- 
 der, there were always two functions wrong; those of the nervous system on the 
 one hand, those of the digestive system on the other. And I am sure you will com- 
 monly find mdications of a faulty state of both these systems. " The two," he used
 
 TIC DOULOUREUX. 43" 
 
 to say, " were the common parents of a numerous progeny of very dissimilar local 
 diseases. In tic douloureux, you must seek to put the digestive organs right, or to 
 soothe the nervous system, according as the one or the other may seem to be the 
 principal and primary cause of the disease. Take away one of the parents, and there 
 will be no more propagation." 
 
 In these cases the unheakhy state of the digestive apparatus may be marked by 
 obvious signs ; a furred tongue, loss of appetite, costive bowels : or it may reveal 
 itself by no other symptom than the pain. It may depend upon the mere presence 
 of acid in the stomach. Dr. Rigby tells us that having suffered in his own person 
 an intense attack of tic douloureux, which opium did not assuage, he swallowed, at 
 the suggestion of a friend, some carbonate of soda dissolved in water. The effect 
 was almost immediate : carbonic acid was eructed, and the pain quickly abated. 
 More often the cause of offence appears to lie in some part of the intestines ; and 
 purgatives do good. Sir Charles Bell — drawing a bow at a venture — achieved the 
 cure of a patient upon whom much previous treatment had been expended in vain, 
 by some pills composed of cathartic extract, croton oil, and galbanum. He mixes 
 one, or two, drops of the oleum tiglii, with a drachm of the compound extract of colo- 
 cynth ; and gives five grains of this mass with ten grains of the compound galbanum 
 pill at bed-time. I mention the exact proportions and dose, because other cases have 
 been since reported, both by Sir Charles and by others, in which the same prescrip- 
 tion was followed by the same success. 
 
 When the disease occurs in a rheumatic individual, and especially when, as is 
 sometimes the case, it alternates with rheumatism of other tissues, the remedies which 
 have been found useful in rheumatism deserve a fair trial ; guaiacum ; colchicum ; 
 calomel and opium. 
 
 When all has been done that can be done towards restoring or improving the 
 general health, we may turn our thoughts to local remedies. It is plain that these 
 must be inefficient when the local pain results from constitutional causes that are un- 
 redressed, or perhaps incurable. Yet even then topical measures may soothe the 
 pain for a while. 
 
 One of these topical expedients, which promised well when first thought of, is the 
 division of the trunk of the painful nerve, so as to cut off the nervous communica- 
 tion, through that main channel at least, between the painful part and the brain. 
 This was originally proposed by Dr. Haighton, and was at first attended with some 
 little success ; but in a great number of instances it has signally failed, as indeed might 
 have been expected. In Dr. Pemberton's case the several branches of the filth pair 
 were cut by Sir Astley Cooper : but in vain. When there is any reason to think 
 that the disease has a constitutional origin, or a local distant origin, the division, or 
 even the excision, of a part of the nerve must be perfectly useless. It would be as 
 reasonable (as Mr. Abernethy has observed) to expect to cure gout by cutting the 
 nerve that goes to the great toe : or to perform castration with the view of remedying 
 that pain in the testicle which is apt to be produced by the passage of a calculus 
 through the ureter. Nevertheless there are cases, in which the division of the 
 nerve, or some other surgical operation, is required. If you can make out that there 
 is any tumour pressing upon or adherent to some part of the nerve — or if some 
 foreign body, as a splinter, or a shot, should be ascertained to be in contact with the 
 surface of the nerve, or to be entangled in its substance, the tumour or the foreign 
 body may be removed by the knife, with the strong expectation that a cure will be 
 llius effected. And if this cannot be done, or if the. nerve itself be altered in struc- 
 ture, either from disease or injury, (I am referring now to neuralgia in general, and 
 not merely to that in which the facial branches of the fifth pair of nerves are impli- 
 cated,) under those circumstances it will become a very proper subject of delibera 
 tion whether the nerve should be divided, or even the limb amputated. 
 
 In the Medical and Physical Journal there is a case described by Mr. Jeffries, of 
 a violent facial neuralgia, cured by the removal of a small fragment of china, which 
 had been lodging in the cheek for fourteen years. And Mr. Descot mentions an 
 instance in which a very severe affection, of ten years' standing, was removed by 
 the extraction of a carious tooth. I saw, not many days ago, a young woman whoso
 
 432 - TIC DOULOUREUX. 
 
 fing(?r had been amputated for very acute neuralgic pain which she had suffered m 
 jr.; and the amputation had been successful in liberating her from that pain. 
 
 Sometimes we may hope to afford relief to the suffering patient by means which 
 tend to remove or lessen the exciting cause of the paroxj^sms. Of this [ may m,en- 
 tion one remarkable example, Avhich fell in part under my own observation : although 
 I had nothing to do with the treatment. I was asked, a few years ago, by a friend, 
 to go with him to call upon a relation of his, who laboured, he said, under tic dou 
 loureux : he did not wish me to see her professionally, but was desirous that I 
 should witness what he considered an extraordinary complaint. I saw a young girl, 
 about twelve or thirteen years old, very pale and dehcate, lying on a sofa ; and I 
 learned from her and from her mother that she was subject to the most excruciating 
 agony in one side of her face and neck. The pain came on whenever she swallowed 
 anything: the act of deglutition proved invariably the exciting cause of the torment. 
 She was at that time under the care of a practitioner who had desired that she might 
 eat mutton-chops three or four times of a day. Of course this was a sentence full 
 of misery to her ; but so desirous was she to get rid of her disease, that she resolved 
 steadit)^ to follow the directions enjoined her. This plan was to be tried for at least 
 a month ; after that time, if she were no better, her mother had resolved to consult 
 another practitioner who had been much recommended to her. I should say that 
 she had already consulted a great number of medical men ; for the malady had 
 existed nearly two years. At the end of the month she was worse than at the 
 beginning; and the new practitioner, Mr. Pennington, was called in. He acted, hke 
 a man of sense and sagacity, upon the fact that the act of swallowing always gave 
 rise to the pain ; and he advised that she should not attempt to swallow for twenty- 
 four hours. That period passed without any return of the pain ; but it immediately 
 recurred upon her eating a morsel of bread. The result of this experiment, how- 
 ever, encouraged him to hope that the morbid habit might be broken through' by a 
 sufficiently long abstinence from swallowing. And as she had been subjected to a 
 great variety of fruitless treatment, he gave her no medicine, but advised that she 
 should refrain altogether from taking food or drink by the mouth. Nourishing injec- 
 tions, composed of beef tea with an egg beat up in it, or of milk, were thrown into 
 the rectum, two or three times a day. This plan was persisted in for a longer time 
 than I should have supposed she could have endured it. No nutriment whatever 
 was taken by the mouth for five weeks and three days, and no paroxysm of pain 
 occurred. At the end of that period the pulse sank suddenly, from between seventy 
 and eighty, to thirty-five beats in a minute ; and thereupon Mr. Pennington thought 
 he had carried his experiment far enough ; and deemed it advisable to administer by 
 the mouth a dessert-spoonful of beef-tea twice a day. This was continued for four 
 days without producing any return of the pain. A small piece of fish was then 
 allowed, and afterwards some chicken ; and proceeding thus cautiously, in the course 
 of a month she was able to eat and drink anything, without the slightest inconve- 
 nience. 
 
 1 should state, however, that some time afterwards, the neuralgia returned in 
 another situation, affecting the left knee : and this was remedied by a different mode 
 of treatment. She is since dead. 
 
 "When other means fail, or in conjunction with other means, local applications to 
 the affected part may be tried. Belladonna will sometimes materially palliate the 
 pain : so will opium : but within the last few years a new anodyne has been brought 
 into use ; and it really seems to have been of essential service in several instances 
 of this most painful disorder. 1 allude to aconitine: the active principle of the 
 monkshood. The property belonging to this plant, of benumbing sensation, has 
 long been know'n. Sir Benjamin Brodie found many years ago that after chewing 
 its leaves, a remarkable numbness of the lips was left, which lasted some hours. We 
 may understand therefore the beneficial operation of the aconitine upon a part of 
 which the sensibility is unduly exalted. It is only very recently that pure aconitine 
 has been procured ; and consequently it has not yet been very extensively employed, 
 and the less so on account of its very high price : but what experience we have of 
 ;t, as a benumber of pain, is highly encouraging. It has been of singular benefit to
 
 TIC DOULOUREUX. 433 
 
 a surgeon who formerly lived in Charterhouse Square, and whose case is well known, 
 1 believe, to the profession. Mr. Spry had suffered greatly, for eight years, under 
 very acute neuralgia affecting the parts supplied by the lowermost or mental branch 
 of the fifth pair of nerves. After exhausting almost every expedient that ever has 
 been recommended for tic douloureux, except that of dividing the nerve, he was 
 induced to make trial of the aconitine. It was mixed with cerate, in the proportion 
 of one grain to one drachm, and a small portion of this was smeared over tlie track 
 of the painful nerve once or twice a day for six days. By that time he had entirely 
 lost the pain. He states, I understand, that the appHcation of the ointment produced 
 a sense of numbness, which continued for twelve, or eighteen hours. Dr. Hue, who 
 first told me of Mr. Spry's case, told me at the same time that he knew of two others 
 in which the same apphcation had been equally successful. This encouraged me to 
 try it upon my patient, whom I mentioned before, and who happened at that time to 
 be in the hospital. I bought, for ten shillings, five grains of the aconitine at Mr. 
 Morson's. in Southampton Row, where I knew it would be genuine. One-third of a 
 drachm of ointment, containing one-third of a grain of the alkaloid, was smeared 
 two or three limes a day over my patient's face, and the attacks presently diminished 
 in intensity, and in a few days ceased altogether. He soon after left the hospital, so 
 that I cannot tell whether the cure was permanent. I presume it was so, as he did 
 not return. The particulars of Mr. Spry's case have been published by Mr. Skey 
 in the nineteenth volume of the Medical Gazette. Tt is now (1841) six years since 
 the aconitine was applied, and the pain (as Mr. Skey has recently informed me) has 
 never recurred. It used to be excited by gentle friction of the hand, or by a current 
 of cold air, but Mr. Spry "can now face any wind or temperature with impunity."* 
 In the same paper Mr. Skey relates another instance of the utility of this substance 
 in facial neuralgia. It occurred in one of his patients at St. Bartholomew's Hospital. 
 
 This is a remedy therefore which is not to be neglected. Even if it only allayed 
 the pain for a time it would be highly valuable. But, judging from the instances 
 now referred to, we may hope that, in some forms of tic douloureux, the aconitine 
 may be found equal to their cure. It seems probable that the recurrence of the pain 
 is sometimes kept up by the influence of habit ; and will cease if the habit can for 
 a while be broken. You must take care, however, to obtain a genuine article. The 
 manufacture of aconitine is difficult, and therefore the cost is considerable. Mr. 
 Skey, in the Bartholomew case, failed with some aconitine that had been imported 
 into this country, but succeeded at once when he employed the same quantity of Mr. 
 Morson's preparation. 
 
 A few years ago Mr. John Scott published a little book on the disease we are now 
 considering, with the professed object of introducing to general notice a species of 
 local treatment which he had found successful in several long-standing and previously 
 obstinate cases. It is well to be aware of these things, though probably the aconitine 
 ointment will beat Mr. Scott's. Mr. Spry used Mr. Scott's ointment, but withou-t 
 benefit. It consists of the iodide of mercury, mixed with lard, in the propoition of 
 two scruples to the ounce : and it is rubbed into, or placed in contact with, the affected 
 surface, until some degree of irritation is produced. 
 
 [In several cases of neuralgia, of different parts of the body, w^liich, for a number of years, 
 had resisted a variety of plans of treatment, we have seen almost immediate relief, and in s 
 few, a permanent removal of the disease result from acupuncturation. In other cases, how 
 ever, no benefit has resulted from the operation.. — C] 
 
 There is a kind of hce-ache, which cannot properly be reckoned as a species o( 
 neuralgia, for it does not occur in short stabbing paroxysms, nor is the pain acute 
 enough to entitle it to the name of tic douloureux ; but which is very common, very 
 distressing, and under ordinary treatment sometimes very intractable. It is called 
 by some a rheumatic pain ; it occupies the lower part of the face, the jaw princi- 
 pally, and the patient cannot tell you exactly whereabouts it is most intense. It is 
 often thought to proceed from toothache, and bad or suspected teeth are extracted. 
 
 • This gentleman is since dead. 
 
 38 2m
 
 •134 SCIATICA — HEMI CRANIA. 
 
 but with no good effect. Now I allude to this for the sake of saying that some years 
 ago I was instructed by an experienced old apothecary, that this face-ache might be 
 almost always and speedil)' cured by the muriate of ammonia; — a medicine that we 
 seldom give internally here, although it so much used in Germany. And I have 
 again and aeain availed myself of this hint, and been much thanked by the patients 
 for the good I did them with this muriate of ammonia. It does not always succeed ; 
 but it often does. It should be given in half-drachm doses, dissolved in water, or in 
 almost any vehicle, three or four times a-day. if the pain does not yield after four 
 doses, you may cease to expect any benefit from it. In two or three instances of a 
 similar kind that I have recentlj^ had to treat, I have found the iodide of potassium, 
 in doses of five or six grains, work a speedy and permanent cure. This induces me 
 to suppose that the pain in some of these cases is periosteal. I so judge from the 
 ascertained efficacy of the iodide in other periosteal affections attended with pain. 
 
 Tic douloureux is the principal form of severe neuralgia which you may expect 
 to meet with, in regard to acuteness of suffering and difficulty of cure. Two other 
 forms, more common, and luckily more tractable, are generally spoken of under the 
 same head : sciatica, namely, and hcmicrania. I have very little to say, in this 
 place, of either of these. Sciatica, or pain radiating from the sciatic notch, and fol- 
 lowing the course of the sciatic nerve, is sometimes an inflammatory complaint, and 
 yields to the remedies of inflammation — bleeding and Mistering : sometimes it is 
 plainly a part of rheumatism ; and then may often be relieved by calomel and opium, 
 or by colchicum : sometimes, again, it results from irritation within the pelvis, affect- 
 ing the nerve before it emerges externally ; this irritation may be connected with a 
 disordered state of the kidney, and I suspect that it is in such cases that the oil of 
 turpentine is of so much use : lastly, it is sometimes a purely nervous and neuralgic 
 pain : and then the treatment applicable to facial neuralgia will, mutatis mutandis, 
 be applicable to it. I had some time ago a butler under my care at tne hospital, 
 whom I am afraid I did not manage well. He suffered severe sciatica, and I had 
 him cupped and blistered, and gave him a variety of medicines, for some time, to 
 httle purpose : at last he got what I ought, I suppose, to have given him at first, viz., 
 the carbonate of iron, and was presently well. 
 
 Hemicrania is simply headache, confined to one side, and occupying generally 
 the brow and forehead, but sometimes aflecting very exactly one moiety of the head. 
 It is the migraine of the French, the megrim of our vernacular language ; each of 
 these terms being obviously traceable to the same Greek root. It is often attended 
 with sickness ; and in many instances it is periodical, coming on every day at a 
 certain hour, lasting a certain time, and then subsiding. Like the other forms of 
 neuralgia, hemicrania may be produced by various causes, which are, however, 
 almost all of them such as tend to debilitate the system : it sometimes occurs in con- 
 nection with hysteria ; sometimes it plagues women who have suckled their infanta 
 too long; sometimes it acknowledfres the same cause as ague ; and sometimes also 
 it occurs Independently of all other disease, and when no obvious exciting cause can 
 be traced. 
 
 Whatever may be its origin, it is usually a very manageable complaint. When 
 it is associated with evident antemia, steel and the shower-bath may be expected to 
 cure it. When its visits are strictly periodical, it will yield to quina. Arsenic is 
 considered by many to have a specific power over the complaint ; and I believe that 
 four or six drops of the liquor arsenicalis, given three or four times a day, with due 
 attention to the state of the bowels, will be almost sure to remove hemicrania in nine 
 castas out of ten in which it occurs. But steel or bark, being milder and safer drugs, 
 are, casteris paribus, to be preferred. 
 
 I say this disorder often acknowledges the same cai(se as ague; namely, the 
 miasm of marshes, or malaria : and as that cause, mysterious as it is in some respects, 
 ".xerts apparently its primary or chief influence upon the nervous system, and as 
 rtgue has no definite seat in the human body, if it be not in the nervous system, I 
 shall not find a more convenient place in these lectures for the consideration of ague
 
 INTERMITTENT FEVER. 435 
 
 than here, at the close of the remarks which I had to make respecting the diseases 
 of the brain and nerves. In the next lecture, then, I shall begin to speak of Inter- 
 mittent Fever. 
 
 LECTURE XL. 
 
 Intermittent Fever. Phenomena of an Ague Fit. Species and varieties of Inter- 
 mittents. Predisposing causes. Exciting cause. Malaria ; known only by its 
 effects ; places which it chiefly infests ; conditions of its production ; its ejects 
 vpon the human body; injiuence of soils in evolving it. 
 
 I AM now to enter upon the consideration of that disorder of which the trivial 
 English name is ague, and which is called by nosologists intermittent fever. This 
 is one of the diseases which are known to us only in their respective group of symp- 
 toms. Before we can inquire successfully into its history, it is necessary that we 
 have the group of symptoms which identify it set fairly before us. I must, there- 
 fore, describe the phenomena of ague. 
 
 You will observe that ague resembles several other maladies that essentially 
 belong to the nervous system, in being paroxysmal. A certain series of symptoms 
 occurs, and then the patient reverts to a state of health : but this alternation com- 
 monly happens (or would happen if the disease were left to itself) a great many 
 times. You may therefore look upon this succession of attacks as so many repe- 
 titions of a short distemper; or you may regard the whole period during which 
 the attacks continue to recur at brief intervals, as being occupied with one single 
 disease. 
 
 An ague fit is composed of three distinct stages ; and they are severally named, 
 from the phenomena that characterize them, the cold, the hot, and the sweating 
 stages. 
 
 A person who is on the brink of a paroxysm of ague, experiences a sensation of 
 debility and distress about his epigastrium ; becomes weak, languid, listless, and 
 unable to make any bodily or mental exertion. He begins to sigh, and yawn, and 
 sireich himself; and he sooa feels chilly, particularly in the back along the course 
 of the spine ; the blood deserts the superficial capillaries ; he grows pale, his fea- 
 tures shrink, and his skin is rendered dry and rough, drawn up into httle promi- 
 nences, such as may at any time be produced by exposure to external cold, and 
 presenting an appearance somewhat hke the skin of a plucked goose : hence it is 
 called goose's skin, and in Latin cutis anserina. Presently the slight and fleeting 
 sensation of cold, first felt creeping along the back, becomes more decided and more 
 general ; the patient yee/s very cold, and he acts and looks just as a man does who 
 is exposed to intense cold, and subdued by it; he trembles and shivers all over; his 
 teeth chatter, sometimes so violently that such as were loose have been shaken out ; 
 his knees knock together ; his hair bristles shghtly from the constricted state of the 
 integuments of the scalp ; his face, lips, ears, and nails turn blue ; rings which be- 
 fore fitted Closely to his fingers become loose ; his respiration is quick and anxious ; 
 his pulse frequent sometimes, but feeble ; and he complains of pains in his head, 
 back, and loins : all the secretions are usually diminished ; he may make water 
 often, though g(^nerally he voids but httle, and it is pale and aqueous ; his bowels 
 are confined, and his tongue is dry and white. 
 
 After this state of general distress has lasted for a certain time, it is succeeded by 
 another of quite an opposite kind. The cold shivering begins to alternate with 
 flushes of heat, which usually commence about the face and neck. By degrees the 
 coldness ceases entirely ; the skin recovers its natural colour and smoothness ; the 
 collapsed features and shrunken extremities resume their ordinary condition and bulk. 
 But the reaction does not stop here ; it goes beyond the hedlthy line. The face 
 becomes red and turgid ; the general surface hot and pungent and dry ; the templos
 
 436 INTERMITTENT FEVER. 
 
 throb; a new kind of head-ache is induced ; the pube becomes full and strong, as 
 well as rapid ; the breathing is again deep, but oppressed ; the urine is still scanty, 
 but it is now high-coloured ; the patient is exceedingly uncomfortable and restless. 
 At length another change comes over him : the skin, which, from being pale and 
 rough had become hot and level, but harsh, now recovers its natural softness ; a 
 moisture appears on the forehead and face ; presently a copious and universal sweat 
 breaks forth, with great relief to the feelings of the patient ; the thirst ceases ; the 
 tongue becomes moist ; the urine plentiful but turbid ; the pulse regains its natural 
 force and frequency ; the pains depart ; and by and by the sweating also terminates, 
 and the patient is again as well, or nearly as well, as ever. 
 
 This is surely a very remarkable sequence of phenomena : and it would appear 
 still more remarkable if it were less familiar to us. The earlier symptoms are all 
 indicative of debility, and of a depressed state of the nervous system. There is the 
 same sensation of exhaustion, with incapacity of exertion, which is produced by 
 fatigue. The sighing, yawning, and stretching, all notify debihty. The paleness 
 of the surface, and constriction of the skin, and collapse of the features, are all owing 
 to the retirement of the blood from the superficial capillaries. The skin shrinks, 
 but the parts containing the bulbs of the hairs cannot contract so much as the other 
 parts, and therefore the surface becomes rough, and the hairs bristle up, or become 
 erected in some degree. HorrlpUatio is the learned term for this state of the surface. 
 The coldness of the skin is another consequence of the emptiness of its blood- 
 vessels ; and the tremors which are always indicative of debility, seem to depend 
 upon the coldness. The chattering of the jaws has been (it is said) so violent as to 
 fracture the teeth. This you may believe or not as you please, but certainly the 
 whole bed is often strongly shaken by the shivering of the patient. The necessary 
 accumulation of the blood in the larger and internal vessels offers a reasonable expla- 
 nation of the distressed and anxious breathing. 
 
 In their attempts to render a " ratio symptomatum," authors have sometimes spoken 
 of the hot stage as though it were a necessary consequence of the cold. But if the 
 cold fit be in any sense or degree the cause of the hot fit, it can only be so partially. 
 There must be some other cause for these reasons. The cold stage may occur and 
 never be followed by the hot ; or the hot stage may come on without any previous 
 cold stage ; and when they do both happen, they are not by any means proportioned 
 to each other. When we thus see that a supposed cause is not always followed by 
 the effect, and that the effect is sometimes produced without the agency of the sup- 
 posed cause, and also that the supposed cause and the effect are not proportioned to 
 each other, we cannot but conclude that the supposed cause is at most but a partial 
 and accessory cause. We can more easily conceive how the hot fit may conduce 
 to bring on the sweating stage. The stronger action of the heart and the more forci- 
 ble propulsion of the blood will fill the superficial vessels, and in this way the natural 
 secretions may be restored. We see exactly the same thing happen when the force 
 of the circulation is increased by exercise : the extreme vessels receive a larger sup- 
 ply of blood, and sweat ensues. 
 
 There are many curious facts to be observed in respect to the paroxysm of an 
 intermittent, such as it has been now, in general terms, described. In the first place 
 the paroxysm returns. Cullen makes this a part of his definition ; and quibbling 
 objections to his statement have been made, which are scarcely deserving of men- 
 tion. Thus it is said that this circumstance should not have been introduced into 
 the definition, because it is not necessarily or iiuivcrsalh/ true ; that the patient may 
 die in the very first paroxysm ; or that he may be cured by the proper remedies of 
 ague, before a second paroxysm has time to show itself. But all this is captious tri- 
 fling. The paroxysms, if the disease be left to itself, will recur for a certain length 
 of time ; and, unlike the paroxysms in many of the spasmodic diseases which we 
 have lately been speaking of, they recur at regular periods, and often with singular 
 punctuality. This is a circumstance which we should waste our time in attempting 
 to account for. Dr. Cullen has tried to explain it on the principle of some diurnal 
 habit of thfe body ; but the truth is, that no satisfactory explanation of it has ever
 
 INTERMITTENT FEVER. 437 
 
 been given, and we must be content, for the present at least, to receive it as an ulti- 
 mate fact ; and, doubtless, a very strange and interesting fact 
 
 For distinguishing some equally curious varieties of these successions and alterna- 
 tions of disorder and health, certain terms have, by common consent, been adopted 
 by pathologists ; which terms it is necessary that I should explain. The period that 
 elapses between the termination of one paroxys.a and the commencement of the 
 next is called an intermission ; while the period that intervenes between the begin- 
 ning of one paroxysm and the beginning of the next, is called an interval. As the 
 paroxysms are liable to vary in length, the intermissions may be very unequal, even 
 when the intervals are the same. When the intermissions are perfect and complete, 
 the patient resuming the appearance and sensations of health, the disorder is an in- 
 termittent fever. When the intermissions are imperfect, the patient remaining ill 
 and feverish, and uncomfortable in a less degree than during the paroxysm, tlien the 
 complaint is said to be a remittent fever. 
 
 But, confining ourselves for the present to intermittents, it is another curious pro- 
 perty of this complaint that, although the intervals are commonly constant in each 
 case, and quite regular, they differ in duration in different cases. Upon this circum- 
 stance is founded a division of agues into species. When the paroxysm occurs at 
 the same hour every day, the patient is said to have quotidian ague. When it 
 comes on at the same hour every other day, appearing and remaining absent day by 
 day alternately, he is said to labour under tertian ague. The paroxysm, strictly 
 speaking, repeats itself every second day : and if the species I first mentioned be 
 fitly termed quotidian, that in which the fits occur on alternate days ought to be 
 styled seciindan. But nosologists have chosen to reckon the day on which the pre- 
 ceding fit happens as the first : and then the day on which the fit next to it will hap- 
 pen, in the species now under consideration, is the third. In the same way, when 
 a paroxysm absents itself for two whole days, and then recurs, the complaint is 
 called a quartan ague. These are the three principal species or types of intermit- 
 tent fever. It follows, of course, from wnat I have been stating, that in the quoti- 
 dian type, the interval is twenty-four hours ; in the tertian, forty-eight ; and in the 
 quartan, seventy-two. 
 
 Each of these types has some other characters peculiar to itself. Thus, the parox- 
 ysms of the quotidian ague begin in the morning; those of the tertian, at noon; 
 those of the quartan, in the afternoon. These are the rides. You are not to expect 
 to find them always or rigidly observed ; for the most part you will find that they 
 are observed. It is probable that quotidian paroxysms, occurring at noon or at night, 
 have sometimes been ascribed to ague, when they were merely symptoms of some 
 local disease or inflammation ; or perhaps accessions of hectic fever. It is observed 
 also of the paroxysms, that when the disease is about to yield, they often occur later 
 day after daj% before they take their final departure. This is caWedi postponing : 
 and when they occur earlier than their stated hour, the paroxysms are said to antici- 
 pate. Now a postponing quotidian may be deferred till noon. But when the dis- 
 ease is pursuing its regular undisturbed course, the rule is such as I have men- 
 tioned. 
 
 The' three principal types differ from each other, not only in their respective inter- 
 vals, and in the periods of the day at which the paroxysms severally commence, but 
 also in the duration of the paroxysms ; and in the proportions which the stages of 
 these paroxysms bear to each other. The average duration of the paroxysm in the 
 quotidian is ten or twelve hours; and of course the average duration of the intermis- 
 sion is nearly the same. The tertian paroxysm commonly begins at noon, and is 
 finished the same evening ; its average duration may be estimated at six or eight 
 hours. And that of the quartan does not exceed four or six hours. 
 
 You must observe, also, that while the quartan has the longest interval and thu 
 shortest paroxysm, it has the longest cold stage ; whereas the quotidian has the 
 shortest interval and the shortest cold stage, but the longest paroxysm. To express 
 these facts in mathematical language, the length of the paroxysm varies inversely as 
 the length of the cold stage ; inversely also as the length of the interval. 
 
 Of these three principal types or species, the tertian is by much the most com- 
 
 2m2
 
 138 INTERMITTENT FEVER. 
 
 mon : but the quotidian and quartan are neither of them unfrequent wherever ague 
 is rife. 
 
 I should tell you that there are other types also spoken of, as quintans and sextans : 
 but they are scarcely worth our attention. It is probable that when they are ob- 
 served (and that is very rarely) they are merely irregular quartans, postponing per- 
 haps for a day or two. They never prevail epidemically. Galen describes one of 
 these ; so does Van Swieten. Boerhaave talks of a septiman, and even octavans are 
 mentioned ; or if you want still more of the marvellous, PHny, the naturalist, infonns 
 us that a certain Improvisatori was in the habit of having a paroxysm once a year, 
 and that exactly on his birth-day ; yet he died at a good old age. 
 
 There are, however, some curious modifications of the three principal types ; or 
 rather of two of them, the tertian and the quartan. For instance, a paroxysm may 
 occur daily, and yet the ague not be of the quotidian type, but of the tertian. The 
 paroxysm of one day will differ from the paroxysm of the next, but exactly resemble 
 that of the third day ; while the paroxysm of the second day will be like that of the 
 fourth ; and so on alternately. And these diflt;rences will be decidedly marked ; 
 the paroxysms of two consecutive days will come on at different hours, and will differ 
 in duration and severity. This form of ague is called the double tertian. One case 
 of this kind, very distinctly characterized, was some time ago under my care in the 
 hospital. 
 
 There is another form of double tertian. Two fits will occur on the same day — 
 Monday, for example, one in the morning, the other in the evening; on Tuesday 
 there shall be no fit ; on Wednesday again two ; on Thursday none ; and so on. 
 The Latin nomenclature is more precise than the English in denoting these varia- 
 tions. The form I have last mentioned, in which two dissimilar paroxysms occur 
 every other day, is called tertiana duplicafa, while the other form, in which there is 
 a fit every day, but those on the alternate days resemble each other, is called tertiana 
 duplex. 
 
 In the same way you may have a double quartan. In that case, a paroxysm 
 occurs on two days in succession, and leaves the third day free ; then it returns 
 on the fourth day as it was on the first, and on the fifth as it was on the second, and 
 leaves the sixth day free hke the third, and so on. This is the quartana duplex. 
 But two fits may happen in one day — say on Monday ; none on Tuesday or Wed- 
 nesday ; and two again on Thursday. This is the quartana duplicata. Nay, the 
 paroxysm of quartan ague may recur every day, and so far resemble a quotidian; 
 but the fit of the first day will differ from those of the second and third, and resemble 
 that of the fourth : the fit of the second day will be dissimilar from that of the first 
 or that of the third, and like that of the fifth ; and the fit of the third will be unlike 
 that of either of the two preceding days, and find its counterpart in that of the sixth. 
 This is a triple quartan ; and where three paroxysms occur on the first day, which 
 we will again suppose to be Monday, and none on Tuesday or Wednesday, but 
 three again on Thursday, corresponding respectively to the first three, we have the 
 quartana triplicata. And there are other complications still, with which I need not 
 trouble you. In Dr. Cleghorn's book on the diseases of Minorca, you may find a 
 very good and authentic account, evidently drawn from nature, of the irregular types 
 and varieties of ague. They are well worthy of the attention of any among you who 
 may be liktly to practise abroad. 
 
 Some physicians have used the words doidAe tertian, and so on, in the hteral sense, 
 and have supposed that two or more distinct agues coexisted. This savonrs a good 
 deal of the error that I formerly warned you ajjainst, of looking upon diseases as 
 separate entities, and not merely as modes of being and of acting different fiom those 
 whicr. are proper to the state of health. The vulgar always regard disorders in this 
 light. A coachman by whose side I sat while travelling from Broadstairs to Mar- 
 gate, was speaking of the rarity of ague in that part of the Isle of Thanet. His 
 father, he said, once had the complaint, and when he was on a visit to him, the 
 coachman, at Ramsgate, a fit came on. The son administered to his suffering parent 
 a glass of brandy : whereupon " he threw the agy off his stomach ; and ir looked 
 
 I
 
 INTERMITTENT FEVER. 439 
 
 for all the world like a lump of jelly." Thai was the only occasion on which he 
 had ever " aeen the agy." 
 
 Besides these varieties in type, some other deviations from the normal and regular 
 paroxysms require to be noticed. 
 
 Sometimes the paroxysm is incomplete : it is shorn of one or more of its stages : 
 the heat and sweating occur without any previous rigors ; or the patient shaken, but 
 has no subsequent heat ; or the sweating stage is the only one of the three that 
 manifests itself. These fragments of a fit are often noticeable when the complaint is 
 about to take its departure ; but they may also occur at other periods of the disease. 
 Sometimes there is no distinct stage at all: but the patient experiences frequent and 
 irregular chiUs, is languid and uneasy, and depressed. This state is commonly 
 known among the inhabitants of our fenny and aguish districts as the dumb ao-ue, 
 or dead ague ; the patient is said not to shake out. 
 
 Again, there is often observed a tendency to a change of type in the course of the 
 same disease affecting the same person. The quotidian will be transformed into a 
 tertian ; a tertian into a quartan ; or, on the other hand, a quartan into either of these. 
 I have already noticed the fact that the paroxysms will also alter their time of inva- 
 sion, sometimes coming later and later in the day, at each recurrence, sometimes 
 earlier and earlier. When the paroxysm thus postpones, the disease is growing 
 milder : when it anticipates its usual period of attack, the disease is increasing in 
 severity. The postponement or anticipation, therefore, of the fit, has a close relation 
 to the prognosis. 
 
 There are yet other cases, in which from first to last no determinate type or order 
 of succession is observed by the paroxysms ; and these cases authors speak of as 
 erratic forms of ague. 
 
 There are also many modifications or complications observable in the symptoms 
 which constitute the fits. Occasionally each paroxysm is attended by violent deli- 
 rium : this is most common, I believe, in the hot stage. This symptom has been 
 known to be almost constant throughout an epidemic. Sometimes the patient is 
 convulsed in the paroxysm; or syncope comes on; or tetanic rigidity; or petechiae 
 lakes place on the skin, and disappear with the paroxysm. These deviations from 
 the common and regular kind and order of the symptoms may sometimes depend 
 upon the constitutional predispositions of the person affected ; but there is another 
 way also in which they may be explained. 1 shall presently have a good deal to 
 say upon the one grand — 1 may say sole — exciting cause of intermittents. Now 
 exposure to that cause, a residence in aguish districts, will sometimes impart a periodic 
 character to other diseases: and I apprehend that this explanation will apply to 
 many of the instances which have been observed of hysterical, tetanic, or other 
 paroxysmal complaints, occurring at perfectly regular intervals. 
 
 The duration of ague — of the whole disease, and not merely of a separate pa- 
 roxysm — it is not easy to estimate. If persons who laboured under it were always 
 removed at once from the influence of the exciting cause, and were always suffered 
 to remain without treatment calculated to check the malady, we might then find 
 materials for determininn- its average natural duration. But we have not these data. 
 In point of fact, ague sometimes consists of a very few paroxysms only, half a 
 dozen, or four, or three, or even of one fit ; and on the other hand, they may be pro- 
 tracted over a space of several weeks, or months ; nay, of many years. 
 
 An ague may attack a person at any time ; but they are much more common in 
 spring, and in autumn, than in the otlier seasons of the year: so that you will hear 
 and read a good deal of vernal intermittents, and of autumnal intermittents. The 
 autumnal agues are, cniteris paribus, the more severe and dangerous. The quotidian 
 is most common in the spring; the quartan in the autumn; and the tertian is Av- 
 quenlly met with both as a vernal and as an autumnal ague. You will bi.'ar in mind 
 ihat in all this I am stating the prevailing rules ; which are liable lo "umerous ex- 
 ceptions. 
 
 Ague is one of those disorders of which (as of common inflammation) ah pensons, 
 
 at all periods of their existence, seem to be susceptible, when submitted to the influ 
 
 nee c^ the specific exciting cause. Individuals of all 'igcs, from sucking infants w.
 
 440 INTERMITTENT FEVER. 
 
 persons of four-score, are liable to it, but they are not equally subject to it. It is 
 less likely {cxteris paribus) to affect the very young, and the aged, than those of 
 middle life. However, the very old are by no means exempt from the operation of 
 the cause of ague : and with respect to the very young, some extremely curious 
 statements have been made. It is said that persons have had ague before they were 
 born. We know that the period of intra-uterine life is obnoxious to many forms of 
 disease ; for we trace the consequences of such disease, in visible changes of struc- 
 ture, immediately after birth. Pulmonary tubercles constitute one malady to which 
 the fcetus in utero is liable: hydrocephalus is another: acute inflammation of the 
 peritoneum a third. And there can be no doubt that various specific poisons influ- 
 ence, occasionally, the included being, even although they may have no sensible 
 effect upon the parent. The fcetus may thus contract small-pox, which sometimes 
 proves fatal to it, sometimes not. The daughter of my bed-maker at Cambridge had 
 a child ill of hooping-cough in the house with her while she was in the last months 
 of pregnanc}'^ ; and the infant in the womb must have caught the disease, for I was 
 assured that he hooped the very day he came into the world. The sins of the parent 
 are thus visited often upon the child, when, before its first breath is draAvn, its frame 
 is contaminated by the virus of syphilis. And in like manner unborn infants are 
 capable of being affected by the poison that produces ague. One case in proof of 
 this is recorded by Dr. Russell, in his History of Aleppo. The woman had tertian 
 ague, Avhich attacked her, of course, every other day: but on the alternate days, 
 when she was well and free, she felt the child shake ; so that they both had tertian 
 ague, only their paroxysms happened on alternate days. Bark was prescribed for 
 her ; and it cured the little one first, and afterwards it cured the mother. 
 
 One probable reason why ague more commonly affects persons about the middle 
 period of life, than those near its extremes, is that the former are much more likely 
 to be exposed to the primary exciting cause. And the same reason may be given, I 
 presume, for another fact ; viz., that the complaint is much more frequently seen in 
 men than in women. 
 
 Among the circumstances which predispose to ague, debility has a powerful in- 
 fluence. It is important to be aware of this, as it concerns the prophylaxis, and the 
 management of the patient after the disease has been subdued. Soldiers have been 
 exposed to the exciting cause, Avithout becoming affected by it, while strong and in 
 good health ; and have fallen ill of intermittent fever upon being weakened by ex- 
 ertion and fatigue. When I have told you that debility, any how produced, consti- 
 tutes a predisposition to intermittent fever, I need scarcely add that all the multiform 
 causes of debility may also be regarded as predisposing causes'of this same diease; 
 as they are of so many others. 
 
 But the strongest predisposing cause of all is an actual occurrence of the disease 
 itself. The effect of former intermittents upon the system is such that the complaint 
 may be reproduced by agencies which under any other circumstances would be quite 
 inoperative in exciting ague. I have stated already my persuasion that, strictly 
 speaking, there is but one exciting cause of intermittent fever: but in making that 
 statement I refer to \\.s first production. The disease leaves the body in a condition 
 in which other injurious influences may, of themselves, be sufficient to renew it. 
 It brings into play a new order of exciting, or rather of re-exciting causes. If a 
 person were never exposed to the malaria, he would never, as I believe, have ague : 
 but having once had ague, he may many times have it again, although he should 
 never again be subjected to the direct influence of the malaria. The late Dr. James 
 Gregory of Edinburgh, had a brother-in-law who illustrated well in his own person 
 the efffcls of predisposing circumstances in respect to ac^ue. This gentleman was a 
 strong, active man, and commanded a battalion in the West Indies ; and he escaped 
 for a long time, while others were falling down around him in remittent fever. At 
 last he was wounded by a musket-ball which passed through his shoulder. He in- 
 sisted, much asxainst the will of the surgeon of the regiment, on resuming his duties 
 oe?ore his strength was completely restored ; snd the consequence was that he was 
 immediately attacked by a remittent fever of such violence, that his hfe was for some; 
 ume despaired of. Bu*: this was not all. The remittent disease assumed by degrees
 
 INTERMITTENT FEVER. 441 
 
 a distinctly intermittent form, and became a tertian : and at last he got well, and 
 strong, and came over to this country. But for a long while, though to all appear- 
 ance his health was re-established, ague fits would from time to time occur ; and 
 they came precisely at the day and hour on which they would have happened if the 
 tertian had continued with its original type ; and shght causes were sufficient to re- 
 produce them. He had marked in an almanack, the days of the expected accession, 
 and on those days it recurred, for some time, whenever the east wind blew. This 
 very circumstance, the east wind, is a common re-exciting cause in such cases ; ex- 
 posure to cold in any way is another. 
 
 The exciting cause of intermittent and remittent fevers — the primary exciting 
 cause I mean, that without which ague would never occur at all — deserves a some- 
 what particular consideration. I need scarcely say that it consists in certain invisible 
 effluvia or emanations from the surface of the earth, which were formerly called 
 marsh miasmata, but to which it has, of late years, become fashionable to apply the 
 foreign term malaria. In some respects the latter designation is the more conve- 
 nient of the two. 
 
 The malaria is a specific poison, producing specific effects upon the human body. 
 In its medical sense, it is not simply bad air, or impure air, although the word is 
 loosely employed by many to express any mixed kind of contamination of the at- 
 mosphere. Thus we hear of the malaria of London : but ague, even when it occurs 
 in London, is very seldom indeed, now-a-days, of London growth. The impure air 
 incident to large and populous cities is prejudicial enough to health, as I formerly 
 took occasion to show you : but it does not generate fever : neither continued fever, 
 nor intermittent. 
 
 [The author certainly cannot mean to assert, as his language would seem to imply, that no 
 form of fever is generated by " the impure air incident to large and populous cities," but 
 that all fevers are produced by a " specific poison" resulting from other causes than those by 
 which the atmosphere is rendered impure in the crowded, unventilated, and filthy lanes, 
 courts, and alleys, which abound in suburbs of most large cities. That typhus and typhoid, 
 bilious, and yellow fevers are generated in large and populous cities, no one, we presume, 
 will pretend to deny, but of their dependence upon a specific aerial poison we have not as 
 yet been furnished with any satisfactory evidence. — C] 
 
 The emanations which cause ague have been called marsh miasmata, because they 
 are notoriously common in marshy places. But they are not peculiar to marshy 
 places. For this reason, and for brevity's sake, I prefer using the single word mal- 
 aria. In this country, thank God, we witness its milder evils only, and those not 
 very often ; but it is the bane and scourge of large portions of the world. Whether 
 you practise here or abroad, it is very fit that you should know the qualities, habitats, 
 and habits, of this wide-spread poison. The mildest form of fever to which it gives 
 birth is the intermittent fever, or ague ; but in climates and places where it exists in 
 greater abundance and intensity, the fever becomes remittent, or even assumes the 
 continued form. This has led to strange errors, and proved a fertile source of dif- 
 ference and controversy amongst medical men : not a few of whom confound the 
 severe continued fevers which spring from the malaria, and which are never conta- 
 gious, with the severe continued fevers usually called typhous, which are unques- 
 tionably communicable from person to person. 
 
 The effluvia which thus form the sole exciting cause of intermittent and remittent 
 fevers proceed from the surface of the earth, and are, probably, gaseous, or aeriform : 
 at any rate they are involved in the atmosphere. But i\\( j are imperceptible by 
 any of our senses. Of their physical or chemical qualities we really know nothing. 
 We are made aware of their existence only by their noxious effects ; and the 
 inference that they exist was not made till within the last century and a half. — Time 
 out of mind, indeed, it had been matter of common observation that the inhabitants 
 of wet and marshy situations were especially subject to these definite and unequi- 
 vocal forms of disease. But the Italian physician, Lancisi, was the first, so far 
 as I know, to put forth distinct ideas concerning malaria, in his book, published 
 about lt!95, De noxiis paludum cjffluviis. This is the great original work upon 
 the subject.
 
 442 IiNTERMITTENT FEVER. 
 
 To the production of this deleterious agent, a certain degree of temperature seems 
 necessary. It does not appear to exist witliin the arctic circle : nor does it manifest 
 itself during the colder seasons of more temperate climates. It is very seldom 
 traceable beyond the 56th degree of north latitude ; and it is supposed to require for 
 its development a continuous temperature higher than 60° of Fahrenheit's thermo- 
 meter. The nearer we approach the equator, the more abundant, virulent, and per- 
 nicious does the poison become, wherever it is evolved at all. — In this climate it gives 
 rise to intermittonls, and principally to tertians. As we go south, in Spain, and 
 along the shores of the Mediterranean, the remittent becomes the predominant form ; 
 and (what is very instructive) remittents there contracted often improve into inter- 
 inittents upon the removal of the patient to a colder climate. Under the tropical 
 heats, in the West Indies, for example, the fevers very frequently assume the conti- 
 nued form. 
 
 And another condition of the development of the poison soon becomes apparent 
 It requires a certain degree of moisture. Of all these regions, malaria, showing 
 itself always by its effects alone, infests certain parts only ; which parts are, most 
 generally, remarkable for their humid and swampy character. Thus, in this island, 
 intermittents are produced chiefly, I may say almost exclusively, along the eastern 
 coast ; in parts of Kent, Essex, Cambridgeshire, Norfolk, Lincolnshire, and the East 
 Riding of Yorkshire : and in each of these counties there are marshes, or fens, or low 
 grounds and lands that are occasionally overfloAved. Many of these spots have, 
 within the last fifty years, been drained, and brought under cultivation ; and agues 
 are consequently much more rare in England than they formerly were. In Syden- 
 ham's lime they were very frequent, and very fatal indeed, in this metropolis. James 
 I. and Oliver Cromwell both died of ague contracted in London. At present (as I 
 said before) we seldom meet with them. — Except in the year 1827, I have never, 
 since I have been in practice, known ague to be at all common here. This compa- 
 rative freedom from malaria is mainly owing, no doubt, to the improved character of 
 the draining and sewerage. 
 
 Agues, or aguish fevers, are endemic along every part of the low and level coast 
 of Holland. In Italy, the Pontine marshes, near Rome, have possessed for ages an 
 infamous celebrity of the same kind. The whole of the district called the Marcmna, 
 which stretches for about thirty leagues along the shores of the Mediterranean, and 
 which in some places is ten or twelve leagues broad, is rendered dangerous, and 
 almost uninhabitable, by the vast quantity of malaria annually evolved from its soil. 
 In America large districts are, for the same reason, prohfic of disease. The late 
 Bishop Heber, in his Narrative of a Journey through the Upper Provinces of In- 
 dia, gives the following striking picture of the influence of the malaria in that part 
 of the world. It seems to be alike pestiferous to man and beast. 
 
 "I asked Mr. Boulderson if it were true that the monkeys forsook these woods 
 during the unwholesome months. He answered that not the monkeys onl\-, but 
 every thing which has the breath of life, instinctively deserts them from the begin- 
 ning of April to October. The tigers go up to the hills; the antelopes and wild 
 hogs make incursions into the cultivated plain ; and those persons, such as dak- 
 bearers, or military officers, who are obliged to traverse the forest in the intervening 
 months, agree that not so much as a bird can be heard or seen in the frightful soli- 
 tude. Yet during the time of the heaviest rains, while the water falls in torrents, 
 and the cloudy sky tends to prevent evaporation from the ground, the forest may be 
 passed with tolerable safety. // is in the extreme heat, and immediulehj after the 
 .'xiins have ceased, in May, the latter end of August, and the early part of Septem- 
 ber, that it is most deadly. In October the animals return. By the latter end of 
 that month the wood-cuiters and the cow-men again venture, though cautiously. 
 From the middle of November to March troops pass and repass, and with common 
 precaution no risk is usually apprehended." 
 
 Peisons who live in England might perhaps be disposed to think lightly of the 
 
 malaria, had not such fearful evidence of its appalling power been brought home to 
 
 the experience of our countrymen, in the early part of the present century, by the 
 
 esull of the unfortunate expedition to Walcheren. Sir Gilbert Blane has given an 
 
 \
 
 INTERMITTENT FEVER. 443 
 
 account of the ravages it ihere committed among our troops. You may see his 
 paper, to which I shall presently again refer, in the third volume of the Mcdico-Chi- 
 riir sliced I'ransuctions. 
 
 Not only a certain degree of heat, and a certain quantity of moisture, but the pre- 
 sence of all the four elements of the ancients, would appear to be requisite for the 
 production of this poison. Air of course there must be ; and earth also is essential. 
 If heat and moisture were alone adequate, we should find the fever prevailing among 
 sailors when out at sea: but it is not so, whatever may be the temperature under 
 which they cruise. It is when they approach the coast, or land upon it, that they 
 are attacked. The water of marshes has been examined under the microscope, and 
 analyzed again and again, with a view to the discovery of the nature of this pesti- 
 lential agent ; but in vain. A more likely Avay to detect the noxious material would 
 seem to be by examining the air of malarious districts ; and this has been done 
 carefully and repeatedly by expert chemists ; and with the same want of success. 
 The poisonous princi})le eludes the test of the most delicate chemical agents. 
 
 Where there are are much heat, and much moisture, there we usually find also 
 much and rank vegetation, and much vegetable dissolution and decay. The belief 
 was as natural, therefore, as it has been general, that the putrefaction of vegetable 
 matters was somehow or other requisite to the formation of the poison that exists so 
 commonly in swampy situations. This belief has descended, almost unquestioned, 
 from the time of Lancisi ; and it obtains almost universal acceptance, I fancy, among 
 phj'sicians of the present day. Yet very strong facts have been adduced to show 
 that the decomposition of vegetable substances is only an accidental, though a fre- 
 quent, (iccompuniment of the miasm ; and not by any means an essential condition of 
 its evolution. 
 
 In the first place, the decomposition of vegetable matter goes on abundantly vnth 
 out the production of m.alaria. The rotting cabbage-leaves of Covent Garden, and 
 .hose w'hich taint the air of the streets from the neglected dust-holes of London, 
 during the hot weather of summer give rise to no ague. The same may be said of 
 the putrefying and offensive sea-weed, which is deposited in large quantities upon 
 some very healthy parts of our sea-coast. But the converse facts are the njo^t 
 remarkable and conclusive. I have stated that marshes are not necessary to pro- 
 duce malaria; but Dr. William Ferguson — a physician who has had, and who has 
 well used, very suflicient opportunities of investigating the question — shows that 
 vegetation is not necessary : that the peculiar poison may abound where there is no 
 decaying vegetable matter, and no vegetable matter to decay. As the prevailing 
 belief is, in my opinion, an erroneous one, and as it is really of great importance that 
 correct views of this subject should be taken and disseminated by medical men, I 
 will mention a few of the most striking of the facts detailed by Dr. Fercjuson. They 
 are contained in a very interesting paper " On the Nature and History of the Marsh 
 Poison,''^ published in the Edinburgh Philosophical Transactions. 
 
 In August, 1794, after a very hot and dry summer, our army in Holland encamped 
 at Rosendaal and Oosterhout. The soil, in both places, was a level plain of sand, 
 with a perfectly dry surface, where no vegetation existed, or could exist, but stunted 
 heath plants. It was universally percolated to within a few inches of the surface, 
 with water which, so far from being putrid, was perfectly potable. Here fevers of 
 the intermittent and remittent type appeared among the troops in great abundance. 
 It is interesting to observe that the soil in Walcheren is precisely similar. Sir Gil- 
 bert Blane describes it as consisting " of a fine white sand, known in the eastern 
 counties of England by the name of silt, and about a third part of clay." It was 
 after a hot and dry summer, also, that the British army suffered in that island from 
 the endemic fever, to a degree which Dr. Ferguson speaks of as "being almost un- 
 precedented in the annals of warfare." 
 
 In the year ISOO, several regiments of our army in Spain took up an encamp- 
 ment in a hilly ravine which had lately been a water-course. Pools of water still 
 remained here and there among the rocks, so pure that the soldiers were anxious to 
 bivouack near them for the sake of using the water. Several of the men were seized 
 vvilh violent remitting fever before they could move from the bivouack the next morn
 
 444 INTERMITTExXT FEVER. 
 
 ing. "Till tb^n (says Dr. Ferguson) it had always been believed amongst us thsS 
 vegetable putrefaction (the humid decay of vegetables) was essential to the produc- 
 tion of pestiferous miasmata ; but in the instance of the half-dried ravine before us, ^ I 
 from the stony bed of which (as soil never could lie for the torrents) the very exist- M 
 ence even of vegetation was impossible; it proved as pestiferous as the bed of a 
 fen." 
 
 After the battle of Talavera, the army retreated along the course of the Guadiana 
 river, into the plains of Estremadura. The country was so arid and dry for want 
 of rain, that the Guadiana itself, and all the smaller streams, had in fact ceased to be 
 streams, and were no more than lines of detached pods in the courses that had for- 
 merly been rivers. The troops there " suffered from remittent fevers of such destruc- 
 tive malignity, that the enemy, and all Europe, believed that the British host was 
 extirpated." 
 
 Cividad Rodrigo is situated on a rocky bank of the river Agueda, a remarkably 
 clear stream ; but the approach to it on the side of Portugal is through a bare, open, 
 hollow country, that has been likened to the dried-up bed of an extensive lake; and 
 upon more than one occasion, when this low land, after having been flooded in the 
 rainy season, had become as dry as a brick-ground, with the vegetation utterly 
 burned up, there arose to our troops fevers which, for malignity of type, could only 
 be matched by those before mentioned on the Guadiana. 
 
 Many more facts to the same purpose are related in Dr. Ferguson's paper, which 
 is in every way well \vorth your perusal. He tells us " that in the most unhealthy 
 parts of Spain, we may in vain, towards the close of the summer, look for lakes, 
 marshes, ditches, pools, or even vegetation. Spain, generally speaking, is then, 
 though as prolific of endemic fever as Walcheren, beyond all doubt one of the driest 
 countries of Europe ; and it is not till it has again been made one of the wettest, by 
 the periodical rains, with its vegetation and aquatic weeds restored, that it can be 
 called healthy, or even habitable with any degree of safety." 
 
 Our time will not allow of my extracting any further evidence on this point ; one 
 circumstance of contrast, however, I am unwilling to omit. 
 
 The river Tagus is, at Lisbon, about two miles broad ; and it separates a healthy 
 from a very unheakhy region. On the one side is a bare hilly country; the founda- 
 tion of the soil, and of the beds of the streams, being rock, with free open water- 
 courses among the hills. This is the healthy side. But the Alentejo land, on the 
 other side, though as dry superficially, being perfectly flat and sandy, is most pesti- 
 ferous. Moreover, in and near Lisbon there are numerous gardens, where they keep 
 water, durino- the three months' absolute drought of the summer season, in stone 
 reservoirs. These reservoirs, containing water in the most concentrated state of foul- 
 ness and putridity, are placed close to the houses and sleeping rooms : the inhabitants 
 literally live and breathe in their atmosphere. " Yet no one ever heard or dreamt 
 of fever being generated amongst them from such a source ; though the most igno- 
 rant native is well aware that were he only to cross the river, and sleep on the sandy 
 shores of the Alentejo, where a particle of water at that season had not been seen 
 for months, and where water, being absorbed into the sand as soon as it fell, was 
 7iever known to be putrid, he would run the greatest risk of being seized with re- 
 mittent fever." 
 
 Now these facts, and facts like these, ^eem to prove that the malaria, and the pro- 
 duct of vegetable decomposition, are two distinct things. They are often in company 
 with each other, but they have no necessary connection. "Whoever, in a malarious 
 country, waits for the evidence of putrefaction, will wait, says Dr. Ferguson, too long. 
 For producing malaria it appears to be requisite that there should be a surface capa- 
 ble of absorbing moisture, aiad that this surface should be flooded and soaked with 
 water, and then dried : and the higher the temperature, and the quicker the drying 
 process, the more plentiful and the more virulent (more virulent probably because 
 more plentiful) is the poison that is evolved. 
 
 The putrefaction o^ animal matter is sometimes spoken of as an element in the 
 lormation of the malarious poison. But the evidence I have just set before you re- 
 futes this sup position as completely as it excludes the alleged necessity of vegetable
 
 INTERMITTENT FEVER. 445 
 
 decay. I hoj^e to prove to you, in a future part of the course, that neither animal 
 nor vegetable decomposition is sufficient to generate fever of any kind. 
 
 Dr. Ferguson's facts are generally. in accordance with the observations which 
 others have made upon the same subject : and his views will be found to account for 
 some phenomena which the ordinary theory of vegetable putrefaction did not cleverly 
 explain. 
 
 There is good reason for believing that in all cases the poisonous emanations pro- 
 ceed from parts ot the surface that have been flooded and then dried, rather than 
 from parts that are still wet, or putrid. And this elucidates a circumstance very 
 often noticed, viz., that neighbouring places — especially high and low lands lying 
 near each other — change their character in respect to salubrity upon the occurrence 
 of rains. The low grounds, which bad previously been very dangerous, become 
 healthy when they are flooded over: and the higher lands, which are made wet, 
 and which rapidly dry again, produce the malaria abundantly. For the same reason, 
 the edges or borders of swamps, which of course expand or contract according to 
 the wetness or dryness of the season, are more unsafe than their centres. The 
 drying and half-dried margins of the purest streams may be prolific of the evil, when, 
 from the want of confining banks, those margins have been flooded by the rising of 
 the waters. 
 
 There is no observation more general than that, in malarious places, agues and 
 remittent fevers abound more in hot and dry years than in those which are cold and 
 moist. And this influence of temperature it is which mainly determines the differ- 
 ences observable in regard to these fevers at different elevations, and in different 
 seasons of the year. In the higher grounds of the West Indies agues occur as in 
 this country : as you descend, and the mean atmospheric temperature increases, 
 remittents are met with : and in the lowest and hottest parts the fever becomes con- 
 tinued. The following instructive facts are stated by Dr. Ferguson. In 181<J, the 
 British garrison of English Harbour, in Antigua, was disposed in three separate 
 barracks, on fortified hills surrounding the dock-yard. One of the barracks vi^as on 
 an eminence named Monk's Hill, six hundred feet above the level of the marshes. 
 The other two were situate on an eminence called the ridge, one at the height of five 
 hundred, and the other at the height of three hundred feet. So pestiferous were the 
 marshes among which the dock-yard was placed, that it often happened to a well- 
 seasoned soldier, coming down from Monk's Hill, and mounting the night-guard in 
 perfect health, to be seized with furious delirium while standing sentry, and to ex- 
 pire within less than thirty hours after being carried up to his barracks, with a yellow 
 skin, and having had black vomiting. Those in the barracks on Monk's Hill ivho 
 did not come doivn, the superior officers, the women, children, and drummers, had 
 no fever of any kind. Seventeen artillerymen, in the barrack at the height of three 
 hundred feet, did not come down to the night-guards. (We shall see hereafter that 
 malarious places are always most dangerous at night.) Every one of these men 
 was attacked with remittent fever, of which one of them died. At the barrack on 
 the top of the ridge, at the height of five hundred feet, there scarcely occurred any 
 fever worthy of notice. Thus, in the same place, the malaria, in the level plain, 
 caused continued fever, resembling, and I believe identical with, yellow fever : at the 
 elevation of three hundred feet it gave rise to remittent fever ; and at the height of 
 five hundred or six hundred feet its influence was scarcely felt at all. In the neigh- 
 bourhood of the Pontine marshes you see the villages perched curiously on the inter- 
 vening hills ; the Itahans having been taught by experience that these elevated spots 
 afforded comparative security against the effects of the miasmata. 
 
 Wherever the malaria prevails, it produces its peculiar consequences chiefly in 
 certain seasons : and it is in the autumn especially that agues and aguish fevers occur; 
 that is to say, after the heats of summer : and the hoUer and drier the precedmg 
 summer, the more frequent and fatal are the autumnal fevers. The Pontine marshes 
 iie to the southward of Rome ; and Horace, you know, says or sings, 
 
 Frustra per autumnos nocentern 
 Corporibus metuemus austrum. 
 
 2n
 
 446 INTERMITTENT FEVER. 
 
 The efft'Cts of these morbific effluvia upon the human body vary much under dif 
 ferent circumstances. Where ihey are most concentrated and deadly, their opera- 
 tion may be almost immediate. Witness their speedy influence upon the soldiers 
 who descended at night from Monk's Hill. So also sailors, who have gone on shore 
 for a single night only, have been attacked by the fever before they could return to 
 the ship. On the other hand, when the emanations are less copious, or less virulent, 
 there is sometimes a long and uncertain period of incubation. The disease remains 
 latent, or the poison lies dormant, for a considerable space of time. Many of the 
 soldiers who were exposed to the malaria at Walcheren did not experience its bad 
 effects until after they had returned, and had even resided several months in England. 
 In the same way, labourers, especially the itinerant Irish, will go down in the 
 autumn for harvest work into Lincolnshire, and bring back the seeds of the disorder 
 within them, and yet may not be attacked with ague for weeks or months ; upon 
 the occurrence of an east wind perhaps, or after unusual exposure to cold and wet. 
 We trace in all this some analogy with, the animal contagions ; but the period of 
 incubation is more irregular and accidental ; and it is probable that in many instances 
 the ague would not happen at all, but for the concurrent operation of some other 
 malign influence. 
 
 Another fact worthy of notice in respect to the agency of the malaria upon the 
 human frame, is that it affects strangers much more readily and decidedly than the 
 natives of the place. In other words, habit mitigates the injurious effects of the 
 poison. Persons become seasoned to it. At "Walcheren, though almost every adult 
 among the lower classes had laboured, in the course of his life, under the endemic 
 intermittent, yet they were infinitely less subject to it than strangers : and they will 
 not believe that their beloved birth-place is unhealthy. Sir Gilbert Blane says that 
 persons of education, and even medical men, denied indignantly that their country 
 was less healthy than any other ; and attributed the sickness wliich raged among our 
 troops to some trivial circumstances of diet or habits, and not to any insalubrity of 
 the air. This is a curious moral feature ; but a very general one. In the pestilen- 
 tial plains of Estremadura the superstitious natives, unable or unwilling to ac(!:ount 
 for a disease of a type so uncommon, among the soldiers, Irom any unw'holesomeness 
 of the air, declared that they had all been poisoned by eating mushrooms. 
 
 It was found, also, at Walcheren, that the strangers who survived the first attacks 
 became thereafter much less liable to the endemic fevers. The French general, 
 Monnet, who had held the command at Flushing for seven years, had acquired a 
 knowledge of this fact, and endeavoured to turn it to practical account. He recom- 
 mended that troops should not be frequently changed ; for when it was the custom 
 to send battalions from Bergen op Zoom every fourth night in succession, to work on 
 the lines of Flushing, these men never failed, upon their return, to be taken ill in 
 great numbers. General Monnet therefore advised, however displeasing it might be 
 to the officers, that a stationary garrison should be retained at Walcheren, in order 
 that the men might be habituated or seasoned to the air {acclimates,) and he adduced 
 the instance of a French regiment which suffered in the second year of its being 
 stationed there only one-half the sickness and mortahty which it suffered during the 
 first year; and hardly suffered at all in the third year. 
 
 But although the natives and residents in malarious places are not so liable as new 
 comers to the violent and distinct forms of fever, they are chronically affected by 
 the insalubrity of the atmosphere. They are spoken of by travellers as being puny, 
 sallow, and sickly ; feeble in body and spiritless in mind ; as having yellow faces, 
 swelled bellies, and wasted hmbs ; as being subject to dropsies and fluxes ; phleg- 
 matic, melancholy, and short-lived. 
 
 One remarkable exception is mentioned by Dr. Ferguson. From some peculiarity 
 or idiosyncrasy (which he conjectures may be somehow connected with the texture 
 of the skin) the negro appears to be proof against endemic fevers. " To him marsh 
 miasmata are in fact no poison ; and hence his incalculable value as a soldier, for 
 field service, in the West Indies. The warm, moist, low, and leeward situations 
 where these pernicious exhalations are generated and concentrated, prove to him 
 congenial. He dehghts in them, for there he enjoys hfe and health, as much as his
 
 INTERMITTENT FEVER. 447 
 
 feelings are abhorrent to the currents of wind that sweep the mountain tops, where 
 alone the whites find security against endemic fevers." 
 
 No very certain or extensive observations have yet been made in respect to the 
 kind of soil from which the miasmata are most apt to be extricated. Such as is 
 loose, penetrable, porous, and sandy, appears highly favourable to their formation. 
 So are soils which, containing much clay, are very retentive of moisture. One 
 curious fact, however, bearing upon this question, seems to have been made out : 
 viz., that what is termed peat-bog, or peat-moss, is not productive of malaria. Many 
 parts of Scotland and of Ireland, that are occupied by large tracts of marsh in which 
 the peat-moss abounds, are completely free from these fevers. Dr. BisseL affirms 
 that the exhalations from black peat-moss do not occasion intermiltents, " at least in 
 high moors under a clear sharp air." Now in the climate of Virginia, this counter- 
 acting influence of a sharp air can scarcely be looked for : yet it is a remarkable fact, 
 that though the provinces of North America, especially North and South Carolina 
 and Virginia, are full of ague, that disease is never seen among the inhabitants near 
 the country of the Dismal Swamp, a moist tract of 150,000 acres on the frontiers 
 of Virginia and North Carolina. Weld, the traveller, informs us, that this immense 
 tract is covered with trees and 'abounds with water, which appears the moment the 
 shallowest trench is dug. The water is brown, hke brandy, but quite clear, and not 
 unpalatable. Its colour is ascribed by the inhabitants to the roots of juniper ; and 
 it is said to be diuretic. (Craigie.) 
 
 LECTURE XLI. 
 
 Jigue, continued. Speculations respecting its periodicity. Habits and properties 
 of the malaria; most noxious at night ; lies near the ground ; is carried along 
 by winds ; cannot pass across water ; attaches itself to trees ; is diminished by 
 the increase of cultivation and of population. Ultimate effects of the poison on 
 the body. Jigue formerly thought salutary. Prognosis. Propriety of stopping 
 the disease. 
 
 You will remember the progress we made, at our last meeting, in the subject of 
 intermittent fever. I described the ordinary phenomena of a paroxysm of ague ; 
 and afterwards mentioned certain unusual symptoms with which it is sometimes 
 complicated. The three principal types of ague were also dehneated ; the quotidian, 
 the tertian and the quartan : as well as their respective characters, and intervals, and 
 varieties, and changes of type. I spoke, too, of the predisposing causes of inter- 
 'mittent fever, which may all be briefly included under the head of circumstances 
 that tend to debilitate the body: the strongest predisposing cause of all be:ng a 
 former attack of the disease. And I began to consider the great exciting cause of 
 agues and aguish fevers — the malaria. I first directed your attention to the circum 
 stances under which the malaria appears to be evolved. Since the time of Lancisi 
 it had been very generally supposed that the humid putrefaction of vegetable sub- 
 stances was necessary to the production of this peculiar and wide-spread poison ; and 
 that heat accelerated the putrefactive process. That was Dr. Bancroft's opinion. 
 That also is (I believe) the opinion held, and stated in lectures, by many pathologists 
 at the present time. I showed you, from facts which rest upon Dr. Ferguson s 
 authority, that this notion is founded in mistake : that the products of the vegetable 
 decay and decomposition may and do often coexist with malaria, but are distinct and 
 separable from it, and by no means essential to its formation. There is reason to 
 believe that the flooding of a porous earthy surface with water, and a subsequent 
 drying of that surface under a certain degree of heat, constitute the sole or main 
 con litions of the generation of the poison. We found that the efl^ects of the malaria 
 are modified by the temperature of the place : that in low and hot situations it may
 
 \ 
 
 448 INTERMITTENT FEVER. 
 
 give rise to an affection not distinguishable in its symptoms from yellow fever; and 
 that in proportion as the locality is higher and cooler, the fever tends to assume first 
 the remittent, and then the intermittent type : that the period of incubation — the 
 
 f)eriod which intervenes between exposure to the malaria and the invasion of the 
 ever — is extremely variable in duration : that the poisonous efiiuvia affect straiin-ers 
 more certainly and more severely than natives of the place : that persons may be- 
 come in some sort seasoned to the malarious districts : but that, with the exception 
 of the negroes in the West Indies, the inhabitants of places much infested with the 
 peculiar miasmata, are feeble, and sickly, and short-lived 
 
 There was one point which I briefly adverted to, and dismissed perhaps too un- 
 ceremoniously : I mean the very curious fact of the regular periodic recurrence of 
 the paroxysms of intermittent fever. I ought, I think, to have informed you of the 
 views which pathologists have entertained respecting the explanation of that singular 
 circumstance ; although it must be confessed that the solution of the phenomenon is 
 still to be sought for. A great number of persons have tried their hands, however, 
 upon this question. Many of the earlier attempts at explanation are either quite hy- 
 pothetical, or totally insufficient and illogical. Wilhs ascribed the intermission to a 
 periodic development of the fermentable matter in the blood. But if any such de- 
 velopment took place (of which we have no evidence) we should be no nearer the 
 mark : the question would still recur, why the development of this matter should 
 happen periodically : and the same remarks apply to various other so-called expla- 
 nations brought forward by different writers of considerable reputation. Reil referred 
 the intermittence of fevers to some general law of the universe ; by which he meant, 
 I believe, some vague generalization of such facts as the alternation of light and 
 darkness, the periodic recurrence of the seasons, the ebbing and flowing of the tides, 
 the succession of appetite and satiety, of the states of sleeping and waking, and so 
 on : but this evidently is no explanation at all. M. Bailly ofl^ers a very singular 
 conjecture upon the subject : he attributes the periodic phenomena to the modifi- 
 cation necessarily induced in the human system, and particularly in the function of 
 circulation, by the alternate change of position from the upright to the recumbent, 
 and from the recumbent to the upright, every twenty-four hours ; and he adduces in 
 corroboration of this notion the alleged fact that animals, which undergo no such os- 
 cillation of posture, are not subject to intermittent fevers ; but this is said not to be a 
 fact. Rodet and Charpentier affirm that horses are liable to such complaints. Dr. 
 Macculloch refers to the case of a dog which laboured under a regular tertian ague 
 for some years ; the cold paroxysms taking place always at three o'clock in the 
 afternoon. Even if this were not so, M. Bailly's theory fails to account for the oc- 
 currence of continued fevers. If his views were correct, then we might avoid 
 having ague by refraining from these changes of position from the vertical to the 
 horizontal during sleep, and back again upon awaking. Recently M, Roche has 
 put forth the opinion that the attacks of ague are periodic, because the causes of 
 them are periodic. And if this could be made out, the conjecture would carry with 
 it some show of reason. He observes that the spring and the autumn are the 
 seasons in which intermittent fevers chiefly break out, especially the autumn : and 
 that during those periods there is a very sensible difference in the temperature and 
 humidity of the atmosphere by day and by night, and even within the space of three 
 or four hours ; that a consequent alternation of action and reaction is thus produced 
 in the human body, and soon becomes an established habit. Throughout a part of 
 the twenty-four hours, the operation of the miasmata is slight, or not manifest at all ; 
 while during another part of that period it is in full energy, and at about the same 
 time daily. The emenations (which he conceives to proceed from putrefying vege- 
 ble matter) are most abundantly disengaged during the hottest part of the day ; these 
 watery effluvia are dissolved by the warm air to a certain amount ; but after sunset, 
 they are again deposited, and deposited the more copiously in proportion to the cold- 
 ness of the atmosphere at that time ; and coming in contact with the surface of the 
 body, with the mucou« membrane of the air-passages, and perhaps also with that of 
 the digestive organs, and being absorbed by those surfaces, it occasions the phe-
 
 MALARIA. 449 
 
 nomena which constitute an ague fit. The influence of the miasmata being mter- 
 mittent, we need not wonder, he says, that their effects should be intermittent too: 
 and then he goes on to ascribe the repetition of the paroxysms, after the cause has 
 ceased to be applied, to that tendency observable in the animal system to reproduce 
 certain actions, simply because they have been produced before ; in one word, to 
 the effect of habit. At length the habit wears out ; which accounts for the sponta- 
 neous recovery of those who are removed from the malarious district. 
 
 It seems to be a very serious objection to M. Roche's theory, that the disease does 
 not show itself, sometimes, for weeks or months after the patient has been ex 
 pased to the miasmata. His theory fails altogether also to account for the dif- 
 ferent types of intermittent fever. The differences of type are indeed opposed to the 
 theory. 
 
 After all it is most probable that CuUen had discovered a part though not the 
 whole of the truth respecting the periodicity of intermittent fevers, when he 
 ascribed it to some law of the animal economy whereby it is subjected in many 
 respects to a diurnal revolution. " Whether this depends," he says, " upon the 
 original conformation of the body, or upon certain powers constantly applied to it, 
 and inducing a habit, I cannot positively determine ; but the returns of sleep and 
 watching, of appetites and excretions, and the changes which regularly occur in the 
 state of the pulse, show sufficiently that in the human body a diurnal revolution takes 
 place." But he also is much perplexed with the differences of type ; and all that 
 he can say on that point amounts to this — that as the three principal types observe, 
 severally, a particular time of day for their accession, and as quartans and tertians 
 are apt to become quotidians, these to pass into the state of remittents, and these 
 last to become continued ; and that as even in the continued form daily exacerba- 
 tions and remissions are generally to be observed — all this marks the power of di- 
 urnal revolution. 
 
 A most interesting experiment, as it appears to me, performed by M. Brachet 
 upon himself, shows in a strong hght the influence of acquired habit in continuing 
 cenain unnatural states of the system when once they have been originated : the ex- 
 periment connects itself also with the pecufiar phenomena of intermittent fever. 
 Towards the end of the month of October, in the year 1822, M. Brachet took a cold 
 bath at midnight, for seven nights in succession, in the river Saone. On the first oc- 
 casion he remained a quarter of an hour in the river; on the second, half an hour; 
 till at length he was able to stay in the water a full hour at a time. After each bath 
 he betook himself to a warm bed, and in a short lime became affected with consider- 
 able heat, followed by copious perspiration, in the midst of which he fell asleep. 
 At the end of the seven days M. Brachet ceased to repeat this experiment ; but what 
 was his surprise at finding, on the following nights, between twelve and one 
 o'clock, that all the phenomena of a true ague fit appeared in due order and suc- 
 cession ! As, however, this ar'ificial paroxysm was not very severe, and as he felt 
 quite well during the day, M. Brachet determined not to interfere with it ; but to 
 observe the result. Six times it recurred with great regularity. On the seventh 
 night after he had omitted the baths, he was summoned, towards midnight, to a 
 woman in labour : the ride to her house heated him, and on his arrival he kept up 
 the heal by placing himself before a large fire, and from that time the febrile phe- 
 nomena ceased to recur. 
 
 The facts and theories which I have thus brought roughly together, in respect to 
 the periodicity of agues, are not without interest, but they show that we have yet 
 much to learn on this subject. Granting that habit may have its share m coiuinuinir 
 the regular recurrences, we want some explanation of the return of the second and 
 third fit, after certain determinate intervals, to give a beginning to the habit. Ih 
 respect to the quotidian. Dr. Cullen's diurnal revolution might come to the rescue . 
 but this principle evidently will not apply to the tertian type. I know of no two- 
 day, or bidual habit. And the objection holds still more strongly in regard to quar- 
 tans. Indeed in quotidians themselves there is much ditficulty in applying the ex- 
 planation, for though by anticipating, or postponing, they mat/ come on at differeui 
 hours of the day, yet their usual and natural paroxysms occur, nol in the evening 
 29 ' 2 N 2
 
 450 INTERMITTENT FEVER. 
 
 T 
 
 but in the morning, when, on the principle of diurnal habit, there should be the least 
 tendency to exacerbation of febrile action.* 
 
 In yesterday's lecture, I pointed out the favourite habitats, if I may so speak, of 
 the malarious poison. I have still a k\v observations to make respecting its ascer- 
 tained habits and properties. Some of the laws to which it is subject are of great 
 practical importance, and ought to be popularly known"; much more ought every 
 medical man to be familiar with them. 
 
 [n the first place, all malarious districts are (as I have already hinted) much more 
 dangerous at night than in the day-time. Whether the poison be then more copi- 
 ously evolved, or whether it be merely condensed and concentrated by the dimi- 
 nished temperature, or whether the body be at that time more susceptible of its influ- 
 ence, it certainly is most active and pernicious during the hours of darkness. To 
 sleep at night in the open air in such places is almost to ensure an attack of the 
 fever. Lancisi was quite aware of this, and devotes a chapter to the question, "Cur 
 juxta paludes noctu prgesertim indormientes magis quam vigilantes Itedantur?" It 
 has repeatedly been observed among the crews of ships, when off a malarious coast, 
 that the sailors could go on shore in the day to cut wood, or for other purposes, with 
 impunity ; while the men who remained on shore through the night, guarding the 
 water-casks, were man}?- or all of them seized with the fever. Take one instance as 
 a sample of many. It is recorded by Dr. Lind. In 176G the Phoenix ship of war 
 was returning from the coast of Guinea. The officers and ship's company were 
 perfectly healthy till they touched at the island of St. Thomas. Here nearly all of 
 them went on shore. Sixteen of the number remained for several nights on the 
 island. Every one of these contracted the disorder, and thirteen of the sixteen died. 
 The rest of the crew, consisting of 280 men, went in parties of twenty or thirty on 
 shore in the day, and rambled about the island, hunting, shooting, and so on : but 
 they returned to the ship at night ; and not one of those who so returned suffered 
 the slightest indisposition. Exactly similar events occurred the following year, with 
 the same ship, at the same place, where "she lost eight men out of ten, who had 
 imprudently remained all the flight on shore;" while the rest of the ship's com- 
 pany, " who, after spending the greatest part of the day on shore, always returned 
 to their vessel before night, continued in perfect health." Many more examples of 
 the same kind are stated or referred to by Dr. Bancroft in his book on the Fellow 
 Fever : a book which is rich in information respecting the malaria. 
 
 The reapers in the "Campo Morto" — a well-named part of the Maremna which 
 1 yesterday mentioned — are permitted to sleep for two hours about noon. They 
 do so at that time without danger : but when the dews of evening have fallen down 
 upon the earth, which serves them for their bed, it is then that the poison puts forth 
 its most deadly power. Upon this principle Lancisi admonishes those who in sum 
 mer travel through the Pontine marshes, not to do so by night, as many had been 
 accustomed to do, in order to avoid the greater heat of the day : and similar advice 
 is still given at Rome to all strangers. Though the passage requires but six or eight 
 hours, there are numerous instances of travellers who, in consequence of their having 
 crossed these fens during the night, have been attacked, wath violent and mortal 
 fevers. 
 
 The practical lesson to be derived from a knowledge of this fact is too obvious to 
 dwell upon. In malarious countries the open air at night must be avoided. — " Early 
 to bed" is always ? good and wholesome rule; but the other half of the proverb, 
 " early to rise," becomes, in such countries, an unsafe precept. At least it is hazard- 
 ous to leave the house early. 
 
 Secondly, the malaria loves the ground. It tends downwards. Whether this 
 Jesuits from its specific gravity, or from its adhering to the moisture suspended in 
 the lower strata of the atmosphere, or from some pecuhar attraction for the earth's 
 surface, I cannot tell you. There is reason to suppose that the poison combines 
 bomehow, or becomes entangled, with fog : and fogs usually brood and settle, at 
 
 • I would beg to refer the reader to Dr. Holland's interesting chapter (in his Medical Notes 
 >*nd Re/ledions, published since these lectures were delivered) " On INIorbid Actions of Inter- 
 vijttent kind." — T. W.
 
 MALARIA. 451 
 
 night especially, upon the surface. This may be one reason why lying down to 
 sleep in the open air at night is so very perilous. The lower rooms of the same 
 house may contain the noxious effluvia, while the upper are free. " In all malari 
 ous seasons and countries," says Dr. Ferguson, "the inhabitants of ground Jioors 
 are uniformly affected in a greater proportion than those of the upper stories. Ac- 
 cording to official returns during the last sickly season at Barbadoes, the proportion 
 of those taken ill with fever in the lower apartments of the barracks exceeded that 
 of the upper by one-third, throughout the whole course of the epidemic. At the 
 same time it was observed that the deep ditches of the forts, even though they con- 
 tained no water — and still more the deep ravines of rivers and water-courses — 
 abounded with the malarious poison." Dr. Hunter, in his work on the diseases of 
 the army in Jamaica, says, " The barracks of Spanish Town consist of two floors, 
 the first upon the ground, the second on the first. The difference in the health of 
 the men on the two floors was so striking as to engage the attention of the Assembly 
 of the island : and upon investigation it appeared that three were taken ill on the 
 ground floor, for one on the other. The ground floor was not therefore used as a 
 barrack afterwards," Mr. Ralph, in a table printed as an appendix to a paper of 
 Dr. Ferguson's in the eighth volume of the Medico-Chirurgical Transactions, states 
 the results of an inquiry into the comparative healthfulness of the upper and lower 
 apartments of barracks in Barbadoes, to have been that the individuals residing in 
 the lower apartments were attacked in the proportion of two to one of those living in 
 the' upper : and with certain apparent exceptions, which I shall notice presently, 
 experience is uniformly in favour of the proposition that the poison is most preva- 
 lent and destructive near the surface of the earth, and does not rise high into the 
 atmosphere. 
 
 To specify the sanatory precautions dictated by an acquaintance with this pro- 
 perty of the malaria, must be quite superfluous. 
 
 Thirdly, the malaria is movable by the wind. It is capable, therefore, of being 
 carried from the spot where it was generated, and to other places which might else 
 be free from it and healthy. In this respect it is analogous to a heavy fog or vapour : 
 and, in some cases, it is accompanied by a palpable mist ; to which, perhaps, it may 
 cling. The following passage relative to this subject occurs in Bishop Heber's 
 Journal. " From Cheeta Talao our road lay through a deep and close forest, in the 
 lower parts of which, even in the present season, the same thick milky vapour was 
 hovering as that which I saw in the Terrai, and which is called essence of owl." 
 This Terrai is the region which I mentioned in the last lecture as being so pestife- 
 rous, that it is deserted, during certain parts of the year, by every living creature. 
 
 This conveyance of the poison, like a cloud or fog, from one part of the surface 
 of the ground to another, it is very important to attend to in all places ; and espe- 
 cially so in tropical climates, where the wind blows for a long time together from 
 the same quarter. We are thus enabled to account for the apparent exceptions to 
 the last-mentioned property of the malaria, viz., its preference of low to elevated 
 situations. You will readily understand how the miasmata may roll up, and hang 
 accumulated upon, the side of a hill towards which. a current of air sets steadily from 
 or across a neighbouring marsh. Nay, the poison may be thus blown over a hill, 
 and deposited on the other side of it. In this way, I presume, are to be explained 
 the following curious facts, related in Dr. Ferguson's paper. 
 
 The beautiful port of Prince Rupert's, in the island of Dominica, is a peninsula 
 which comprehends two hills of a remarkable form, joined to the main land by a flat 
 and very marshy square isthmus to windward, of about three-quarters of a mile in 
 extent. The two hills jut right out on the same line into the sea, by which they 
 are on three sides encompassed. The inner hill of a slender pyramidal form, rises 
 from a narrow base nearly perpendicular, above and across the marsh from sea to 
 sea, so as completely to shut it out from the port. The outer hill is a round-backed 
 bluff promontory, which breaks off abruptly, in the manner of a precipice above the 
 sea. Between the hills runs a very narrow clean valley, where all the establish- 
 ments of the garrison were originally placed; the whole space within the peninsula 
 being the driest, the cleanest, and the healthiest surface conceivable. It was speedily
 
 452 INTERMITTENT FEVER. 
 
 found that the barracks in the valley were very unhealthy ; and to remedy this fault, 
 advantage was taken of a recess or platform near the top of the inner hill, to con- 
 struct a barrack which was completely concealed by the crest of the hill from the 
 view of the marsh on the outside, and at least three hundred feet above it : but it 
 proved to be pestiferous beyond belief. In fact no white man could possibly live 
 there, and it was obliged to be abandoned. At the time this was going on, it was 
 discovered that a quarter which had been built on the outer hill, on nearly the same 
 line of elevation, and exactly five hundred yards further removed from the swamp, 
 was perfectly healthy ; not a single case of fever having occurred in it from the time 
 it was built." 
 
 There is a striking anecdote given by Lancisi, showing, on a small scale, the effect 
 of the wind in carrying the malaria with it. Thirty ladies and gentlemen had sailed 
 to the mouth of the Tiber on an excursion of pleasure. Suddenly the breeze shifted 
 to the south, and began to blow over a marshy tract of land situated to windward of 
 them. Twenty-nine of the thirty were immediately after attacked with tertian 
 ague. So also Humboldt informs us that the town of Cariaco is afflicted with inter- 
 mittents by the north-west wind conveying across it the miasmatic emanations of the 
 Laguna of Campona. 
 
 And as the wind may thus transport the malaria to a distance, and thereby render 
 a spot unhealthy which naturally would not be so : so also it is often of service in 
 clearing the poison from other places, and preventing its concentration. 
 
 A knowledge of these facts ought to be valuable in determining the choice of 
 encampments, and of sites for dwelling-houses in aguish districts. Settlers in hot 
 chmates, especially where trade-winds prevail, would do well to avoid founding towns 
 on the lee side of any swampy or suspicious ground. The outlets of rivers are 
 commonly selected, for the convenience of commerce : and there is often a right and 
 a wrong bank. I believe that most of the principal towns in the West Indies are 
 built, for the advantage of the outward-bound vessels, upon the western, or lee side 
 of the island. 
 
 Fourthly, it is a singular, but well-ascertained fact, that the miasmata lose their 
 noxious properties by passing over even a small surface of ivater. Probably they 
 are absorbed by it. And this is another proof of their tendency downwards. Many 
 instances have already been referred to, where some of the crew of a ship have 
 landed on a malarious coast, and have all been attacked by the fever ; while the rest 
 of the sailors, who remained on board, continued all healthy and well, though the 
 ship was close to the shore. You could not have a better or more striking example 
 of this than what took place at Walcheren. "Not only the crews of the ships in 
 the road of Flushing were entirely free from the endemic ; but also the guard-ships 
 which were stationed in the narrow channel between this island (Walcheren) ai 1 
 Beveland. The width of this channel is about six thousand feet, yet, though some 
 of the ships lay much nearer to one shore than to the other, there was no instance of 
 any of the men or officers being taken ill with the same disorder as that with which 
 the troops on shore were affected." This Sir Gilbert Blane has told us ; and it is 
 curious that Sir John Pringle made the very same remark in the very same place in 
 1747. He is speaking of the diseases of the campaign in Dutch Brabant ; espe- 
 cially in reference to four battalions which had remained for some time in Zealand: 
 and "he says, " But Commodore Mitchell's squadron, which lay all this time at anchor 
 in the channel between South Beveland and the island of Walcheren, in both which 
 places the distemper raged, was neither afflicted with the fever nor the flux, but 
 amidst all that sickness enjoyed perfect health ; a proof that the moist and putrid air 
 of the marshes was dissipated, or corrected, before it could reach them." 
 
 It is probable that this peculiarity has led to an erroneous and contracted estimate 
 of the space throucrh which the poisonous effluvia can be carried upon land, by the 
 wind. Although the distance to which they are capable of being so conveyed. 
 A'ithout losing their morbific power, has never been precisely defined, there can be 
 no doubt that it is considerable. In Italy, according to Dr. Macculloch, the poisonous 
 exhalations of the lake Agnano have been ascertained to reach as far as the convent 
 of CamaldoU, situated on a high hill three miles distant.
 
 MALARIA. 453 
 
 Fifthly, another remarkable property of the marsh poison, is its attraction towards, 
 and its adherence to, the foliage of lofty umbrageous trees: so that it is very danger- 
 ous, in malarious places, to go under large thick trees, and still more dangerous 
 to sleep under them. But this property, thus a source of peril to those who are 
 ignorant of it, affords when known and rightly made use of, a mode of protection 
 and remedy against the influence of the miasmata. In the territory of Guiana, 
 where large trees abound, the settlers live fearlessly, and unhurt, close to the most 
 pestiferous marshes, and to leeward of them, provided that a screen or beh of trees 
 be interposed. New Amsterdam, in Berbice, hes on the lee side of an immense 
 swampy forest, in the direct tract of a strong trade-wind that blows night and day, 
 and pollutes even the sleeping apartments of the town with the stench of the marshes; 
 yet it brings no fevers. The inhabitants are well aware that it would be almost 
 certain death for an European to sleep, or even to remain after nightfall, within the 
 verge of the forest. To cut down the trees would not only be a perilous operation 
 in itself; but would let in pestilence to the town. 
 
 This property also of the malaria, as well as the use to which it may be turned, 
 was known to Lancisi. He describes the vast increase of agues and remittent fevers 
 in Rome during the summer of 1G95, after a great overflowing of the Tiber, by 
 which the lower part of the city, and the fields adjacent, had been inundated in the 
 preceding winter. The bad effects of this flood were felt throughout the whole of 
 Rome, with the exception of one particular quarter, which was protected by a belt 
 of trees around it. Lancisi even addressed a remonstrance to the Pope against a 
 project which was entertained of felling some wood near the Pontine marshes, be- 
 tween them and the city. He endeavours to show that woods and groves were first 
 made sacred on account of their conservative influence in this way, to prevent their 
 ever being cut down. 
 
 It would appear, from the facts I have just been detailing, that dwellings unfortu- 
 nately built in the vicinity of marshes, might sometimes be rendered safe and salu 
 brious by encircling them at a little distance by a hedge of trees— or (perhaps) even 
 by drawing round them a broad moat of water. Such experiments deserve, at least, 
 a fair trial. 
 
 Sixthly, the production and consequently the efTects, of the malaria are prevented, 
 or lessened, by cultivation. It is to this, that the diminution of agues in this country 
 is mainly attributable. The fenny lands have been drained ; and many of them 
 brought under the plough. Dr. Craigie states that East Lothian, in Scotland, was 
 at one time so productive of malaria, that it was quite an expected thing that the 
 reapers in harvest should be attacked with ague ; but that now, in consequence of 
 the perfect tillage, and the numerous tracts of wood with which the country is 
 covered, that disorder is quite unknown there. Converseljs in regions which have 
 been suffered to fall out of cultivation, intermittent and remittent fevers multiply. 
 The more thoroughly any country is cultivated, the more fully, in general, it is 
 peopled also : and in many places the prevalence of these fevers has been observed 
 to diminish and increase with the increase and diminution of the population. Caeleris 
 paribus, agues are much less common in large towns than in country villages. This 
 has been oddly enough accounted for by saying that populous cities are so full that 
 there is no room for the malaria. A much more rational and probable explanation is 
 that which ascribes the freedom of crowded towns, and thickly inhabited districts, to 
 the number of fires burned in them. 
 
 Many instances might be adduced to show that the more any place naturally pro- 
 ductive of malaria, is depopulated, the more evident does the power of the poison 
 become. The Italians date the introduction of the malaria into the Maremna, from 
 the great plague in the sixteenth century, since which period the inhabitants of thai 
 district have never been sufficiently numerous to counteract the bad air which in 
 creases as population and agriculture diminish. 
 
 Bishop Hcber, in the narrative I quoted before, bears testimony to facts of th« 
 same kind with those I have now been stating. He says, " At the foot of the lowest 
 hills, a long black level line extends, so black and level, that it might seem to have, 
 been drawn with ink and a ruler. This is the forest, from which we are still re-
 
 454 INTERMITTENT FEVER. ' 
 
 moved several coss, though the country already begins to partake of its insalubrity. 
 It is remarkable that this insalubrity is said to have gi'eatly increased in the last 
 fifteen years. Before that time, Ruderpoor, where now the soldiers and servants 
 of the Police Thanna die ofTso fast that they can scarcely keep up the establishment, 
 was a large and wealthy place, inhabited all the year through, without danger or 
 disease. The unfavourable change is imputed by the natives themselves to depopu- 
 lation. The depopulation of these countries arose from the invasion of Meer Khan, 
 in 1805. He then laid waste all these Pergunnahs, and the population, once sa 
 checked, has never recovered itself." 
 
 When persons having intermittent fever are unable to leave the unhealthy situa 
 tion in which they have been exposed to the influence of the malaria — and espe- 
 cially when they are placed under unfavourable circumstances in respect to food, 
 and clothing, and shelter — the disease is apt to become exceedingly serious, leading 
 to disorder of the sensorium, and great disturbance of the abdominal viscera, even 
 in the intermissions ; sickness, diarrhoea, dysentery, diseases of the liver. 
 
 [Dr. S. A. Cartwriglu, of Natchez, asserts, that the ptssieua grandiflora, or floating plant of 
 the liayons and lakes of lower Louisiana, has the power of preventing the development of 
 malaria in regions particularly adapted to its generation, He affirms, also, that "it purifies 
 all stagnant water in which it grows — that of the lakes and bayous inhabited by it, being as 
 pure to the sight, taste, and smell, as if it had just fallen from the clouds." He ascribes to 
 the presence of and the peculiar "hygienic or health-preserving properties of this plant,'' the 
 remarkable exemption of the inhabitants of lower Louisiana from " malarious or miasmatic 
 diseases." "The fact," he remarks, "that the region of country in which this aquatic plant 
 abounds, is exceedingly healthy, can be established beyond cavil or dispute; it nevertheless 
 contains more stagnant water and swamps than any other inhabited district, of the same 
 extent, in the United States." — C] 
 
 In Zealand, the biliary functions suffer so much during the complaint, that it is com- 
 monly known among the inhabitants of that country under the name of the gall fever. 
 The frequent unnatural concentration of the blood in the internal parts may afford 
 a reasonable explanation of these phenomena. When death takes place, morbid 
 appearances present themselves such as might he expected : hepatic alterations ; 
 inflammation and ulceration of the mucous membrane of the alimentary canal : but 
 the most characteristic morbid condition produced by repeated attacks of intermittent 
 fever consists in enlargement of the spleen ; Avith or without induration of its sub- 
 stance. That viscus is sometimes enormously increased in bulk, so as to be felt, 
 and even its outline seen through the integuments of the abdomen. It has been 
 known to weigh nearly eleven pounds. So common is this state of the spleen, that 
 it is familiar to the observation of the vulgar, who have even given it a name : it is 
 called among the inhabitants of the fenny parts of this country, the ague cake. I 
 beheve that whenever the abdominal circulation is much embarrassed, and the 
 abdominal veins gorged, as they must be during the cold stage of an intermittent, 
 the spleen in particular becomes distended with blood. Constantly we see this 
 happen when the passage of the blood through the portal vessels is impeded by 
 disease of the liver. Now this distension may not thoroughly subside perhaps at 
 once. If the paroxysms of ague be frequently repeated, we may understand how 
 the spleen may become fuller of blood on each successive occasion. It may be that 
 a portion of the blood coagulates ; or that inflammation of a slow kind is set up in 
 the stretched covering of that organ. At all events, this is a veiy common sequel 
 of ague ; and it can scarcely be doubted that the repeated congestions of the internal 
 vessels and viscera are the determining causes of the ague cake. 
 
 Independently of the paroxysm of ague, there is ample evidence to show the 
 mjurious influence of the malarious districts upon the general health. In this 
 country suT:h effects are not much seen ; but in places where the malaria is more 
 constantly and abundantly present, the race of inhabitants deteriorates. Their 
 stature is small; their complexion sallow and yellowish; the)'' are prematurely old 
 and wrinkled ; even the children early acquire an aged aspect ; and the spirits and 
 intellects of those who dwell in these unhealthy spots are low and feeble, and par- 
 take of the degeneration of the-'r bodily qualities.
 
 MALARIA. 455 
 
 It is therefore strange that a notion should ever have prevailed, of the salutifcrous 
 eiTects of an attack of ague. But such a notion may be traced from very nearly 
 our own times up to the earliest records of physic. " The late Dr. James Sims, 
 who was a physician o!' some note in this town, felt convinced, at the commencement 
 of the illness which terminated his life, that he should recover if he could catch an 
 ague : and he went down into one of the marshy districts expressly for that purpose ; 
 but returned to London without having succeeded, complaining that the country had 
 been spoiled by draining, and that there were no agues to catch. The superstitious 
 Louis XL entertained a similar opinion, and prayed to the Lady of Selles that she 
 would confer upon him a quartan ague. Our monarch, James the First, had more 
 sensible notions on that score. There is an old English proverb which says, 'An 
 ague in the spring, is physic for a king;' and when this was repeated to him by his 
 courtiers, he, being then ill of that disease, answered that the adage might be appli- 
 cable to a young man, but that it would not do for an old one like him. In fact, as 
 I mentioned before, he died of his ague. The same doctrine has, hou'-ever, been 
 handed down to us by the father of physic himself. Hippocrates says, in the fifty- 
 seventh Aphorism of his fourth Section, vno oxa^^aov, vi -tita-vov svoxfMi/j-svco, ftvpsfo^ 
 (Ttiysvoixsvoi %vH to vov!;t;ua. And Celsus, in his capital digest of the medical know- 
 ledge of his time, preserves the same opinion, with some apparent astonishment 
 that it should be true. ' Denique ipsa febris, quod maxime mirum videri potest, 
 saepe prajsidio est.' I recollect hearing Dr. Graham, the professor of botany in 
 Edinburgh, relate the following anecdote in one of his clinical lectures, — His brother 
 was intimate with the professor of natural history at Cremona ; and this gentleman 
 was resolved to put the truth of the aphorism that I have quoted from Hippocrates 
 to the test. Accordingly he sent a patient afflicted with epilepsy, to pass a night or 
 two in a marshy place, where the malaria was known to be so abundant and so 
 powerful that (e\v escaped ague, who were there exposed to its influence, and the 
 twofold design succeeded admirably. The patient got an ague, and lost his epilepsy. 
 The worthy professor contented himself with moderating and keeping in check the 
 new complaint, thus intentionally produced, for a period of six months, when he 
 administered its coup de grace in a few doses of Peruvian bark ; and the epilepsy 
 never returned. If I had believed that this could have been any thing more than a 
 mere coincidence, I should have told you of it before, when I was speaking of the 
 treatment of epilepsy. I should rather imagine the notion thus prevalent for so long 
 a time, that ague had a salutary tendency, and that it was wrong to stop it too soon, 
 to have originated in the difficulty which physicians found in stopping it, before its 
 cause was so well understood, and the specific for it was discovered. They found 
 it obstinate under the feeble and inert methods then employed, and therefore they 
 endeavoured to persuade their patients, and perhaps themselves, also, that the disease 
 had better proceed a certain length. 
 
 I have very little to saj^ in addition to what you must have inferred from what I 
 have already said, as to ihe prognosis in intermittent fevers. In cold countries, such 
 as ours, it is almost always favourable. Of course it will be modified by the pre- 
 vious condition of the patient : if he was beforehand the subject of serious organic 
 visceral disease, or if he be very old or infirm, the supervention of ague may destroy 
 him. But to persons of tolerable heaUh and strength prior to the setting in of the 
 ague, we may confidently promise a acre. In warm countries intermittent fevers 
 are much more dangerous: and are sometimes very rapidly fatal. They are often 
 accompanied by most severe affections of the head, stupor, delirium, convulsions ; 
 and of the alimentary canal, diarrhoea, sickness, and not unfrequently the black 
 vomit. They are prone, also, in those climates, to run into the remittent or conti 
 nued form; and this tendency is shown by long protracted paroxysms, or by the 
 anticipation or doublincr of the paroxysms. In all countries quartans are cured with 
 more difficulty than either tertians or quotidians. And quartans are most common 
 in the autumn : and accordingly autunmal intermittents are more pernicious and in- 
 tractajiile than the vernal. This fact has passed into a proverb in Italy ; which 
 proverb has been thus translated into Latin, " Febris autumnalis — vel est longa, vel 
 lelhulls.''' The longer intermittents have lasted, the more difficult also are they tf
 
 456 INTERMITTENT FEVER. 
 
 cure : and certainlj^ there is much more danger of visceral disease in those that are 
 of long standing. 
 
 It is probable that agues, such as we see in this country, would generally, under 
 favourable circumstances, terminate in spontaneous recovery, provided that the 
 patient could be put beyond the further operation of the malaria, protected from 
 exposure to wet and cold, and suitably nourished. But possessing as we do a spe- 
 cific cure for ao^ue, if there be such a thing as a specific, there would be no sense in 
 our allowing the spontaneous recovery to be made : or rather Ave should be inex- 
 cusable, knowing as we do that the complaint is the more obstinate the longer it has 
 lasted, and that it tends to the establishment of organic visceral disease, we should 
 be inexcusable if we did not stop it as quickly as we can. The disease is always 
 distressing to the patient, and always debilitating. It may be dangerous, even in 
 these climates, to weak or old persons : and it is dangerous to all persons in hot cli- 
 mates. " If the first fit (says the wise and observant Heberden) has been marked 
 so clearly as to leave no doubt of its being a genuine intermittent, the remedy should 
 be immediately given in such a manner as to prevent, if possible, a second." There 
 needs very little preparation of the patient before administering the specific substance 
 which is to cure him ; and which every one here knows before he hears me say so, 
 is the celebrated Peruvian bark, or its active principle as presented by the salts of 
 quina. The old practice was to wait a few returns of the fits, either till some hypo- 
 thetical ferment had taken place, or until supposed morbid matter had been expelled 
 by vomiting or purging. There is, however, one very simple and short preparative 
 which I am in the habit of using, and which I learned at Cambridge. You are 
 aware that Cambridge is situated on the very edge of the fenny country which ex- 
 tends along that part of the east coast of the island. Numerous patients afflicted with 
 ague come in from the surrounding villages ; and Dr. Haviland found that many of 
 these had taken quina before they applied for assistance as out-patients at the hospi- 
 tal ; but with very poor success. Now these cases readily gave way — the patient 
 remaining in all other circumstances as before — after the operation of a calomicl 
 purge. I have adopted this practice, therefore, upon his recommendation ; but it 
 does not delay the specific treatment. I generally prescribe three grains of calomel 
 with six or eight grains of rhubarb at bed-time, and commence with the quina the 
 next morning. Very lately, in perusing the late Dr. Baillie's posthumous volume, I 
 met with the following passage : — " 1 have known a good many cases in which bark 
 alone would not cure an ague. In all these cases, as far as I now recollect, Avhen a 
 grain of calomel was given every night for eight or ten nights, bark cured the ague 
 in the course of a few days. This practice I learned from my friend Dr. David 
 Pitcairn." 
 
 I believe that calomel given once in a purgative dose is enough. 
 
 But first of all what is to be done for the patient while he is in the fit ? I confess 
 to you that I seldom give myself much concern on that head. In ague, as we see it 
 in this country, nature generally prompts the patient what to do ; to cover himself 
 up in bed, and apply warmth to his feet, and to take some hot drink during the 
 rigors ; to adopt a cooler regimen during the hot stage ; to Avipe his skin dry, if the 
 sweating should be very profuse or protracted. But in hot countries, and in severer 
 forms of intermiuent, the patient really requires some help ; and therefore I must 
 consider shortly in the next lecture the management of the paroxysm ; and I am the 
 more jound to do so, because certain measures which I do not think necessary' or 
 judicious, at any rate for the complaint as we see it here, have lately been stronorl 
 "■ecommended durins: the ague-fit.
 
 TREATMENT. 457 
 
 LECTURE XLII. 
 
 Treatment of Intermittent Fever ; during the paroxysm ; during the intermis 
 
 sions. Prophylaxis. 
 
 I WAS about, when we last separated, to consider the treatment of ague : first, 
 during the paroxysm ; secondly, during the intermissions. 
 
 In this climate we need not, I say, encumber a patient in an ague-fit with too 
 much help. But in hot countries, where the disorder is apt to run into the remit- 
 tent, or even the continu d form, and where, during its violent and rapid course, 
 internal organs are liable lO sustain serious damage, the best, and indeed almost the 
 only time for the effectual interference of the physician is in the first assault or pa- 
 roxysm of the disease. 
 
 The objects of treatment during the paroxysm are, to alleviate the uneasy sensa- 
 tions of the patient : to abridge, if possible, their duration, by shortening the fit ; and 
 to avert the danger which, under certain circumstances, may arise from intense inter- 
 nal congestion long continued, or from the severity of particular symptoms. 
 
 Now in the cold stage of ague, diluent drinks have been recommended, and cor- 
 dials, and external ivarmth, and opiitm, and emetics, and blood-letting. One would 
 suppose that if some of these expedients were useful, others could scarcely be so too. 
 The diluent drinks are very proper : and 1 should allow the patient to use his own 
 discretion in the choice of them. It was customary, formerly, to prescribe medicated 
 drinks of this kind ; and one pleasant, but neglected ptisan still lingers in our Phar- 
 macopoeia, the decoctum hordei compositum. Now-a-days we are contented with 
 the simple barley-water, toast and water, weak tea, gruel, and the like. These dilu- 
 ents should be taken warm, and for persons who are very feeble or exhausted, they 
 may be made gently cordial ; weak negus, for example, or white wine whey, may 
 be given. 
 
 External warmth, being what nature and common sense would suggest, is cer- 
 tainly advisable and beneficial in the cold fit ; even the warm bath, if it can be pro- 
 cured. In some places it is the custom to await an expected fit iii the warm bath. 
 When this cannot so conveniently be obtained, the pediluvium may be employed ; 
 or the patient may be put into a warmed bed, and have bags of hot salt or bran ap- 
 plied to his epigastrium; and a hot bottle, or a hot brick, wrapped up in flannel, to 
 his feet. Or, what perhaps is best of all, he may have a hot air bath applied to him, 
 as he lies in bed. This may be very easily done, by means of a semi-cylinder or 
 cradle of wicker work, closed at one extremity by a board. This is laid over the 
 patient, and then covered with blankets. Through a hole in the centre of the board 
 one end of a curved iron tube is passed ; the other end, expanded into a bell, looks 
 downwards : and a spirit lamp being placed beneath it, the air between the wicker 
 work and the sick person is soon made very hot. This apparatus was constructed 
 many years ago, by Dr. Gower, when he was physician to the Middlesex Hospital ; 
 where its utility has been fully proved. External warmth applied in some one of 
 these ways, affords singular comfort oftentimes, and contributes to shorten the cold 
 stage. And the same may be said of friction, with stimulating liniments, along the 
 course of the spine. Lind found that, in children, rubbing the spine with an embro- 
 cation composed of equal parts of soap liniment and laudanum, at the approach of 
 the cold stage, often prevented the paroxysm. 
 
 Opium has often been exhibited in the cold stage, with the view of cutting short 
 the fit ; and not without some success. The strongest evidence of its usefulness in 
 that stage of the paroxysm is furnished by Dr. Trotter, in his Medicini Nautica. 
 Agues being very frequent among the crew of the Vengeance, he resolved to try the 
 full effect of opium in preventing the fit. At its first approach a dose of laudanum 
 (never less than thirty drops) was given ; if this did not bring on some wanuth 
 within ten or fifteen minutes, from twelve to twenty drops more were administered 
 In most cases, "in a few minutes an exhilaration of spirits was perceived ; the pvls** 
 
 2o
 
 458 INTERMITTENT FEVER. 
 
 from being weak, quick, and sometimes irregular, became less frequent, full, and 
 equal ; an agreeable warmth was diffused over the whole frame, and every unplea- 
 sant feeling vanished, sometimes in a quarter of an hour. The patients were them- 
 selves surprised at the sudden change in their sensations." Dr. Trotter speaks of 
 these as being the completest cures that ever came under his observation. If, at the 
 next period, the paroxysm threatened to recur, the opiate was repeated always with 
 the same success. " Few instances were met with where any indisposition indi- 
 cated a third attack, at the expected period of accession." Notwithstanding this 
 testimony, it appears that opium is still better adapted to another stage of the 
 paroxjrsm. 
 
 Emetics were formerly much prescribed in the cold stage, at its earhest approach. 
 Cullen recommends them ; and they may sometimes be useful, in spite of Chomel's 
 assertion that they are always hurtful. That they have gone so much out of fashion 
 is, however, a proof that they cannot be depended upon for cutting short the parox- 
 ysm. Vomiting is itself no small distress to many persons ; and for my own part, 
 I should not think of giving an emetic unless some indications of a loaded and op- 
 pressed state of the stomach weje present ; such as nausea, an ill taste in the mouth, 
 a coated tongue, and foul breath. A scruple of ipecacuanha will, even then, be 
 sufficient. The object is to empty the stomach effectually, but mildly. I would not 
 give antimony. Irritability of the stomach, in the more violent of these fevers, is 
 too apt to arise spontaneously. Sir Gilbert Blane tells us that the greatest impedi- 
 ment to the cure of the severer intermittents at Walcheren, in their early stages, 
 proceeded from the extreme irritability of stomach, which made it difficult to admi- 
 nister the requisite medicines. In hotter chmates nausea and vomiting are still more 
 common and more urgent ; and we have to guard against the risk of inducing or 
 aggravating these symptoms. " Emetics (says Dr. Mackintosh, in his Practice of 
 Physic) have been often extolled, but I believe eveiy experienced tropical physician 
 will agree with me in cautioning young practitioners against their indiscriminate em- 
 ployment. Irritability of the stomach is one of the most frequent and troublesome 
 symptoms ; and once excited, it is always difficult, and in many cases impossible to 
 restrain it. I have seen emetics exhibited, and the vomiting has continued till death, 
 in spite of every remedy." 
 
 [We have repeatedly prevented the accession of the chill by administering to the patient, 
 just before the period when it was expected, an emetic of ipecacuanha, and after this had 
 ceased operating, immersing his feet in hot water, and, as soon as he is placed in bed, giving 
 him from 30 to 40 drops of laudanum, or a teaspoonful of the camphorated tincture of opium. 
 By this treatment not only is the chill prevented or shortened, but the whole paroxysm is 
 often rendered milder. — C] 
 
 Latel\^ the practice o[ blood-letting m the cold stage has been revived (for it is 
 not a new practice), and strongly recommended by the physician whose name I have 
 just mentioned ; and whose opinion carries with it the more weight from its having 
 been founded on much personal experience in the treatment of these fevers. Dr. 
 iVlackintosh affirms that bleeding, performed in the cold stage, will often stop at once 
 the paroxysm, and with it the disease : that even when its curative effects are less 
 decisive, it will generally stop the cold stage and shorten the paroxysm, and mitigate 
 its severity, and afford speedy and great ease to the distressful sensations of the 
 patient; and that any subsequent paroxysms which may occur will be mild and few. 
 One bleeding, he says, is commonly sufficient ; sometimes two are required : seldom 
 more than two. The blood is to be suffered to flow till the patient feels rehef : wliich 
 usually consists in hberation from pain of the head and loins; freedom of respira- 
 tion ; the departure of the painful sensation of cold ; and the cessation of the tremors 
 and of tiie debility. Most of the patients fall asleep after the operation. These 
 effects have been pr educed by the abstraction of an ounce and a half of blood ; they 
 ha?e sometimes (but rarely) required for their production twenty ounces. 
 
 Now this is the piece of practice to which I adverted at the "close of yesterday's 
 lecture, as being, iU my humble opinion, inexpedient and not to be recommended* • 
 9t least in the agues of this country. I have seen a good many cases, first and last, 
 und certainly I have never seen one in which I could have thought such an heroic 
 
 T
 
 TREATMENT. 459 
 
 remedy necessary, in the cold stage ; if indeed it be, in that stage, a remedy at all. 
 But I do not desire to oppose my experience alone, or my judgment, to that of Dr. 
 xMaclcintosh. His method has been tried, since he first made it public, by various 
 practitioners in this country. Drs. Townsend and Law, of DubHn, found it fail in 
 the majority of cases. In Dr. Stokes's hands, the most usual effect of blood-letting 
 in the cold stage was, to check the shivering ; and, next to this, to mitigate iis severity, 
 without abridging its duration. In most instances, no modiiicalion was produced ot 
 the hot and of the sweating stages. In Dr. Kelly's experience, the general effect 
 was, to shorten the cold stage, and to render the hot one milder ; but in some cases 
 it seemed to aggravate the symptoms. iVIr. Gill found that, although the blood-Jetting 
 might cut short the cold stage, it appeared to lengthen the period of febrile disturb- 
 ance. Confining myself, then, to intermittents, as they show themselves in this cli- 
 mate, I cannot advise you to adopt the practice introduced by Dr. Mackintosh — of 
 bleeding in the cold stage. I object to it because it appears to me quite unnecessary; 
 because it is not such as the nature of the symptoms would suggest ; because it 
 tends to produce subsequent debility, which we should not needlessly inflict ; and 
 because the experience of other sober-minded men, who have given the method a 
 fair trial, does not bear out the statements made by Dr. Mackintosh in respect to its 
 usefulness. 
 
 At the same time, after a careful perusal of nearly a hundred cases adduced by 
 Dr. Mackintosh to illustrate the efficacy of this measure, I think it highly probable 
 that blood-letting may constitute the most important part of the treatment, in the 
 very outset of the severer malarious fevers of hot climates ; attended as they are 
 with a degree of internal congestion and disturbance which is dangerous to the integ- 
 rity of vital organs. 
 
 []\Ir. Twining, in his ^vork on the Diseases of Bengal, bears strong testimony in favour 
 of bleeding in the cold stage of intermittents. In the greater number of cases he lias found 
 it to arrest the paroxysm ; that is, the occurrence of the hot and sweating stages is pre- 
 vented. In the majority of patients, when the bleeding has been preceded by a course of 
 niilu purgatives, there will be no return of the disease, provided attention is paid to keep 
 the body properly clad and to guard against exposure to atmospherical vicissitudes. In this 
 manner, he remarks, we cut short the fever, and guard against those ulterior visceral engorge- 
 ments and indurations, by which it is too often prolonged, until the constitution is completely 
 ruined. 
 
 The only period of the cold stage at which bleeding is proper, Mr. Twining states to be, 
 at the very commencement of the rigor, or just when the coldness and shivering are com- 
 pletely established. lie has found that, in general, it is sufficient to take from an adult 
 twelve or fifteen ounces of blood, and in the most robust European he would limit the 
 quantity to be taken at one bleeding to twenty ounces. After the arm is tied up the patient 
 should be permitted to lie quiet in bed for an hour or two — but not heated by being covered 
 with too many bed-clothes ; he should be immediately supplied with a cup of warm tea, 
 gruel or thin sago. 
 
 According to Mr. Twining, " the requisites to ensure success from bleeding in the rigor, 
 are, 1st, the preliminary course of moderate purging; 2d, that the blood be taken, from a 
 large orifice, quite as soon as the coldness and rigor are fairly established ; and 3d, that the 
 patient be bled in a recumbent posture, and no more blood be taken than is suflicient to 
 arrest the paroxysm." 
 
 In robust plethoric patients, who, during the intervals of the paroxysm, complain of head- 
 ache, and morbid tenderness on pressure over tlie abdomen, and pain or uneasiness in the 
 chest, the disease will seldom be arrested by the first bleeding; in many cases, they will 
 Lave repeated paroxysms in each of which the use of the lancet will be required. Patients, 
 also, in whom the jiaroxysm, more especially the cold stage, is attended with vomiting, Mr. 
 Twining has found to require the repeated abstractions of small quantities of blood during 
 the rigors. — C] 
 
 If, in this country, bleeding be requisite at all, it is in the hot stage. But it is not 
 requisite at all, except when there appears to be danger of some internal inflatnma- 
 tion. The best remedy of the hot stage is undoubtedly opium. Dr. Lind, who 
 wrote after large experience, says that he never saw a person die in the cold fit, but 
 had known several carried off' in the hot one, with strong convulsions and delirium. 
 He happened to notice the beneficial effect of an opiate given while the patient was 
 very hot and feverish. He determined, therefore, to make further trial of opium 'ii
 
 460 INTERMITTENT FEVER. 
 
 the paroxysm. " Having at that lime (says he) twenty-five patients labouring undei 
 intermitting fevers, I prescribed an opiate for each of them, to be laken immedial elij 
 after the hot fit, provided the patient had then any inquietude, headache, or anV 
 such symptom usually subsequent to the fever. The consequence was, that nine- 
 teen in twenty-two received immediate relief; the other three had no occasion to 
 take it. 
 
 " Encouraged by this surprising success, I next day ordered the opium to be given 
 during the hot fit. In eleven patients out of twelve to whom it was thus adminis- 
 tered it removed the headache, abated the fever, and produced a profuse sweat ; 
 which was soon followed by a perfect intermission. Since that time 1 have pre- 
 -jcribed an opiate to upwards of three hundred patients labouring under this disease: 
 and I observed, that if taken during the intermission, it had not the least effect either 
 in preventing or mitigating the succeeding fit ; when given in the cold fit, it once or 
 twice seemed to remove it ; but when given half an hour after the commencement 
 of the hot fit, it generally gave immediate relief." 
 
 Dr. Lind goes on to state that he found the influence of opium more uniform and 
 constant in intermitting fever than in any other disease ; and more quick and. sensible 
 than that of any other medicine. 
 
 Very little need be said in regard to the sweating stage. Up to a certain pomi the 
 perspiration is to be promoted and encouraged. When the uneasy feelings of the 
 patient have abated, it should be restrained! ; not suddenly but with caution. Now 
 the sweating may be promoted by diluents ; by keeping the patient in bed, and 
 covered with moderately warm clothes ; by sippings of hot gruel or of hot chicken 
 broth. On the other hand, when the sweating has continued long enough, it may 
 be stopped by drying the patient with towels, changing his linen, and getting him up 
 out of bed. 
 
 It is well to bear all this in mind ; but I repeat once more that in agues, such as 
 you are hkely to meet with in this country, it is unnecessarj^ and therefore objection- 
 able, to be over-busy during the paroxysm. Wherever the disorder assumes a dis- 
 tinctly intermittent form, the most important part of the practice is that to be employed 
 during the intermissions. Now there are certain general remedies advised lor 
 adoption in this period ; and there are certain specific remedies. The general reme- 
 dies are bleeding, emetics, and purgatives. They need not detain us a moment. 
 Blood-letting may be used if there be any apparent tendency to local inflammation, 
 or any marks of severe topical congestion ; especially in young and robust subjects. 
 Barring such circumstances, there can be no occasion to bleed your patient in the 
 intermissions. 
 
 An emetic given a short time before the expected paroxysm has been known- to 
 prevent its accession ; and even has sometimes cured the disease. But we can stop 
 the parox3'sms by gentler and better means ; so that I should not prescribe an emetic 
 unless 1 saw symptoms of a foul and loaded stomach. 
 
 Purgatives should always be given at the outset. They clear the stomach and 
 intestines of hurtful accumulations, which are apt to impede the beneficial operation 
 of the quina, or of other drugs given to check the disorder. I mentioned in the last 
 lecture my own custom in this matter; viz., to give a couple or three grains of 
 calomel with eight or ten of rhubarb at bed-time ; and to commence with the specific 
 remedies the next Aviy. 
 
 Of these specific remedies, bark and arsenic are by far the most certain and im- 
 portant ; but a multitude of others have been highly praised for possessinof similar 
 virtues. 1 shall by and by say a word or two about some of these, because bark is 
 dear, and arsenic is scarcely a safe drug to be entrusted to the hands of unprofessional 
 persons ; and yet it is often expedient, in country places, where ao-ues are rife, to 
 provide the poor with remedies which they may have at hand ; and which should 
 both be reasonably cheap, and perfectly safe. 
 
 I shall not detain you with any account of the difficulties and objections which 
 were thrown in the way of the Peruvian bark, upon its introduction into the materia 
 niedica about the middle of the seventeenth century. Its use met with the most 
 violent opposition, even from physicians of the highest authority. It was resisted by
 
 TREATMENT. 461 
 
 Stahi and Hoffman ; and Boerhaave was never quite reconciled to it. Sydenham, 
 by his example and recommendation, greatly promoted its adoption in this country. 
 All this history is sufficiently curious and interesting, but I have no time for it : and 
 you will doubtless hear it from one of my colleagues. I will merely say that in the 
 Peruvian bark we have one of the very few specifics that we can boast of possessing; 
 and that, unhke most other highly vaunted substances, so far from falHng off from the 
 accounts first given of its virtues, it has acquired in the lapse of time an increase and 
 stabihty of reputation. 
 
 Neither shall I enter at all into the consideration of the qualities of the several 
 species of cinchona ; nor of the several principles that may be educed from them , 
 nor of the modes in which the quina even may be best procured. This would not 
 belong legitimately to my province. I must suppose that the professors of chemistry 
 and of materia medica have furnished you with the sulphate of quina which is the 
 only preparation of the bark I intend particularly to notice: and my business is to 
 tell you what I know in respect to its employment as a remedy for ague. 
 
 I may observe, however, that this is a remedy to which we could never have been 
 led by any process of reasoning. It is a matter of pure empiricism. We know 
 nothing of the seat or of the essential nature of the disease ; we are equally in the 
 dark as to the modus operandi of the quina in curing it ; yet our knowledge of ague, 
 upon the whole, estimated in reference to its precision and practical bearing, is more 
 satisfactory than of many other complaints, with the seat and nature of which we 
 are much better acquainted. The group of symptoms is so distinct, that we have no 
 trouble or doubt as to the diagnosis ; and experience has taught us a remedy which 
 is all but infallible. 
 
 The discovery of quina and its saks formed a great era in the history of the materia 
 medica. As far as my own experience goes, the sulphate of quina has quite super- 
 seded the necessity for exhibiting any other form of cinchona for the cure of ague. 
 Before quina was unshrouded by the chemist, the bark in substance was the only 
 form in which the remedy could be confidently relied upon : and I am old enough 
 to be aware of the infinite superiority of the salt, over the actual bark. To obtain 
 the desired effect, it was often necessary to give it in such quantities as almost justi- 
 fied x\Ir. Abernethy's sarcastic way of speaking of it and of physicians. He said the 
 doctors talked of throwing in the bark, as if it were to be pitched into the stomach 
 with a shovel. The sulphate of quina lies in a much smaller compass, and a more 
 commodious form ; and it does not cause that insupportable nausea which the woody 
 mass of the powdered bark was so apt to occasion. 
 
 I am in the habit of giving two, and sometimes three, grains of the sulphate of 
 quina every four or six hours during the intermissions, to those patients v/hom 1 have 
 occasion to treat for ague. This plan has succeeded so well, that 1 have never been 
 templed to try any other. I may, indeed, say that I have never known it fail to 
 stop an ague ; and to stop it speedily : so that very few parox3'sms have occurred 
 after the patient has begun to take the medicine. You may give it in the infusion 
 of roses, which contains a convenient quantity of sulphuric acid, to ensure the solu- 
 tion of the sulphate of quina. It changes the colour of the infusion, however, and 
 renders it pinker and opaque. Whether the draught be more or less elegant on that 
 account, I will not take upon me to say ; I know that the virtue of the quina is not 
 much interfered with by the change. In private practice, I commonly prescribe 
 as many drops of dilute sulphuric acid as there are grains of the quina, with a drachm 
 of the tincture of orange-peel, and a drachm of the syrup of the same ; completing 
 the draught with water. This I find my patients commonly approve of, except in its 
 bitterness, which, in solution, nothing can disguise. Or that salt may be administered 
 in the shape of a pill : it is best, however, and surest in solution. 
 
 A question has been raised, whether this remedy should be given in repeated 
 doses during the intermissions, or whether one very large dose should be given a 
 short time before the paroxysm is expected. Dr. Home made some experiments 
 on that point in the clinical wards of the Edinburgh Infirmary, some time ago; and 
 he thought that the result was in favour of the plan of giving the bark regularly at 
 short intervals. I have told you the amount of my own experience, which, how 
 
 2o2
 
 462 INTERMITTENT FEVER. 
 
 ever, is not very great ; nor have I had any severe cases to deal with. I think it 
 not improbable that my patients would have been cured quite as soon if I had given 
 the remedy in half the strength. Dr. Barker, of Dublin, has found small doses 
 equally effectual with large ones; and this is very likely to be the case with specific 
 remedies. It would appear, however, that in some quartans it is better to give large 
 doses before the return of the paroxysm. Dr. EUiotson gives large doses just after 
 the paroxysm ; and then smaller doses during the remainder of the intermission, at 
 regular periods. A great majority of those who suffer ague are poor persons. Of 
 course, the first object is to make the cure as speedy as possible ; the next to make it 
 as cheap as possible. So that it is not a matter of indifference, or mere speculative 
 curiositj', to ascertain with how little quina you may cure an ague. I repeat that it 
 has not happened to me to be disappointed, when I have given the medicine in small 
 doses, as already described : which amount to abont twelve grains in twenty-four 
 hours ; but, then, I suppose my cases have been well behaved and submissive. 
 Dr. EUiotson states that he is continually obliged to give twenty or thirty grains 
 in the twenty-four hours, before he can cure the complaint ; sometimes in ob- 
 stinate quartans, forty-five grains ; and he mentions one case in which a scruple 
 of the sulphate of quina, with ten minims of the liquor arsenicalis, were given every 
 eight hours in vain, but succeeded perfectly when given every six hours. 
 
 It appears also, upon the testimony of careful observers, that in warm climates 
 larger doses are required ; and that it takes a larger quantity, upon the whole, to 
 repel the complaint. In the aguish tracts of Italy, in the Maremna, small doses are 
 said to be inadequate ; and the physicians there are in the habit of giving twelve, 
 twenty-four, or even thirty grains at a time : and in one recorded instance, the dose, in 
 seven days, was got up to lOS grains, before the ague was arrested. The medium 
 dose, in many parts of America, seems to be eight grains. 
 
 It sometimes happens that the irritability of the stomach is so great as to make it 
 difficult to introduce a sufficient quantity of the remedy into the system. This diffi- 
 culty was very much felt at Walcheren : it is in a great measure removed since the 
 discovery of quina. But even the quina sometimes sits ill on the stomach ; and it 
 is often very difficult to get children to swallow any preparation of bark, on account 
 of its bitter taste. It is an important thing to know, therefore, that it has been found 
 scarcely less effectual, in curing the disease, when thrown into the rectum. The 
 menstruum in which it is dissolved should not exceed two or three ounces, lest the 
 bowel should reject it. Its expulsion may sometimes be prevented by adding a 
 few drops of laudanum to the enema. 
 
 [The quinia may also be administered endermically ; from 4 to 10 grains being sprinkled 
 upon a blistered surface, once, twice or oftener, according to circumstances, in the course of 
 the day. That the remedy will produce its specific effects when thus exhibited we know 
 from experience. — C] 
 
 It is said that bark in substance will sometimes cure the disease when quina 
 fails. I have never witnessed this : but in obstinate cases I would give the quina in 
 the decoction of bark. 
 
 [It is very certain that the quinia, even when given freely and in large doses, will occa 
 sionally fail in arresting the disease, and that the majority of such cases will be promptlj 
 cured by the bark in substance. This we have seen repeatedly to occur. — C] 
 
 You must not be satisfied with merely stopping the paroxysms. Patients will 
 often be too ready to give up their medicine, as soon as the paroxysm has once 
 missed. But the disease is very apt to recur; and it will always be right and pru- 
 dent to go on with the quina for ten days or a fortnight after the patient seems cured, 
 gradually diminishing, after the first week, the amount and the frequency of the 
 doses. 
 
 There have been some curious facts observed in regard to the relapses that are apt 
 to take place after the bark or the quina has been omitted. Clark, of Dominica, 
 states that if no more of the remedy be taken, in the West Indian ague, than is 
 barely sufficient to stop a fit, and then the bark is suspended, a relapse may take 
 place on the eighth day, in the case of a quotidian ; on the fourteenth or fifteenth
 
 TREATMENT. 463 
 
 in the case of a tertian or double tertian ; and on the twenty-first or twenty-second 
 in the case of a quartan : thus making (you see) in eacli type, seven periodi- 
 cal revolutions from the time the fit was suppressed to the next attack ; and the 
 fit was found to return on the proper day, at the same hour at which it would have 
 returned if its course had not been interrupted by the administration of the remedy. 
 All this is very curious, and inexplicable : but it points clearly to the propriety 
 of continuing the remedy for some time after the disease appears to have vanished. 
 
 [The Quini(B Sulphas Impurus of the United States Pharmacopceia, known in Philadelphia 
 under the name oi Extract of Bark, given in pills of from 3 to 5 grains every four hours, will 
 seldom fail in preventing the paroxysm of the disease. — C] 
 
 Arsenic is another substance which has great and unquestionable power over ague. 
 It carries Avith it these marked advantages : it is efficacious ; it is cheap ; and it is 
 tasteless. It is well adapted by these qualities for the poor, and for children, and for 
 patients of every age and rank in whom there is much irritability of stomach present; 
 but then it has also the serious disadvantage of being an active poison. One over- 
 dose may be fatal : and even its long-continued use in minute doses leads some- 
 times to evident and lasting disorder of the health. Arsenic, therefore, is an unsafe 
 remedy to be trusted in the hands of the ignorant. It should never be administered 
 except under the immediate supervision of a medical eye ; and even then it requires 
 to be given with much caution. Its bad effects may be very certainly prevented, 
 however, by care and attention : and it becomes a valuable instrument of cure, and 
 should be adopted without scruple, in cases where its operation can be watched, and 
 where the quina does not agree with the stomach, or fails to stop the disease. I 
 often prescribe arsenic for other complaints ; but, as I said before, I do not recollect 
 ever having been foiled in removing ague by the sulphate of quina. Some persons 
 are of opinion that relapses are less frequent after the cure by arsenic than after the 
 cure by bark. It would require a large induction of particular facts to make that 
 point clearly out. 
 
 When substances, which even in small quantities prove active poisons, are used 
 as remedial agents, it is convenient to have some definite form in which they may be 
 administered at all times, and in all places. The liquor potassse arsenitis of the 
 London Pharmacopoeia supplies such a form. This is the form in which arsenic 
 was recommended to the public by Dr. Fowler : and it is therefore sometimes called 
 Fowler^s solution. It was founded upon an analysis of the tasteless ague drop, 
 which had been in considerable repute in some parts of England. The pharmaco- 
 po^ial preparation is an arsenite of potass in solution. There are eighty grains of 
 arsenic in the new or imperial pint, and therefore four grains in an ounce of the so- 
 lution. Ten minims two or three times a day are a full dose for an adult : and you 
 had better commence with not more than five minims. Ten minims contain one- 
 twelfth of a grain. Twice that quantity has been administered at once ; but this 
 ought not to be done except when the system has been gradually inured to the 
 arsenic, and thereby enabled to bear such a dose. It is a good precaution not to give 
 this corrosive substance on an empty stomach. 
 
 The poisonous or hurtful effects that we have to look out for, when arsenic has 
 been prescribed, are loss of appetite, nausea, and sometimes vomiting ; griping pain 
 of the stomach and bowels, and diarrhcea ; and if the medicine be continued, faint- 
 ing is often added. Other symptoms, less constant, perhaps, and less important, are 
 painful and hot tumefaction and stiffness of the face and eyehds, or even a tingling 
 eruption something like nettle-rash. These effects may, I believe, be controlled by 
 adding a few drops of laudanum to each dose ; but I would rather advise you to sus- 
 pend the use of the arsenic ; or to leave it off altogether. When this is done, the 
 unpleasant symptoms will readily yield to mild laxatives, followed by opiates. 
 
 [The arsenical solution is a remedy admirably adapted for the cure of intermittent feve» 
 wlien it occurs in children, to induce whom to take the quinia in any form will be found 
 often impossible. When cautiously administered, and its effects are carefully watched, wi" 
 have never known any disagreeable eflects to result from the arsenic, and we have em 
 ployed it somewhat extensively. — C]
 
 464 INTERMITTENT FEVER. 
 
 T 
 
 When the paroxysms continue to recur in spite of the bark, it has been recom- 
 mended (and I think the plan a good one), to try to stop them by arsenic ; and 
 then, the })eriodic recurrence having been broken, to employ sulphate of quina to 
 prevent a relapse. 
 
 These, then, quina and arsenic, are the two sheet-anchors to which we trust in 
 the cure, of ague. A host of other remedies, I say, have had their praises sung. 1 
 do not intend to enumerate them. But there are a few which I think it right to 
 mention, for reasons already assigned. There is strong evidence of the efficacy of 
 some of them ; they are cheap, and easily accessible, and above all, safe ; and, there- 
 fore, in aguish districts, they may with much propriety and benefit be recommended 
 to the poorer classes, or distributed by Lady Bountifuls. 
 
 [The ferrocyanuret of iron is certainly a very valuable remedy in cases of intermittent 
 fever. Stokes places it in efBcacy after qtiinia and the arsenical solution, and perhaps he is 
 right in so doing; it will, however, often succeed in preventing the recurrence of the pa 
 roxysms, given in the dose of six grains every three hours. — C] 
 
 One of these is willoiv-bark ; in substance, or in decoction. If this does cure 
 agues, as it is affirmed to do, it w'ould seem as if Providence had placed the anti- 
 dote alongside of the poison ; for these trees, as you know, abound and flourish in 
 marshy places. The bark of the willow furnishes an alkaloid substance called saJi- 
 cine, in which the febrifuge property is believed to reside. Holly-leaves, and ilicint . 
 derived from them, stand in much the same repute in France, as willow-bark and 
 salicine here. 
 
 Another curious remedy, said to be very successful, is the web of the black spider, 
 which inhabits barns, stables and cellars. This substance has been tried on a tolera- 
 bly large scale, and the testimony to its influence in curing agues is very strong. 
 Dr. Craige has given this account of it. In the year 17G0, a number of prisoners 
 from the vanquished squadron of Thurot having been landed in the Isle of Man, 
 Dr. Gillespie, who was practising there, found that many of the agues which came 
 to prevail both among these prisoners and the inhabitants of the island, obstinately 
 resisted bark and such other remedies as he had recourse to. He was informed, by 
 an old French physician belonging to the squadron, of the alleged efficacy of cob- 
 web, in certain forms of the disease. He therefore made trial of cobweb, and founo 
 it to answer admirably. He was successful with it in more than sixty cases of dif 
 ferent types, in the Isle of Man, and he had further experience of its utility subse 
 quently in Ayrshire. 
 
 After this, the same remedy was tested in the West Indies, by Dr. Jackson, to 
 whom Dr. Gillespie had recommended it. Dr. Jackson's observations were made 
 in the hospital of the army depot, in the West Indies, in 1801. Several cases of 
 ague, on which bark, arsenic, or mercury, singly or alternately, had made either a 
 very temporary impression or none at all, were selected for experiment. In four of 
 these cases, two pills, containing each five grains of cobweb, were given at intervals 
 of two hours, commencing six hours before the expected time of recurrence of the 
 paroxysm. The fit did not return. 
 
 [We have employed the spider's web in this manner in a number of cases, and in many 
 of them found it very promptly to suspend the paroxysms — as effectually, certainly, as th<» 
 quinia ; in a few cases, however, it failed. — C] 
 
 On subsequent trials it was found not only to arrest the course of agues, but to 
 remove various symptoms, such as pain, delirium, vomiting, griping, in ague, and 
 VI continued fever, when these symptoms were unconnected with inflammation. 
 
 Charcoal is another substance which has been found effectual for the cure of 
 intermittent fevers. You may find an account of it in the tenth volume of the Edin- 
 burgh Medical and Surgical Journal. It would seem to be especially useful in 
 those cases in which there is a marked disturbance of the digestive organs ; nausea, 
 flatulence, hiccup, diarrhcea, or dj^senter}'. It is said generally to cure the complaint 
 by the time two drachms of it have been taken. It may be given in doses of ten or 
 twenty grains, in arrow-root ; or with a few grains of rhubarb. If the power of this 
 sub&tance should be confirmed by future observations, a cheap remedy would thus
 
 I 
 
 TREATMENT. 465 
 
 DC open to the poor. A clergyman of my acquaintance assures me that he seldom 
 fails to cure agues among his parishioners by administering to them the snuffs of 
 candles, which he takes care to have collected. He does not inform them of what 
 his black powder consists. I presume that its virtue may proceed from the char- 
 coal it contains ; unless it is derived from the confidence his flock is accustomed to 
 place in his specific. The veiy same remedy, the snuff of a candle, is mentioned 
 by Lind. 
 
 Fiperine, the crystaUine salt of pepper, has obtained a considerable reputation, of 
 late years, as a remedy for intermittent fever. It was largely tried by an Italian 
 physician, Meli ; and Dr. Gordini has repeated Meli's experiments at the hospital 
 at Leghorn. The following are the general conclusions at which these physicians 
 have arrived : — 1. Piperine, in doses of six or eight grains, cures intermittents. 2. 
 It is more efficient in powder than in pills. 3. It succeeds in certain cases in which 
 the sulphate of quina fails. And 4. It is more effectual in preventing relapses. I 
 have seen letters from some practitioners in this country, bearing testimony to tlie 
 power of the piperine. That pepper will cure ague,, has long been the vulgar 
 belief; and a very popular remedy for the disease is a teaspoonful of pepper in a 
 glass of gin. 
 
 I presume that the efficacy of chamomile flowers in the removal of intermittent 
 fever is to be attributed to the piperine which they have been asct-rtained to contain. 
 These flowers had been long in use for the treatment of ague, before the Peruvian 
 bark was discovered ; and they are said to have accomplished a cure, since that 
 lime, after the bark had failed ; but this was before the quina had been educed from 
 it. Fleberden advises us to have recourse to chamomile flowers, if the bark should 
 disappoint us. I am always willing to embrace an opportunity of referring to his 
 commentaries, for the exact observations they contain, but above all for the beautiful 
 Latinity of which the whole book is an example. I recommend it strongly to you, 
 as being, next to C(,'lsus, the best model you can study for good medical Latin. In 
 reference to the point before us he says, "Cortex, quanquam rite sumtus, interdum 
 parum efficax est; quo in casu suspicio erit ventriculum sordibus onustum vin 
 remedii impedire. Itaque vomere oportet ; quo facto, febris raro non cedit. Gluod 
 si redire perseveret, confugiendum est ad flores chamsemeli, quorum contriorum scru- 
 pulus dandus est loco drachmae cinchonoe, et ad idem proescriptum repetendus. Hos 
 flores, sic sumtos, semel atque iterum profecisse expertus sum." 
 
 Several mineral substitutes for the bark, or for arsenic, have been tried and found 
 useful. Preparations of iron and of zinc. From 5 to 10 grains of the sulphate pf 
 zinc have been given several times a day ; or 3 grains of the oxide of zinv" every 
 three hours. Sir Gilbert Blane says that both in the West Indies and in London, 
 intermittents have been cured by the use of this oxide, when they had previously 
 resisted the bark. Sir James Mac Grigor speaks of it also in terms of praise ; from 
 what he saw of its effects in the agues of the Peninsula during the war. 
 
 Some of the remedies of this mysterious disorder operate upon the mind, or lather 
 upon the nervous system, through the mind. Hence it becomes probable that the 
 drugs which have such power over the disease, act also on the nervous system, 
 throutjh the body. And hence also we derive a confirmation of the opinion, that 
 the disease itself is essentially a disease of the same nervous system. Ague has 
 ofien been cured by the agency of strong mental emotion, such as sudden and great 
 ioy, anger, terror, or eager expectation. Thus we read that Quintus Fabius Maxi- 
 mus was cured of an old quartan on the day of a great battle. Strong iin])ressions 
 upon the imagination, producing feelings of disgust and horror, have had the same 
 effect: such as those caused by drinking blood, swallowing a spider gently bruised, 
 and wrapped up in a raisin, or spread upon bread and butter; keeping a spider sus- 
 pended from the patieni's neck in a nutshell, till it dies; and the like. The un- 
 doubted success, in many cases, of charms, must be referred to the principle oC faif/i. 
 The patient recovers, because he firmly believes in your power lo cure him. Dr. 
 Gregory used to relate the case of a patient in the clinical wards in Edinburgh, 
 wno, with sundry ceremonies, swallowed some word, written on a slip of paper: the 
 result was, that he had not another paroxysm And I perfectly recollect hay-ng a 
 30
 
 4GC INTERMITTENT FEVER. 
 
 great awe, when I was quite a child, of my maternal grandmother, because she was 
 reputed to have the power of curing agues by means of some charm. I believe all 
 that she did was to assure the poor people who came to be relieved from their ague, 
 that they should have no more of it offer such a day; and their implicit reliance 
 upon this prophecy brought about its fulfilment. There seems to be this general 
 principle obserA'able in respect to agues, and to most other diseases which occur in 
 paroxysms, viz., that after they have continued for some time, their further continu- 
 ance depends more upon the efTect o{ habit than any thing else: and this habit 
 may be broken by strong impressions made upon the nervous system ; and the cure 
 of one paroxysm is often thus the cure of the disease. We have seen examples of 
 the existence of this morbid haoit in hysteria, and in some cases of epilepsy. C'ft'leris 
 paribus, that physician will be the most successful in these disorders, who is best 
 able to acquire the confidence of his patient, and to gain a powerful influence over 
 his mind. 
 
 There is no disease in which the prophylaxis is of more importance ; but this you 
 v.'ill have gathered from the facts which were stated in the two preceding lectures. 
 The disposition to relapse is strongest soon after the disease has been removed ; but 
 it generally continues long, perhaps even for fife. The late Dr. Macmichael caught 
 an ague many years before his death, by sleeping on a rock somewhere in Greece ; 
 and he was ever after subject to occasional attacks of periodic headache, and other 
 aguish symptoms, for which he was obliged to have recourse to bark or arsenic. Of 
 course one essential point in the prophylaxis is the withdrawal of the patient from 
 the influence of the exciting cause ; taking him away from the malarious locality. 
 But this cannoi always be done ; and when it cannot, we must impress upon him 
 those cautions which arise out of the facts ascertained in regard to the operation of 
 the malaria upon the human body. Persons who have been exposed to the exciting 
 cause, or who have once had the fever, should, in whateATr place they may happen 
 to be, avoid over-fatigue, and exhaustion of all kinds ; sudden exposure to cold or 
 heat ; and the neglect of changing wet clothes ; wet shoes and stockings, for instance. 
 In a malarious district persons should bear in mind the facts, that the miasmata ar-e 
 much more virulent in the night-time than in the day ; and close to the surface of 
 the earth, than in a higher part of the atmosphere. They should refrain, therefore, 
 from going out late in the evening, or early in the morning ; and they should rather 
 select the attic than any other floor for their bed-chamber. They who are obliged 
 to go out in the morning in countries where agues are rife, should take care not to 
 go out fasting; a good hot breakfast should be first taken, or at any rate some mode- 
 rate stimulus. A crust of bread and a glass of wine, or a small quantity of ardent 
 spirit, will fortify the system against the pestilential miasma. Measures of this kind 
 have been found extremely beneficial in the navy : the giving, for instance, the men 
 a warm breakfast before going out in the morning on malarious shores in boats, 
 whatever the hour of starting might be. Generous diet, and a fair allowance of fer- 
 mented liquor, are proper also for all persons in aguish countries. The late Dr. 
 James Gregory used to mention in his lectures an anecdote in point, told him by his 
 father. The elder Dr. Gregory studied at Leyden, under Boerhaave; and twenty- 
 four other Enghsh students were living there at the same time : that is, they were 
 called English, on account of their common language, but they were in fact composed 
 of Encrlish, Irish, Scotch, West Indians, and Americans. The celebrated John 
 Wilkes and Charles Townsend were among the number. These twenty-five students 
 lived a good deal together ; in truth they were cut, as the phrase is, by the Dutch, 
 for some raffish behaviour on their parts. However, of the twenty-five, only one 
 was a water-drinker. The other twenty-four drank each a bottle of claret daily; 
 and the water-drinker, and he alone, fell ill of ague there. 
 
 Persons who have recently become residents in aguish districts, or who even hap- 
 pen to be travelling through them, would do well to take moderate doses of quina by 
 way of safeguard. And in regulating the bowels, which, of course, is of much im- 
 portance, warm stomachic laxatives should be made use of, rather than cold aperi* 
 onts, such qs the neutral salts. 
 
 !
 
 EPISTAXIS. 467 
 
 There is just one more expedient wliich I would suggest as not unlikely to affoil 
 complete protection to those who are of necessity exposed to the malaria ; and it is, 
 that they should wear an orinasal respirator. It is impossible that as a breeze is 
 filtered of the poison which, was mingled with it, by passing through a dense mass 
 of foliage, so, on a smaller scale, the air inspired in breathing may be strained and 
 purified, and rendered harmless, in its transit through the sieve-like structure of Mr. 
 Jeffreys' ingenious instrument. The principle of the suggestion is not new ; but 
 this mode of applying it has not, so far as I know, hitherto been tried. It is said 
 that by surrounding the head with a gauze veil, or conopeum, the action of malaria 
 is prevented ; and that thus it is possible even to sleep in the most pernicious parts 
 of Italy without hazard of fever. Dr. MaccuUoch says that in Malta, and elsewhere, 
 this behef is universal : and hence the popular practice of covering the mouth and 
 nose with a handkerchief in the morning on going out, or in other suspicious circum- 
 stances : a practice (he observes) the efHcacy of which is attested, as far as popular 
 belief can attest any thing. Can it be the moisture which accumulates upon the 
 handkerchief from the breath, that confers the protection ? 
 
 LECTURE XLIII. 
 
 Epistaxis. Bronchocele ; Cretinism: their Phenomena and probable Causes. 
 Medical and Surgical Treatment of Bronchocele. 
 
 I YESTERDAY finished what I had to say respecting intermittent fever ; its symp- 
 torns ; its cause ; and its cure. The subtle poison which produces it is thickly dis- 
 tributed over the fairest portions of the habitable globe : blighting human health, and 
 shortening human life, more often, and to a far greater numerical amount than any 
 other single cause whatever. Known only by its noxious effects, holding out no 
 signal of its presence, this unseen and treacherous enemy of our race has yet been 
 tracked to its haunts and lurking places, and detected in some of its habits. It was 
 necessary, therefore, that I should enter somewhat fully into the history of the mal- 
 aria, and show how it may sometimes be shunned, sometimes be averted ; how, also, 
 in this climate at least, the effects it has already produced upon the human body 
 may be successfully combated. But I shall not pursue in further detail, the ravages 
 committed by this invisible agent, and the remedies they require, in hotter and 
 less favoured regions than our own. Of these personally, I know nothing ; and I 
 must refer you, for information on such diseases, to authors who have seen and 
 treated them : particularly to Drs. Lind, Jackson, Bancroft, Johnson, and Sir William 
 Burnett. 
 
 It is customary, with writers and lecturers, to pass from the consideration of ague 
 to that of continued fever. A paroxysm of ague has been regarded as exhibiting a 
 paradigm or sample of fever in general. But this has always appeared to me rather 
 an ingenious refinement than a useful matter of fact. Practically, I see nothing to 
 be gained by the association. Intermittent fever, it is true, does often run, in hot 
 climates, into the remittent, and the remittent into the continued form. But these 
 are very different disorders from the continued fever with which, in these climates, 
 and in this country, we have to do. Intermittent fever, and continued fever, as we 
 see them, differ in their phenomena, in their course, and in their treatment. They 
 are alike, inasmuch as they are both called fever, and both are attended, in some part 
 or other of their course, with pyrexia; but, in essential symptoms, I have known 
 many a compound fracture more like continued fever than any ague we are likely 
 to witness. I shall take up the subject of continued fever, then, in connection with 
 the eruptive febrile diseases, with which it has many strong links of analogy ; and 
 I resume the consideration of the disorders that come within the province of the 
 physician, according to their anatomical seat.
 
 468 EPISTAXIS. 
 
 After what was stated 0*" .lemorrhafje in general, in an earlier part of the course, 
 I hardly know whether epistaxis needs or deserves any formal notice. There are, 
 however, some points relating to this simple, and commonly harmless hemorrhage, 
 which it may be worth v^'hile very briefly to touch upon. Sometimes it is a remedy ; 
 sometimes a warning; sometimes really in itself a disease. The readiness with 
 which the mucous lining of the nasal passage pours forth blood is familiar toS.he 
 experience of every schoolboy, who " often wipes a bloody nose." A slight blow, 
 brisk exercise, a strong bodily effort, a fit of sneezing, or the summer heat, is suffi- 
 cient, in many boys, to make the nose bleed ; and this facility of hemorrhage furnishes, 
 often, an index of some unnatural state of the circulation : and especially of undue 
 fullness of the vessels of the head. But the import of this symptom is not always 
 the same. Epistaxis may, indeed, be taken as affording an epitome of the various 
 forms of hemorrhage by exhalation. In childhood and early youth it is idiopathic, 
 dependent upon active congestion, and probably arterial. It is nature's favourite 
 mode of blood-letting at that period of life. In old age it is symptomatic, the result 
 of passive or mechanical congestion, and probably venous. In some adult persons 
 it happens periodically, and is habitual: and its suspension, rather than its occur- 
 rence, becomes a token of disease or of danger. In young women it is not seldom 
 vicarious of suspended menstruation : in men it is apt to take the place of hemor- 
 rhois. Lastly, it may proceed from disease in the nares themselves ; or form a part 
 of a more general hemorrhagic disorder. 
 
 It is unnecessary to go at length into the phenomena of epistaxis. The main 
 phenomenon becomes obvious at once both to the patient and to those around him : 
 and the accessory and incidental circumstances are easily discoverable when the 
 attention is aroused to them by the sight of the blood. Usually the blood flows 
 guflalim; in a succession of drops: but these may follow each other so fast as to 
 constitute a little stream. Sometimes a few drops only fall ; sometimes several pints 
 are lost. A moderate hemorrhage of this kind is generally succeeded by a sense of 
 relief and refreshment. A large efflux of blood may cause pallor, faintness, debility, 
 exhaustion, even deatb. 
 
 Active idiopathic epistaxis, as it occurs in children, is almost always salutary, and 
 may be left to work its own cure. When it runs into excess, or is too often repeated, 
 it may be checked by applying cold water to the forehead and to the bridge of the 
 nose. The sudden contact of some cold substance with a distant part of the surface 
 of the body will often have the effect of restraining the hemorrhage : apparently by 
 producing a general and sympathetic constriction of the superficial blood-vestels. 
 This is doubtless a reflex phenomenon. The nursery remedy is to slip a cold key 
 down the child's neck, between its back and its clothes. The aspersion of cold water 
 is iitill better. Besides these external appliances, cooling laxatives should be given : 
 and if the bleeding proves obstinate, some astringent internal remedy may be thought 
 proper. I have, myself, hitherto found none so efficacious as the acetate of lead. 
 But I have been recently informed by Dr. Latham that his experience has led him 
 to trust much to mercury in the management of epistaxis ; and that the same indica- 
 tions have governed him, in adapting its use to this form of hemorrhage, as serve to 
 guide him in cases of inflammation. Thus, when the hemorrhage has been profuse 
 and frequent, and moderate depletion by blood-letting, or by purgatives, has not 
 arrested it, he has brought the constitution rapidly under the influence of mercury; 
 and as soon as the mouth became sore, the hemorrhage has ceased, not a drop more 
 of blood has been lost. Again, when the epistaxis has been, not copious, but habitual 
 or frequently recurring, without any excess of vascular action, or any other apparent 
 ailmenc in the constitution at large. Dr. Latham has often cured his patient by a 
 moderate salivation, gradually induced, and continued for a few weeks. 
 
 In conversing with Dr. Southey on the same subject, I find that he also has been 
 taught by experience to rely upon mercury as almost a specific remedy for obstinate 
 hemorrhage, occurring under similar conditions, from whatever organ of the body it 
 may proceed. 
 
 This plan of treatment it is therefore my purpose to prove, as future opportunity 
 Miay permit. 
 
 I 
 
 H
 
 EPISTAXIS. 469 
 
 When epistaxis begins to show itself in advanced life, it is a symptom which 
 cannot safely be neglected : for it indicates that the veins of the head are loaded. It 
 implies a morbid condition that requires to be redressed. You will look for disease 
 of the heart — or for threatenings of apoplexy — and take your measures accordingly 
 The blood-vessels which ramify upon and beneath the pituitary membrane, commu 
 nicate by indirect inosculation with the veins and sinuses of the skull, as well as 
 with the jugular veins. You see, therefore, how it is that hemorrhage from this 
 membrane may perform the office of a safety-valve, and protect the important organ 
 within the cranium from impending mischief. 
 
 On the other hand, when epistaxis, which is known to have been habitual, fails to 
 recur at or about the usual periods, you will look, with a jealous care, into your 
 patient's state, and watch for and obviate any tendency to plethora capitis. 
 
 When epistaxis forms a part of more general hemorrhagic disease — as when it 
 occurs among other symptoms of purpura — its treatment merges in that of the whole 
 malady. 
 
 In any case, if the flow of blood be excessive, and cannot be restrained by the 
 ordinary remedies, but is exhausting the patient's strength, it becomes an absolute 
 disease : and it will be requisite to staunch the blood by manual expedients. 
 
 These consist in stopping the bleeding orifices mechanically : which is most effec- 
 tually to be done by plugging the cavity. A dossil of lint must be carefully inserted 
 into the bleeding nostril. Its mechanical effect, which is pressure, may be chemi- 
 cally aided by first wetting the lint with a saturated solution of alum. The mode 
 of introducing these plugs it is the business of the surgeon — and not mine — to teach. 
 The operation is not a very comfortable one either to bear or to perform. 
 
 A very simple mechanical remedy has been lately announced by Dr. Negrier, of 
 Anglers ; who discovered it (he says) by mere accident. The patient is to raise one 
 or both of his arms above his head, and to hold them for some little time in that 
 position. Dr. Negrier declares that during an experience of three years he has 
 never known this method fail to arrest the bleeding. His explanation of its modus 
 operandi is not very satisfactory. The expedient itself is however so easy, so prompt, 
 and even if unsuccessful so harmless, that its real value deserves to be tested — 
 and will soon probably be settled — by an ampler trial. 
 
 [In cases of frequently recurring or long-continued epistaxis, blisters to the nape of the 
 neck will be found, in general, a very etfectual remedy. — C] 
 
 Before we trace this mucous membrane downwards, through the mouth, to the 
 inside of the throat, let me turn your attention to a singular disorder which may be 
 deemed external, for it is scarcely more than skin-deep : I mean that enlarged state 
 of the thyreoid gland to which tlie name o( bronchocele has been given. This u )rd 
 is not merely derived from the Greek, but was used by the Greek writers in the 
 same sense in which we now employ it. In Switzerland, where it is very common, 
 and in France, the complaint is called goitre ; a corruption, it is believed, of the 
 Latin "guttur," the throat. It is known in England as the Derbyshire neck; from 
 its frequent occurrence in that country. 
 
 The term bronchocele has been sometimes applied indiscriminately to all protu- 
 berances or swellings in front of the throat; or at any rate, to all enlargements of 
 the thyreoid gland ; whereas it should be restricted to hypertrophy of that part . an 
 exaggeration of its natural structure, with augmentation of its volume. The texture 
 of the gland becomes coarser; its blood-vessels grow larger and more numerous ; us 
 cells are magnified, and fdled with a thick, viscid secretion. It usually presents a 
 soft, smooth, elastic tumour, which is neither painful, nor tender, nor discoloured. 
 The lobes of the gland become more obvious. Sometimes the whole tumour ia 
 irregularly lobulated : sometimes the exact form and relative proportions of the gland 
 are preserved, each lobe and portion being equally increased in size. Occasionally 
 there is a soft uniform or irregular swelling, without much distinction of parts. 
 Alibert states that the right lobe is more frequently enlarged than the left. Mr, 
 Rickwood found it so in every instance of bronchocele that came under his notice 
 in the neighbourhood of Horsham. 
 
 2p
 
 470 BRONCHOCELE. 
 
 Unless the tumour be very large, it follows all the motions of the larynx : and this 
 IS a point of considerable importance whenever the diagnosis is at all doubtful. It 
 is just possible that an enlarged lymphatic gland, or an encysted tumour in the 
 neighbourhood of the larynx, or even a collection of pus thereabouts, might, in some 
 degree, embarrass the diagnosis. But, by placing the head and neck in different 
 successive positions, swellings of this accidental kind may, in general, be ascertained 
 to be unconnected \^-ith the larynx : and they do not follow its up and down move- 
 ments when the act of deglutition is performed. 
 
 It is of importance to know, also, that the gland itself is subject to different kinds 
 of enlargement. It may swell from inflammation, chronic or acute : and then it 
 will be hard, and tender, and painful. But it does not seem very prone to inflame ; 
 and probably Dr. Copland is right in his opinion that inflammation occurs sponta- 
 neously in this organ in scrofulous persons only. Baillie and Ahbert speak of it as 
 being occasionally the seat of cancer: but that must be very rare. Sometimes carti- 
 laginous or ossific deposits take place in the gland. It is necessary, I say, to be 
 aware of these circumstances, and to distinguish one kind of thyreoid tumour from 
 another : for some of the morbid changes just referred to are clearly be3'ond the 
 power of any medicine to remove ; and if all forms of enlargement incidental to this 
 part are lumped together under one common name of bronchocele, we shall be 
 liable to arrive at false conclusions concerning the power of remedies over that 
 disease. 
 
 Bronchocele is not, in itself, a painful disorder : nor does it taint the s)^stem, or 
 affect the constitution in any way. It has no character of malignancy about it. It 
 is always, however, a deformity ; and, by its mechanical effects, that is, by its weight 
 when large, and by the pressure it exercises on contiguous parts, it may occasion 
 great distress, and suffering, and even death itself. The size, and the effects, of the 
 tumour both vary much in different cases ; but its injurious effects are not always, 
 though they are generally, in proportion to its bulk. Sometimes there is no more 
 than a slight fullness of the throat, which some persons, I beheve, think rather 
 graceful than otherwise. Now and then, the swelling, after its first commencement, 
 develops itself with great rapidity; but its ordinary progress is slow. It often con- 
 tinues for months, or years, without reaching any extreme or very troublesome mag- 
 nitude. Sometimes it remains stationary for a considerable time, and then suddenly 
 increases without any apparent cause. The worst effects of bronchocele are its 
 interference with the circulation, and with respiration. By its pressure it may 
 obstruct the free descent of the blood through the veins of the neck, and give rise to 
 headache, giddiness, noises in the ears, confusion of thought, and a turgid condition 
 of the head and face. Or, by pressing upon the wind-pipe, it may cause hoarse- 
 ness, wheezing, and d3^spncea. It may even impede deglutition. But these effects, 
 I say, do not depend ahogether on the actual size of the tumour. A very large 
 goitre may produce no other inconvenience than what results from its weight and 
 i-ts unseemly appearance. It may surround all the front and sides of the neck like 
 a thick collar, and rise as high as the ears ; or it may hang down, in a pendulous 
 lump, and be supported upon the chest. Nay, the tumour is said to descend, in 
 some rare instances, so low as to be in contact with the abdomen : and Alibert 
 mentions one case in which the swelling was of a tapering cylindrical shape, and 
 reached to the middle of the thigh. On the other hand, a small tumour, not bigger 
 than one's fist, especially if it happens to occupy the ce.itral portion, or what is 
 called the isthmus, of the gland, may so press inwards upon the trachea as mate- 
 rially to hinder the breathing, and even to threaten suffocation. A pupil now 
 attending the hospital has informed me of a case, which he himself saw, of death 
 produced by the encroachment of a bronchocele ; not so much, however, from suffo- 
 cation as from starvation : for the swelling encircled the trachea, and came at last to 
 press so much upon the woman's oesophagus, that she could not get food into her 
 stomach. I suppose that the reason of these differences may be sometimes found in 
 the manner in which the tumoui: grows, and in its relative situations. When it is 
 bound down by the muscles of the neck, it presses, as it continues to enlarge, upon 

 
 I 
 
 BRONCHOCELE. 471 
 
 the parts behind it. Wlien it is not so confined, the skin readily yields, and the 
 entire growth of the tumour takes place anteriorly. 
 
 This disease is much more corgmon in women than in men. Indeed we seldom 
 see it, in this country, except in females. Yet I happen to have an example of it 
 now, (December, 1S37) in a male among my patients in the hospital. Dr. Andrew 
 Crawford states that forty-nine cases were admitted into the Hampshire County 
 Hospital, in ten years, and forty-eight of these were in women. Of seventy patients 
 treated in the Chichester Infirmary in nine years, two only were males, asd they 
 were boys of a very feeble and feminine habit, and backward for their years. 
 Among one hundred and sixteen patients of Dr. Manson, fifteen were men. Taking 
 an average from these three lists, we have one male for twelve females. It is well 
 to bear in mind that our fashion of dress renders a small bronchocele much more 
 noticeable, much less easily concealed, in women than in men. In the former the 
 swelling has been knowm to come on, or at any rate to increase rapidly, during their 
 confinement in child-bed : and it is frequently observed to undergo a temporary en- 
 largement at the menstrual period. Dr. Copland has seldom met with an instance 
 in the female, unconnected with some kind of irregularity in the catamenial discharge, 
 or disorder of the uterine functions ; and he never saw a case in which the disease 
 made its appearance before the period of coimmencing puberty. In Switzerland, 
 and in some parts of India, where the complaint is much more prevalent than here, 
 the proportion of males affected is greater ; and it begins, often, prior to the age of 
 puberty, in both sexes. It seldom shows itself earlier than the age of eight or ten. 
 Dr. EUiotson states, indeed, that he himself, when in Switzerland, saw goitre in a 
 little boy only four years old ; and the natives told him that it rarely made its appear- 
 ance before the age of six. But children have been born goitrous. M. Godelle, 
 physician to the hospital at Soissons, had a preparation of the body of an infant, 
 which only hved a few hours, and which came into the world with a goitre ; the 
 mother being a.Tected with the same disease. A case is mentioned in the London 
 Medical Repository of a child born in Derbyshire with bronchocele of considerable 
 size. The disease, therefore, undoubtedly may be congenital ; and one of the 
 facts I have just mentioned points to the question of its being hereditary. It is said 
 to be so ; and there is much probability in favour of that opinion. Children born 
 of goitrous parents often have goitre. But that, you will say, may depend upon 
 their being in the same place, and exposed to the same causes, which produced bron- 
 chocele in the mother or father. Dr. Crawford states, however, that he knew a 
 woman, with goitre, whose grandmother, father, paternal aunt, and cousins, also had 
 it, although they did not all live in the same place, and no other person in their 
 respective neighbourhoods was affected by the disease. 
 
 Admitting what seems probable, that the disease may sometimes be hereditary in 
 the sense in which I formerly explained that term, there can be no doubt that it is 
 often acquired. 
 
 In the first place, bronchocele is endemic — prevalent in certain localities, and 
 scarcely occurring elsewhere. And persons who, being previously well, go to live 
 in those localities, often become affected with the complaint : and persons who mi- 
 grate /ro'm those localities, having the complaint upon them, sometimes get rid of it 
 by the mere change of residence. The physical circumstances of the places thus 
 selected by the disease have been studied with the natural hope of discovering what 
 the cause may be of an effect so singular. Some morbific quality of the air v^'as long 
 suspected. The habitats of the unknown cause of bronchocele appeared at first 
 sight to be very much like those of the mala/ia. Goitre abounds in the hollows of 
 many mountainous districts ; among the Alps, for example, and in the Pyrenees 
 This was notorious to the ancients. Juvenal asks — 
 
 Quis tumidum giittur miratur in Alpibus? 
 
 And it is in the deep, close, and humid valleys of Switzerland, which lie at tnt 
 feet of, and between, high mountains, that bronchocele is most common. Several 
 writers, who have personally investigated this subject in places where goitre is rife, 
 concur in the belief that it depends upon insalubrity of the air, ari'^ing from the pe
 
 472 CRETINISM. 
 
 culiarities of the situation. They affirm that it is most frequent in low, damp, con- 
 fined spots, wliere the stagnant atmosphere Ls seldom stirred by wholesome breezes ; 
 and where the sun, in summer, has great power. Dr. James Johnson remarks, "We 
 find in the Valais (one of the Swiss cantons) and in the lower gorges or ravines that 
 open on its sides, both cretinism and bronchocele in the most intense degrees. As we 
 ascend the neighbouring mountains, cretinism disappears, and goitre only is observed. 
 And when we get to a certain altitude, both maladies vanish." Dr. Reeve, again, 
 states thai all the cretins he saw were in adjoining houses in the little village called 
 La Batia, situated in a narrow corner of the valley, the houses being built up under 
 ledges of the rocks, and rll of them very filthy, very close, very hot and miserable 
 habitations. In villages situated higher up the mountains, no cretins are to be 
 seen. 
 
 The cretinism mentioned in these quotations is a strange and melancholy disease: 
 a sort of idiocy, accompanied by (and doubtless dependent upon) deformity and im- 
 perfection of the bodily organs. The mental affection exists in all degrees, from 
 mere obtuseness of thought and purpose, to the complete obliteration of intelligence. 
 Many of the cretins are incapable of articulate speech; some are blind, some deaf, 
 and others labour under all these privations. They are mostly dwarfish in stature, 
 with large heads, wide vacant features, and goggle eyes, short crooked limbs, flabby 
 muscles, and tumid bellies. The worst of them are insensible to the decencies of 
 nature, and obey, without shame or self-restraint, every animal impulse. In no 
 other class of mortals is the impress of humanity so pitiably defaced. 
 
 More recent and extensive observation of the localities infested b}^ goitre have ren- 
 dered it improbable that the disease derives its origin from any deleterious properties 
 of the air. Certainly it is not owing to any thing that is common to all mountain- 
 ous countries. Some parts of Switzerland are free from it. So are the Highlands 
 of Scotland. It is met with also in flat situations — as in Norfolk. I have seen 
 several cases of it in Cambridgeshire, which is a venj flat country'. Tn one village 
 in particular, about five miles from Cambridge, it is extremely common. There are 
 some striking facts collected by the celebrated and philosophic Humboldt, which go 
 to show that the prevalence of bronchocele does not depend on any particular 
 configuration of the surface of the earth, nor on any peculiar condition of the 
 atmosphere. He tells us that in South America bronchocele is met with, both in 
 the upper and the lower course of the ^Magdalen river ; and in the flat high country 
 of Bogota, 6000 feet above the bed of the stream. The first of these regions is a 
 thick forest ; while the second and third present a soil destitute of vegetation. The 
 first and third are exceedingly damp ; the second peculiarly dry. In the first the 
 air is stagnant : in the second and third the winds are impetuous. In the first twd 
 the thermometer keeps up all the year at 22 or 23 degrees of the Centrigrade scale : 
 in the third it ranges between 4 degrees and 17. 
 
 The researches of Mr. M'Clelland, in India, lead to the same conclusion. He found 
 goitre extremely frequent in one portion of the district which he surveyed, while the 
 other portion was almost exempt from the complaint, "although an equality of 
 moral as well as physical circumstances appeared to affect the whole. The external 
 Alpine characters of the province are the same in every part ; the inhabitants all 
 belong to the same tribes of Hindoos, and are subject to fevver irregularities in their 
 mode of life than any other people in the world." 
 
 The dilFerent localities of the villages, in the portion where goitre was not preva- 
 lent, he describes as being as diverse as can well be imagined. " Some are erected 
 on narrow ridges, others in deep valleys, surrounded by abrupt and lofty mountains ; 
 others on rugged declivities between lofty peaks on one side, and deep ravines on the 
 other, into some of which the sun can scarcely penetrate. The different altitudes of 
 these villages vary from 2000 to 6000 feet." 
 
 Facts of this kind have turned the attention of scientific inquirers towards the only 
 other obvious source to which the disorder could, with probability, be attributed, viz., 
 [He quality of the ivater used for drinking. Wherever goitre prevails, the popular 
 belief assigns it to the water, as a cause : and the more accurately the search is pro- 
 'S'Tuted, the more strength and Hkelihood does this supposition acquire. Its very
 
 CRETINISM. 473 
 
 universality is a presumption in its favour. The disease was formerly ascribed to 
 the use of snoiv water : a notion which originated, I imagine, in its frequent occur- 
 rence in Alpine regions. But the people in almost all the valleys of Switzerland 
 drink the water that comes from the Glaciers ; while bronchocele is known in some 
 of the valleys only. It prevails also in certain spots where pump water is used, and 
 there the people accuse the pump water of producing it. Besides, goitre occurs in 
 other countries, where the snow never lies long, as in Derbyshire ; and even in Su- 
 matra, where there is no snow. Dr. Bally, a native of a goitrous district in Switzer- 
 land, beheves that bronchocele is caused by certain zvaters, which issue from the 
 hollows of rocks, trickle along crevices of the mountains, or rise froia the bowels of 
 the earth. And in support of that opinion he refers to some fountains in his own 
 neighbourhood, the drinking of the waters of which will produce, or augment, goi- 
 trous swellings, in eight or ten days. Such of the inhabitants as avoid these waters 
 are free, he says, from goitre and cretinism. In Captain Franklin's narrative of his 
 expedition to the shores of the Polar sea, there is the following statement, made by 
 his fellow-traveller Dr. Richardson : — " Broncliocele or goitre is a common disorder 
 at Edmonton. I examined several of the inhabitants afflicted with it, and endeavoured 
 to obtain every information on the subject from the most authentic sources. The 
 following facts may be depended upon : — The disorder attacks those only who 
 drink from the water of the (Saskatchanan) river. It is, indeed, in its worst state, 
 confined almost entirely to the half-bred women and children who reside constantly 
 at the fort, and make use of river water, drawn in winter, through a hole made in 
 the ice. The men, from being often from home on their journeys through the plain, 
 where their drink is melted snow, are less affected : and if any of them exhibit during 
 the winter some incipient symptoms of the complaint, the annual summer voyage to 
 the sea-coast generally effects a cure. The natives who confine themselves to snow 
 water in the winter, and drink of the small rivulets which flow through the plains 
 it) the summer, are exempt from attacks of this disease. A residence of a single year 
 at Edmonton is sufficient to render a family bronchocelous. Many of the goitres 
 acquire great size. Burnt sponge has been tried, and found to remove the dis- 
 ease : but an exposure to the same cause immediately reproduces it. A great 
 proportion of the children of the women who have goitres are born idiots, with 
 large heads, and the other distinguishing marks of cretins. I could not learn 
 whether it was necessary that both parents should have goitres to produce cretin 
 children." 
 
 We are able even to go a step further, and to announce a probable conjecture as 
 to the specific quality of the suspected water. Bronchocele is very prevalent in 
 Nottingham and its neighbourhood ; and the vulgar there ascribe it (so Dr. Manson 
 informs us) to the hardness of the water. You know that the rough practical dis- 
 tinction between soft and hard water is that the former dissolves soap, while the 
 latter decomposes it. The hardness is generally occasioned by the presence either 
 of sulphate of lime, or of carbonate of lime. In the one case the remedy is to mix 
 the carbonate of an alkali with the water; in the other you simply boil it. Now the 
 well water in and about Nottingham is more or less hard, and unfit for the purpose 
 of washing. Dr. Coindet, of Geneva, declares that the use of hard or pump water 
 in the lower streets of that town brings on the goitre very speedily. At Cluses, on 
 the Arve, numerous cretins and goitrous persons are seen in the streets : lofty clifts 
 of limestone tower over the town, and through its caverns copious streams of water 
 find a passage. The soil in the neighbourhood of Edmonton was found by Dr. 
 Richardson to be calcareous, and to contain numerous fragments of magnesian lime- 
 stone. In a Treatise on English Bronchocele, very recently published. Dr. Inglis 
 states his belief tliat the presence of magnesian limestone always implies the co- 
 existence of the disease. " Take (he says) that ridge of magnesian limestone run 
 ning from north to south through the centre of Yorkshire, and margining the shires 
 of Derby and Nottingham. All along that line we have goitre to a very great 
 extent; whereas, on our diverging to either side, the disease is found to diminish." 
 
 These scattered indications that the hurtful quaUty of the water is somehow de- 
 rived froia its contact with limestone rocks, receive a powerful corroboraliou from *.\uf 
 
 2p3
 
 474 CRETINISM. 
 
 result of Mr. M'Clelland's minute and valuable inquiries, which were carried on in 
 the province of Kemaon, south of the Himalayan mountains. I have not been able 
 to obtain his book ; what I am about to tell 3'ou I take from a full and instructive 
 notice of it in the fifteenth number of the British and Forcis^n Medical Review, 
 Mr. M'Clelland finding goitre very abundant (as I mentioned before) in one great 
 section of a district, and almost entirely absent from another section, set himself to 
 find out in what other particulars these sections were distinguished from each other. 
 He ascertained that they completely agreed " in external aspect, altitude, and cli- 
 matology," but differed remarkably " in their geognostic relations ; and this distinc- 
 tion was even traced down to the very villages in which the disease is found, with 
 such perfect nicety, as to enable one almost to predict, « priori, on examining the 
 rocks of a neighbourhood, whether the inhabitants are affected with goitre or not." 
 
 It would be impossible for me to give you even an abstract of Mr. M'Clelland's 
 numerous observations ; but I select one or two striking instances in favour of his 
 opinion that the endemic prevalence of goitre is connected with the use of water im- 
 pregnated with calcareous salts. 
 
 One extremity of the long village Deota, which occupies half a mile of the foot 
 of Durge mountain, is inhabited by Brahmins ; the other by Rajpoots and Domes. 
 Of the first caste there are about twenty persons, all of whom are free from goitre. 
 There are forty of the second, and two-thirds are affected, more or less. Of the third 
 caste, forty-six in number, nearly the whole are goitrous. " To what cause can we 
 ascribe the immunity of one caste of the inhabitants of this village, and the almost 
 universal affijction of the other two castes? They are all alike well fed, and have 
 little toil ; their land producing the requisites of life almost without labour. Differ- 
 ence of caste does not here imply a diflerence of pecuniary circumstances, and con- 
 sequently of the comforts of life. In these respects the three castes in this village 
 are on perfect. equality. Nor will hereditary predisposition acquired by intermar- 
 riages be sufficient to explain the interesting fact : for the affected parlies are con- 
 fined to the Rajpoots and Domes, who cannot intermarry, while the Brahmins and 
 Rajpoots may. The village is raised about one hundred feet above the level of the 
 valley ; and the mountain, at the foot of which it is situated, rises with a gentle 
 slope, and is not in this vicinity at all rugged. It is chiefly composed of transition 
 limestone, and the village is erected on a conglomerated rock, composed of calcare- 
 ous tuff, inclosing fragments of other rocks. There is a spring in the valley, about 
 one hundred yards from the village, bearing on its first appearance the character of 
 a mineral spring. The water bursts forth with strong ebulhtion, in the quantity of 
 at least forty gallons in a minute, and agglutinates the sand and gravel by which it 
 is surrounded, by the deposition of calcareous tuff. The temperature and quantity 
 of the water are the same at all seasons. The former inhabitants of the village, 
 aware perhaps of the noxious effects of this spring, had an aqueduct formed, by which 
 water is conveyed into the Brahnn'n portion of the village from a distant source. 
 The aqueduct having been suffered to get out of repair, the quantity of water it 
 transmits is reserved exclusively for the Brahmins; except during the rainy season, 
 wdien, the water being plentiful, the Rajpoots also use that of the aqueduct ; but the 
 Domes have no alternative at any season but to use the water from the spring." 
 
 I'he valley of Baribice is elevated 4000 feet above the sea. Its eastern extremity 
 is composed of c/nyslafe, and in five villages, containing 152 inhabitants, there is 
 not one goitre. The other extremity of the valley is partly composed of limestone ; 
 and of lSi2 inhabitants, distributed in six villages, 70 are affected with goitre: but 
 Duc3'gong, one of these villages, supplied with water from clayslate, has not a single 
 case of the disease; while Agar, only half a mile distant, and containing .50 inha- 
 bitants, has no less than 40; and of that number 20 are cretins. They use the v/ater 
 wnich issues from an old copper-mine in limestone, and which contains carbonate 
 of lime, and of soda, but no sulphate. 
 
 Mr. M'Clelland affirms that in the course of his personal inquiries, which extended 
 over 1000 square miles, and which were prosecuted without regard to any theory, 
 no instan/'e occurred in which goitre prevailed to any extent where the ^illage.s 
 were not situated on or close to limestone rock.
 
 CRETINISM. 475 
 
 [In the United States the disease is prevalent in many of the valleys siluuted in tlie moun- 
 tainous regions of New Hampshire, Vermont, New York, Pennsylvania and Virginia ; many 
 of these regions abound in limestone rocks. — C] 
 
 Cretinism has a close, but an ill-understood, connection with goitre. Wherever 
 cretinism is endemic, bronchocele never fails to be abundant. But bronchocele may- 
 prevail in a place where there are no cretins. With but few exceptions, cretins are 
 goitrous ; whereas many of those who have bronchocele are not affected with cre- 
 tinism. The two disorders either spring from the same cause, requiring for their 
 joint production that this cause should be in active operation : or, if they have sepa- 
 rate causes, these frequently co-exist and act in combination. It is said, I know not 
 with what accuracy, that when both parents are goitrous for two generations in suc- 
 cession, the offspring, being in the third generation, are sure to be cretins. Cer 
 tainly cretinism is most common where bronchocele is most common, and especially 
 in mountainous places. It occurs in the Pyrenees as well as in the Alps, in the 
 mountains of Syria, in the hilly parts of China, and in the Himalayan regions. Yet 
 cretinism is confined within much more Hniited bounds than goitre. Saussure, Fo- 
 dere, and Dr. Reeve, agree entirely as to the circumstances under which cretinism 
 appears to be most commonly engendered in Switzerland. They say that the dis- 
 ease is usually met with in valleys which are nearly surrounded by high and steep 
 rocks, where there is but little circulation of air, and where the inhabitants are ex- 
 posed to the direct rays of the sun, and to the reflection of them from the rocks ; and 
 also to effluvia from marshes. It is in the filthy habitations built in these close, hot 
 and humid situations, that cretinism abounds most. The children that ate taken 
 away from the low valleys, and carried up, when young, into the high grounds, 
 escape the disease ; or even get the better of it if removed soon enough. And the 
 amendment is said to be perceptible even in a very few daj's. These facts have led 
 many persons to conclude that cretinism, if not bronchocele, depends on some condi- 
 tion of the uir. It appears to me probable that the exciting cause of both is the 
 same, and that the local circumstances just now mentioned operate as predisposing 
 causes only. Cretinism, as well as goitre, was observed, by Ramond, in the " open, 
 well-watered, and well-ventilated valleys of the Pyrenees." 
 
 There are some difficulties opposed to the implicit reception of the opinions formed 
 by Mr. M'Clelland and by others, respecting the origin of these diseases. And the 
 facts upon which those opinions are grounded, are not without apparent exceptions. 
 Moreover, the actual substance which exercises or confers the noxious power, has 
 yet to be ascertained. This etiological problem, so fufl of interest, is not solved. 
 One step more, and probably one step only, remains to be taken. We look to the 
 medical geologist, for its complete solution ; and I trust that, now, we have not long 
 to look. The deleterious agent has been traced, with tolerable certainty, to water : 
 and hence to some element of the soil washed by that water. And if what at present 
 is probable only, shall hereafter be proved, — namely, that the hidden cause of goitre 
 and of cretinism lurks in some chemical quality of man's natural beverage — it can 
 scarcely be doubled that chemistry will be found ready to supply a simple and effec- 
 tual corrective of the evil. This hope it is which makes it so important that medical 
 men should be accurately possessed of the present state and bearings of the ques- 
 tion ; and prepared to take advantage of every opportunity that may arise from its 
 practical determination. For surely it would be a noble achievement of our art, and 
 a signal blessing provided for hundreds of human beings yet unborn, thus to prevent 
 the deformity, the discomfort, and sometimes the danger, of bronchocele ; and to 
 forbid, in its very source. and fountain, the more hideous and loathsome disfigurement 
 of mind as well as of body that distinguishes the wretched cretin. 
 
 i ought, perhaps, to tell you, that other causes, many of them very vague and un 
 satisfactory, have, at different times, been assigned. Thus Valentin supposes the 
 disease to be more common in women than in men, simj)ly because women more 
 frequently have the neck uncovered. It has been affirmed that young females who 
 have taken the veil in Catholic countries have lost their goitres in consequence of the 
 change then made in their costume ; and a medical man in Guatimala asserts that
 
 476 CRETINISM. 
 
 the same infirmity has sensibly diminished among the men in that part of the world, 
 since cravats became fashionable there. These views of the matter accord with some 
 whimsical notions entertained by the late Sir Anthony Carlisle. He held that the 
 chief purpose of the thyreoid gland was to protect the delicate organ of the voicu 
 from the injurious influence of cold ; and he consequently regarded the tumour of 
 bronchocele as being rather of a sanative than of a morbid nature. He looked upon it 
 as an additional greatcoat thrown over the important instrument of speech, in circum- 
 stances of extraordinary need. His theory agrees with some of the facts on which 
 other theories, not perhaps more plausible, have been founded. Thus, although 
 snow water may not be, indeed I may say certainly is not, the cause of bronchocele 
 from any pecuhar quality that belongs to it, yet the disorder is confessedly frequent 
 in many places where snow water is habitually drunk ; i. e., as Sir Anthony would 
 have reasoned, where very cold water is frequently drunk ; the swelling being a 
 provision of nature to obviate the hurtful effects which might else be produced on 
 the larynx by these cold potations. The summer change for the better, described 
 by Dr. Richardson, consists also with the same theorj'^ ; which would suggest the 
 covering an incipient bronchocele continually with warm clothing, such as flannel, 
 to check its growth, to obviate its necessity, and so gradually to occasion its subsi- 
 dence. And this plan is mentioned, I see, by Bouillaud, among the curative indi- 
 cations. 
 
 I mention these theories, not because I have any faith in them myself, but as being 
 curious specimens of the manner in which the human mind strives to account for 
 obscure phenomena ; and as showing how readily facts may be called '»,nd pressed 
 into the service of very slender and infirm hypotheses. 
 
 One very important point in the treatment of bronchocele is obvious ; the removal 
 of the patient, if that can be done, from the infected locality. When this has been 
 effected, or when the disorder occurs sporadically, as it sometimes does, we may 
 administer drugs with better hope and advantage. Now a great variety of empirical 
 remedies have been recommended for the cure of bronchocele, concerning most of 
 which it would be a waste of time for me to speak at all. The remedy which, as 
 an internal medicine, has of late years superseded all others, and acquired the repu- 
 tation of a specific against goitre, is iodine : and it certainly has a remarkable influ- 
 ence over the genuine unmixed form of the disease, whether endemic or sporadic — 
 the hypertrophied gland ; yet it does not, perhaps, merit the title of specific in the 
 same absolute sense as that in which we say that bark is a specific for the ague, or 
 sulphur for the itch. Dr. Coindet, of Geneva, was the first who made this remedy 
 extensively known. Dr. Slraub, however, of Hofwyl, has laid claim to the priority 
 of its use. Probably that happened in this matter, which has often happened in 
 others, viz., that the slate of knowledge was ripe for such a discovery, and it was 
 made by each of these physicians independently of the other. Dr. Coindet's name, 
 however, has been inseparably connected with the application of iodine to the cure 
 of bronchocele, in a work which, if he had no other claim to be remembered, would 
 immortalize his lOcmory ; — I mean Sir J. Herschel's profound and beautiful Dis- 
 course on the Study of Natural Philosophy ; — a book which I should advise those 
 among you who have not already read it, to make themselves master of as soon as 
 they have leisure to do so. He thus strikingly illustrates an observation of his own, 
 that mighty benefits often accrue to science from the casual experience of even un- 
 scientific or iUiterate persons. "A soap manufacturer remarks that the residuum of 
 his ley, when exhausted of the alkali for which he employs it, produces a corrosion 
 of the copper boiler, for which he cannot account. He puts it into the hands of a 
 scientific chemist for analysis: and the result is the discovery of one of the most 
 singular and important chemical elements — iodine. The properties of this being 
 studied, are found to occur most appositely in illustration and support of a variet}' of 
 new, curious, and instructive views then gaining ground in chemistry; and thus 
 exercise a marked influence over the whole body of that science. Curiosity is 
 excited ; the origin of the new substance is traced to the sea plants from whose 
 ashes the principal ingredient of soap is obtained ; and ultimately to the sea-water 
 Itself. It is thence hunted through nature, discovered in salt-mines and springs, and 
 
 I
 
 TREATMENT. 477 
 
 pursued into all bodies which have a marine origin : among the rest into sponge. A 
 raedical practitioner, Dr. Coindet, of Geneva, then calls to mind a reputed remedy 
 for the cure of one of the most grievous and unsightly disorders to which the human 
 species is subject, the goitre ; which infests the inhabitants of mountainous districts 
 to an extent that, in this favoured land, we liave happily no experience of, and which 
 was said to have been originally cured by the ashes of burnt sponge. Led by this 
 indication, he tries the effect of iodine on that complaint, and the result establishes 
 the extraordinary fact that this singular substance, taken as a medicine, acts with the 
 utmost promptitude and energy on goitre, dissipating the largest and most inveterate 
 in a short time, and acting (of course, hke all medicines, even the most approved, 
 with occasional failures) as a specific, or natural antagonist, against that odious 
 deformity." 
 
 It is curious enough, and marks the accuracy with which the effects of remedies 
 may be observed, that not only had burnt sponge been found efficacious in removing 
 bronchocele, but the bladdervvrack also, the fucus vesiculosus, the plant that, with 
 others of the same family, yields the soda wherewith the iodine was found combined. 
 Dr. Gairdner, who v^'as the first I believe in this country to write on the effects of 
 iodine, accounts for the frequent failure of even large doses of the burnt sponge, by 
 showing that it was much adulterated with charcoal. Dr. Manson, of Nottingham, 
 has published the following tabular statement of the results of the employment of 
 iodine by himself. He had treated one hundred and sixteen patients, of whom fif- 
 teen were men, and the rest women. Of the fifteen men, ten were cured, three 
 were improving and under treatment at the time of his publication, one was dismissed 
 for irregular attendance, and one was much reheved. Of the one hundred and one 
 women, sixty-six were cured, nine much relieved, two received no benefit, ten were 
 discharged for irregular attendance, and fourteen were improving under treatment. 
 Of the whole one hundred and sixteen, therefore, there were seventy-six positive 
 cures, or two-thirds of the entire number; and only two positive failures. Dr. Coin- 
 det was successful in about the same proportion of cases. This is strong evidence 
 of the power of the remedy. Dr. Manson found that in some, but not in all indivi- 
 duals, after the preparations of iodine had been given internally for a certain time, 
 they were apt to occasion headache, giddiness, sickness of stomach, with some degree 
 of languor, and inaptitude for exertion. His plan in such cases was to suspend the 
 use of the medicine, or to reduce the dose. The following effects of the iodine are 
 stated by Dr. Coindet as having occurred in his practice : — Acceleration of the 
 pulse, palpitation, dry cough, watchfulness, marasmus, and prostration of strength. 
 Sometimes swelling of the legs, tremors, painful hardness of the bronchocele, dimi- 
 nution of the breasts, or a remarkable increase of appetite supervened ; and he adds, 
 that in almost all the instances which he had observed, a very rapid diminution, or a 
 disappearance more or less complete, took place, during these symptoms, of even 
 hard, bulky, and old bronchoceles. His doses varied I'rom somewhat less than a 
 grain to somewhat more than a grain and a half. This was certainly, as Dr. Manson 
 has suggested, too large a quantity of this powerful drug for the generality of patients. 
 The management of the remedy is now belter understood. I have never seen any 
 of tlie unpleasant consequences enumerated by Dr. Coindet. These practitioners 
 gave the iodine in the form of a tincture. But this is a bad mode of exhibiting it " 
 for the tincture is decomposed in any aqueous menstruum, and the vidine thrown down 
 to the bottom. Under such circumstances the patient may at one time get no iodine 
 at all, and at another time a dangerous dose : for you are aware that iodine is an ac- 
 tive irritant poison. But if you mix iodine with iodide of potassium, it is then held 
 in solution : and this is the form in which it is now commonly given. In the last 
 edition of the Pharmafioposia there is a Liquor Fotassii lodidi compositus, made 
 by dissolving five grains of iodine, and ten of the iodide of potassium, in a pint of 
 distilled water. This will doubtless, in future, be much prescribed. It is a dilute 
 preparation. There is one grain of iodine in four ounces of the liquor. An ounce 
 would, therefore, be a very sufe dose, but you may begin with a couple of drachms, 
 and hxcrease the quantity, if need be, gradually : for not only Dr. Manson, but Dr 
 Copland also, who states that the remedy has been very successful in his hands
 
 478 BRONCHOCELE. 
 
 adv^ocates small, unirritating, what are sometimes called alterative doses. Simple 
 friction is said to have had the effect of diminishing the tumour; and friction with 
 some ointment or Jiniment containing iodine should be employed whenever the inter- 
 nal exhibition of the remedy is contra-indicated: or in addition io its internal use. 
 There is an authorized form for that purpose also in the Pharmacopoeia — the Uru 
 gucntinn lodini Composition. A small portion of this may be rubbed upon the 
 tumour night and morning. I need not add that besides great care in watching 
 for the specific ill efft^cts of the iodine upon the system, no less care is to be taken 
 in correcting the state of any other function which may be faulty, and in improving 
 the general health. 
 
 Such is the best medical treatment of bronchocele ; and such is the plan which 
 you will always do well to make cautious trial of in the first instance : and with re- 
 spect to surgical treatment I may observe, that so long as the disease is merely a 
 deformity, so long as it does not interfere with any of the important functions of the 
 body, nor produce serious discomfort — does not distress the respiration by pressing 
 upon the trachea, nor impede deglutition by pressing upon the oesophagus, nor de- 
 range to any great degree the circulation through the head by pressing upon the 
 great blood-vessels of the neck, nor grievously encumber the patient by its weight — 
 we should not be justified (in my opinion) in performing or advising any surgical 
 operation for the removal or the diminution of the tumour. Of such operations the 
 three principal are, extirpation of the whole gland ; the passing a seton through the 
 tumour, and so exciting suppuration in it, whereby its substance is broken down and 
 destroyed ; and, tying the arteries which supply it with blood. The first of these 
 methods, extirpation, has been performed when the wen was small ; but few patients 
 imder such circumstances would consent to the operation ; and few surgeons would 
 now-a-days, I presume, advise or undertake it; and in cases where it might seem 
 more expedient, that is, where the swelling is large, and suffocation is threatened by 
 its pressure on the trachea, the execution of this measure would be exceedingly diffi- 
 cult and dangerous ; for the arteries are so much dilated in these cases that perilous 
 hemorrhage might be expected from their division, especially when their close vicinity 
 to the carotids is considered. Such large goitres come to involve also, by their lateral 
 extension, very important nerves there situated. In one case where excision was 
 attempted, the hemorrhage was so alarming that the surgeon was obliged to desist in 
 the middle of his task ; and the patient actually died of hemorrhage a few days 
 afterwards. I believe that this operation may be considered as wholly abandoned 
 by surgeons in the present day. 
 
 The introduction of a seton into the tumour has been more successful. This prac- 
 tice was revived som.ewhat more than twenty years ago by Dr. Quadri, of Naples ; 
 who supposed, indeed, that he had been the first to devise it. You will find an 
 account of his mode of proceeding in the tenth volume of the Medico-Chirurgical 
 Transactions, by Dr. Somerville. The seton is passed through the substance of the 
 gland, and retained there a considerable time ; the chief caution necessary is to 
 avoid the enlarged blood-vessels. Dr. Quadri affirms that the larger trunks of the 
 thyreoid arteries will not be endangered unless the seton needle be passed so deeply 
 as almost to touch the thyreoid cartilage ; and that hemorrhage from any of the 
 branches of those arteries that may be wounded when the seton is inserted more 
 superficially, will not be attended with hazard. This plan was followed in one case 
 by ulceration and sloughing, and the patient died. An example of the success of 
 this treatment occurred in the practice of Mr. James, of Exeter ; the tumour was 
 almost entirely removed, and the patient was for some time in London for the pur- 
 pose of showing himself to the medical men here. But he also had passed through 
 a good deal of suffering and peril. 
 
 The expedient of tying one or more of the thyreoideal arteries, and so starving 
 the tumour, has been attended with varied success. It has been done on the conti- 
 nent ; and several times in this country : there is a case of it by Mr. Coates, of Sahs- 
 bury, in the same volume of the Medico-Chirurgical Transactions. His patient 
 Wds nmch relieved for a time, and supposed herself cured. But the tumour gradually 
 returned, and caused her death by suffocation. Sir B. Brodie has also performed a 
 
 I
 
 CYNANCHE PAROTID^A. 479 
 
 «milar operation ; and I have myself seen one very satisfactory instance of the rame 
 thing, the operation having been done by the late Mr. Earle, in St. Bartholomew's 
 Hospital. The patient was a young woman with an immense bronchocele, which 
 for some time previously had obstructed her breathing, and of which the effect on 
 the trachea seemed to be every day increasing. There was loud wheezing, and great 
 difficulty of respiration, and cough, and extreme emaciation : and it was plain that 
 the girl must soon die suffocated if nothing were done for her relief. One of the 
 arteries, I think the superior thyreoidal, was tied, without much difficuhy, on one side. 
 After the operation, the tumour on that side shrunk considerably ; the distress of 
 breathing was removed ; and the patient presently recovered so much of her former 
 strength, and flesh, and comfort, that she was unwilling to have any thino- more 
 attempted, and left the hospital. After some time, however, she came back ao-ain of 
 her own accord, and requested that the artery on the other side might be tied also. 
 This was accordingly done, and a further reduction of the tumour took place. The 
 shrinking, however, if I remember rightly, was not so striking or complete after the 
 second operation as after the first : but the patient was certainly rescued, upon the 
 whole, from imminent death, and put into a condition of ease and at least temporary 
 safety ; the tumour that remained constituting merely a deformity. I never heard 
 of her afterwards. In a case very similar to this, related by Mr. Crawford in the 
 Cijdopsedia of Praclkal Medicine, Mr. Wickham, of Winchester, tied one of the 
 arteries, with much immediate, but no ultimate benefit. The goitre gradually dimin- 
 ished for about six weeks, and then (in consequence, I presume, of the establish- 
 ment of a collateral arterial circulation) it as gradually enlarged again till it was as 
 big as ever. 
 
 Of these surgical expedients there is not one, of which the average results have 
 been sufficiently prosperous to warrant its repetition, except in cases where life is 
 put in jeopardy or made miserable by the swelling; and where other methods, and 
 particularly the treatment by iodine, have been tried, and have failed. One excep- 
 tion, perhaps, I should here make. The tumour sometimes evidently contains a 
 quantity of fluid, either in one of its enlarged cells, or in a distinct cyst. Now the 
 cell, or cyst, may in such cases be punctured, and the contained fluid let out, with- 
 out much risk. This was done in one instance by.my colleague, Mr. Arnott. He 
 kept the orifice open ; and the cyst shrank, and Avas at last obliterated, and the wo- 
 man was much gratified by this diminution of her load. 
 
 LECTURE XLIV. 
 
 Cynanche Parotidxa. Spontaneous Salivation. Aphthx. Cynanche Tonsillaris. 
 
 The Greek writers on medicine apply the terms awwyxn and xway;^?; to inflamma- 
 tory affections occurring about the throat, and more or less interfering with the func- 
 tions of respiration and deglutition : and the Latins employed the word angina in 
 nearly the sanrie sense. CuUen, in his Nosology, has made a genus of Cynanche, 
 although the diseases which he has included in that genus have but little connection, 
 except that the parts they occupy lie near to each other. Some of them, indeed, 
 have their seat in different, though almost contiguous, portions of the same mem- 
 brane ; and are apt, sometimes, on that account, to pass one into the other. In 
 general they are alHed rather by proximity of situation than by community of 
 symptoms. 
 
 I mention these things, because there being a great disposition in the present day 
 to rr-name diseases, and to affect a more precise and scientific nomenclature than 
 sufficed for Cullen, if I adopted the more modern appellations without adverting to 
 the old ones, which have been current so many years, you might experience some 
 difficulty in your reading, in determining wha; disease was intended, when it was 
 merely namrd. For my own part, I think there i? much inconvenience in altering
 
 480 CYNANCHE PAROTIDiEA. 
 
 the established nomenclature ; and especially in changing such arbitrary terms as, 
 though they may not be scienlijic, are yet definite, and convey no erroneous notions 
 respecting the nature of the disorder. I shall give you, however, in most cases, both 
 the old and the new denominations. 
 
 Now one of the maladies in Dr. Cullen's genus Cynanche — though not the first 
 in the order he follows — is cynanche purotidsca. It is an inflammatory affection of 
 the salivary glands, and of the parotid gland in particular. Accordingly it is called 
 parotUis now-a-days. It is not, however, mere inflammation of the parotid, arising 
 from any cause whatever; and therefore parotitis, unless some epithet be added, is 
 less exact than cynanche parotidsea. The vulgar have given it just as good an arbi- 
 trary name as the learned ; and they call it, in this country, the mumps. AA'ith the 
 Scotch it is, I believe, the branJiS. 
 
 The disorder need not detain us long. The parotid swells ; tumefaction takes 
 place beneath the ear ; and if the submaxillary and sublingual glands are not impli- 
 cated in the outset, they soon participate in the tumefaction, in most instances ; so 
 that the swelling extends from beneath the ear along the neck, towards the chin, and 
 the swelled parts are hot and painful, and very tender when touched. The aspect 
 of the patient becomes curiously deformed. Sometimes one side only is afl^ected ; 
 sometimes both sides at once ; but most commonly of all, first one side and then the 
 other. These local symptoms are attended with slight fever. But the only func 
 tion that is materially affected is the motion of the lower jaw, which is impeded by 
 the swelling. The inflammatory condition almost always terminates after a few 
 days, in resolution, under the use of the antiphlogistic regimen, and the application 
 of external warmth. The disease reaches its height in about four days, and then 
 begins to decline ; and its whole duration may be stated, on an average, at eight or 
 ten days. 
 
 This complaint often prevails epidemically : when it afTects one person in a family. 
 or school, it usually aflects several others, simultaneously or in succession, ft chiefly 
 attacks children and young persons. There can be no doubt that it spreads by con- 
 tagion ; and it seldom happens that the same person is twice affected by the mumps. 
 These are remarkable circumstances, and give the malady a peculiar and specific 
 character. I do not dwell upon them now, because they beking also to a very 
 interesting group of diseases, M-hich will require to be particularly considered 
 hereafter. 
 
 Another curious circumstance connected with the disease, and one which has 
 some bearing upon its treatment, is that, in many cases, upon the subsidence of the 
 swelling of the neck and throat, and particularly when it subsides quickly, the testir 
 cles, in the male sex, become swollen and tender, and the inummx in the female. 
 It is said, but I do not know whether the observation be constantly true, that the 
 testicle, or the breast, of tJie same side Avith the inflamed parotid, suffers. Some- 
 times the testicle wastes a-vay after the swelling recedes; a circumstance which is 
 known occasionally to happen when inflammation of that part arises from other 
 causes. This, however, is not usual. In general the inflammation subsides and 
 ceases in the one gland as it does in the other; the swelling is neither very painful 
 nor long continued. But sometimes a more serious transference takes place, from 
 the testicle to the brain : this I have never witnessed ; but then, to say the truth, I 
 have not often been called upon to treat the mumps, and my personal experience of 
 it is limited. I find it stated that the metastasis to the testicle is considered as rather 
 a fortunate circumstance, because it serves as a sort of protection against metastasis 
 to ihe brain ; but I suspect this to be a mistake. Inflammation of the brain, or of 
 its membranes, has sometimes occurred on the disappearance of the parotid swell- 
 incf : but it has much oftener supervened, I believe, upon the retrocession of the 
 inflammation from the testicle or mamma. It is said also that the inflammation 
 sometimes rtr-iurns from the testicle to the parotid, and back again ; oscillating thus 
 two or three times between the two glands. Fortunately, the metastasis to the brain 
 iS much more rare than that to the testicle. 
 
 The treatment of the mumps is simple. It consists in the observance of the anti- 
 pnlogistic regimen ; mild diaphoretics ; laxative medicines, if the head aches, or the
 
 SPONTANEOUS SALIVATION. •^l' 
 
 bowels are confined ; and warm fomentations, or dry warm flannel, to the neck and 
 throat. The tendency observed in this complaint to a change of place — to metastasis 
 to more important organs — forbids us from using very active measures to check or 
 fiiibdue the inllammalion. Nor are such measures necessary. We are not to bleed, 
 nor violently to purge such patients, nor to apply cold to reduce the sweUing. 
 Jjuckily, hot applications are not only the most safe and proper, but the most grateful 
 also to the feelings of the patient. If suppuration should ensue — which is unusual 
 and unlikely, but which sometimes does occur from extension of the inflammation to 
 the neighbouring areolar tissue — poultices must be substituted for the fomentation. 
 Warm apphcations, and rest in the horizontal posture are to be recommended when 
 the inflammation leaves the salivary glands, and attacks the testicles ; or if the pa- 
 tient will not, or cannot, lie up, the testicle must be supported by a suspensory 
 bandage — a bag-truss. If the inflammation of the testicle or mammae be very vio- 
 lent, we must apj)ly leeches, and afterwards poultices ; but this will not often be 
 required, or advisable. Finally, if the inflammation should fly to the brain, we must 
 lay aside our previous caution, and treat the disease in that active manner which the 
 inflammation of so important a part of the body demands. No worse metastasis can 
 occur on the cessation of the phrenitis. I have fully spoken heretofore of the treat- 
 ment to be pursued in that disease, and I have nothing to add respecting it now, 
 except that it may be right as an auxiliary expedient, to try to reproduce the inflam- 
 mation in the parotid, or testicle, or mamma, by irritating applications — mustard 
 poultices, for example — in the hope of thus producing what is called revulsion, and 
 of diveriing the disease from the brain to the part which it previously occupied. 
 
 You know that there is another specific form of parotitis, which is apt to be 
 induced by mercury. Of this I have already spoken. When it is severe, it may 
 be treated by leeches, without any dread of such metastasis as occurs in the mumps. 
 It is usually, though not always, accompanied by a profuse discharge of the secre- 
 tion proper to the glands affected ; and it is attended also by sponginess and swell- 
 ing of the gums. 
 
 1 presume that when inflammation of these salivary glands is not attended with 
 ptyalism, the parenchyma of the gland, or the areolar tissue which enters into its 
 composition, is principally affected ; and that when there is much sahvation, the 
 membrane lining the secretory and excretory ducts is implicated. We see the same 
 distillations in other analogous organs. 
 
 Profuse ptyalism sometimes occurs without any obvious cause, and is then said to 
 be idiopathic, or spontaneous : and this is a circumstance which it concerns you to 
 be aware of, both as practitioners and as medical jurists. The same tenderness and 
 swellijig of the salivary glands, the same copious secretion and excretion of saliva, 
 nay, even the same fetor, or a smell which can scarcely be distinguished from it — 
 the same collection of symptoms which is familiar to you as indicating the specific 
 action of mercury upon the human system — will arise sometimes (but very rarely) 
 when not a particle of mercury has been administered. Several other substances 
 are well known to have the occasional efftit of producing an increased, and even a 
 profuse flow of saliva: preparations, for example, of gold, of copper, of antimony, 
 and of arsenic. The cttstor oil is said to ha^e sometimes the same consequence 
 Digit? is certainly has ; and the iodide of potassium ; and sometimes, I believe, 
 opium. Now and then ptyalism is met with as a symptom among others, of preg- 
 nancy. Occasionally it results from some local irritation within the mouth ; from a 
 decayed or misplaced tooth. But what I principally wish to call your attention to 
 is the fact that salivation may occur as an idiopathic complaint. In the twenty- 
 sixth volume of the London Medical and Physical Journal, there is an instance of 
 it described by Mr. Davies, in which two or three pints of saliva were discharged 
 daily for some time. This flux at length ceased under the use of laxative medicines 
 In the second volume of the Transactions of the College of Physicians is an extra- 
 ordinary example of the same thing, related by Mr. Power. A young lady, of six- 
 teen, spat from sixteen to forty ounces of saliva daily for upwards of two years. Mr. 
 Power believed that the ptyalism in this case was originally excited by wool, whicii 
 he found, in a fetid state, in her ears. In the Revue Medicale there is an acccuni 
 31 2q
 
 482 APHTHA. 
 
 given of a patient who was cured of a spontaneous plyalism after spitting nine pints 
 daily for nine years and a half. You may see another instance, as related by Dr. 
 Prout, in the old series of the Jinnals of Philosophy. Dr. Pereira states that he 
 has seen a dozen such cases; and he describes one which was fatal, not from the 
 ptyalism, however, but from slouohintj of the cheek: and this is no uncommon cir- 
 cunistante. In certain cases of idiopathic inflammation and ulceration of ttie gums 
 or cheeks, from some constitutional unsoundness, there may be extensive sloughing 
 ptyalism, and a very offensive odour, rnuch resembling that which mercury pro- 
 duces. I have met Avith one example only of well-marked spontaneous ptyalism ; 
 and some of its circumstances were so peculiar, that they may be worth relating. 1 
 was taken out to Bayswater, by a medical friend, in the beginning of the year 1833, 
 to see a little girl, ten years old, who had been in a state of salivation from the 5th 
 of November in the preceding year. Up to that time she had been a heakhy lively 
 child, with nothing very remarkable about her, except that she Avas habitually sub- 
 ject to profuse perspirations, which had a very acid smell ; so that the washerwoman 
 was always aware which were her clothes, when she came to wash them, by this 
 smell. She then sudden!}-- became indisposed, had a httle headache, and began to 
 spit a good deal. This was noticed by her mother, and pointed out to her medical 
 attendant, before airy medicine was given her ; and mercury, on that account, was 
 religiously withheld. But in spite of all treatment the ptyalism went on increasing. 
 When I saw her she was spitting three pints of sahva in twelve hours : transparent, 
 rather dark-coloured, and with a small quantity of foam on its surface. There was 
 nothing amiss with her teeth, or her gums, and no fetor of the breath. She was 
 greatly emaciated, and resembled, in some respects, a person worn down by diabetes. 
 From the very commencement of the spitting, the acid perspiration had ceased, and 
 even the vapour had failed to make her sweat. A great variety of remedies were 
 tried, under Dr. Nevison's superintendence, but without the least good effect. At 
 last came the visitation of the influenza, in April of that year. The girl became 
 severely affected by that disorder; and thereupon the salivation disappeared, and 
 has not returned. I heard to-day that she is in excellent health. 
 
 Should you meet with cases of the same kind, you will search for some cause of 
 irritation in the neighbourhood of the salivaiy glands, and especially in the state of 
 the teeth and gums ; and finding none, you will seek further for the cause of the 
 salivation in some deviation from the natural condition of one or other of the principal 
 functions of the system : and you will regulate your treatment acce-dingly. I do 
 not know of any specific plan of cure to be recommended : but it is certainly of im- 
 portance that you should be acquainted with the fact, that ptyalism sometimes exists 
 as a separable and independent malady. Astringent washes are found, sometimes, 
 of service ; a solution of alum, or the infusion of catechu. 
 
 Before I proceed to the diseases pertaining to the interior of the fauces and throat, 
 let me take this opportunity of saying a few words in respect to aphthse. They 
 form the characteristic symptom of an especial disease of infancy: and they are apt 
 to occur in the course of other diseases in adult age; and are then of some im 
 portance as guides in forming our prognosis, and even in determining our plan of 
 treatment. 
 
 AphthfB consist in small, irregular, but usually roundish white specks, or patches, 
 scattered over the surface of the tongue, and the lining membrane of the cavity of 
 ^he mouth and fauces; the angles of the lips, the cheeks, the palate, the pendulous 
 velum, the tonsils, the pharynx. They look like little drops of tallow, or morsels 
 of curd, sprinkled over those parts; they project a little above the surrounding sur- 
 face ; and, in fact, they are mostly formed by elevated portions of the mucous epi- 
 dermis, covering a small quantity of a serous or gelatinous fluid, which separates the 
 epidermis from the subjacent corium. These portions of the epidermis detach 
 Jiemselves, and fall off; leaving behind them a reddish raw-looking surface, or 
 sometimes a foul and ash-coloured spot : and successive crops of these aphthae are 
 .ipt to be formed. 
 
 Noxv children in arms who exhibit these aphthae, are said to have the thrush
 
 APHTHAE. 483 
 
 This occurs at an early age ; seldom, or never, I believe, after the period of lacta- 
 tion is over. The spots occasion some inconvenience in themselves — the mouth is 
 rendered hot and tender by them. The child may be eager enough to take the 
 breast, but is observed to do so with pain and wailing whenever the mouth is applied 
 to the nipple, and attempts to suck or to swallow are made. 
 
 But these aphthae, thus occurring in infants, are attended with other symptoms of 
 disorder : such as drowsiness, sickness, diarrhoea, and some feverishness. And 1 
 believe, a general notion prevails, that the same aphthous condition which is visible 
 in the tongue and mouth, pervades, in such cases, the whole of the ahmentary canal. 
 But this must be a mistake. That some morbid condition exists throughout that 
 tract is highly probable, but true aphthcE can only form on those mucous surfaces 
 which are provided with a continuous epidermis. This erroneous notion has been 
 strengthened, perhaps, by the observation of aphthous spots on the pharynx and 
 oesophagus. The complaint sometimes appears to be the result of improper diet, in 
 children brought up by hand; or of milk of a bad quahty, from an unhealthy or in- 
 temperate nurse. It generally lasts eight or ten days. It is not attended with much 
 danger, except in certain cases, when the surface is left brown or bluish after the 
 loosening and separation of the crusts. In such cases, the local affection is apt to 
 run into a bad kind of gangrenous ulceration, and the discharges from the bowels 
 become slimy and shreddy. 
 
 In almost all instances of the thrush in children, there is acidity of stomach present. 
 Care, of course, is to be taken to discover and to correct any error of diet ; and any 
 unwholesomeness in the quahty of the food. And antacids are to be administered. 
 I know of no form of medicine better adapted to remedy the diarrhoea of infants than 
 the pulvis sodse cum hi/drai'gijro of our hospital Pharmacopoeia ; composed of two 
 parts of the pulvis cretae compositus, two parts of the dried carbonate of soda, and 
 one part of hydrargyrum cum creta. From three to five grains of this powder may 
 be given thrice daily : and for the local affection of the tongue and mouth, the mel 
 boracis is a capital application. It may be painted on the aphthous parts with a 
 camel's hair pencil. 
 
 Aphthce occurring in adults, in the course of other diseases, are often the har- 
 bingers of dissolution. They denote considerable debility ; and they point out the 
 propriety of sustaining the patient's strength, by bark, wine, and nourishing food. It 
 is remarkable how treatment of this kind will sometimes tell. I had a patient last 
 summer who lived for some months, and in tolerable comfort, after a second attack 
 of apoplexy. Every now and then he would have a crop of aphthae appear, which 
 was always an admonition to us that he not only would bear, but that he required 
 some tonic. A more generous diet, with bark, would dissipate them in a day or 
 two. 
 
 Borax is an excellent application for aphthse, whether they occur in adults or in 
 infants. I have known it afford great comfort to patients who were in the last stage 
 of plithisis, and to whom the aphthous state of the mouth was a source of consider- 
 able distress. Equal parts of mel boracis, and syrup of poppies, make a good form. 
 Or an agreeable as well as useful gargle may be made by mixing two drachms of 
 borax, with an ounce of mel rosae, three ounces of decoction of quince seeds, and four 
 ounces of water. 
 
 Aphthae seem sometimes to depend upon mere derangement of the stomach. A 
 nobleman who is well known' as a bon vivant, can never eat shell-fish (so I am told 
 by his physician) without finding, within two hours, that his mouth is full of aphthae. 
 Even lobster-sauce will serve him thus. I look upon this as a sort of internal 
 urticaria. 
 
 [The disease of the mouth occurring in infants duririgj the period of suckling, in wliich the 
 tongue, and the inner surface of the lips and cheeks are covered, to a greater or less extent, 
 with minute portions of a white matter resembling curd — and which constitutes the tnugttel 
 of tlie French writers, the thrush or children's sore mouth of nurses, and the aphthcB lactumiiixi 
 and aphtha infantiles of the older physicians, is evidently a very distinct affection from the 
 aphtha which occurs in the adult as well as in the infant. The first depends upon an ery 
 thematic inflammation of the mucous membrane of tlie mouth, in which an altered seoro
 
 484 APHTHAE. 
 
 lion, in the form of small and curd-like particles or flocculi, or, as in other diphtheritic 
 inflammations, of large patches of a soft pseudo-membranous matter, takes place upon the 
 surface of the inflamed membrane. Upon the separation of these morbid exudations, the 
 membrane beneath is found to be smooth, and without any solution of continuity. According 
 to Guersent, the curd-like exudation is deposited beneath the epithelium, and its separation 
 is consequent upon the rupture of the latter; Plumbe is of a similar opinion ; Guyot and Bil 
 lard, however, never saw it, excepting upon the surface of tlie epithelium, and this accords 
 Avith our own experience. 
 
 In mild cases, the inflammation of the mouth quickly disappears, the particles of curdy 
 matter becoming detached, fall oiT, and leave the membrane beneath of a smooth and healthy 
 appearance. In other cases the inflammation continues for a greater length of time with 
 little abatement: the spots of curd-like matter increase in number, and, occasionally, form 
 by their union large patches, often of considerable thickness — these patches, sooner or later, 
 become detached and fall off, and their place is quickly supplied by a new exudation : and 
 this separation and renewal of the patches continue as long as the inflammation lasts. In 
 some instances, the patches upon the tongue, lips, and cheeks, coalesce, and the whole of 
 these parts become coated with a whitish, granulated crust, which not unfrequently extends 
 into the fauces, pharynx, and, occasionally, into the larynx. 
 
 In situations where a number of children are crowded together, in ill-ventilated apart- 
 ments, the patches of exudation acquire often a dark colour, the breath of the infant becomes 
 fetid — the submaxillary glands enlarged and painful, the face sM-oUen and of a dusky-red 
 hjie — the lips and gums become tumid, and bleed upon the slightest touch, vhile a fetid 
 sanious saliva flows constantly from the mouth. Diarrhcea often attends, the discharges being 
 dark-coloured and highly offensive. The disease, in its milder forms, is rather troublesome 
 than dangerous — and it may be removed very speedily by an appropriate treatment; but 
 when it is attended by the symptoms last described, it is very apt to terminate fatally, death 
 being occasionally preceded by a deep comatose condition. 
 
 There exists some difierence of opinion among medical writers as to how far the morbid 
 exudation characteristic of this affection extends beyond the mouth and favices. It is gene- 
 rally admitted that, in severe cases, it has been found in the oesophagus, as far down as its 
 cardiac orifice : but, while some, including Billard, have asserted that it has been observed 
 throughout the whole tract of the alimentary canal, others, with Veron, maintain that, in no 
 instance has it been met with beyond the cesophagus — the curd-like crusts, occasionally 
 found in the stomach being, as they suppose, conveyed thither from the mouth by degluti- 
 tion. Guyot gives a case, in which the disease was detected, after death, throughout nearly 
 the whole tract of the intestines. In the few opportunities we have had of examining the 
 state of the alimentary canal in infants who have died whilst labouring under this disease, 
 we were unable to trace the exudation beyond the oesophagus — a similar statement is made 
 by Dewees and Eberle. 
 
 We are to recollect that the disease just described is the result of an erythematic inflam- 
 mation of the mucous membrane of the mouth; aphtha, however, are produced by a follicu- 
 lar inflammation of the same membrane. This aflection is more commonly observed about 
 the period of dentition than at an earlier age — it is particularly liable to occur in children 
 of a lymphatic temperament, or in whom htematosis has been rendered imperfect, by impro- 
 per or innutritions food, a damp and cold, or impure and stagnant atmosphere, exclusion 
 from the light, and neglect of cleanliness. It is, also, of very common occurrence during 
 most of the chronic aflections, especially of the intestinal canal, in persons of all ages. 
 
 In the commencement of the disease the mucous membrane of the mouth becomes in- 
 creased in redness, and upon the inner surface of the lips and cheeks, on the sides and infe- 
 rior surface of the tongue, and, occasionally, over the greater part of the soft palate, there 
 soon appear a number of distinct white specks, M-hicli, upon examination, are found to be 
 small transparent vesicles, of a grayish or whitish colour, each being surrounded at its base 
 by a raised, hard ring of a red colour more or less decided. These vesicles often occur in 
 groups, or they may cover the whole of the lining membrane of the mouth and fauces; ex- 
 tending, in some cases, into the cesophagus, and throughout the alimentary canal ; while in 
 other cases they penetrate into the pharynx, and, according to some writers, into the larynx 
 and even the trachea. The follicular inflamiuation will often continue for some time, as 
 just described, without making any further progress, and it may often be arrested before 
 ulceration ensues. Usually, however, the vesicles enlarge in size, rupture, and give discharge 
 .0 a whitish matter; a superficial idcer now occurs, witii slightly elevated edges, and sur ' 
 rounded by a circle of inflammation. These ulcers often secrete a white, curdy matter, 
 which adheres, at first, to their surface, but becomes subsequently detached, and is either 
 swallowe.! or ejected with the saliva. It is often succeeded by a new exudation of a simi 
 lar matter, and thus, in protracted cases, the crusts of curdy matter are repeatedly detached 
 and renewed; or only a portion of the crusts are detached, while the general layer of curdy 
 Miatter remains adherent, often for weeks. When the aphthous ulcerations are numerous, 
 axid in close contact, this curd-like exudation may spread from one to the other, and form a
 
 CYNANCHE TOxNSILLARIS. 485 
 
 'ayor, often of considerable thickness and extent. Occasionally, the exudation from the 
 ulcers is mixed with a small portion of blood ; it then forms dark-coloured-crusts, which have, 
 act unfreqiiently, been mistalcen for gangrenous sloughs. 
 
 Upon the subsidence of the inflammation the ulcerated follicles readily cicatrize without 
 leaving any permanent scar. 
 
 Occasionally, particularly in children of debilitated habits, and who are deprived of pro- 
 per hygienic influences, the aphthous ulcerations become gangrenous, their edges shrink, and 
 assume a ragged, flabby appearance ; a brownish slough forms in their centre, which, on 
 separating, leaves a granulated surface of a vermilion hue ; or, in place of a slough, the 
 ulcers become covered w^ith a brown, creamy fluid, that exhales a very decided gangrenous 
 odour. The parts surrounding the ulcers become tumid, soft, and of a violet hue. From the 
 half-open mouth of the child is discharged a ropy, often fetid, saliva. The countenance 
 becomes pale and puffy; the pulse feeble; and the entire surface of the body pallid, and 
 deficient in sensibility: — repeated vomiting, profuse diarrhoea, and a tympanitic condition of 
 the abdomen, generally occur ; and occasionally, hiccup with frequent eructations, and the 
 patient finally dies, according to Billard, without febrile reaction or cerebral excitement. — 
 (See Condie on Diseases of Children, page 126 et seq.) 
 
 Recently, M. Gruby has attempted to show that, aphthae and muguet are invariably pro- 
 duced by the development of a cryptogamic vegetable. 
 
 According to tire researclies of this gentleman, the affection consists, at first, of small, coni- 
 cal, whitish elevations, tv/enty-five millimetres in diameter, dispersed over the mucous mem- 
 brane of the mouth. These elevations quickly augment in size, and extend rapidly over the 
 adjacent surface, until, finally, the whole of the mouth, fauces, and sometimes the entire ex- 
 tent of the alimentary canal, appear to be covered with a pseudo-membranous layer, from 
 two to three millimetres thick, and strongly adherent to the subjacent tissue. When a por- 
 tion of this substance was examined under a microscope, M. Gruby found it to be composed 
 entirely of a collection of cryptogamic plants, the roots of which, of a cylindrical form, trans- 
 parent, and about one-four hundred and eightieth part of a millimetre in diameter, are im- 
 planted in the cellules of the epithelium. During their development, projections from these 
 roots penetrate the entire series of cellules of which the epithelium is composed, to arrive at 
 the free surface of the mucous membrane. 
 
 According to M. Gruby, these cryptogamic plants have considerable analogy with the spo- 
 rotrichiura described by some botanists. Being very fragile, they become detached by the 
 movements of the tongue and lips, and mixing with the food, are carried into the alimentary 
 canal, a considerable portion of the mucous coat of which they subsequently cover. Those 
 children in whom this extension of the disease takes jilace to any great extent, fall into a 
 state of marasmus, and soon die. 
 
 M. Gruby, having never detected in the white substance of aphthce or muguet any thing 
 else than the cryptogami just described, and the cellules of the epithelium, — there being, in 
 no instance, any product of inflammation present, — considers himself authorized to conclude 
 that aphthae are neither more nor less than a vegetation occurring upon the living mucous 
 membrane. Views precisely similar to those of JNI. Gruby have been advanced by Dr. Berg, 
 of Stockholm. 
 
 Dr. Oestorlein has also submitted the matter of aphtha3 and muguet to microscopic exami- 
 nation, and has been able to detect in it a vegetation similar to that described by the ob- 
 servers just named. This vegetation he has met with, however, only at the period of the 
 fullest development of the aphthie or muguet, which latter he considers to be the product of 
 an exudation resulting from an inflammatory condition of the mucous nrembrane ; the pro- 
 duction of the confervas being purely accidental. He attempted, repeatedly, to transplant 
 them to other animal tissues or fluids, but without success. — C.] 
 
 Hard by the salivary glands lie the tonsils : and one of CuUen's species of 
 cynanche is the cynanche tonsillaris ; in more modern language, tonsillitis, or amyg- 
 dalatis : or, in the vernacular, quinsy, common inflammatory sore throat : a disease 
 which, though internal, is yet within the reach of our sight, and easily recognized. 
 
 The popular term quinsy is in truth, traceable — through the French csqidnancie 
 — to the scientific term cynanche. 
 
 This common and troublesome disorder occurs with very unequal severity in dif- 
 ferent cases. The differences depend upon the extent of the disease, and upon the 
 number and variety of the parts which it involves : for it is seldom limited entirely to 
 the tonsils, but spreads to the uvula, the velum palati, the salivary glands, the pha- 
 rynx, and even to the root of the tongue, and the neighbouring areolar tissue. When 
 the inflammation is superficial it does not produce any great distress, even though it 
 may be diffused. When it penetrates through and beyond the mucous membrane, 
 it is apt to end in suppuration, and to harass the patient much : the tonsils sweJJ to 
 
 2<i3
 
 486 CYNAxNCHE TONSILLARIS. 
 
 an enormous size, and at length deep abscesses form in them. The disease is worsl 
 of all when the back part of the tongue, and the muscular and areolar tissue there- 
 abouts, become implicated : it may chance to reach even the larynx, and then it 
 is always and extremely perilous. 
 
 Under its more ordinary forms, cynanche tonsillaris generally manifests itself, at 
 first, by a slight degree of uneasiness and difficulty in swallowing ; with a constant 
 dryness and sense of constriction in the fauces, and a feeling as if some foreign sub- 
 stance were sticking there. Upon inspecting the throat, more or less of inflamma- 
 tory redness and swelling is seen of one or both of the tonsils. Sometimes both of 
 them are affected at once. Very frequently one only is first attacked : and the 
 swelling begins in the other as it ceases in the first. This is just what occurs in 
 manj^ instances also of cynanche parotidsea. The uvula is commonly enlarged and 
 elongated, and of a scarlet colour. Sometimes it drags upon the back part of the 
 tongue, or dangles into the pharynx, causing the disagreeable sensation of a foreign 
 body continually present, and provoking, by its mere contact, painful and fatiguing 
 acts of deglutition. More frequently the uvula may be seen to be adherent to that 
 tonsil which is most swollen. The dryness of the fauces soon gives place to a copi- 
 ous secretion of transparent mucus, which is frothy and viscid, and sticks to the in- 
 flamed surface so as to be detached with difficulty ; and the patient is tormented by 
 continual and painful efforts to hawk up, or to swallow, this mucus. In an early 
 stage of the disease opaque whitish spots appear upon the red tonsil. They are ex- 
 udations from its surface, or the discharged contents of the mucous crypts there 
 situate. It is important that you should be aware of this, lest you mistake such 
 specks for ulcerating or sloughing points, such as occur in some other affections of 
 the throat, but which are not common in the outset at least of this. 
 
 When the inflammation is violent, the submaxillary and parotid glands sometimes 
 swell, and become tender on pressure : and, less frequently, the patient is troubled 
 by profuse ptyalism. In other words, the inflammation spreads from the tonsils to 
 the salivary glands, and secondary parotitis occurs ; sometimes with and sometimes 
 without an augmentation of their natural secretion. Unable, or unwilling, to swal- 
 low the abundant saliva, the patient allows it to dribble from his mouth. 
 
 Now and then, although the act of swallowing is difficult and painful, you per- 
 ceive on looking into the fauces, no appearance which can account for these symp- 
 toms. The inflammation is seated lower down in the throat ; out of sight. This 
 cannot with propriety be called cynanche tonsillaris ; indeed, it forms a distinct spe- 
 cies, the cynanche p/utrijngca of CuUen. I mention it here because it really does 
 not require any separate consideration. 
 
 The pain in cynanche tonsillaris is felt almost solely during the act of deglutition; 
 which is difficult also from the mechanical narrowing of the passage by the enlarged 
 glands. When both tonsils are afl^cted at once, and much swollen, they push for- 
 wards the anterior pillars of the velum palati, and project in the shape of two great 
 balls of flesh, into the arch of the fauces, so as to leave a very small space only be- 
 tw^een them ; and they sometimes even meet and touch each other, and cause ul- 
 ceration by their mutual pressure. When attempts are made to swallow hquids, 
 they are apt to return through the nose ; the backward passage can no longer be 
 shut in consequence of the tumid and fixed condition of the velum palati. The pa- 
 tients are unable to swallow even soft solids ; indeed the pain of swallowing is so 
 great, that they are not easily persuaded to try. In severe cases pain shoots from 
 the throat to the ear along the course of the eustachian tube ; and this is considered 
 important, as being indicative of suppuration. I believe that suppuration does occui 
 111 the majority of the cases which are attended with this symptom. Sometimes 
 there is tinnitus aurium, and partial deafness, from the obstruction produced to the 
 passage of air through the eustachian tube : either by closure of its extremity in con- 
 .sequence of the swollen state of the parts about it, or by some thickening of its lining 
 membrane from an extension of the inflammation along its channel. 
 
 When the inflammation is intense, and involves the root of the tongue, the patient 
 becomes unable to open his mouth sufficiently to allow the fauces to be seen ; and 
 the inflamed parts can be examined only by means of one's finger. In some instances
 
 CYNANCHE TONSILLARIS. 487 
 
 the power of separating the jaws is so limited, as not to admit the introduction of 
 the finger : and the tongue is incapable of any motion. 
 
 In ordinary cases, however severe the disease may be, there is scarcely any 
 affection of the breathing. But the throat is so blocked up, and the free play of the 
 velum palati so impeded, that the speech is altered ; becoming thick, guttural, and 
 inarticulate. You may often recognize the disease by the peculiar sound of the 
 patient's voice, without looking into his throat. When the swelling of the tonsils is 
 very great, the breathing does sometimes become impaired ; and it is in such cases 
 alone, or nearly in such cases alone, that this disease is at all alarming. 
 
 Cynanche tonsillaris is commonly attended, from the very outset of the inflam- 
 mation, by smart inflammatory fever : severe headache often, and a rapid pulse, rising 
 to 120 beats in the minute, or more. The constitutional disturbance runs higher 
 than we might have expected, considering the limited extent of the local inflammation, 
 and the comparatively small importance of the part inflamed. At the same time 
 there is very little of that debility and anxiety which are observed, as we shall see 
 hereafter, in common continued fever. 
 
 The inflammation crften terminates by resolution ; but when it is violent or long- 
 continued, it very frequently leads to the formation of pus. When the mucous 
 secretion increases in quantity, and becomes less viscid, while the difliculty of 
 swallowing diminishes, and the febrile symptoms decline, resolution may be expected. 
 Suppuration, on the other hand, may be looked for when the inflammation is un- 
 usually intense, when, by the swelling of the tonsils, the breathing is impeded, when 
 a pulsating pain is felt, shooting to the ear, when the patient can scarcely open his 
 mouth, or protrude or move his tongue, when there is more than usual external 
 swelling, and when the symptoms increase, or even fail to remit, after five or six 
 days have elapsed. Rigors sometimes accompany and announce the suppuration : 
 and afterwards the pus may be often seen shining through the membrane covering 
 the tonsils. In many cases, however, it lies so deep that it cannot be detected by 
 the most careful examination. At length the little abscess bursts ; and the relief 
 thereupon experienced by the patient is sudden and striking. All at once the pain 
 ceases: he can swallow, and he feels himself well; and often indeed he is well, or 
 nearly so. The matter discharged has always a nauseous taste and a remarkably 
 fetid smell : and sometimes the fetor, or the ill taste, is the only sign, besides the 
 improvement in the symptoms, that indicates the rupture of the abscess ; the pus 
 being so small in quantity as when mixed up with other matters, easily to escape 
 notice, or (what frequently happens), passing backwards into the stomach by an in- 
 voluntary movement of deglutition. Suppuration sometimes, but rarely, takes place 
 externally, in the areolar tissue of the neck, as well as internally. 
 
 The termination in gangrene is spoken of in books : and it is just possible : but it 
 never happens, I imagine, except in unhealthy constitutions ; or when tonsiUitis 
 occurs as a compUcation of more general disease, such as scarlet fever. It is much 
 more common to see repeated attacks of cynanche tonsillaris produce what used to 
 be absurdly called scirrhus, a permanent enlargement and hardening of the tonsils. 
 While they are in this state, a low kind of inflammation is very readily re-excited in 
 them. The enlarged tonsils are generally irregular, and notched ; something like 
 the surface of a walnut shell; and a white or yellow secretion is often to be seen 
 lying in the hollows. This appearance may be easily mistaken, by an inexperienced 
 eye, for ulceration. 
 
 There is not much risk of your confounding cynanche tonsillaris with any other 
 complaint. The various species of cynanche enumerated by CuUen are separated 
 each from the others by certain broad lines of distinction : all derived, however, from 
 different combinations of two symptoms; — dyspnoea and dysphagia. Thus, in 
 cynanche tonsillaris, deglutition alone is difHcult ; and when you look into the ^Jiroar 
 you see at once why it is difficult. There is equal difficulty of swallowing, and 
 equal freedom of respiration, in cynanche pharyngea ; but the cause of the dysphagia 
 is not visible. In cynanche trachcalis, the respiration is much afl^ected ; the facility 
 ot swallowing not affected at all. In cynanche laryngea both these functions are 
 implicated; there is difficulty of swallowing as well as difliculty of breathing.
 
 488 CYNANCHE TONSILLARIS. 
 
 Cynanche paro/idcca is distinguished by tlie absence of both the symptoms ; its title 
 to the name of cynanche is therefore equivocal. Many of these points will soon 
 come under our notice again. 
 
 Cynanche tonsillaris is supposed to be most frequent among the young and 
 plethoric. But it certainly occurs very often also in persons who are pale, and spare, 
 and feeble; and in those of middle age. Some individuals appear to have, by 
 nature, a strong predisposition to the disease ; and in them its attacks are more or 
 less periodical ; recurring at particular seasons, and commonly during the variable 
 weather of spring and autumn. This peculiarity runs sometimes in families. 
 The liability to the complaint is also very much increased by repetitions of the 
 attacks. 
 
 The only exciting cause worth mentioning, almost the sole cause indeed, is expo- 
 sure to cold. Not unfrequently it assails so many persons at the same time as to be 
 epidemic ; and for that reason it has sometimes been thought contagious. But it 
 has no contagious property whatever. Although we often see several members of 
 the same family affected by it at once, yet we may learn, upon careful inquiry, that 
 its commencement in the different cases has been too nearly simultaneous to admit 
 the supposition of its having been communicated from one to another. The patients 
 have all been exposed to the same unwholesome influences, which operating upon 
 similar constitutions, such as those who are sprung from the same parents may be 
 expected to possess, have produced similar effects. This prevalence of the disorder 
 at certain times and places, is connected, no doubt, with some peculiar conditions of 
 the atmosphere. 
 
 The prognosis is almost always favourable. Not but what death may be produced 
 by this disease, under pecuHar circumstances, and when the inflammation is un- 
 usually violent and extensive. The late Dr. Gregory, of Edinburgh, used to men- 
 tion in his lectures one instance, the only one he had met with among many hundred 
 cases, of death from cynanche tonsillaris. He did not see the patient till he was 
 moribund: and he suspected that it was combined with typhus fever. The only 
 fatal case that I ever witnessed occurred some years ago at the Middlesex Hospital, 
 in one of my own patients. He was a stout young man, 20 years old, a private 
 coachman. The complaint was clearly traced to his having got wet through, more 
 than once, a day or two before it came on. Besides the ordinary symptoms of 
 cynanche tonsillaris, there was great external swelling on both sides of the throat, 
 and the patient was unable either to open his mouth, or to move his tongue. The 
 inflammation involved not the tonsils merely, but the base of the tongue, the saHvary 
 glands, and the surrounding areolar tissue. At length suppuration took place. The 
 abscess broke internally, and pointed also externally, just below the symphysis of 
 the chin, where it was opened with a lancet. Two days after, there was a sudden 
 gusli of blood from the mouth. So immovable were his jaws that it was impossible 
 to determine from which side the hemorrhage proceeded ; it was stopped, however, 
 apparently by the treatment adopted. A fortnight later, the bleeding recurred pro- 
 fusely. It was now evident that the blood was arterial, and that it came from the 
 left side of the throat. Preparations were made for tying the common carotid on 
 the left side ; but just as the operation was about to be begun, the j)atient expired in 
 our presence. His death was shocking, but full of pathological interest. He did 
 not sink, as you ma}' have supposed, in the way of syncope, from loss of blood ; 
 but by suffocation. The blood passed down the trachea and into the lunjjs; and he 
 had been so weakened l>y the previous hemorrhage, that he could not expel the 
 blood so introduced, which actually choked him. A large clot was afterwards found, 
 filling up the wind-pipe. I felt this man's pulse beat firmly and regularly, for a 
 mmule perhaps, after his last effort to breathe. On examining the body it was dis- 
 covered that the abscess had opened internally behind and below the left tonsil. 
 The lingual branch of the carotid artery crossed the site of the abscess; and had 
 been severed and laid open b}'' ulceration. From this vessel the fatal hemorrhage 
 had come. 
 
 It should be borne in mind also, that cynanche tonsillaris does sometimes, by ex- 
 .t'lision of the inflammation to the neighbouring parts, superinduce that very formi-
 
 CYNANCHE TONSILLARIS. 
 
 489 
 
 (lable species of cynanche, of which I am soon to speak, the cynanche laryngea. 
 All cases in which the breathing is in any degree affected, should excite suspicion, 
 and strict scrutiny ; although the dyspnoea may be produced by the mere sweUing of 
 the tonsils. 
 
 You will understand, then, that cynanche tonsillaris may, under unusual and 
 untoward circumstances, prove a fatal disease; but that it is so very rarely indeed. 
 In almost all cases we may say that the life of the patient is not in danger. 
 
 In the uncomplicated and milder form of the disease, when the inflammation is 
 superficial and the fever slight, no great activity of treatment is requisite. The 
 patient should be kept within doors, and even in bed: for a troublesome tendency 
 to a recurrence of the disorder may be fostered by neglect or imprudence. Cooling 
 sahne purgatives will be proper, and the antiphlogistic regimen. A strip of flannel 
 may be put round the neck, and some stimulating embrocation applied to the exte- 
 rior of the throat, beneath the ramus of the jaw : the compound camphor liniment is 
 well adapted to this purpose. Some such plan as this will generally suffice, not 
 indeed to stop the inflammation of a sudden, nor to put an end at once to the fever, 
 but to cause the complaint to run its course evenly, arid to go on to resolution in a 
 few days. Commonly it is not completely over until both the tonsils have been 
 attacked in succession. 
 
 When you catch the disorder in its very outset, I believe you may sometimes 
 succeed in cutting it short by an emetic: a scruple of ipecacuanha, for example, 
 with a grain of tartarized antimony. In all cases it is right to administer a brisk 
 purgative. 
 
 A great variety of astringent, acid, and other gargles, have been employed in this 
 disease ; and their good elfects have, I apprehend, been much over-rated. Many 
 cases would do quite as well, or belter, without them ; for in the early stages strong 
 astringents, and the straining and movements of the throat that accompany their use, 
 may even be hurtful, and increase the pain and the inflammation. The only gargle 
 which I should consider admissible in the commencement of the malady is a gargle 
 of warm milk and water. I have known of one instance in which quinsy suddenly 
 attacked a gentleman who was extremely anxious to use his throat, in public speak- 
 ing, the next day. He occupied himself perpetually, for some hours, in this sort of 
 fomentation of the tonsils with hot water ; and with such good effect that on the day 
 following he was able to accomplish his object. Still there are cases in which, at 
 certain stages of the disease, detergent gargles are serviceable, by assisting the excre- 
 tion of the mucus that collects in the fauces, and by correcting fetor. A weak solu- 
 tion of chlorine in water answers well. In more chronic sore-throats, stimulatinor 
 gargles may often be employed with advantage. When the inflammation is violent 
 a slightly stimulant linctus is preferable; it cuts the phlegm as they say, i. e., it 
 promotes its detachment and removal. Of this kind, currant-jelly is one of the best- 
 But far better than any thing else, as a local application to the inflamed fauces, is 
 the steam of hot water; whether we are hoping for resolution of the inflammation 
 or whether we desire to promote and hasten the process of suppuration already begun 
 The inhaler introduced by myself into the Mid- 
 dlesex Hospital, and elsewhere, though somewhat 
 clumsy in appearance, is the most convenient and 
 effectual that I am acquainted with. I show it to 
 you. It was invented in Edinburgh by a friend 
 of mine long since dead, Mr. Hercy. It will stand 
 upon a table, or lie upon a pillow; and a large 
 volume of steam is carried inwards against the 
 fauces by the mere natural breathings of the pa- 
 tient. Most of the inhaling machines that I have 1 
 seen require a sucking effort, like that made in 
 smoking a pipe : an effort that is apt to be irksome 
 and fatiguing, especially in pulmonary diseases ; 
 
 for some of which this method of applying vapour directly to the suffering part is a» 
 useful as it is for sore-throats.
 
 490 CYNANCHE TONSILLARIS. 
 
 Blistering the outsidt of the throat is a fa vol rite remedy with many. When 
 early applied, a blister often does much good, and probably prevents suppuration in 
 some cases. But I have found blisters of uncertain efficacy ; they leave a mark 
 which lasts for some time, and which patients of the other sex are apt to complain 
 of. For these reasons I prefer mere rubefacients ; the liniment I mentioned before, 
 or the compound soap liniment, or a mustard poultice folded between two layers of 
 .hin hnen. 
 
 In more severe cases leeches applied to the upper part of the throat, just below 
 the angles of the jaw, have been found to give sensible relief: and in the VA'orst 
 degrees of the disorder, when there is much outward swelhng, and the jaws and 
 tongue are fixed, leeches are absolutely requisite. It may be proper to take blood 
 from the arm also. The necessity for active depletion must be measured by the 
 severity of the local symptoms, the intensity of the fever, and the general strength 
 and condition of the patient : and of these things a little experience will teach you 
 to judge. 
 
 It is not to be expected that either leeches or blisters will be of much use afier the 
 process of suppuration has commenced ; nay they may sometimes be injurious by 
 retarding it. it is frequently a difficult matter to determine whether pus has yet 
 formed or not. 
 
 I have already admonished you to make a careful examination of the throat, and 
 to watch your patient narrowly, whenever he experiences any difficulty of breathing. 
 Dyspnoea may be produced by the mere swelling of the inflamed part ; and when it 
 concurs with much enlargement of the tonsils you had better pierce them with the 
 lancet. If they contain matter, it will be evacuated ; and if not, the bleeding pro- 
 duced by the puncture will generally reduce the swelling somewhat, and relieve the 
 patient. There is an instrument made on purpose for this small operation, consisting 
 of a lancet enclosed in a flat silver sheath, from the end of which it is made to pro- 
 trude, to a certain extent only, by pressing upon a spring. The instrument should 
 be directed towards the centre of the fauces, and not outwards, in order to avoid 
 wounding important vessels or nerves. Dr. Cullen indeed says, "this does not 
 require much caution :" but notwithstanding this high authority, I must warn you 
 that puncturing or scarifying the tonsils is an operation not to be carelessly, or rashly, 
 or wantonly performed. Portal mentions a case in which a skilful surgeon, in scari- 
 fying the tonsils of his patient, wounded as he supposes some ramification of the 
 internal carotid, and the patient was presently dead. That artery lies, as you know, 
 very near the tonsil ; and only a few years ago, in Ireland, it was struck by a sur- 
 jreon while scarifying a gentleman's tonsil; and the gentleman died in three minutes. 
 This I was told by the late Dr. Barclay. The case I related just now of faial hemor- 
 rhage from the lingual artery points to the same danger : and since that case occurred 
 two others involving similar hazard have fallen under my own notice, and impressed 
 me with a strong feeling of the necessity of caution. A man was brought into the 
 hospital with profuse hemorrhage from the right tonsil or its immediate neighbour- 
 hood, the consequence of syphilitic ulceration of those parts. He had lost ihree or 
 four quarts of blood, and was nearly dead. His life was saved by Mr. Mayo, who 
 tied the common carotid on that side. 
 
 Last February (1838) a boy from Harrow School was placed under my care, in 
 whom cynanche tonsillaris came on during convalescence from scarlet fever. So 
 much swelling was there of both tonsils that they met, and pushed the uvula out- 
 wards before them, and the breathing was much impeded. A surgeon who was in 
 attendance with me punctured the tonsils. The next day a good deal of hemor- 
 rhage took place ; and this recurred, several times, to a considerable and even an 
 alarming amount. When the clots that formed were wiped away with a sponge, 
 he blood could be seen welling out in a little stream, wiih a pulsating motion, from 
 a small incision in the left tonsil. The hemorrhage was ultimately, after much trouble 
 and anxiety, arrested, by applying a pencil of lunar caustic freely, within the bleed- 
 ing orifice. Lint, wetted with the muriated tincture of iron, or with a saturated 
 Kolution 01 alum, is a fit application in similar accidenis.
 
 ACUTE LARYNGITIS. 491 
 
 Mr. Lawrence, who saw this case, told me that he once knew a patient die of 
 Jiemorrhage from the tonsillar artery. 
 
 1 ought, perhaps, here to add, that very recently, Mr. Joseph Bell, of Barrhead, 
 has strongly recommended the internal administration of powdered guaiacum, in 
 large doses, as being almost specific in the cure of cynanche tonsillaris. He gives 
 as much as half a drachm, suspended by means of mucilage, in a draught, every six 
 lOurs. Mr. Bell has no doubt that this remedy, if timely administered, will cut the 
 disease short in ninety-nine cases out of a hundred. It has been found successful in 
 othpr hands also. I have never had an opportunity of trying it. 
 
 The chronic enlargement of the tonsils, to which I have s'l-eady adverted, is some- 
 times productive of great inconvenience and distress, and ev^n of danger. Its occa- 
 sional consequences are — an habitual trouble in swallowing; confused and inarticu- 
 late speech ; deafness in various degrees, from occlusion of the eustachian tubes; 
 more or less impediment of breathing; and even spasm of the glottis, and impending 
 suffocation. The enlargement may, in such cases, be somewhat reduced, I believe, 
 by repeatedly passing a stick of lunar caustic over the surface of the tonsils ; but a 
 much readier and better plan is to amputate them, in part at least. This may be 
 done by a ligature ; or still better by scissors, or by a sort of small guillotine invented 
 for that purpose. It is not a very painful operation. Mr. Arnott removed one lately 
 from one of my hospital patients; and a very few days ago (December, 1838) Mr. 
 Mayo brought two, in a piece of paper, to the hospital. He had just before cut 
 them ofT for a patient whose respiration they had much embarrassed. 
 
 [Recently the application to the enlarged tonsils of the iodide of zinc, is said to have the 
 effect of causing their rapid absorption. The article is prepared by placing a clean plate 
 of zinc over a jar or vial, and sprinkling iodine over it. In a short time the iodine is 
 deposited in the vessel, in the form of a semi-fluid deliquescent substance. This is to be 
 applied pure, to the surface of the enlarged tonsil, by means of a earners hair pencil, or a 
 piece of sponge, secured to a suitable handle. It is to be held on for a short time, and re- 
 peated every two or three days, until the object is accomplished. The application is fol- 
 lowed by a pimgent smarting, which lasts for twenty or thirty minutes, but by no other 
 inconvenience. Dr. Goddard, of this city, we are informed by Dr. Parrish, in his annual 
 Report on Surgery, read to the College of Physicians, has used the remedy extensively, and 
 speaks very favourably of its effects. He has found it to possess the property of inducing 
 a rapid absorption of the enlarged tonsil, by a sort of shrivelling process, without the forma- 
 tion of a slough. It does not, like the chloride of zinc, spread to the surrounding healthy 
 structure, and hence, may be used without the fear of injury from being swallowed. (Sit»»- 
 mary of the Trans, of the College of Phijs., of Philadelphia, No. vii, page 191.) — C] 
 
 LECTURE XLV 
 
 ^cute Laryngitis. Symptoms. Treatment ; Blood-letting. Tracheotomy, Mer-' 
 cury, Antimony. Anatomical Characters of the Disease. ^Causes. Secondary 
 Laryngitis. Oedema of the Glottis. Chronic affections of the lAirynx. 
 
 The disease of which I have next to speak is of far more serious character than 
 those which were considered in the last lecture. Cynanche laryngea, or acute 
 laryngitis, has proved rapidly fatal in a large proportion of the instances in which it 
 has been known to occur. Yet, when the patient is seen tolerably early, and the 
 nature of the malady is clearly perceived, and the source of peril thoroughly under- 
 stood, I believe that our art is sufficient, in most cases, to rescue the sufTerer from 
 the fate that hangs over him. It is of the greatest importance, therefore, that you 
 should be able to recognize laryngitis when you meet with it, and that you should 
 comprehend the principles according to which it requires to be treated. 
 
 What is laryngitis ? It consists, as that term implies, in inflammation oi the pans 
 composing the larynx : and especially of the mucous membrane that covers tho
 
 492 ACUTE LARYNGITIS. 
 
 laryngeal cartilages, including the epiglottis. The inflammation may be, and some- 
 times is, exactly limited to the larynx ; but frequently it extends also to the posterior 
 fauces, the velum palati, and the tonsils. 
 
 The symptoms of acute inflammation of the larynx are these. The patient com- 
 plains of sore-throat. If you look into his throat you Avill commonly perceive some 
 redness of the velum and uvula, and of the fauces generally. But there is a degree 
 of restlessness and anxiety about tlie patient more than proportionate to the apparent 
 inflammation. Among the earliest of the symptoms that bespeak danger, and ought 
 to excite alarm, is difficulty of des:httition, for Avhich no adequate cause is visible in 
 the fauces; and to this is presently added difficulty of breathing, for which no ade- 
 quate cause can be discovered in the thorax. The mode and character of the respi- 
 ration are peculiar; it is attended with a throttling noise; the act of inspiring is 
 protracted and wheezing, as though the air was drawn in through a dry narrow reed. 
 If you ask the patient what is the seat of his distress, ivhere the disease is situated, 
 he points with his finger to the pomum Adami. If he coughs, he coughs whh a 
 peculiarly harsh, stridulous, husky, abortive sound. He either speaks quite hoarsely, 
 or (what is more common) all power of audible voice in the larynx is lost, and he 
 speaks by means of his lips and tongue only, in a whisper. There is tenderness of 
 the larj'ngeal cartilages ; they are painful when pressed externally. The face is 
 flushed ; the skin hot and dry ; the pulse hard. As the disorder advances, the pa- 
 tient's general distress increases ; but some of the symptoms alter; his countenance 
 becomes pale or livid, anxious and ghastly ; his eyes protrude ; he is miserably un- 
 quiet, impatient for some relief, declares or makes signs that he wants air, and begs 
 that the windows may be opened : and if he does not obtain timely relief, he pe- 
 rishes — he dies strangled. 
 
 The pathology of this terrible disease is extremely simple. The membrane 
 covering the interior surface of the instrument of the voice suffers inflammation. 
 One effect of inflammation in mucous membranes is a thickening of those membranes; 
 they become turgid and swollen. Another frequent effect is the effusion of serous 
 fluid in the subjacent areolar tissue. B}' such tumid thickening of its lining mem- 
 brane, the chink called the rima glottidis is narrowed : it is still further diminished 
 in breadth whenever the membrane is lifted and protruded by infiltration of the tissue 
 beneath it: it is so nearly closed up, that air cannot pass inwards in sufficient 
 quantity to sustain the vital functions: a small portion only of the blood returned to 
 the lungs from the right side of the heart undergoes the requisite change from venous 
 to arterial. The miserable patient grows drowsy and delirious, and dies b}^ a slow 
 process of strangulation. If the rima glottidis becomes quite closed up, his suffer- 
 ings and his life are quickly at an end. 
 
 This disease affords a good instance of a truth which was announced in a former 
 part of this course of lectures ; viz., that the danger of a morbid change may de- 
 pend entirely upon its situation. It is so, eminently, with laryngitis. The inflam- 
 mation is sometimes limited to a spot of membrane not bigger than a square inch. 
 If a square inch and no more of the same membrane, a little lower down, in the 
 trachea, were inflamed in the same manner and degree, the complaint would be quite 
 unimportant. Cynanche laryngea derives all its peril from the circumstance that the 
 inflammation tends to shut up what may well be called the jamtu vitsc. The part 
 afll^cted subserves two purposes : it is the organ of speech ; and it forms a portion 
 of the channel through which air is conveyed from without into the lungs. Both of 
 these purposes are impeded in laryngitis. Now the animal function of speech may 
 be entirely and permanently suspended without any danger to life. The function of 
 ••espiration, which, though under the influence of the will, is an organic function, 
 will not bear to be suspemled, even for a few minutes ; and life cannot be long sus- 
 tained when it is inuch impeded. 
 
 The difficulty of swallowing is a remarkable symptom, and almost always present. 
 Yet it is not absolutely universal ; for Mr. Lawrence describes a case in Avhich it did 
 not occur. It appears to depend, in some measure, upon the tumid and tender con- 
 dition of the whole membrane which is common to the larynx and pharynx, and 
 ■which is pressed upon as the larjmx rises in the act of deglutition : but this symptom
 
 ACUTE LARYNGITIS. 493 
 
 depends also, and in a greater measure, upon the state of the epiglottis, which is often 
 enlarged, and fixed by the swelling in an erect position, and unable to execute its 
 natural valvular office ; so that when the patient makes efforts to swallow, a portion 
 of the food or drink gets into the larynx, and a paroxysm of choking dyspnoea ensues. 
 By pressing down the back part of the patient's tongue, and getting him at the same 
 moment to make a coughing effort, you may sometimes obtain a sight of the tumid, 
 red, and upright valve. 
 
 The dyspnoea is constant : yet there are pauses of comparative ease and quiet ; 
 and thert are, commonly, periods of severe aggravation and urgent distress. It is 
 probable taat the permanent narrowing of the chink by the inflammation and its con- 
 sequences is from time to time increased by spasmodic contraction of the muscles 
 that close the glottis. 
 
 This is the first disease that has come before us, in which the respiration has been 
 primarihj impeded. If you call to mind what was stated in one of the early lectures 
 respecting death by apncea, you will be at no loss to understand the manner in which 
 life is destroyed in laryngitis. 
 
 This formidable malady has always existed ; for you may trace examples of it, 
 under various names, even in the writings of the ancients. But it is only in recent 
 times that it has been singled out from the rest of the angiuce, and made a separate 
 object of study. It has numbered some distinguished medical men among its victims : 
 Dr. David Pitcairn, Sir John Macnamara Hayes, Sir George Tuthill. The cele- 
 orated General Washington died of it. When it has caused death it has generally 
 run a rapid course, and proved fatal before the fifth day. It has carried the patient 
 ofT in less than twelve hours. 
 
 It is of the utmost consequence to make an accurate diagnosis. Laryngitis is 
 easily distinguished from cynanche tonsillaris by the extreme and peculiar dyspnoea 
 which attends it. There may be difficulty of breathing in the latter disease, from 
 enormous sweUing of the tonsils ; but then such swelling will mostly be visible. In 
 laryngitis the marks of inflammation to be seen on inspection of the fauces are gene- 
 rally slight and trifling, and quite inadequate to explain the difficulty of swallowing. 
 Do not, however, forget that laryngitis may supervene upon cynanche tonsillaris. 
 Again, cynanche laryngea is readily discriminated from cynanche pharyngea ; in 
 which complaint there is great pain and difficulty in deglutition ; but the breathing 
 is quite free. In cynanche tracheahs, or croup, which I shall next describe, the 
 breathing is afTected, and the swallowing is not. 
 
 What is to be done for a patient labouring under acute laryngitis ? How and when 
 tire we to employ the great remedy for acute inflammation— blood-letting ? or are 
 we to employ it at all ? These are points concerning which it is quite necessary that 
 your minds should be prepared and prompt to decide. If you look merely to the 
 results in the recorded cases of this fearful complaint, you will scarcely find an 
 answer to the question. In some of them copious bleeding appeared to save the 
 patients ; in others, it was of no service, but rather seemed to accelerate their death. 
 Sir John Macnamara Hayes suffered two attacks of cynanche laryngea. In the first 
 he was freely bled. Dr. Roberts, of Bishop Stortford, informs us that the first bleed 
 ing was attended with considerable relief; the second also with manifest advantage, 
 and by the third, his safety appeared to be ensured. Fifteen years afterwards he 
 died of the same disorder, for which he was again bled and leeched, under the care 
 of the late Dr. Baillie. Washington was largely bled, and died. Again, a Dr. 
 Francis, of New York, recovered from acute laryngitis after copious venaesection. 
 It is evidently needful to consider and determine the circumstances under which we 
 are to use, or to withhold, the lancet. 
 
 Bleeding, to be serviceable, or safe, must be performed early. There is, perhaps, 
 no disease in wl>ich the xatpoj o|v;, the fleeting opportunity, is more conspicuous than 
 m this. When I say that you must bleed early, if at all, I do not mean that you 
 are to reckon so many days or hours from the commencement of the disorder; but 
 you must ascertain what progress it has made ; for it travels sometimes at a railroad- 
 pace. You must look to your patient's actual condition ; and I apprehend that your 
 practice, in respect to blood-letting, may be safely guided by the following rules. If 
 
 2r
 
 494 ACUTE LARY.NGITIS. 
 
 there bo high inflammatory fever present, and the skin is hot, the pulse firm and 
 full, and the cheeks are red, and the lips florid, you may bleed your patient with 
 decision and advantage. But if his powers are beginning to sink under the poison- 
 ous influence of imperfectly aerated blood, if his skin be cold, or even cool, his face 
 pale or leaden, his lips blue, his pulse small and feeble, his mind wavering — you 
 will do no good by blood-letting: nay, you will increase the debility which already-' 
 exists, and hasten the fatal catastrophe. 
 
 With regard to local blood-letting, and to counter-irritation, there is one remark 
 made by Dr. Farre of much practical importance. It is a common practice, in affec- 
 tions of the throat, to appl}^ leeches over or near the laryngeal cartilages, and after- 
 wards to place a blister there. Now serous infiltration of the neighbouring parts 
 often follows leech-bites ; and the effect of a bhster in producing serous effusion often 
 extends beyond the skin : and the cartilages of the throat he very near the surface ; 
 and it is possible that cedema of the glottis might be produced, or augmented, in 
 consequence of these topical remedies. It will be better, therefore, when we wish 
 to take blood locally, to take it by cupping from the back part of the neck : and when 
 we desire to produce counter-irritation, it will be prudent to lay a blister on the upper 
 part of the sternum, rather than to the front of the throat. 
 
 In the advanced stage of the disease, medicine, I fear, can effect but little. 
 
 But surgery may be more successful. 
 
 The danger arises from the mechanical obstacle to the entrance and exit of air into 
 and from the lungs ; and this state of peril admits of a mechanical remedy. If an 
 artificial opening be made between the obstructed part and the lungs, the air is again 
 freely inhaled and freely expelled; the blood undergoes the vital change from pur- 
 ple to scarlet ; and the patient is placed in a condition of safety. He continues to 
 respire through the hole thus drilled in the trachea, until the inflammation of the 
 larynx has subsided ; the thickening of the membrane disappeared ; the submucous 
 infiltration been re-absorbed ; and the vocal instrument restored to its natural integ- 
 rity ; and then the aperture in the wind-pipe may be suffered to heal, and the patient 
 will again draw his breath through its natural channels. 
 
 This is one of the triumphs of the healing art. It requires a knowledge of the 
 general pathology of the disease, i. e., an acquaintance with the facts that acute in- 
 flammation may aff'ect the larj-nx almost exclusively, and that its tendency is to nar- 
 row the fissure of the glottis, and destroy life by suffocation. It requires a knowledge 
 of the symptoms of such inflammation : and it requires an accurate knowledge of 
 all the essential circumstances of the particular case. For it is not every case in 
 which the transit of air through the slit in the larynx is hindered, that is a fit case 
 for the operation of tracheotomy. Some years ago there was brought to me by a 
 surgeon a man breathing with considerable labour and constraint, the air passing 
 through the larynx with an audible hissing noise. The surgeon wished to know my 
 opinion of the propriety of opening the patient's wind-pipe. He had come to the 
 conclusion that there was ulceration of the membrane lining the larynx, with thicken- 
 ing; that the cause of the sibilous respiration was partly mechanical, partly spasmo- 
 dic ; the little muscles that close the glottis acting with injurious energy in conse- 
 quence of the neighbouring irritation : and he thought that this mischief in the 
 larynx would have a better chance of being repaired, if the functions of the organ 
 could be for a lime suspended. He was aware, however, of the necessity of ascer- 
 taining what was the condition of the lungs ; and he had not studied auscultation 
 long enough to trust his own ear in that matter. The patient was pale and thin, and 
 emaciated ; and three minutes sufficed to convince me that his lungs were exten- 
 sively disorganized. His respiration was not so difficult as to threaten suffocation ; he 
 was not dying of the laryngeal obstruction ; and I recommended that he should not 
 be subjected to an operation which might curtail his existence, but could not effect a 
 ■;ure. The man died soon after ; and we examined his body together. There was, 
 as my friend had supposed, ulceration of the membrane near the chordce vocales, 
 and the lungs were full of suppurating or softening tubercles. I mention this case 
 to show you that it is necessary to ascertain the condition of the thorax generally, 
 before we perform or sanction such an operation as tracheotomy. Not that there is
 
 ACUTE LARYNGITIS. 495 
 
 anything very formidable, or painful, or dangerous, in the operation itself. But if 
 we cut a hole in- a patient's throat, who is sure to die soon after of some other 
 incurable complaint, we shall incur the risk of being charged with having killed 
 him. Do not misunderstand me, however. If a patient's life be threatened by acute 
 laryngitis, or by laryngeal oedema, and we are sure of that, and if at the same time 
 we are sure that he carries another mortal disease about him, we are not for that 
 reason to let him die, if we can help it, of the laryngitis ; any more than it would 
 be 'lawful for us to administer a drachm of prussic acid to a man condemned to bo 
 hanged the next morning. But we must state the whole of the case plainly to the 
 patient's friends, and propose the operation as a mode, not of effecting an absolute 
 cure, but of staving off the immediate danger. 
 
 And here let me repair an omission of which I was guilty when speaking just 
 now of the diagnosis. My object was to guard you against mistaking laryngitis for 
 some other malady : but I must also warn you against the converse error, that of 
 mistaking some other malady for acute laryngitis. I can assure you that such a 
 mistake has been made ; and tracheotomy has been performed, too, when there was 
 no disease in the larynx , and the practitioners by whose authority it ivas performed 
 have been ungenerously reproached for their error, although no harm beyond the 
 slight pain and inconvenience of the operation resulted from it. The cases in which 
 this blunder has been committed have nearly all, I believe, been cases of aneurism 
 of the thoracic aorta, which by its pressure on the first divisions of the air-passages, 
 or on the nerves thereabouts distributed, had caused that kind of laboured andstridu- 
 lous breathing which is characteristic of laryngitis. I may venture to say that no 
 person who has had opportunities of educating his ear for the purposes of ausculta- 
 tion, and has made a proper use of those opportunities, could ever overlook such a 
 comphcation as this. I have myself seen a woman (I mentioned her case before) 
 whose trachea was laid open by a surgeon while she was suffering under mere hys- 
 teria ; so closely did that disease mimic laryngitis. 
 
 When you have good evidence that a mechanical obstruction to the passage of the 
 air exists in the larynx, and that the tubes beyond the larynx are pervious and free ; 
 there are two things which I would urge upon you. First, I would most earnestly 
 advise you not to wait too long before you propose or perform tracheotomy ; and 
 secondly, never to omit performing it merely because it may appear to be then too 
 late. If, in the acute and limited disease, an artificial opening be made while the 
 patient's strength is yet entire, and before his whole system is poisoned with venous 
 blood, or his lungs are overwhelmed with sanguine congestion and serous effusion, it 
 will almost infalhbly save his hfe. But if the sinking of the vital power has got 
 beyond a certain point, tracheotomy will not, in that case, rescue him. It is bad and 
 foolish practice to wait, and try other methods, and postpone the operation as a last 
 resource, when the circulation is evidently loaded with unarteriaHzed blood. In my 
 own case I should choose to be operated on early ; the moment that 1 found early 
 blood-letting was not telling upon the local distress, and that any shade of duskiness 
 became perceptible in the skin ; just as I should choose to be operated on at once 
 for strangulated hernia, after one fair attempt had been made by a skilful hand to 
 return the bowel ; without waiting till inflammation set in, or had been caused by 
 the taxis. On the other hand, if you do not see your patient until his powers are 
 nearly exhausted, do not abstain from the operation even though you may feel con- 
 vinced that it will be unsuccessful ; for if it does not save life, it will disarm death 
 of its agony. A patient will lie sometimes for hours, painfully labouring for breath 
 in deep and strong catches, at considerable intervals from each other : in fact, he is 
 just in the condition of a man with a cord round his neck, not pulled quite tight 
 enough to suffocate him at once. Besides, it is not always easy to say whether the 
 period of possible recovery is yet gone by. I had a female patient in the hospital 
 who had suffered one or two attacks of frightful dyspnoea, in which the main dilR- 
 cuhy was referred to the larynx; but she had rallied from them before any steps 
 could be taken for performing tracheotomy. On the next occasion, however, the 
 seizure was so sudden and rapid, that although Mr. Arnott was luckily in the hospital 
 at the time, the woman was, to all appearance, dead, before he could "re found and
 
 496 ACUTE LARYNGITIS 
 
 brought to her bedside. Respiration had entirely ceased. This quietude of the 
 larynx rendered the operation more easy. Mr. Arnott speedily made an opening 
 into the trachea ; some air was blown in through the aperture, and then pressed out 
 again ; and presently the natural respiration was renewed. The woman recovered: 
 the orifice healed up, and she left the hospital. Three or four months afterwards 
 word was brought that she had died at her own home after a short attack, and when 
 there was no one at hand to open her windpipe. We got permission to examine 
 the body, and found a large ulcer in the trachea, near the larynx ; which ulcer by 
 its irritation had occasioned, as we presumed, the spasmodic closure of the glottis. 
 A preparation exhibiting the diseased parts is on the table before you. You see that 
 there was an enlargement of the thyreoid gland. This had probably nothing to do 
 with the symptoms. There was also a large ulcer in the left bronchus. 
 
 Mr. Goodeve, surgeon to the Clifton Dispensary, operated on a patient in whom 
 "no pulse could be found at the wrist; his face was suffused with blood, and his 
 lips hvid ; and it was hard to say whether he breathed or not :" yet he recovered. 
 
 It so happens that there is at present (December 1838) under Dr. Wilson's care, 
 in the hospital, a woman named Slack, who was rescued when almost in articulo 
 mortis, by the same expedient. She had chronic disease of the larynx ; but a sud- 
 den aggravation of the symptoms occurred ; she became stupid and comatose, her 
 countenance was cadaverous, her skin covered with a cold clammy sweat, and her 
 breathing, which had been stridulous and laryngeal, had almost, if not quite stopped. 
 She was making short, gasping efforts to respire, not oftener than twice in a minute. 
 Her pulse was intermittent, and extremely feeble. In this state the house-surgeon 
 (Dr. William Merriman) made a small incision in the skin over the cricoid cartilage, 
 and then thrust a large trocar into the windpipe. Air rushed through the opening, 
 the respiration returned, the pulse revived, and the stupor passed away. This hap- 
 pened on the 1 0th of October. She is still in the ward ; the aperture has closed up ; 
 and though she is not well, she is living;. 
 
 What is the reason, you may ask, of these different and inconsistent results ? How 
 is it that tracheotomy shall reanimate one patient, whose last breath, but for its help 
 was already drawn, who was already motionless in apparent death; and yet shalJ 
 fail to save another patient, who is still alive, and sensible of his danger, and strug- 
 gling with his disease ? The difference depends, I make no doubt, upon the timt? 
 that elapses between the commencement of extreme dyspnosa, and the performance 
 of the operation ; upon the slow or the speedy completion of the stranghng process 
 And this, again, obviously depends upon the manner and degree in which the pas- 
 sage is narrowed. When the obstruction, though considerable, is incomplete, and 
 does not rapidly augment, the respiration continues to be performed, however, im- 
 perfectly. Meanwhile the brain gets oppressed, the circulation tends to stagnate, 
 and, above all, the lungs become gorged with black blood, and clogged up by effu- 
 sion into their cells and substance. Secondary causes of apnosa are thus established, 
 which do not cease when the primary cause is at length removed, by the unbarring 
 of the main channel for the admission of air. Whereas when the access of the 
 atmosphere is suddenly or soon shut out, the lungs are not thus mortally injured, 
 but remain capable of resuming their functions when they are again supplied 
 with air. 
 
 Tracheotomy, then, will be the most likely to succeed, while the patient is still 
 lively and strong ; and after that the chance of success will be worse in those cases 
 in which the apnoea has been slow in its progress, than in those in which it has 
 been rapid. I repeat that, in threatening circumstances, the operation should be done 
 earhj ; but that it should not be withheld, through despair, at any period of the 
 disease. 
 
 The effect produced upon the condition of the patient by the timely formation of 
 in artificial gbttis is very striking. The moment that the scalpel penetrates the 
 rings of the trachea, air begins to hiss through the incision ; and when a fair opening 
 is established, and a full inspiration is drawn in through the wound, several forcible 
 expirations generally succeed, whereby a considerable quantity of niwcus is expelled, 
 which could not pass the contracted apertu'-e of the natural glatis. Then the
 
 ACUTE LARYNGITIS. 497 
 
 bi*eathing soon becomes easy, the anxiety and distress are followed by a perfect calm, 
 and usually the exhausted sufferer sinks into a tranquil slumber. This sleep is apt 
 to be from time to time interrupted by the clooging up of the orifice with frothy 
 mucus. It is requisite that some intelligent person should remain by the patient, 
 to assist him in these emergencies, or he may still be throttled, notwithstanding the 
 apparent prosperity of the operation. 
 
 When a sufficient hole has been made in the instrument of the voice, belovv the 
 glottis, the voice of course becomes extinct, or nearly so ; and the patient is as unable 
 to utter a cough as he is to use vocal language. Now this it is of some importance 
 to notice, for he often wants to cough, in order to clear the air-passages of mucus, or 
 of blood, by which they may be embarrassed ; and he may be helped to do so, or 
 taught to help himself. First he should draw in a full breath, and then stop the ori- 
 Itce for a moment with his finger, while he makes the expiratory effort. And as the 
 parts within the larynx recover, the patient, by a similar manoeuvre, may enable 
 himself to speak aloud. 
 
 As actual examples are more interesting and often more instructive than an ab- 
 stract of results, I will tell you in a summary manner the history of a case of laryn- 
 gitis, which occurred in one of my hospital patients, in the latter part of the year 
 18;i2. He was an old man, about sixty. His name was Kent. He was brought 
 to the hospital bloated with anasarca, which was most conspicuous in his legs and 
 thighs. His breathing was laborious and difficult, and attended with a wheezing 
 noise, audible at some distance. He could not lie down : he had a hard, but not full 
 pulse. The dropsical swelling had come on suddenly five or six days before ; and 
 in the outset his face (he said) was so pufl^ed up that he could scarcely see. He 
 had been bled to the amount of a pint and a half, according to his own account, on the 
 previous evening. I had a vein opened immediately, and twenty-four ounces of 
 blood were drawn ; and eight ounces more were taken from the chest by cupping. 
 He was thoroughly purged with calomel and senna. The bleeding gave him very 
 little relief, so far as the respiration was concerned ; but the next morning the ana- 
 sarca had totally disappeared. I found him sitting up in bed, breathing with much 
 effort, and with a loud stridulous noise which accompanied both inspiration and ex- 
 piration. He referred all this uneasiness to two points; one of these was the 
 larynx, the other the ensiform cartilage. He swalloAved with great pain and diffi- 
 culty ; and every attempt to do so excited a fit of choking cough. There was no 
 morbid appearance visible in the fauces : every part of his chest sounded well on 
 percussion, and the murmur of healthy respiration could everywhere be heard in the 
 lungs, almost drowned, however, in the louder laryngeal noise. As his strength was 
 entire, I had him again cupped, to twelve ounces, at the back of the neck ; and pre- 
 scribed three grains of calomel every three hours. He also inhaled the steam of hot 
 water. 
 
 Upon visiting him again the same evening, I found the dyspnG3a increased. Each 
 act of respiration was attended with a loud croupy noise. His countenance was be- 
 ginning to be anxious and ghastly. He was restless ; and his pulse was less firm. 
 Being now firmly convinced that the operation of tracheotomy was the only thing 
 that could save him, and that it could not be safely delayed, I sent to request that Sir 
 Charles Bell would come and perform it. By the time he arrived the restlessness 
 had increased. The patient was shifting perpetually from one side of the bed to the 
 other, as if seeking some new point of support : his face had become pale ; and his 
 lips were turning livid. He spoke with sudden, and as it were with convulsive 
 eflbrts; stating earnestly how thankful he should be to have the obstacle to his 
 breathing removed ; and pointing to the larynx as the seat of his distress. 
 
 The ordinary operation, under such circumstances, is by no means an easy one to 
 perform. Its difficulties were well exemplified in this patient. In the first place he 
 was sitting up ; he could not bear to be placed in the recumbent position. Then the 
 dyspnoea caused him instinctively to elevate his shoulders, and sternum, and clavi- 
 cles, to the utmost, so that the trachea was sunk deeply into the thorax ; and the 
 larynx was in constant and rapid movement up and down with a plunging motion, 
 like that of the piston of a steam engine. Sir Charles, after some trouble, succeeded 
 33 2r2
 
 498 ACUTE LARYNGITIS. 
 
 in cutting out a piece of the cartilage ; for a mere slit did not suffice : it closed tightly 
 during every inspiration, although it was open enough during expiration. At length, 
 when ihe air was freely admitted, the breathing became gradually easy. I shall 
 never forget the whole spectacle : there sat the poor man gasping and fighting for 
 breath ; his face covered with sweat, and wearing the most anxious expression. By 
 and by what I have called an artificial glottis is opened for him ; and presently after- 
 wards, though half a dozen candles (as Sir Charles has himself painted the scene) 
 are held close to his face, to throw light upon ihe wound, and though the surgeons, 
 their hands smeared with blood, are still busy about his throat, making arrangements 
 to ensure the patency of the orifice, the patient falls fast asleep. It was necessary 
 to place an assistant behind him to prevent his head from nodding forwards, and 
 deranging the apparatus in the wound. Nothing can express more strongly than 
 this fact the great distress and fatigue which had previously existed, and the perfect 
 relief afforded by the operation. 
 
 This man ultimately got quite well; and he has since shown himself occasionally 
 at the hospital, in excellent health. There were two or three points about the case 
 which I am unwilling to pass over without notice. It was evident that after the 
 opening was made in his windpipe, he still breathed in part through the rima glot- 
 tidis also; for the stridulous sound did not wholly cease. The aperture was formed 
 as low as the circumstances of the case appeared to permit : the tube was perforated 
 in the membranous space between the thyreoid and cricoid cartilages. Strictly 
 speaking, laryngotomy was the operation performed. I do not enter into the con- 
 sideration of the best place for making the opening; that point you will be taught 
 by the professor of surgery : but it was observed in the case in question, that the 
 slightest touch of the irritable mucous membrane, with a hook or a probe — especially 
 if the touching instrument was turned vpicords towards the glottis — produced a fit 
 of coughing, and a paroxysm of still more laborious breathing. For some days after 
 the operation, it was noticed that a part of whatever liquid he swallowed appeared 
 immediately at ihe wound. Now this proved as plainly as if we could have seen 
 the parts, that the epiglottis was thickened, and erected, and incapable of performing 
 its protective function to the larynx : and it accounted for the paroxysm of choking 
 cough produced by each act of deglutition. At first the lining membrane of the, 
 larynx and trachea was so irritable, that the patient could not bear to have a metal- 
 lic tube inserted ; and an ingenious contrivance was adopted for keeping the orifice 
 from being covered over by the lips of the wound. They were held apart by two 
 bent wires, which were tied together at the back of his neck. After twenty-four 
 hours had elapsed, the irritability of the mucous membrane had so far abated that he 
 was able to breathe through a canula. 
 
 There cannot be a doubt that this man was snatched from the very jaws of death 
 by the intervention of the surgeon. A function indispensable to life was nearly sus- 
 pended ; and a substitute for the faulty organ was provided by art, until the inter- 
 rupting cause was removed. Scarcely a year passes over our heads without the 
 occurrence of one or two such events in the hospital. When lecturing upon this 
 subject last season, I was able to show you a female patient whose life had been 
 saved in a similar way. And there is now also (December 11, 1839), in Pepys' 
 ward, a rescued man, with the tube still in his windpipe. The operation was done 
 on the spur of necessity by Mr. Tomes, the present house-surgeon, with a trocar. 
 The patient, who was previously in a state of extreme distress, said, in a faint whis- 
 per, as soon as the opening was effected, "It's all right now." 
 
 He had been exposed to rain and cold about a week before ; and had suffered 
 pain and tenderness of the larynx. Prior to his admission he had been bled, and 
 sahvatcd, and had a blister on the throat ivhich embarrasacd the operation. 
 
 Within the last eight years the operation of tracheotomy has been performed in 
 me Middlesex Hospital fourteen times. Seven of the patients recovered ; seven 
 died. In two of the seven fatal cases, the condition of the patients was. hopeless at 
 the time of the operation. In four at least of the five others much relief from suffer- 
 ing was afforded by it, and life apparently prolonged. One of the patients was a 
 young child : the opening was made by a trocar ; much blood got into the air-pas-
 
 ACUTE LARYNGITIS. 49& 
 
 sages, and the cLild, which seemed to be sinking previously, died within the hour. 
 Life might, I think, have been preserved in this case, by a timely operation, pro- 
 perly done. For a trachea so small, the scalpel is preferable to the trocar. But in 
 the adult subject I haA^e seen the larynx penetrated so neatly, easily, and speedily, 
 both by Mr. Arnott and by Mr. Shaw, with a small curved trocar, tliat I am per- 
 suaded of the general superiority of that method over the common operation with 
 the knife or scissors. If this be granted, the fit place for the opening must be the 
 membranous space between the thyreoid and the cricoid cartilages. The superja- 
 cent skin is first nicked with a scalpel : the larynx is then fixed for a moment by 
 the operator's left hand, while with his right he thrusts the instrument steadily 
 inwards and downwards. 
 
 I have said nothing hitherto about the use of mercury in this acute disorder, be- 
 cause I hold it to be of very secondary importance, and because I have been anxious 
 not to divert your attention from the two great practical points, bleeding and trache- 
 otomy. Mercury may very fitly be given in those cases and circumstances m which 
 blood-letting appears proper ; but we cannot depend upon it ; we cannot reckon upon 
 its influencing the system in time; nor upon any marked improvement of the symp- 
 toms when it does produce its specific effects. After the operation it is, for the most 
 part, unnecessary. 
 
 Nor do I recommend the employment of tartar-emetic, powerful as that drug is 
 known to be in subduing inflammation of the mucous tissues. In the swollen and 
 unpliant state of the epiglottis it would not be prudent to excite, or to hazard, vomit- 
 ing. The contents of the stomach passing upwards would be apt to enter the un- 
 protected larynx, and to cause hurtful, distressing, and even perilous attacks of suffo- 
 cative cough. 
 
 In the examination of fatal cases, sometimes the thickened membrane forming the 
 edges of the rima glottidis is found covered with viscid mucus, which had formed 
 an additional impediment to the passage of air towards and from the lungs : some- 
 times pus is discovered, lying in the sacculi laryngis, or scattered among the carti- 
 lages and surrounding muscles : and sometimes the chief morbid condition is the 
 infiltration of the submucous areolar tissue. The effect in all cases is the sam.e, that 
 of closing up, wholly or partially, the narrow fissure between the arytenoid carti- 
 lages. The state of the epiglottis I have several times described. 
 
 This very serious disease is a disease of adult age ; it is not often known to occur 
 in children. They again are almost as exclusively liable to croup: and cynanche 
 laryngea has been called the croup of adults. But as the part occupied by croup, 
 and the event of the inflammation, are both difl^erent from those of laryngitis, this 
 name, croup of adults, is objectionable. I may remark, however, that sometimes in 
 rue croup, the inflammation, besides specially affecting the membrane of the trachea, 
 extends to that of the larynx also. 
 
 [Children are very liable to a mild form of laryngitis accompanied unth a spasmodic 
 affection of the glottis. The disease is marked by many of the symptoms of gennine croupv 
 and is probably the most common form of croupal disease met with in this country.- -C] 
 
 The main exciting cause of laryngitis is exposure to cold, or to cold and wtt. My 
 hospital patient, Kent, was a seller of small wares in the streets, and must, therefore, 
 have been habitually in the way of such causes. The first attack of the disease in 
 Sir J. M. Hayes was brought on by exposure at an open window to the night air 
 for some time, while he was undressed, and in a profuse state of perspiration, with 
 a strong breeze blowing upon him. Dr. Craigie states that young persons from tro- 
 pical climates, from the West Indies for example, are apt to be attacked by laryn- 
 gitis soon after their arrival in Europe. 
 
 The disease is liable to be produced also by mechanical violence, or chemical 
 injury done to the larynx. It has been caused, on several occasions, in children, by 
 their atteinpting to swallow boiling water from the spout of a tea-kettle ; and life ha-* 
 been saved in such cases by the performance of tracheotomy. The mineral acids, 
 taken as poisons, have excited the disease. Fatal laryngitis has followed the incau- 
 tious application of ammonia to the nostrils, in cases of hysteria, and of suspended 
 animation : and I once knew a man nearly killed by the inhalation of the fumes
 
 500 ACUTE LARYNGITIS. 
 
 evolved from cinnabar thrown upon a hot iron, in what is called fumigafion of th« 
 throat for venereal ulceration of that part. I am afraid that I must confess also to 
 have once seen acute laryngitis produced by a bungling attempt to introduce the 
 stomach-pump, in a case of poisoning. i. 
 
 In all these cases the lar}mgitis is primitive. But laryngeal inflammation, and « 
 especially laryngeal oedema, not unfrequently take place, and prove suddenly fatal, 
 in the course of other diseases. I have apprised you that in cynanche tonsillaris, the 
 inflammation sometimes steals onward to the larynx. I have seen two or three cases 
 of erysipelas of the head, attended, as it almost always is, with sore throat, wherein 
 death took place suddenly and unexpectedly, and where the epiglottis, and the 
 edges of the fissure of the glottis, were found to be oedematous : the inflammation of 
 the throat had extended to the areolar tissue beneath the mucous membrane of those 
 parts, and had led to the effusion of serous fluid there. The very same thing is apt 
 to happen in other forms of exanthematous disease attended with sore throat, and 
 especially in small-pox, measles and scarlet fever. I have known a similar condi- 
 tion of inflammatory oedema arise from a mercurial sore throat in a broken-down 
 constitution, Tn these cases the laryngeal affection is consecutive, and secondary; 
 and in all of them the great remedy is the formation of a sufficient aperture beneath 
 the obstructed glottis. In all of them, also, the essential symptoms, warranting and 
 demanding the operation of tracheotomy, are the same. 
 
 A distinction has been made between laryngitis and oedema of the glottis ; and 
 it is a just and real distinction. Qildema of the loose areolar tissue subjacent to the 
 mucous membrane of the glottis, is, indeed, one common consequence of inflammation 
 of that membrane : but it may occur independently of inflammation. The hps of 
 the glottis become tumid and dropsical ; sometimes, (as I have just pointed out,) 
 in consequence of a low inflammatory action in the throat, but sometimes also 
 from obstruction of the veins leading from that part. When laryngeal dyspnoea 
 accompanies aneurism of the thoracic aorta, it may, in some instances, result from 
 local dropsy tlius produced ; and then tracheotomy is fully justifiable, and indeed 
 demanded. 
 
 The main practical difTerence between mere oedema glottidis and acute laryngitis, 
 is this : that in the former, there being no fever or inflammation, blood-letting is not 
 requisite ; and the operation of tracheotomy becomes the sole resource to which, in 
 the extremity of danger, we can look for help. Mere oedema glottidis is seldomer 
 attended with dysphagia, too, than is laryngitis : yet if the epiglottis be involved in 
 the oedematous swelling, and unable to shut over the glottis, the act of swallowing 
 will be followed by strangling cough, and increased dyspncEa. 
 
 Besides the afTcctions which I have now described or referred to, the larynx is 
 Fiable to chronic disease : to chronic injlammation ; chronic thickening of the mem- 
 brane ; slow idceralion : necrosis of its cartilages. Chronic inflammation and ulce- 
 ration of that part are very common in consumptive patients. It is attended first 
 with hoarseness, then with aphonia, a barking or stridulous cough, and all the melan- 
 choly accompaniments of tubercular phthisis. There has accordingly been a species 
 of phthisis spoken of as phthisis lurijngea. But in most, if not in all cases, this 
 laryngeal afTection is only a part of the complaint under which the patient labours ; 
 and what I have further to observe respecting it, I shall postpone until we come to 
 the consideration of tubercular consumption, 
 
 Acain, the membrane lining the laryngeal cartilages is not unfrequently thickened 
 and ulcerated in secondary syphilis ; giving rise to a hoarse croaking voice, and a 
 noisy and painful breathing. In such cases, or in chronic thickening of the same 
 parts from common inflammation, you may do great good by gently introducing mer- 
 cury into the system, until the gums rise. I have again and again seen the uneasi- 
 ness about the throat, the noisy respiration, the rough or whispering voice, all cease, 
 as if by enchantment, so soon as the specific influence of the mercury became 
 manifest. There was a woman Avho used to apply at the Middlesex Hospital for an 
 affection of this kind : whether it was syphilitic or not I could not well determine, 
 but she lost it under the employment of mercury, two or three times : the complain*
 
 CHRONIC AFFECTIONS. 501 
 
 returning again after the interval of a few months, upon the re-application of some 
 irritating cause. In another female patient, who was long under my care in the 
 hospital with similar symptoms, every thing failed to give permanent relief, till I 
 began to leech the neighbourhood of the larynx repeatedly. She had four leeches 
 applied, I think, every night, and then every other night, for a fortnight or three 
 weeks ; the hoarseness and difficulty of respiration gradually diminishing all the 
 time, until at length the perfect use of the instrument of the voice was restored. In 
 these cases, while using local depletion, or mercury, it is often necessary to uphold 
 the strength of the patient by nourishing but unstimulating diet : and it is always 
 expedient that the organ should be kept, as much as possible, in a state of repose. 
 
 It is said that a little practice will enable a person to pass his finger into a patient's 
 throat, and to familiarize his sense of touch with the ordinary condition of the upper 
 part of the respiratory apparatus, so as to be able to detect swelling, or irregularity, 
 or thickening about the chink of the glottis. And great advantage is said to have 
 been obtained from applying remedies directly to the diseased or irritable part. This 
 practice was much followed by the late Mr. Vance, who had been for many years a 
 naval surgeon ; and he called it, in naval phrase, swabbing the affected organ. A 
 small piece of sponge, secured with a string, or fastened to the end of the finger of 
 a glove, is dipped in a strong solution of nitrate of silver, and then carried down into 
 the throat, as far as that spasmodic state of the muscles which the attempt induces 
 will permit, and pressed downwards against the superior surface of the larynx. I 
 believe other stimulating applications are sometimes employed in the place of the 
 nitrate of silver. Now of this method of cure I do not know much, except by report. 
 I have heard that many cases of chronic hoarseness and cough have speedily been 
 cured by it. But I have more than once had what seemed satisfactory evidence of 
 the beneficial effect of this expedient. The man Kent, whose case I have related, 
 gradually regained the power of easy breathing through the natural passage ; and 
 the opening, which Sir Charles Bell had made, closed up perfectly. About a week 
 after this took place, he began again to respire with a wheeze almost as audible as 
 that which existed at the time of his admission : and to speak in a hoarse voice ; and 
 a night or two after the return of the wheezing, he had a paroxysm of extreme 
 dyspnoea. I began to be afraid that the whole process of laryngotomy and the 
 metallic tube would be again requisite. However I got Sir Charles Bell to examine 
 the interior of the throat, and we agreed that it would be advisable to swab the 
 epiglottis and upper part of the air-passages with a strong solution of lunar caustic. 
 For he had no fever, and we thought it probable that the membrane might have 
 been left lax, and in a state to be benefited by astringents. Sir Charles applied the 
 sponge with very little difficulty ; and the next day the breathing was greatly im- 
 proved, and the hoarseness almost gone : and he never had, from that time, any 
 recurrence of troublesome dyspnoea. 
 
 Mr. Arnott has twice or thrice, at my request, swabbed the upper part of the 
 larynx for intractable hoarseness and aphonia : but with no good, nor any bad con- 
 sequence. 
 
 The lining membrane of the larynx is liable also to warty growths, which impede 
 the entrance and exit of air, and ultimately destroy life. There are several examples 
 of that kind on record. I extract the following from my note book : — 
 
 George Tenon la Font, aged 11, admitted March 4, 1828. He speaks in a 
 whisper; complains of difficult breathing, and of cough. Inspires with a loud 
 wheeze. Coughs with a sort of whistling sound, as through a narrow tube. — The 
 cough is most troublesome at night. Expectoration mucous, and inconsiderable in 
 quantity. 
 
 H?is been ill, in this way, all the winter — having had hooping-cough in the pre- 
 ceding autumn. There are marks of cupping on his throat. Little can be heara 
 in the chest, the loud wheeze of his respiration obscuring all other sounds. In about 
 a fortnight his gums were brought under the influence of mercury. No perceptible 
 improvement ensued. A careful examination was again made of the thorax, and 
 the conclusion arrived at was, that the obstacle to his respiration lay in the larynx 
 or upper part of the trachea, and that the lungs themselves were not concerned
 
 502 CYNANCHE TRACHEALIS. 
 
 After this, a blister to the throat, a seton near the thyreoid cartilage, smaL doses of 
 ipecacuanha, emetics, and iodine were successively tried — but in vain. Towards 
 the end of the month he began to suffer occasional, very violent, and apparently- 
 spasmodic attacks of extreme dyspnoea. He died during the night, two months after 
 his admission. For some days before he had been manifest!)^ worse than usual, 
 was more feeble, wandered somewhat, and complained that his vision was imperfect. 
 No noticeable increase had taken place in the difficult}'- of breathing, except during 
 the paroxysms of aggravation already mentioned. His death was sudden, and pro- 
 bably took place in one of these paroxysms. 
 
 When the body was examined, the lungs were found sound as to structure, but 
 copiously infiliered, especially on the left side of the thorax, with serous fluid. At 
 the very top of the larynx, involving the base of the epiglottis and the vocal cords, 
 was a considerable warty growth, closing the rima glottidis almost entirely. The 
 excrescences sj^rang chifjly from one continuous base, and branched out precisely 
 after the manner of what is vulgarly called a seedy wart. There were, however, 
 several distinct smaller growths or warts. The main excrescence, having several 
 heads, passed upwards from and through the rima, and so came to act partly as a 
 valve during inspiration, which was always sensibly more difficult than expiration. 
 
 Ought tracheotomy to have been performed in this case ? I now think so. But 
 supposing it to have been done, and to have been successful, the boy would have 
 been under the necessity of breathing through an artificial tube for the remainder of 
 his fife. 
 
 There are two excellent specimens of warty growths in the larynx upon the table 
 before you. 
 
 I might have referred, when speaking of chronic enlargement of the tonsils, in the 
 last lecture, to the case of a little boy at present under the care of one of my col- 
 leagues. He was brought to the hospital on account of great dyspnoea, and a hissing 
 respiration, produced apparendy by two enormous tonsils. With some difficulty 
 (arising from his unmanageable age) a large part of one of the tonsils was cut off 
 with scissors : but after the operation (either from some fresh swelHng of the parts, 
 or from pressure made by the remaining tonsil, which grew downwards, I under- 
 stand, into the throat), his difficulty of breathing became extreme ; and it was thought 
 necessary to perform tracheotomy, which afforded him signal relief. He breathed 
 for some time through the artificial opening in his windpipe. At length the other 
 tonsil was partly removed : and the child is now well, and about to be discharged. 
 
 LECTURE XLVI. 
 
 Cynanche Trachealis ; Symptoms; Pathology; Prognosis; Treattnent Child' 
 crowing, or Spurious Croup, 
 
 I PROCEED this afternoon to another of Dr. Cullen's species of cynanche ; the last 
 that I propose to consider in this part of the course : viz., cynanche trachealis — 
 tracheitis — croup. 
 
 The essence of this complaint is violent inflammation, affecting the mucous mem 
 brane of that portion of the air-passages which lies between the laryngeal cartilages 
 and the primary bronchi; in one word, of trachea, or wind-pipe. That is the 
 genuine seat of the disease ; but the inflammation sometimes ascends into the larynx; 
 and not unfrequently it dives into the bronchi and into their ramifications. 
 
 [In perhaps tne majority of cases, the inflammation in croup commences in the mucous 
 iiiembrine of the larynx, and from thence extends into the trachea — the disease is there- 
 fore, strictly speaking, a laryngeo-tracheitis. In many instances, however, -we have reason to 
 believe that the inflammation commences in the bronclii, and from thence exter.ds to the 
 tiach'ia; but there are ii'e suspect, very few cases indeed, if any, in which the disease ia
 
 CYNANCHE TRACHEALIS. 503 
 
 confined to the %rach^a. In cases of croup that have terminated rapidly in death, the in- 
 flammation and pseudo-membranous exudation which form so striking a feature in this dis- 
 ease are found only in the larynx and upper portion of the trachea — when death occurs at 
 a later period the exudation is often present in the trachea alone, or in the trachea and 
 bronchi ; it is never /ound to exist in the latter tubes alone. It has been attempted to be 
 shown by Jurin and others, that, in the ordinary form of croup, tlie disease is, in its first 
 stages at least, simply a tracheitis, and that in the more violent and rapid form, (suflbcating 
 croup,) the inflammation is confined to the larynx. Although this is not true, as is shown 
 by tlie result of numerous dissections, yet our observations have shown us, that in cases 
 marked by symptoms of great violence, which are sudden in their onset and rapid in their 
 progress, tlie indications of inflammation are to a mucli greater extent, and the pseudo-mem- 
 branous exudation more cojjious about the larynx, glottis, and upper portion of the trachea, 
 than in cases in which the disease succeeds to bronchitis, runs a more protracted course, and 
 is attended by symptoms of less violence. For a more detailed account of the pathology 
 of croup, the reader is referred to the Editor's Treatise on Diseases of Cliildren, page 301 
 et scq. — C] 
 
 Cullen makes no distinction between cynanche trachealis and cynanche laryngea. 
 Yet they are separated from each other by very definite boundaries. They differ in 
 anatomical position : tliey differ in gravity. Both indeed are serious diseases; but 
 croup is the more serious, because it seldom admits of that mechanical relief whicn, 
 when rendered in time, deprives cynanche laryngea of its dangerous character. 
 The two disorders differ also in respect to the period of life at which they occur. 
 Idiopathic laryngitis is seldom met with except in adults; croup seldom after the 
 age of puberty. Cynanche trachealis is indeed a very remarkable disease, for it 
 exhibits an event of inflammation which does not usually belong to that process when 
 it affects the mucous tissues. In this, too, it differs from larj^ngitis. 
 
 I say that croup is peculiarly a disease of early life. The interval that lies be- 
 tween the two periods of loeaning and puberty, is the time during which its visitation 
 is chiefly to be apprehended. Comparatively few cases of it occur during the first 
 year of infantile life. There are more in the second year than in any other. This, 
 in all probability, is connected with the change that ensues in regard to diet, upon 
 the child's being weaned. Dr. Cheyne, whose experience of croup was very ex- 
 tensive, says, that the younger children are when weaned, the more liable are they, 
 cxteris paribus, to this malady. From the second year onwards the number of 
 children affected with croup gradually decreases. Of ninety-one instances referred 
 to by Jurin, one only was after the tenth year. But it does occasionally happen 
 subsequently to the period of puberty, and up to the twenty-first year ; and even 
 later. A girl of nineteen, one of my hospital patients, died of it. Some of the cases 
 recorded of croup in the adult, were probably, in reality, cases of laryngitis. 
 
 [We Iiave met with the disease most frequently in children between ten months and five 
 years old. By numerous writers the occurrence of croup previous to the seventh months 
 has been denied ; others, however, declare that they have seen it to occur, as a primary 
 disease, repeatedly, at an earlier period. — C] 
 
 It is curious that inflammation should thus, at different epochs of life, fix itself upon 
 limited portions of the same continuous surface, and lead to consequences so diverse. 
 We are unable to give any account of this. 
 
 Cynanche trachealis is frequently preceded by a slighter and more diffused affec- 
 tion of the membrane lining the air-passages. The child has what is popularly 
 called a cold ; sneezes, coughs, and is hoarse. Now with respect to this last symp- 
 tom. Dr. Cheyne makes the following practical remark. Hoarseness (he says) in 
 very young children, does not usually attend common catarrh. When noticed in a 
 district where croup is not unfrequent, it ought to put the parents or the medical 
 attendant of the child upon their guard ; especially as much depends upon the early 
 treatment of the disorder. With these symptoms the child is feverish and fretfui, 
 and does not sleep well. In the course of a day or two the signs peculiar to croup 
 begin to show themselves : they are well stated by Cullen, in his definition of the 
 complaint. " Cynanche, respiratione difficili, inspiratione strepente, voce rauca, 
 tussi clangosa, tumore fere nullo in faucibus apparente, deglutilione parum difficili, 
 cum febre synocha." These are the phenomena that characterize croup. Di/fi-
 
 504 CYNANCHE TRACHEALIS. 
 
 culty of breathintr, and sonorous inspiration. The last is often almost enough, of 
 itself, to identify the disease. Hoarseness; a gruff voice; sometimes a total loss of 
 the power of vocal speech. A very peculiar and distinctive cough, to which the 
 epithet "brassy" has been justly applied ; the noise resembling that which would be 
 occasioned by coughing through a brazen trumpet. This remarkable sound is 
 always easily recognized when it has once been heard. It is a ringing cough ; and 
 '.he expiration has a ringing character ; and either of these, the cough or the expira- 
 tion, is followed by a loud crotcing inspiration. Then there is the negative symp- 
 tom ; the absence of nny difficulty of swallowing; and with all this, inflammatory 
 fever ; a flushed face, hot ."^kin, a frequent hard pulse, thirst. 
 
 However, it is by taking the symptoms collectively, that we judge of the existence 
 of croup, and by the rapid progress of the disease, rather than by any particular or 
 pathognomic sign. Some of the symptoms may occur, separately, when there is no 
 croup. The brassy or metallic cough, for instance, has been known to accompany 
 some chronic affections of the larynx. Dr. Gregory — the late Edinburgh Professor 
 of Physic — knew a man with a venereal disease of the throat who coughed so 
 exactly the cough of croup, that he was admitted into the clinical wards of the 
 infirmary every session for some years, that the students might have an opportunity 
 of hearing this peculiar sound. So also the remarkable crowing inspiration may 
 take place, as we shall soon see, without croup. 
 
 In the outset the fever generally runs high ; and it is of importance, as respects 
 the diagnosis, to mark the presence or the absence of pyrexia. As the obstruction 
 to the passage of air increases, the blood ceases to be duly arterialized : and then, 
 of course, the skin grows dusky, the pulse feeble and irregular, the extremities cold. 
 The cough, also, as the malady thus goes on from bad to worse, ceases to be loud 
 and clanging, becomes husky, and inaudible at a short distance, and the voice sinks 
 into a whisper ; the head is thrown back ; the nostrils, in perpetual motion, dilate 
 widely ; the face is pale and livid, and sometimes bloated ; the pupils often expand. 
 When these indications of sinking have come on, the case usually terminates ill : 
 the bottoms of the feet turn black and hard ; drowsiness supervenes ; some tossing 
 of the arms perhaps ; the breathing becomes gasping and interrupted, and the child 
 dies after an inspiration. 
 
 In other cases the croupy symptoms make their attack very suddenly. A child 
 shall go to bed apparently well, and in the course of the night have all the worst 
 signs of the disease. And it is observable, that whether the attack be altogether 
 unexpected or whether it has been preceded by hoarseness, sore-throat, and catarrh, 
 it usually comes on in the night. 
 
 [These will be generally found, however, to be cases of spasmodic laryngitis or false croup, 
 and to be unattended witli the formation of false membrane in the larynx or trachea. — C] 
 
 Croup resembles laryngitis in this respect, that it runs its course rapidly, proving 
 fatal sometimes within twenty-four, and often within forty-eight hours. It may, 
 however, continue for five or six days before it terminates, whether death or recovery 
 be the result. Dr. Craigie affirms that it is never protracted beyond the eleventh day ; 
 the fatal or the favourable issue having always taken place by that time. Life is de- 
 stroyed, in pure circumscribed tracheitis, by the accumulation in the windpipe of a 
 concrete membrane-like substance, which so frequently attends this disease, and is 
 so peculiar to it, that it is called the membrane of eroiip. In cases of recover}^ this 
 substance has been expectorated in the form of a nearly perfect tube, representing a 
 cast of the trachea; at other times it is coughed up in flat or tubular fragments. In 
 fatal cases it is found sometimes lying in close contact with the mucous membrane, 
 and sometimes quite detached from it ; so that it might have been expelled without 
 much forcing or diflicultv, if the child could have sufficiently inflated its lungs;, and 
 the requisite muscular power had remained, and spasmodic irritabihty of the glottis 
 had not op])osed. 
 
 But, in many instances, this albuminous exudation is not confined to the trachea. 
 It often stretches down to, and enters the ramifications of the bronchi, and reaches 
 ••ven to their termination in the pulmonary vesicles. Sometimes also it is found
 
 CYNANCHE TRACHEALIS. 505 
 
 clothing the mucous membrane belonging to the laryngeal cartilages. This Dr. 
 Craigie denies. But I show you two specimens in which the false membrane, besides 
 filling the trachea, evidently extends into the larynx. One of these comes from the 
 museum up stairs ; the other I have borrowed from the Middlesex Hospital Museum: 
 it is the larynx and trachea of the young woman whom I mentioned just now as 
 having died there of croup, at the age of nineteen. The false membrane reached 
 from the tip of the epiglottis to the bifurcation of the trachea. You see the same 
 thing represented in this excellent plate of Dr. Carswell's, pictured from nature. 
 Usually the adventitious membrane commences just below the larynx, where it is 
 thin and soft : about the middle of the windpipe it is more dense and firm ; lower 
 down in the trachea, and in the bronchi, it is generally looser again, pulpy, and 
 broken: it sometimes, I repeat, penetrates to the very air-cells. What are called 
 (absurdh'^ enough) bronchial polypi, branch-like casts of the smaller ramifications of 
 the air-tubes, are then apt to be coughed up. And even when this concrete substance 
 is not formed, we have other evidence, often, of the extension of the inflammation 
 throughout the whole downward course of the membrane. 
 
 On the other hand, there are a few cases in which this adventitious membrane is 
 not formed at all ; the inner surface of the windpipe is seen to be merely reddened 
 and tumid, and covered with viscid mucus ; or perhaps with a shred or two of con- 
 crete albumen here and there. 
 
 The difficult}'- of breathing, and the characteristic sounds that accompany it, 
 depend, in part, I believe, upon spasmodic contractions. of the small muscles of the 
 lar3nix ; for remarkable aggravations of the dyspnoea are apt to occur, and to subside 
 again ; and these aggravations are sometimes brought on by sudden causes — by the 
 movements of deglutition, for example. 
 
 I shall have to recur to this spasmodic constriction of the glottis : but I may here 
 remark, that because it has not been (and cannot be) seen, doubts have been expressed 
 by some about its having any thing to do with the dyspnoea. Such doubts seem 
 scarcely reasonable. It is easy, at any time, by an effort of the will, to close the 
 glottis, and to prevent the passage of air to and from the lungs. This is mainly 
 effected by the action of the little muscles that bring together the arytenoid cartilages. 
 But those muscles, like the other muscles concerned in respiration, act also inde- 
 pendently of the will, spasmodically therefore, through the reflex function of the 
 spinal cord. And it is by a providential and conservative appointment that they do 
 so act, as janitors, admitting, in the healthy state, the vivifying air, but barring the 
 door against certain hurtful gases, and against solids and liquids which would be 
 injurious to the respiratory apparatus. We know that if a drop of water, or a crumb 
 of bread, or a whiff of carbonic acid gas, gets past the outer defence, the epiglottis, 
 and into the larynx, spasmodic action of the little muscles in question is instantly 
 excited. We cannot see these intruders, and voluntarily resist their entrance, but 
 the unsleeping sentinel is there to guard the passage. We may well conceive, there- 
 fore (and I know not how the supposition can be disproved), that the noisy and diffi- 
 cult respiration of croup may be caused, in part, by spasm. 
 
 [As further evidence of the correctness of this remark may be adduced those cases in 
 which all the diagnostic symptoms of croup are suddenly in<Uiced by an irritation seated in 
 the stomach, as from indigestible food, &c., and are as suddenly removed the moment the 
 cause of irritation is expelled. A medical friend has informed us, that in one of his own 
 children, symptoms resembling croup are produced by eating fish, and are immediately re- 
 moved upon the operation of an emetic. — C] 
 
 The presence of the adventitious tubular membrane in the trachea affords a 
 plausible explanation of one of the symptoms observed in these little patients ; the 
 tendency they show to throw the hea"d back. The cylinder of the membrane is kept 
 open in that position ; whereas, if the head were inclined at all towards the chest, 
 the membrane would be bent upon itself, and the passage through it obstructed. 
 
 This concrete exudation is often adduced to prove that the mucous membranes 
 may exhibit, under certain circumstances, the phenomena of adhesive inflammation. 
 Similar films sometimes form upon, or are thrown off by, the mucous surfaces of 
 the intestines, and of the uterus. \Fhether they are to be regarded as essentially 
 
 2s
 
 506 CYNANCHE IRACHEALIS. 
 
 identical with the layers of coagulable lymph poured forth in inflammation of the 
 serous and areolar tissues, may be made a question. There are certainly some strong 
 points of distinction between them. The concrete membrane of croup is more 
 brittle, less fibrous, more decidedly albuminous, than the false membranes that cover 
 the inflamed pleura, pericardium, or peritoneum. A still more remarkable difference 
 is this, that it is not plastic, in the sense in which that term was formerly explained ; 
 it never becomes organized, never connects itself by blood-vessels with the surface 
 from which it proceeds. On the contrary, it is partially detached ; and by degrees, 
 if the patient live long enough, it is completely separated from the subjacent parts. 
 
 Hypotheses have been framed to account for the limitation of this product of 
 tracheal inflammation to the early periods of life ; and for its variation from the usual 
 products of inflammation of the same part. Dr. Stokes thinks that the predominance 
 of the white tissues in young subjects may explain the greater frequency of croup, 
 with its peculiar membrane, in infants. Dr. C. B. Williams starts the very reason- 
 able supposition that the inflammation involves the submucous areolar tissue, which 
 is abundant during youth ; and that the natural product of this phlegmonous inflam- 
 mation transudes readily through the thin, simple, and delicate mucous membrane 
 proper to that age. 
 
 The formation of this adventitious membrane, and even its renewal, appears to be 
 sometimes very rapid. 1 have here a preparation made by the late Dr. Sweatman, 
 iflustrative of this. It now belongs to the Middlesex Hospital Museum. Upon a 
 child, on the very brink of suflbcaiion from croup, the operation of tracheotomy was 
 performed, at one o'clock in the morning, by Mr. Chevaher. A tubular portion of 
 membrane, of the shape and size of the trachea, was presently forced through the 
 artificial opening. Immediately the child's respiration became easy, and it fell asleep. 
 In the course of the same morning, Dr. Sweatman was hastily summoned, and arriv- 
 ing at eight o'clock, found the child dead. It had slept six hours, and upwards ; and 
 then the distress of the breathing had returned, and was soon fatal. The trachea 
 was found to contain a new tube of lymph, or of concrete albumen. The prepara- 
 tion shows that such a membrane may re-form in that short space of time ; namely, 
 in from six to seven hours. 
 
 The croup is not contagious ; although, like cynanche tonsillaris, and for the same 
 reasons, it is found sometimes existing at the same time, or in quick succession, in 
 more than one child of the same famil\\ Thus two twin children of Dr. Gregory's 
 were seized with croup on the same night. They had both been walking in the 
 evening on the sea-shore during a cold wind. This is in accordance with what Dr. 
 Cheyne has stated, that the attack is almost always noctural, and often when the 
 child has during the preceeding day been exposed to the weather. It frequently 
 occurs sporadically ; but there are places in which the disease appears to be endemic. 
 Dr. Cheyne found it so on the coast of the Frith of Forth. Indeed, the first distinct 
 account of it that we possess was drawn up by Dr. Home, of Edinburgh, in 1705, 
 from much personal observation of its ravages in Leilh and Musselburgh. Cold situ- 
 ations — and damp places, more than such as are merely cold — are subject to the 
 prevalence of this disease, it is accordingly frequent in the seasons of winter and 
 spring. It is said to be most common near the sea-shore, and in the neighbourhood 
 of large bodies of water generally. It occurs in low, moist, what are called in Scot- 
 land came districts, more than in upland situations that are more exposed to cold 
 winds. It is more common at Leith than it is in Edinburgh ; and in Edinburgh, it 
 is most frequent in the lowest parts of the town. This I learned from Dr. Alison, 
 who, having long been physician to a dispensary there, had had ample means of 
 observing the disease. Canal Street and the Cowgate, both low spots, as some of 
 you may know, have long been famous, or rather infamous, for cases of croup. 
 Towns situated on the banks of rivers are more than commonly visited by it; and it 
 has been observed to be particularly frequent among the children of washer-women 
 in such places ; and thus evidently connected with exposure to moisture. It has 
 been known to prevail epidemically in towns so situated after an inundation. And 
 r)r. Alison has made a very curious remark respecting it. He says that it seems 
 *x> bi" often produced by the child's silling, or sleeping, in a room newly washed:
 
 CYNANCHE TRACHEALIS. 507 
 
 and that he has noticed its frequent occurrence on a Saturday night — ihe only day 
 in the week on which it is customary for the lower orders in Edinburgh to wash 
 their houses. 
 
 Like cynanche tonsillaris, and unlike cynanche parotidcea, the croup is exceeding 
 apt to recur. Relapses may happen within a few days after apparent recovery ; and 
 these are very perilous. But besides this tendency to a renewal of the severer symp- 
 toms, the little patients are often affected with cough, and hoarseness, and even with 
 aphonia, for a long lime. And Avhile these relics of the acute attack continue, it is 
 eajily brought back again. The first seizure is generally, I beheve, the worst : but 
 to this rule there are numerous exceptions. 
 
 [The remarks contained in the foregoing paragraph are applicable rather to Spasmodic La- 
 ryngitis than genuine croup. — C] 
 
 Croup is a disorder which justly excites extreme alarm in the friends and parents 
 of the patient : for the prognosis can never be better than doubtful. It is said that 
 four children out of five attacked by it used to die : but that now, the treatment being 
 better understood than formerly, the number of deaths and the number of recoveries 
 are nearly equal. We judge of the probable issue, in a given case, by the apparent 
 circumstances and progress of the malady. If we could see the interior of the air- 
 tubes, we should know that the chance of escape was small, in proportion as the 
 inflammation, and its albuminous product, descended along the ramifications of the 
 bronchi. But in these little patients, and amid the tracheal noises, it is difficult to 
 ascertain the physical state of the lungs. The prognosis is chiefly to be collected 
 from the general condition of the child. If the distress of breathing seems to remit, 
 And free expectoration to come on, while the strength is yet entire, we venture to 
 hope. On the other hand, we begin to despair when the lips are becoming blue, the 
 skin is losing its heat, the pulse is already feeble and intermitting, and the little pa- 
 tient is drowsy or comatose : in other words, when we perceive the final symptoms 
 of death in the way of apnoea. Some few patients die suddenly and unexpectedly 
 without any previous coma. 
 
 The mortality will differ according as the disease is detected early, and treated 
 vigorously, — or otherwise. And with respect to treatment, there is no specific re- 
 medy for this, any more than for any other inflammation. We must put in force 
 the general principles upon which the treatment of inflammation is founded ; adapt- 
 ing them, however, to the malady in question by those particular rules which the 
 experience of the best observers has collected for our guidance. 
 
 I need scarcely say that where cough and catarrh, and especially hoarseness or loss 
 of voice, are noticed in a young child, he should be narrowly watched, and protected 
 against all circumstances likely to excite or to aggravate; inflammation : he should 
 be kept in the house, and put upon farinaceous diet ; and the functions of the bowels 
 and of the skin should be attended to. 
 
 The three remedies that most require consideration are blood-letting, tartarized 
 antimony, and calomel. 
 
 Bleeding is to be unhesitatingly employed when the patient is strong, and ple- 
 thoric, and seen in the outset of the disease. In judging of its mode, and of its 
 amount, we must recollect that what is no more than a topical bleeding in an adult, 
 becomes equivalent, in its effects upon the system, to general bleeding, when it Is 
 used for a very young child. Abstraction of blood, by venesection or cupping in the 
 case of older children, and by leeches in the case of infants, should be practised 
 whenever the symptoms are violent, and there is much fever, and the patient is seen 
 within a few hours after the commencement of the symptoms. The relief that is 
 given by this measure, under such circumstances, is often so decided, that no doubt 
 can remain of its usefulness and propriety. 
 
 It is impossible to lay down any fixed rules for the quantity of blood that shoulo 
 be taken in this complaint. Under two years of age, it should not, sa3's Dr. Cheyne, 
 exceed five ounces. I should esteem that a large bleeding, at that age. Upon an 
 average, a moderate bleeding will be produced by the application of a couple of 
 leeches to an infant in its first year: and an additional leech may be employed for
 
 508 CYNANCHE TRACHEALTS. 
 
 every additional year : so that six may be put to a child five years old ; or eight if 
 he be stout. Dr. Copland estimates the amount of blood which these patients may, 
 with safety, bear, to be somewhat more than an ounce, or as much as an ounce and 
 a half, for everj^ year of their age. Much, however, must depend upon the special 
 circumstances of the case: the quantity of blood extracted by a given number of 
 leeches is less in one instance than in another; and then, of course, the number 
 must be increased. They should be applied at the upper part of the sternum, and 
 not upon the throat itself; for this reason : — that the pressure which may be neces- 
 sary to stop the bleeding, or to regulate its quantity, cannot well be borne upon the 
 throat in these cases. 
 
 After one sufficient evacuation of blood, whether by means of the lancet, or of 
 leeches, or of cupping-glasses applied between the shoulders, it will always be right, 
 before repeating it, to ascertain the effects of other measures ; such as emetics and 
 purgatives, the beneficial operation of which, in this disorder, is often very re- 
 markable. 
 
 Full vomiting sometimes affords relief so sudden and complete, as to lead to the 
 persuasion that the symptoms had been principally owing to spasm. And eyen 
 when the disease is unequivocally inflammation — sometimes even late, but particu- 
 larly in the early part of its course — the effect of a vomit is often very striking. It 
 promotes expectoration ; and is not unfrequently followed by the expulsion of shreds 
 of the adventitious membrane. When blood-letting is employed, it sliould precede 
 the emetic ; or, at any rate, it should precede the act of vomiting. Dr. Cheyne 
 recommends that the bleeding should be practised ten minutes after the emetic has 
 been swallowed. The loss of blood assists the operation of the emetic, and lessens 
 the risk (which is not a fanciful one) of injurious congestion of the vessels of the 
 head during the straining efforts of vomiting. 
 
 It is desirable, not simply to excite the act of vomiting, but to produce and to pro- 
 long a state of nausea and faintness : and so to depress and to keep down the in- 
 creased action of the heart, and to keep empty the capillary vessels of the inflamed 
 part. Now the substance best adapted to this purpose is tartarized antimony. This 
 medicine, as I have often mentioned before, has great power over inflammation of 
 the mucous tissues : and there is one very great advantage belonging to it in cases 
 of croup; namely, that children may be induced to take it without their knowing 
 that they are taking medicine ; for the solution of it has little or no taste : whereas 
 the struggling which is often occasioned by the administration of other emetics may 
 be the cause of much inconvenience, and even of much injury to the patient. It 
 should be dissolved in boiling water, in the proportion of a grain to an ounce ; and 
 the cold solution given, A tea or a dessert-spoonful may be repeated every quarter 
 of an hour, till some efl^ect is produced. When vomiting is thus excited on the very 
 first appearance of the symptoms, and before the disease seems thoroughly formed, 
 it sometimes puts it off: so that no other treatment remains necessary beyond the 
 exhibition of some purgative medicine. But if this perfect relief does not ensue 
 upon the operation of the emetic. Dr. Cheyne advises (and this is in conformity with 
 the practice of many other persons), that a powder, consisting of two, three, or foui 
 grains of calomel, with two or three grains of James's powder, should be given at 
 short intervals; every two or three hours, for example. A dose of castor-oil is to 
 be admmistered occasionally, to clear the bowels. And another expedient, of great 
 efficacy sometimes, and therefore never to be omitted, is the warm bath. This is 
 often properly resorted to just after the act of vomiting, particularly if any tendency 
 to perspiration is apparent. The temperature of the water should not be lower than 
 98° Fahrenheit; and the child should remain in the bath for ten minutes at least. 
 W'iien taken out, he should be wiped dry, and put immediately into bed again. 
 The change for the better produced by the bath is sometimes so marked and so 
 speedy as to strengthen the conclusion that the most distressing of the symptoms had 
 •esulted from spasm. 
 
 The usual efiect of calomel thus frequently repeated is not, as in adults, that of 
 causing salivation, but the discharge of a quantity of green fecal matter, resembling 
 chopped spinach : and when stools of this kind begin to make their appearance.
 
 CYNANCHE TRACHEALIS. 509 
 
 there is often a sensible mitigation of the symptoms. The green colour is a common 
 consequence of mercury given to young children ; and will occur, I believe, Avhat- 
 ever be the disease, when the full effect of calomel as a purgative is obtained. The 
 green matter has been found, after death, in all the intestines, small as well as large, 
 up to the duodenum. I presume that the colour is owing to some chemical action 
 that takes place between the calomel and the bile. We know that calomel does 
 tinge bile green when mixed with it out of the body. It may be, however, that the 
 calomel provokes a flow of altered bile. 
 
 Calomel, thus administered, is the purgative that has received the strongest recom- 
 mendations. Its usefulness appears to have been fully borne out by the test of ex- 
 perience : and the well-known virtue belonging to mercury, of preventing or arrest- 
 ing the effusion of coagulable lymph in other textures, has formed (I conceive) one 
 cogent reason for its adoption in this disorder, of which the chief peril results from 
 the pouring forth of the albuminous part of the blood. But whether mercury really 
 has the same power of controlHng adhesive inflammation, when that process is set 
 up in mucous tissues, which are so commonly exempt from it, may be questioned. 
 On the other hand, the effect of full doses of tartar emetic in restraining active inflam- 
 mation of those tissues is well ascertained : and I should certainly make use of it in 
 the early stages of this dangerous malady. The system can be brought to feel its 
 decided influence with much more certainty, and in a much shorter space of time, 
 than that of calomel : and if it fails to make a beneficial impression, it need not long 
 interfere with the mercurial treatment. Let me quote to you the statement of Dr. 
 Cheyne (whose experience of this disease was far ampler than mine has been,) re- 
 specting the efficacy of tartarized antimony in what he calls the second stage of 
 croup. He recommends that half a grain, dissolved in a tablespoonful of water, 
 should be given to a child two or three years old, every half hour, till sickness and 
 vomiting ensue. In two hours after the last effort of vomiting, the same process is 
 to be recommenced ; and so repeated while the symptoms require it, and the strength 
 will permit. This mode of treatment was suggested to him by the accidental ob- 
 servation of a particular case, in which it was remarkably successful. From that 
 time he placed his whole reliance on that remedy in the second stage of croup ; 
 especially as he had found that blood-letting in that stage only accelerated the death 
 of the patient. He noticed that the cases were few in which he had known children 
 survive the second stage, but in all of these few, they recovered while using a solu- 
 tion of tartarized antimony. He held that no other medicine was, at that stage of 
 the disorder, entitled to confidence. In short, he declared that tartar emetic, so given 
 as to produce continued nausea, had been his sheet-anchor, in the treatment of croup, 
 since the year 1799. This was written in 1801, in a separate work on the patho- 
 logy of the larynx and bronchi ; and Dr. Cheyne recently has affirmed, in the Cy- 
 clopfedia of Practical Medicine, that he still found reason to adhere to the same 
 opinions, and the same practice. 
 
 Now what is good for the second stage, would, a fortiori, I think, be likely to save 
 life, if employed during the earlier stage of the disease. I therefore should say, take 
 blood in the very outset, as largely as may seem prudent : then give the tartar 
 emetic solution in the way already described. As soon as it causes vomiting, and 
 pallor, and a sinking of the pulse, stop ; and suffer the heart to recover itself. And 
 if, with the rallying circulation, the difficulty of breathing returns, have recourse 
 again to the same remedy. The faintness and collapse are sometimes so great as to 
 threaten the extinction of life: the child, with a flying pulse, and a clay-cold sur- 
 face, seems gasping its last. When this happens, a few drops of sal volatile, or of 
 brandy, mixed with water, will presently bring the little patient round again. If no 
 ground is gained after two or three repetitions of the nauseating treatment, then it 
 will be well to make trial of the calomel plan. 
 
 Sometimes the tartar emetic acts severely on the bowels : it may occasionally, 
 therefore, be necessary to combine with it a small quantity of syrup of poppies, or 
 of laudanum. 
 
 Blisters are often applied in this disease ; but with very questionable propriety. 
 In the outset thev are likely to do harm ; in the advanced periods thev are not likely 
 
 2s2
 
 510 CYiNANCHE TRACHEALIS. 
 
 to do good. If used at all, they should be placed, not on the throat, but across the 
 upper part of the sternum. 
 
 [We do not approve of the u«e of blisters in this disease; but if applied, they should onlj 
 be kepi on for a few hours, so as to tender the skin. — C] 
 
 When signs of approaching death have come on — lividity of the lips, coldness of 
 the skin, and a tendency to stupor, the question ivill obtrude itself, whether there 
 may not still be a chance of saving the patient by performing tracheotomy. In the 
 first place you will consider that the operation is much more difficult to execute upon 
 children than upon adults ; and is attended with more perplexing hemorrhaoe. But 
 there is a greater objection than this to tracheotomy in such cases ; an objection 
 which you will have anticipated, namely, the existence of the preternatural membrane ; 
 which often extends so far down, that air would not be admitted into the lungs, even 
 if an aperture in the windpipe were made at the lowest possible point. Another 
 consideration, forbidding much hope of success from this expedient at any period of 
 the disease, is that the ramifications of the bronchi and the ultimate air-cells get filled 
 up with serous, or mucous, or puriform matter, or even sometimes with a mem- 
 branous exudation, whereby suffocation is effected in the lungs themselves. The 
 membrane in the trachea, being tubular, does not entirely exclude the air from those 
 organs ; but it does not admit it in sufficient quantity. Tracheotomy has attain and 
 again been practised in this complaint to no purpose : and I should be inclined to 
 look upon it as absolutely hopeless, but for two instances of its successful perform- 
 ance, recorded in the Medico-Chirurgical Transactions : the one achieved by Mr. 
 Andre, and related by Dr. Farre, in the third volume ; and the other by iVlr. Che- 
 valier, in the sixth volume. These were both apparently desperate cases. Immediate 
 relief followed the operation in both, and the patients recovered perfectly. 
 
 There seem to be just two predicaments in which there is a chance that tracheo- 
 tomy may be useful. They are perhaps rare : yet they have been noticed by several 
 observers. The one is where the preternatural membrane extends but a very little 
 way down the trachea, and is chiefly confined to the larynx ; and the other is where 
 there is no preternatural membrane at all, or only a very slight coating in some part 
 of the trachea, the impediment to the breathing having arisen mainly from the 
 thickening of the mucous membrane. And you will observe that an impediment 
 from this cause will always be the greatest at the narrowest part of the canal: and 
 therefore incision of the windpipe in such a case may be expected to bring relief. 
 The effect produced by the tracheotomy in Mr. Chevalier's case was very instruc 
 tive. Air was fully inspired through the opening, then a strong cough took place, 
 by which a large quantity of viscid reddish mucus was forced out by the natural 
 channel, through the glottis. It was evident that the child could not expectorate before, 
 simply because it could not sufficiently fill its lungs with air to drive the collected 
 mucus out. Dr. Farre gives a circumstantial account of a case in which the adven- 
 titious membrane did not reach more than a finger's breadth below the cricoid car- 
 tilage ; and the rest of the tube was so free that he was convinced the child's fife 
 might have been saved by a timely opening into the trachea. Unfortunatelj', we 
 cannot tell, before death, to what degree or extent the preternatural membrane exists. 
 All that can be said, I think, is, that when dyspnoea and much croup come on sud- 
 denly or quickly, the disease is probably limited to the larynx and upper part of 
 the windpipe : but that when the progress of the disorder is slower, and the croupy 
 symptoms are not so well marked, it is more likely that a greater extent of the tra- 
 chea, below the larynx, participates in the mischief. Our expectations of success 
 from tracheotomy will vary accordingly. It affords a bad chance at the best ; but it 
 affords also, in many cases, the only chance. 
 
 [The subject of tracheotomy in croup is one of considerable interest. — That it may, in 
 many cases, •when timely performed, save the life of the patient, we have the most unques- 
 tionable evidence. In a statement by M. Trousseau of the result of the operation, as per- 
 formed by himself, and by others, according to his method, in one hvmdred and fifty cases, 
 the patients were saved in thirty-nine. In the case of his own child, three weeks old, re- 
 cently published by Dr. Scoutetten, the operation was performed on the thi^ day of the 
 ilisease, under circumstances apparently the most desperate, with complete success — the 
 
 I
 
 CYNANCHE TRACHEALIS. 511 
 
 infant recovering in a short time from the effects of the operation as well as from every 
 symptom of the croup. The class of cases, the period and particular circumstances of the 
 disease in which the operation is most likely to atford relief, are questions of no little im- 
 portance, and we believe that much of the want of success, which many practitioners have 
 experienced in performing the operation, is to be attributed to its having been resorted to 
 under improper circumstances. M. Trousseau, whose experience on this subject has been 
 somewhat extensive, has presented the following as a summary of the prognosis of tracheo- 
 tomy in croup — 
 
 " 1st. If the commencement of the attack dates several days back, if, consequently, the 
 disease has advanced slowly, whatever may be the extent of the false membranes in the 
 trachea and bronchi, the children either recover, or live at least several days after the ope- 
 ration. 
 
 " 2d. But if the disease has been very rapid, even although at the time of the operation, 
 we ascertain that the false membranes do not extend beyond the larynx, the children die 
 very quickly. 
 
 "3d. If previous to the operation, the false membranes have extended to the nares, or if 
 they cover the blistered surfaces ; if the child is pale and somewhat bloated, without hav- 
 ing taken mercury or been bled, or if he has lost much blood, there is little chance of tha 
 operation succeeding. 
 
 " -Itli. If previous to the operation, the pulse is moderately frequent, and if, after it, the 
 pulse remains calm, hopes may be entertained. 
 
 " 5th. It is a bad sign, if, immediately after the operation, the respiration becomes very 
 frequent, without any cough or with very little. 
 " Otli. More boys than girls are cured. 
 
 *^ 7tli. Children under two, and over six years of age, rarely recover. 
 
 " Stli. The more deeply the false membranes have extended, the greater, ccBteris paribus^ 
 the danger. 
 
 " 9th. If the child has been subject to chronic catarrlis, and if he had been suffering from 
 a cold for some time when he was attacked with the croup, tracheotomy is rfiore successful. 
 " 10th. Even when all is going on favourably, very great frequency of respiration is a bad 
 sign. 
 
 ' 1 1th. The more rapid and energetic the inflammation which attacks the wound in the 
 trachea, the better are the chances of success — a sudden sinking of the wound is a mortal 
 sign. 
 
 " r2th. So long as the respiration is silent or the noise is only occasioned by the displace- 
 ment of inucosity, there is nothing to fear; but when the respiration becomes saw-like (ser- 
 ratiquc), in other words, when it is attended with a sound like that produced by a saw cut- 
 ting stone, death is certain. 
 
 '•13th. Tliere is no reason to despair of the patient, even if a pneumonic or pleuritic 
 attack should supervene. 
 
 " 14th. Agitation and sleeplessness are bad signs. 
 
 " 15tli. Should the wound become covered with false membranes; if, after withdrawing 
 the canula, it remains gaping for a long time, or, if after having become entirely cicatrized 
 it reopens largely, the child is in danger. 
 
 " IGth. The sooner after the operation the larynx is disembarrassed, the sooner may we 
 remove the canula, and the more rapid and certain is the cure. 
 
 " 17th. If the croup supervened upon rubeola, scarlatina, variola or pertussis, although 
 tliere is not ordinarily any connection between the malignant angina and these pyrexia, 
 tracheotomy does not succeed. 
 
 " ISth. If the expectoration becomes mucous and catarrhal by the third day after the ope- 
 ration, the children will recover. If there is no expectoration, or it is serous, or like half- 
 dried portions of gum Arabic, they will die. 
 
 " 19th. If the patients react vigorously under tlie injections into the trachea of water or 
 nitrate of silver, and under the sponging out of the trachea, we should not despair, how- 
 ever unfavourable may be the other signs. 
 
 " 20th. Children attacked with convulsions after the operation die, and the younger the 
 patients and the more blood they have lost before or during the operation, the more often 
 convulsions supervene. 
 
 " 21st. When, after the tenth day, the drinks pass almost entirely from the pharynx into 
 tlie larynx and trachea, even if they are readily rejected, the children most generally die. 
 
 " 22il. The increase of the lever after the fourth day, agitation, sinking of the wound, and 
 dryness of the trachea, frequency of the respiratory movements, and attempts to cough, 
 announce the invasion of pneumonia, which, at first lobular, becomes sometimes pseudo- 
 Icbar, and is to be treated by the same means as are usually employed in the pneumonia 
 of chilflren ; we should, however, exclude blisters, because they too often become covereil 
 with false membranes." (See Rilliet and Barthez, Traiti des Mai. des Enfans, t. i 365-''
 
 512 CHILD-CROWING, OR 
 
 There is a sort of bastard croup, with which it is quite necessarj'^ that you should 
 be acquainted, for it is not at all uncommon ; nay, it is far more common in this 
 place at least, than the real disease. It has received a variety of names, which 
 shows that it has been recognized, as a distinct maladj% by various observers. Yet 
 no doubt can be entertained that it has very often indeed been confounded, — and is 
 still continuall)' confounded, — with the true croup, with cynanche trachealis. In 
 their most obvious symptoms the two affections are much alike. The broad and 
 essential distinction between them, is the absence, in the spurious disorder, of inflam- 
 mation and of fever — and consequently of any concrete or other effusion from the 
 mucous membrane of the air-passages. The child is seized all of a sudden, roused 
 perhaps from its sleep by a catch, or interruption of its breathing, more or less com- 
 plete. It strives and struggles to inspire, but is apparently unable to do so ; at 
 length the effort is successful, and the breath is drawn in with a shrill whistling or 
 crowing sound, like that which characterizes the inspirations of croup, or of hooping- 
 cough, and depending, no doubt, upon the same cause — a narrowing (in this com- 
 plaint temporary) of the fissure of the glottis. Spasmodic croup is the most com- 
 mon of its names. It is the thymic asthma of the Germans. My late colleague. 
 Dr. Ley, in a volume upon this curious disorder, published a short time before his 
 death, adopts from Dr. Mason Good the appellation oi laryngismus stridulus. Dr. 
 Gooch called it child-crowing, a homespun term, which I must prefer to the some- 
 what pedantic and cacophonous title bestowed upon it by Dr. Good. The crowing 
 noise, and its concomitant phenomena, take place in paroxysms, which vary in re- 
 spect to frequency and severity, and which are separated by intervals of easy and 
 natural breathing. 
 
 "When the closure of the chink of the glottis is not perfect, the child struggles 
 for its breath : the respiration is hurried ; the countenance generally bluish or livid ; 
 the ej'es staring ; and each inspiration is attended with a crowing noise. When 
 the closure is more complete (and this state was found by Dr. Ley, whose words I 
 am now quoting, to be much the most frequent at the commencement of the pa- 
 roxysm), the function of respiration is entirely suspended for a while ; there is an 
 effectual obstacle to the admission of air. The child makes vehement struggles, by 
 some termed convulsive, to recover its breath. At varied intervals, from a few 
 seconds up to a mmute, or upon some occasions nearly two minutes, air is at length 
 admitted through the glottis, now^ partially open ; and this rush of air, passing 
 through a very narrow chink, produces the peculiar sound. To these symptoms not 
 unfrcquently succeed a fit of coughing or crying, which terminates the scene : or, if 
 the glottis be not thus partially open, the child, at the end of from two to three 
 minutes at the utmost, w^ill die suffocated. Pallid and exhausted, it falls lifeless 
 upon its nurse's arms ; and it is then that the child is generally said to have died in 
 a fit." 
 
 Sometimes, but not always, with the symptoms now described there is a con- 
 tracted state of the flexor muscles of the thumb, fingers, wrist, ankle, and toes ; 
 giving to the foot an appearance approaching to that of club-foot. 
 
 Now till very lately most of those persons who had learned not to confound this 
 child-crowing with true croup, were of opinion that it depended upon cerebral disease 
 or disorder. This was the doctrine of Dr. John Clarke, who has left a very good 
 description of the complaint, which he called "a peculiar species of convulsions." 
 Dr. Ley doubted the correctness of that notion, and believed that the bending of the 
 limbs results rather from feebleness or paralysis of the extensor muscles, than from 
 spasmodic contraction of the flexors. It was obviously a great point to make out, 
 whether the disorder depends upon pressure within the head or not. Our treatment 
 will be regulated by what we know, or believe, in that respect. But what is chiefly 
 original, and very interesting, in Dr. Ley's views concerning this bastard sort of 
 croup is this, that he attributes the temporary closure of the glottis to pressure made 
 by enlarged glands in the neck or chest upon the recurrent nerve, or upon some part 
 of the eighth pair ; " subverting the exact antagonism by which the glottis is automa- 
 tically and involuntarily kept open, and allowing its margins to come together, and 
 to occasion the peculiar kind of inspiration so much hke that of croup." Dr. Lev
 
 SPURIOUS CROUP. 513 
 
 looks upon the aflection altogether as more allied to paralysis than to convulsive 
 movements. This certainly is a very original, but, I think, a mistaken view of the 
 matter ; 1 must refer you, however, to his book for the facts and reasonings upon 
 which it is founded. The important practical fact is, the connection of the child- 
 crowing with tumefaction of the glands in the neck and chest, and with the entangle- 
 ment of the pneumogastric nerve or its branches among these glands. " Scarcely 
 an instance (says he) has occurred to me since my attention has been very much 
 directed to the subject, in which there has not been the strongest foundation for the 
 belief that either the glandulte concatenatae of the neck, or the thoracic absorbent 
 glands, had become morbidly enlarged." 
 
 Even in the short period that has elapsed since Dr. Ley wrote, this curious and 
 intricate knot has been somewhat further (though perhaps it is not yet completely) 
 untwisted. Dr. J. Reid has ascertained, by a well-contrived set of experiments, that 
 the inferior laryngeal (or recurrent) nerve, is an efferent or motor nerve, by which 
 nearly all the movements of the larynx are regulated ; and that the superior laryn- 
 geal is an afferent or incident nerve. We may easily conceive, therefore, how 
 pressure upon, or irritation of either of these nerves, may affect the aperture of the 
 glottis. If the superior laryngeal nerve be implicated, the impression is communi- 
 cated to the spinal cord, and thence reflected, through the recurrent, upon the laryn- 
 geal muscles. Irritation of the gastric ramifications of the par vagum may have 
 the same result. It is an observation of Dr. John Clarke's, that the attacks " very 
 commonly take place after a full meal." Nay, it seems probable that not only any 
 of the afferent fibrils of the eighth pair of nerves, but those of the fifth pair also may 
 have a similar exciting power; for a transient crowing is readily produced in some 
 children, by exposure of the surface of the face and chest to a breeze of wind, or 
 by their being suddenly tossed in the arms of a nurse. We must even suppose that 
 the effect produced upon the central cord may, by reflexion, influence other muscles, 
 and cause the contractions that are sometimes observed in the flexors of the feet and 
 hands. Again, if the recurrent nerve itself be pressed upon, or interfered with, 
 undue contraction or paralysis, according to the kind and degree of interference, will 
 be likely to ensue of the muscles belonging to the glottis. Spasm of those muscles 
 would close the chink, and stop the breath. And Dr. Reid has shown that their 
 palsy, except while tlie breathing is perfectly quiet and tranquil, sensibly impedes 
 inspiration, and alters its character. 
 
 It appears, therefore, that the ingenious view taken by Dr. Ley of the special 
 pathology of this child-crowing disorder, or croup-hke convulsion, merges in the 
 more general principles of reflex function advanced by Dr. Marshall Hall. 
 
 At the same time it is interestiug to observe how Dr. Ley's theory harmonizes 
 with what has been noticed of the predisposing causes of this crowing inspiration. 
 In the first place, it is often manifestly connected with dentition. Now one effect 
 of dentition is the production of glandular swellings of the neck, which happen even 
 in the absence of all strumous taint, but with still more certainty if any such taint 
 exists. And thus he explains the feet, that the disorder has appeared in the most 
 robust as well as in the most delicate infants. Thus, also, he explains another well- 
 known fact, viz., that, when child-crowing accompanies painful dentition, the sj^mp- 
 toms do not vanish instantaneously, as if by magic, the moment that the tooth starts 
 through the gum, but pass off by degrees. Dr. Ley remarks that, " after the gum 
 and enveloping membrane of the tooth have been relieved from swelling and inflam- 
 mation, by the free use of the gum-lance, some time is still required for the irritation 
 and tumid state of the cervical glands to subside." It is not improbable that the 
 gingival irritation alone may sometimes suffice, through the channel of the trifacial 
 nerve, to determine the reflex spasm. 
 
 Again, this child-crowing is found to occur in connection with excoriations behind 
 the ears, and with inflamed and irritable scalp ; and these complaints very frequently 
 lead to enlargement of the absorbent glands of the neck, which enlargement may 
 thus form an intermediate link in the chain of events. And upon some occasionV 
 Dr. Ley has had strong reason to suspect that bronchitis, or other disease of thr 
 33
 
 514 CIIILD-CROWING, OR 
 
 kings, has occasioned enlargement of the bronchial glands, and so given rise to the 
 crowing inspiration. 
 
 I think that Dr. Ley has made out fair grounds for his view of the patholog}' of 
 what is called spasmodic croup. But it is too partial and limited a view. Again, 
 the alleged connection between child-growing and cerebral disturbance is not a mere 
 fancy although its bearing may have been sometimes misapprehended. The cere- 
 bral disturbance is mostlj' the consequence, and not the cause, of the impediment to 
 the function of respiration. 
 
 [We doubt the correctness of Dr. Ley's views, as well as the views of those who refer 
 ihe disease to enlargement of the thymus gland. — For an examination of the facts connected 
 with the pathology o( laryngismus stridulus, the reader is referred to the Editor's Treatise on 
 the Diseases of Children, page 311, et seq. — C] 
 
 The practical fact which you have to remember is, that croupy breathing may 
 occur, and return in paroxysms, when there is no croup. And the practical lesson 
 which you have to learn is, how to discriminate between these two similar, yet dif- 
 ferent disorders. I have already specified the distinctive characters of cynanche 
 trachealis. The complaint that copies it may be known by its sudden accession and 
 its sudden departure ; by the freedom of breathing in the intervals between the pa- 
 roxysms ; by the absence of fever, of preceding or present catarrh, of hoarseness, 
 and of any abiding cough. The diagnosis, easily enough reached when these points 
 are sufficiently attended to, will be still more sure, if you discover enlarged glands in 
 the neck ; or hot, tense, and tender gums. 
 
 According to Dr. Clarke, " convulsions of this description seldom, if ever, occur 
 after the expiration of the third year of a child's life." 
 
 It must be necessary for me to urge the importance of the diagnosis. Those 
 active measures which befit the outset of the inflammatory disease, would be mis- 
 placed and mischievous in the other. It was the result of Dr. Ley's experience that 
 "those children have, upon the whole, a much better chance of being preserved, 
 who are not subjected to very sev'ere discipline, than those who, in compliance with 
 the prevailing doctrine, have been treated by very copious bleeding, large doses of 
 calomel, and such other remedies as the supposition of the invariable dependence 
 of the disease upon cerebral turgescence, or excitement, has suggested." 
 
 Do not, however, imagine, from vvhat I have just been saying, that this disorder, 
 child-crowing, is a trifling disorder, and unattended with danger. It is really a 
 perilous, as well as a terrifying condition. The respiration is sometimes so long 
 suspended that death takes place in the paroxysm. And each paroxysm is accom- 
 panied by a tendency to stagnation and congestion of blood in the brain, lungs, and 
 heart : a tendency which, by its frequent repetition, may lay the foundation of serious 
 and fatal disease in one or other of those vital organs. 
 
 The treatment of this affection must depend a good deal upon the nature of the 
 predisposing and exciting causes. To go into it fully would require that I should 
 speak of the mode of cure in painful dentition, in eruptive complaints about the head, 
 in ceitain pulmonary and cardiac diseases, and in all those conditions which are apt 
 to cause enlargement of the catenated or bronchial glands ; or to fret in some other 
 way the pneumogastric nerves. 
 
 In addition to the special methods of treatment which these disorders may severally 
 need, great care must be taken, in all cases, to regulate the state of the bowels, and 
 of the skin. Fresh air also is a powerful adjuvant ; and sometimes of itself a suffi- 
 cient remedy. Change of place, therefore, and especially a removal from the air 
 of a city or town to the pure atmosphere of the country, should be urged whenever 
 it is practicable. 
 
 In the paroxysm itself the warm bath might be useful, if it could be got ready in 
 time. The application to the throat of a large sponge from which hot water has just 
 been squeezed, is a more accessible, and often a very effecfual expedient. Sprinkling 
 ihe face and chest freely with cold water will sometimes unlock the spasm, and set 
 Jne little sufferer free. 
 1 sbouldjiave stated, that Dr. Ley's views were amply supported by the researches
 
 SPURIOUS CROUP. 515 
 
 that he had made in.to the morbid anatomy of this affection. Had he lived, I should 
 have had it in my power to show you some very beautiful and interesting prepara- 
 tions, illustrative of the connection of the disorder with enlarged glands, which had 
 come to press upon, or stretch, the par vagum, or its branches. As it is, I can only 
 show you the published engraving from some of them, appended to his book. 
 
 [Spasmodic Laryngitis or False Croup is a disease bearing many of the characteristics 
 of genuine croup, and has no doubt been frequently confounded with it. It diliers from it, 
 however, in the absence of any tendency to the formation of false membranes in the larynx 
 or trachea, and in being a far more manageable and less fatal disease. 
 
 The attack of spasmodic laryngitis is usually preceded by slight catarrhal symptoms ; 
 coryza, watering of the eyes, a sense of chilliness followed by flushes of heat; slight hoarse- 
 ness and some cough. Th&se symptoms may continue for twenty-four or forty-eight hours before 
 a paroxysm of the disease is observed. In general this occurs at night ; the child being sud- 
 denly awoke from its sleep by a sense of impending suffocation. He starts up in a sitting 
 posture, or throws himself forwards on his knees. He cries out that he is choking, seems 
 anxious for air, tears off every covering from his throat, and pushes away all who sur- 
 round or offer to assist him. The face becomes swollen and of a dark red or violet hue , 
 the eyes projecting and humid, and the expression of the countenance extremely anxious. 
 The inspiration is long and hissing ; and so loud as occasionally to be heard in an adjoining 
 apartment. There is also, at intervals, a frequent hoarse cough. The voice is constrained, 
 but seldom whispering or abolished. The pulse is quick, and the skin hot. In a short time 
 the paroxysm ceases, and the patient falls asleep. The disease may be confined to a single 
 paroxysm. 2More commonly, however, the child continues during the ensuing day tolerably 
 well, excepting perViaps that he is somewhat hoarse and has an occasional short barking 
 cough, with or without expectoration; and on the succeeding night is again attacked with a 
 paroxysm as on the night previous. The disease may continue thus, with one or two 
 paroxysms each night, for several days, when the paroxysms will cease to recur, and the 
 cough and other symptoms speedily disappear. In some cases, however, the paroxysms con- 
 tinue to recur at shorter intervals, and gradually augmenting in intensity, the patient dies 
 from asphyxia, or, in other cases, after one or more paroxysms, he becomes affected with 
 the utmost inquietude, with almost constant nausea and repeated vomiting, with symp- 
 toms of great exhaustion, cold extremities, and a small frequent pulse, and soon dms. 
 Usually, however, the disease is one very readily controlled, and has seldom a fatal um 
 mination. 
 
 Spasmodic laryngitis is very liable to recur after three, six, nine months or a year, or 
 whenever the child is exposed to cold and damp, or during seasons marked by sudden 
 vicissitudes of temperature. 
 
 Barthez and Rilliet, by whom the term spasmodic laryngitis has been given to the disease, 
 believe it to be dependent upon an actual but slight inflammation of the larynx. This opinion 
 is based upon the fact that its attacks generally follow sudden exposure to cold, and by its 
 being preceded by catafrhal symptoms, and being attended by some degree of febrile excite- 
 ment. In connection with this mild bronchitis there occurs also a spasmodic affection of the 
 glottis, to which they attribute the paroxysms of suffocation. That the disease is attended 
 with some degree of laryngeal inflammation is evident from the result of post-mortem exa- 
 minations. In the few instances in which an opportunity has been afforded for an examina 
 tion after death, traces more or less decided of inflammation of the mucous membrane of 
 the larynx have generally been detected — even when no traces of increased redness are pre- 
 sent, the secretion of the membrane is usually found to be augmented, and of an opaque, 
 yellowish or reddish colour. When, as sometimes happens, death takes place suddenly 
 during a paroxysm, it is probably the result of asphyxia, caused by a complete spasmodic 
 closure of the glottis. 
 
 The disease usually occurs in children from ten months to eight years of age, but more 
 frequently between two and five years. It occurs more often in boys than in girls. 
 
 There is in some families a peculiar predisposition to the attacks of spasmodic laryngitis 
 — nearly all the children becoming affected with it as they attain the age of between two 
 and three years. Though generally sporadic, it occasionally prevails as an epidemic. 
 
 Its occasional cause is almost exclusively exposure to cold and damp, or sudden alterna 
 tions of temperature. After an attack has occurred, the paroxysms may be excited by any 
 sudden or violent mental emotion. 
 
 The prognosis in this disease is generally favourable — but when the occurrence of the 
 paroxysms is prolonged beyond the third day, and constantly augments in intensity — espe- 
 cially when they are succeeded by great restlessness, nausea and vomiting, when the pulse 
 becomes soft and feeble, when a frequent suffocative cough remains, and the patient's strengtr: 
 gradually diminishes, an unfavourable termination is to be apprehended. 
 
 The disease with which spasmodic laryngitis is most liable to be confounded, is pseudo 
 membranous or genuine croup.
 
 516 CHILD-CROWING, OR 
 
 Tlie following comparative diagnostic peculiarities, borrowed partly from M. Valleix 
 and partly from MM. Rilliet and Barthez, will enable us very readily to distinguish the two 
 diseases — • 
 
 In Croup. In Spasmodic Laryngitis. 
 
 There is fever of variable intensity — The symptoms of invasion are slight — . 
 pseudfHnembramms angina, and slight hoarse- there are a slight catarrh, and a cough some- 
 ness. what hoarse — the throat is unaffected — some- 
 There is a gradual increase of the hoarse- times there are no prodroma. 
 ness, and sooner or later a hoarse cough. The attack is sudden — usually at night. 
 
 The fever does not remit; the cough be- Between the paroxysms the patient ap- 
 
 comes hollow and feeble, and the voice faint pears well — the fever disappears or declines 
 
 or extinct. — the voice is rarely extinct. 
 
 The disease is sometimes attended with an There is an expectoration of mucus, 
 
 expectoration of false membrane. The paroxysms of the disease decrease in 
 
 The dyspnoea constantly increases, the violence, 
 croupal sound continues during the parox- 
 ysms — finally the voice and cough become 
 extinct 
 
 The proper treatment of a case of spasmodic laryngitis will depend in a great measure 
 upon the violence of tlie attack and the age of the patient. 
 
 When there are decided indications of laryngeal inflammation, and the spasmodic parox* 
 ysms are intense and prolonged, the application of leeches to the throat, in numbers pro- 
 portioned to the violence of the symptoms, and the age and strength of the child, will be 
 proper. In robust children of five years and upwards, bleeding from the arm will often be 
 productive of the best effects. In no case, however, will it be proper to draw much blood 
 either from the arm or by leeches ; nor should the operation be repeated at short intervals, 
 or too late in the disease — and in the milder cases the abstraction of blood will not be 
 demanded. 
 
 On the first accession of the disease it has been advised by Lehmann to apply a sponge, 
 dipped in very hot water, and then carefully squeezed out, upon the anterior part of the 
 neck, and leave it a moment in contact with the skin — the application being repeated at 
 short intervals. This will produce a redness of the surface, and a general perspiration, 
 which is to be promoted by giving some mild tepid d.iluent. By this simple procedure the 
 paroxysm, we are told, together with all the leading symptoms of the disease may be cut 
 short. 
 
 An emetic given at the commencement of the attack, when followed by the warm bath 
 and sinapisms to the extremities, will generally abate the violence of the paroxysm, and 
 shorten its duration. The exhibition of an emetic, or of small nauseating doses of ipeca- 
 cuanlia, in the intervals of the paroxysms, when considerable hoarseness of the voice, and a 
 frequent short barking cough continue, will generally be found to remove very promptly 
 these symptoms, and prevent tlieir recurrence. 
 
 The bowels should always be attended to, and if not freely and regularly open, a dose ol 
 calomel, followed by castor oil or magnesia, will be proper. 
 
 Blisters to the neck or chest, or between the shoulders, are recommended by some writers. 
 We have seldom seen much benefit to result from their application. When employed they 
 should be allowed to remain on only for an hour or two ; and when removed the part occu 
 pied by them should be covered with a soft emollient poultice. 
 
 In violent cases, subsequent to depletion and the use of the warm bath, much benefit has 
 been derived from the administration of assafcEtida, cither by the mouth or by enema, a 
 few hours after the paroxysm has terminated. Covering the breast with an assafcetida plas- 
 ter we have, also, found to be decidedly beneficial. 
 
 Several of the German physicians recommend in the highest terms the use of musk in 
 this disease. Wendt gave it in the dose of a grain every hour. 
 
 When the paroxysm, from its length and violence, threatens the destruction of the child 
 by asphyxia, the operation of tracheotomy should be performed without delay. 
 
 During the entire continuance of the disease the child should be warmly clad, and kept 
 1 I a warm, well ventilated room. His diet should be light, and of easy digestion, and hi? 
 drinks should consist of weak, lukewarm lemonade, barley or toast water. The utmost caro 
 should be taken to preserve the patient in a state of perfect tranquillity. During the parox- 
 ysms he should be supported in an erect position ; all covering or ligatures being removed 
 liom about the neck. 
 
 Tnere is anotner affection of not unfrequent occurrence, to which attention has been re- 
 cently directed by Dr. Behrend of Berlin (^Journ. der Kinderkrankheiten), that has no doubt 
 been frequently mistaken for spasmodic laryngitis. It is a spasmodic cough of a peculiar 
 character, to which children are liable, and which occurs only during the night.
 
 SPURIOUS CROUP. 517 
 
 This affection is most generally observed in spring and winter; it, however, also frequenl/ 
 •jfcurs during the autumn, and but rarely in summer. It is seldom, if ever, observed lu 
 infants at the breast, but occurs at every subsequent period of cliildhood, and more fre- 
 quently in boys tliau girls. There is no cough whatever during the day, not the slightest 
 catarrhal symptom, and, when put to bed, the child falls into a sound quiet sleep at the 
 usual hour. lu the course of a few minutes, however, it becomes restless, and before awak- 
 ing, coughs violently. It now commences to cry, and the cough becomes more and more 
 severe, until, in some cases, it produces vomiting; after one or two hours of suffering, the 
 child again falls asleep, and passes the remainder of the night quietly. The cough returns 
 at the same hour the following night, and continues sometimes for weeks and even months ; 
 finally, it begins to diminish in violence, tlie fits beconu of shorter duration, and occur at a 
 more advanced period of the night, so that the length of the sleep enjoyed previously to its 
 coming on, is gradually prolonged : — at length the cough disappears entirely and sponta- 
 neously. The subjects of this affection are pale, readily fatigued, and troubled with a cold- 
 ness of the feet towards evening; they eat and play, however, as usual, and appear other- 
 wise to enjoy good health. The nocturnal cough has frequently a catarrhal character, and 
 is generally accompanied with a mucous rattle; sometimes, the cough is dry, croupy, and 
 whistling : the kinks are short, isolated, and uniform, and may recur every five minutes, or 
 extend only to one or two. 
 
 This nocturnal periodic cough cannot be mistaken for genuine croup — which has well 
 marked symptoms ; and it may be distinguished from spasmodic laryngitis by the complete 
 intermission which follows the paroxysms, by its not being preceded by any catarrhal symp- 
 toms, and by the entire freedom from fever throughout the attack. It may be distinguished 
 from hooping-cough from the latter being almost always epidemic, and occurring as well during 
 tlie day as during the night, and always accompanied with a peculiar dyspnoea. In the noc- 
 turnal periodic cough there is no true appearance of suffocation ; the children do not awake 
 suddenly, as in a fit of asthma or spasm of the glottis, but they awake slowly, after having 
 coughed several times during sleep. It most nearly resembles the cough of catarrh or bron- 
 chitis, but it is distinguished from those by the entire absence of the j)hysical signs, and by 
 the nocturnal periodicity of the fits, which arc followed by complete remission. 
 
 Dr. Behrend considers this cough to depend on an affection of the nerves, and bases this 
 opinion chiefly on the symptoms, and on the circumstance of its having frequently appeared 
 after an epidemic of hooping-cough, and whilst intermittent fevers were very prevalent among 
 adults. This latter remark has been made by several physicians whose attention was drawn 
 to this cough by Dr. Behrend. 
 
 The prognosis, we are told, is always favourable. In one case the periodic cough was 
 followed by bronchitis, but this was probably merely accidental. In another case there was 
 repeated epistaxis. 
 
 The disease, upon the whole, is generally more troublesome than serious, and demands 
 no active treatment. Gentle purgatives, as manna with the tincture of rhubarb, given in 
 the evening, with attention to diet and regimen, are recommended. A drachm or two of the 
 liq. acctatis ammonite, in a little sugar, may also be given, before putting the child to bed. 
 One physician found small doses of quinia, given at bed-time, of great service ; another 
 found slight irritation of the skin, chiefly by means of pediluvia, and friction of the soles of 
 the feet with roasted onions, and even enveloping the limbs, after the manner of Preissnitz, 
 beneficial. — C] 
 
 LECTURE XLVII. 
 
 Diseases of the Thorax. General observations. Dyspnoea. Coitgh. Methods 
 of exploring the physical conditions of the chest, by the senses of sight, touch 
 and hearing. 
 
 From the throat — and especially from that part of it with which we were last 
 occupied — the transition is natural and immediate to the thorax. Now the interior 
 of the chest is the theatre of numerous and most important morbid changes. Within 
 that cavity are lodged two of the three organs most essential to life. The heart, 
 lungs, and brain, have been said, by a bold figure of speech, to constitute the tripod 
 of life : and the two former are planted in the thorax. In the same division of the 
 body lie also the greater blood-vessels, and many other parts of scarcely less conse- 
 quence. With respect to the heart, its alternate swinging movement cannot long 
 
 2t
 
 5] 8 DISEASES OF THE THORAX. 
 
 stop, and the patient continue to live : while three minutes' total interruption to the 
 play of the lungs would in most cases be irremediably fatal. And lesser impedi- 
 ments to the free working of either of these two vital organs are productive of much 
 danger and distress ; and lead often to consecutive changes of a very serious kind, 
 in various other portions of the body. 
 
 These parts, of which the function is so indispensable, and of which the disorders 
 are so grave and perilous, are encased in such a manner by the ribs and other 
 boundaries of the chest, that they can neither be seen nor handled. And until i 
 very late period in the history of medicine — until our own times, in fact — the diag- 
 nosis of the formidable maladies that befal the viscera of the thorax was exceedingly 
 uncertain and imperfect. Physicians were able, indeed, by the observation of indi- 
 rect S3'mptoms, manifested through the general system — by remarking the presence 
 of inflammatory fever, I mean — to infer that inflammation had been somewhere 
 lighted up : and' symptoms that denoted disturbed functions of the respiratory appa- 
 ratus — cough, difficult breathing, or local pain — might suffice to apprize them that 
 the inflammation Avas situated in the chest. But what tissue it affected, where" 
 was its exact place, what was its extent, or what were its physical consequences — 
 these were points concerning which they had no means of obtaining any precise 
 Knowledge. "Under the title of pneumonia, or pneumonic inflammation," says 
 Cullen, "I mean to comprehend the whole of the inflammations affecting either the 
 viscera of the thorax, or the membrane lining the interior surface of that cavity : for 
 neither do our diagnostics serve to ascertain exactly the seat of the disease, nor does 
 the difference in the seat of the disease exhibit any considerable variation in the state 
 of the symptoms, nor lead to any difference in the method of cure." You will see, 
 as we proceed, how very inaccurate this last statement would be, if it were made 
 under our present mode of investigating these diseases. " Pneumonic inflammation 
 (he continues), however various in its scat, seems to me to be always known and 
 distinguished by the following symptoms : — Pyrexia, difficult'breathing, cough, and 
 pain in some part of the thorax." 
 
 I state these things to you — who do not recollect the time, as I do, when no medi- 
 cal man in this country could, with truth and candour, say more of his knowledge 
 of diseases of the chest than Cullen said — that you maj' the better estimate the ex- 
 ceeding value of the discovery of what is called the method of auscultation, in the 
 detection and discrimination of disease; and most particularly of thoracic disease. 
 In the present day, we are able to obtain more exact information respecting the dis- 
 orders of the parts contained within the chest, than of any other internal, and there- 
 fore invisible parts of the body. Indeed, in a vast number of instances, we can tell, 
 as accurately as if we saw them, the actual condition of the thoracic viscera : can 
 follow, step by step, the successive processes of disease, or of repair, in which they 
 are involved. We can penetrate beyond the symptoms Avhich denote deranged 
 function, and detect and understand those much less fallible symptoms which arise 
 from alterations of structure. And this vast addition to our pathological knowledge 
 has been given us by the simple application of one of our five senses to the investi- 
 gation of disease, the sense of hearing, which for so many centuries had been 
 (strangely as it now seems) neglected, or but little used. By the assistance of the 
 ear it has come to pass that those diseases which, besides being the most common and 
 the most destructive, were also the most obscure, are now better understood than the 
 diseases of any other internal part whatever. 
 
 The direct symptoms which arise out of the changed conditions of the parts affected 
 in thoracic complaints, are so mixed up with all that we know or can learn of such 
 complaints, that what in other cases is called the morbid anatomy of disease, becomes 
 here a part of its descriptive history. I shall not say, therefore, — as in regard to 
 many other maladies I am obliged or I find it convenient to sa}^ — so and so are the 
 symptoms ; and afterwards, so and so are the morbid appearances : but I shall de- 
 scribe the morbid conditions in the outset, as the only way of rendering the symptoms 
 which result from them intelligible. 
 
 But before I enter upon the subject of auscultation, it may be useful to make a
 
 PHYSICAL SIGNS. 519 
 
 few remarks upon those symptoms of thoracic disease which were previously known, 
 and which depend upon, or rather which express, derangement of the pulmonary 
 functions. 
 
 One of the most constant, and obvious, and distressing, and instructive of these 
 symptoms, is embarrassed or laborious breathing : what is technically called dysp- 
 noea. You know that by a heahhy adult, under ordinary circumstances, the act of 
 respiration is performed, unconsciously almost, about eighteen times in a minute. 
 There is about one act of respiration for every four beats of the heart. In various 
 diseases this proportion is materially altered. The reciprocal movements, by means 
 of which, in measured succession, air is drawn into and again let out of the lungs, 
 are performed with hurry, or effort, or unusual slowness. Dyspnoea implies some 
 deviation from the natural manner or rate of alternately expanding the thorax, and 
 suffering it to collapse again : of inspiring and expiring : in one word, of breathing. 
 The patient himself may, or may not, be conscious of this deviation. In most of the 
 cases in which dyspnoea claims to be regarded as a symptom, he is conscious of it. 
 Now, upon what does this symptom depend ? It may ultimately be referred to an 
 altered proportion between the quantity of atmospheric air that reaches the lungs, 
 and the quantity of blood that is sent into them, from the right side of the heart, to 
 be converted from venous to arterial. That, doubtless, is at the bottom of almost 
 every case of dyspnoea. Let me remind you that respiration is an automatic move- 
 ment ; subject, nevertheless, to the occasional control of the will. The pulmonary 
 branches of the par vagum constitute the principal and constant cxcitor,as the nerves 
 that supply the muscles of respiration are the inotor links of the nervous chain by 
 which the automatic movements are governed. It is believed that the presence of 
 venous blood in the capillary vessels of the lungs forms the natural stimulus to the 
 pulmonary part of the par vagum. In the ordinary breathing of a healthy person, 
 this stimulus or imprt^ssion is not feU ; perhaps because, being slight and habitual, 
 and exactly apportioned to the need of the individual, it is not attended to ; or, it is 
 at once appeased by the admission of air, and the corresponding change in the blood. 
 But when that change is not immediately or perfectly accomplished, then arises the 
 distressful sensation which everybody has felt, but which our own language has no 
 one word to express. The French call it the besoin tie respirer. The English 
 phrase, ward of breath, denotes the peculiar sensation equally well. It calls into 
 exercise, frequently, the voluntary power of performing the mechanical act of breath- 
 ing — a power which is superadded to the automatic process. 
 
 Various are the ways in which the natural manner and frequency of the respira- 
 tory movement may be deranged. They were fully considered when I was on the 
 subject of death by apncca. They all operate, ultimately, by destroying the just 
 equilibrium between the blood and air which meet to undergo chemical changes in 
 the lungs. We have lately been considering certain diseases in which the dilliculty 
 and distress of breathing is often extreme. In croup and laryngitis, the only inlet 
 for the air is narrowed at its very entrance : there is more blood passing through the 
 lungs than can be arterialized under the ordinary motions of respiration : instinctive 
 eflijrts take place to increase the quantity of air : to make up by more numerous 
 acts of inspiration for the diminished amount of air introduced by each single act. 
 For a time these compensatory efforts may suffice. But if the access of air be still 
 impeded, blood begins to circulate through the arteries but half decarbonized, and to 
 linoer and stagnate in the lungs : the lips become livid, and the skin grows dusky. 
 Make, however, a free opening in the pipe that should conduct air to the lungs, and 
 the balance being restored between the blood in those organs and the air that reaches 
 them, the dyspna-a is soon at an end. The quantity of blood being the same tlien, 
 but the air inspired too little, there will be dyspnoea. The very same thing occurs 
 whenever a portion of lung, from being spongy, is rapidly rendered solid. No ai; 
 can then penetrate it, nor perhaps any blood; but the same quantity of olood ai 
 before arrives at the right side of the heart, and is transmitted thence through the 
 pulmonary artery ; and consequently those portions of the lungs which are pervious 
 M blood and air, are supplied with blood in excess, and require air in excess: i. e.i 
 dyspnoea i& necessitated. And you will perceive that similar consequences nay
 
 520 ' DISEASES OF THE THORAX. 
 
 arise from any pressure made upon the lung, obliterating in a certain degree its cel- 
 lular structure ; as b}' fluid collected in the pleura ; by enlargement of the heart ; by 
 aneurism of the great vessels ; by tXjmours, of whatever kind, within the chest ; or 
 jy pressure upwards against the diaphragm by reason of a distended abdomen, whe- 
 ther the distension be occasioned by disease, such as ascites, or by obesit}', or by a 
 , full stomach, or by a gravid uterus. A like disproportion will ensue, if the free 
 expansion of the thorpcic cavitj' be prevented by pain, b}' disease or rigidity of its 
 boundaries, or by palsy of its muscles through interruption of the nervous circle 
 whereon their contractions depend. 
 
 But on the other hand the balance may be destroyed from the opposite quarter: 
 the air admitted during a single ordinary inspiration being the same, the quantity 
 of blood requiring to be converted from purple to scarlet may be augmented ; and 
 in that case also, in order to maintain the due equilibrium, more numerous acts of 
 respiration must be performed : in other words, d3-spncea will arise. This is the 
 case under brisk exercise : the pressure of the muscles upon the veins propels their 
 contents with greater velocity towards the right side of the heart ; the heart contracts 
 more frequently in proportion as it is more rapidly filled with blood; a greater quan- 
 tity than usual is sent through the pulmonary artery to the lungs ; and the individual 
 breathes more quickly, to supplj' this augmented quantity of blood with air : he is 
 out of breath, in a state of dyspncea. But this is not disease. Disease, however, 
 will often have the same effect. The quickened circulation in fevers, any obstacle 
 to the free passage of the blood from the heart into the arteries, will tend to gorge 
 the lungs with blood, to destroy the requisite equilibrium between the air and the 
 blood in those organs, and so give rise to dyspntsa. 
 
 Other conditions still may be mentioned, as predisposing to hurry of the breathing 
 — a peculiar state of the nervous system ; certain qualities of the blood ; — but I need 
 not dwell on these at present. 
 
 There are two important corollaries derivable from what I have now been statinor. 
 In the first place, you must perceive how intimately the functions of the heart and 
 lungs are dependent upon each other; and that disease originating in either of these 
 vital organs may readily be the cause of consecutive disease in the other. We shall 
 have many examples of this before us as we proceed. It would afford materials for 
 an interesting essay, this mutual relation between cardiac and pulmonary disease. 
 At present I merely glance at it in passing. 
 
 In the second place, what I have said of dyspnoea must have sufficed to show you 
 that, taken by itself, it has not much value as a diagnostic symptom. All that it 
 tells us is, that the healthy and natural relation between the quantities of blood and 
 of air in the lungs is disturbed : but to determine the cause of that disturbance — to 
 decide whether the heart be in fault, or the lungs, or both, or neither — we must have 
 recourse to other sources of information. 
 
 Cough is another of the symptoms, mentioned by Cullen, as denoting disordered 
 function of the breathing apparatus. I need scarcely tell you that it is produced by 
 closing the glottis, and then making a sudden and strong expiration. Its purpose is 
 the disiodgement of mucus which may have collected in excess in the air-passages, 
 or of any other source of irritation to the membrane lining those parts. To be effectual 
 it requires the admission of a certain quantity of air, and the possession of a certain 
 degree of muscular strength. I pointed out to you, in the last lecture, a remarkable 
 exemplification of this : the boy whose case is described by Mr. Chevalier in the 
 Medico-CJdrurgical Transactions, was dying of croup; was on the brink of being 
 suffocated by the collection of mucus in his wind-pipe and bronchi, which mucus he 
 was unable to expel: and he was unable, not from defect of muscular strength, but 
 because he could not sufficiently inflate his lungs beyond \he collected mucus. When 
 an ample opening was made in his trachea, he drew in a strong breath, and coughed 
 the mucus up through the rhna gtotlidis. In old and feeble persons labouring under 
 chronic bronchitis with profuse secretion from the mucous surface, strength is often 
 wanting to cough the phlegm up ; and they die suffocated. 
 
 But the sensation which prompts to the acts of coughing may arise from various 
 ;jth'r causes besides the accumulation of mucus in the air-passages. Any slight
 
 PHYSICAL SIGNS. 521 
 
 f , 1. . 
 
 irritation about the glottis ; a long, trailing and tickling uvula ,* the inspiration of 
 
 irritating vapours; pressure of any kind upon the respiratory organs ; may any of 
 them produce cough. Nay, it sometimes is provoked by sympathy with other parts ; 
 an instance of which we have in what is cfJled a stomach-cough. Some morbid 
 condition, some irritation of the stomach exists, which being appeased, the cough 
 ceases. You will recollect the name and the functions of the pneumo gastric nerves. 
 We have, in the fact just mentioned, another example, in addition to those which I 
 glanced at in a former lecture, of irritation of the sentient extremities of one branch 
 of a nerve, declaring itself by uneasy sensations referred to other branches of the 
 same nerve. For these reasons, therefore, cough is not more diagnostic of particular 
 diseases situated in the thorax, than is dyspncea. There are, indeed, certain varieties 
 of cough, as there are certain modifications of the breathing, from which we may 
 obtain very useful information even in respect to the nature and seat of some diseases: 
 and these varieties and modifications I will point out as I go along. 
 
 Let me admbnish you, also, before we come to auscultation, not to fall into an 
 error which has been too common : that of trusting entirely to the ear in the investi- 
 gation of thoracic disease, to the exclusion or neglect of those phenomena which are 
 perceptible by the eye, or by the hand ; or of those indirect revelations which are 
 furnished by the condition of other parts and functions, or by the previous history 
 of the patient. Even before the discoveries of Avenbrugger and Laennec, physicians 
 were too remiss (if we may judge from their writings) in what may be called the 
 mechanical exploration and notice of the actions of respiration. A good deal may 
 be learned, sometimes, by merely placing one's hand upon the chest, or belly, as I 
 shall explain more particularly by and by : and a great deal, also, may be made out, 
 in some cases, by the simple inspection of those parts, when they are uncovered. 
 You may see, for example, that the ribs, in respiration, scarcely move at all, while 
 the belly rises and falls alternately with the descent and ascent of the diaphragm. 
 This is called abdominal respiration. It may arise from a painful condition of the 
 intercostal niuscles, or of the plurse, rendering the patient unwilling to elevate his 
 ribs ; or it may arise from disease of the spinal cord, between the origins of the 
 phrenic nerve and of the intercostal nerves, rendering the patient unable to raise 
 them ; or the same inability may result from disease of the lungs themselves. The 
 symptom may guide us at once to the seat of the malady. Again, the breathing 
 may be entirely thoracic, no motion of the abdomen taking place ; and this may de- 
 pend upon an affection of the diaphragm, or of the pleura which is reflected over it ; 
 or upon disease, accompanied with tenderness, within the abdomen — upon perito- 
 nitis, for example ; or upon mere distension of the abdomen. Or by looking at the 
 naked chest, you may see that one side of it moves, and that the other moves less, 
 or does not move at all : and the motionless side may be of the natural size as com- 
 pared with the other, or it may be flattened and contracted, or it may be round and 
 bulging; and most important conclusions, and most important indications of treat- 
 ment, will flow from a knowledge of these circumstances. The general form of the 
 chest is also instructive. Never neglect, then, to examine the thorax, in cases where 
 it is supposable that the disease may be seated in that part of the body, by your et/e, 
 as well as by your ear. The eye needs but httle training to enable it to perceive 
 and comprehend those signs which are within its sphere : the ear, unfortunately, 
 requires to be carefully educated. I will just remark, further, that in the case of 
 females, no indelicate exposure of the person need be made. In most instances the 
 morbid conditions I have been adverting to may be recognized through a thin lineu 
 covering. 
 
 Auscultation signifies the investigation of internal diseases through the sense of 
 hearing: and it is especially applicable, for reasons which I either have stated or 
 will state, to the study of thoracic diseases. In its full meaning it includes all that 
 we learn by listening to a cough, and all that we gather by striking the chest, and 
 attending to the resulting sound. But in general, the term percussion is used to 
 express this last mode of eliciting information, although the information is conveyed 
 through the medium of the ear: and the word auscultation is applied to the art of 
 distinguishing diseases by listening to internal sounds, by "^leans of the ear piaced 
 
 2x3
 
 T ^ 
 
 522 DISEASES OF THE THORAX. 
 
 in apposition with the surface of the body ; or by means of some conductor of sound 
 interposed between the ear of the listener and the person of the patient. In the first 
 of these two modes the auscultation is said to be immediate; in the second, ??je(/m/e. 
 By percussion we ascertain the degree of resonance, or want of resonance, of the 
 part struck : by auscultation we learn the qualities and modifications of the voice, as 
 reflected through the chest; and of the breathing; and of the sounds of the heart. 
 The invention of the method of percussion we owe to a C4erman, Avenbrugger, who 
 wrote an excellent treatise upon it, which was brought into notice by Corvisart, who 
 translated it. For the more brilliant discovery of auscultation we are indebted, as 
 every body knows, to Laennec. 
 
 Now it will save us much trouble, and conduce, I hope, to your future progress as 
 practical auscultators, if, before I speak of any of the diseases of the chest, I pre- 
 mise some general observations respecting these modern methods of examining the 
 human body, with the view of detecting and discriminating its diseases. Indeed, I 
 could not make myself intelligible unless I did so. 
 
 And first, with respect to percussion, which you will please to recollect is nothing 
 else than auscultation of, or listening to, sounds which we ourselves artificially and 
 purposely produce. 
 
 You know, every child knows, by daily experience, that difl^erent substances, 
 when struck, give out very different modifications of sound. If you strike a drum, 
 you get one kind of sound ; if you strike a brick wall, you get another. The one 
 is loud, trembling as it were, and prolonged ; the other dull, short, and flat. But 
 why should I attempt to describe in words things which are familiar to you already? 
 Bodies that are solid, or inelastic, give the dull flat sound in proportion to their solid 
 thickness, or their want of elasticity. On the other hand, hollow vessels, i. e„ ves- 
 sels containing air, with thin, firm, elastic boundaries, give out a sound more or less 
 approaching in its qualities to that of a drum. : the sound is called a hollow sound 
 from that circumstance. If you have a wooden cask containing air only, it is resonant 
 when struck : fill it half full of water, and the lower part will render a flat sound, 
 the upper empty portion a hollow sound ; less hollow, however, than when the 
 vessel contained no water; fill it up with water, and the whole is dull on percussion; 
 pour out the water, and fill it loosely with wool — it will still be resonant, though in 
 a different and less clear note than when it held air alone. 
 
 Now this experiment may be transferred to the human chest, which is a cavity, 
 bounded by firm, thin, tense, and elastic walls, and containing, in its natural state, 
 the spongy lungs, which are full of air ; and other parts that are solid, whereof the 
 heart is the chief. If you strike the surface of the chest (it requires a little knack 
 to do it properly), and if the blow falls over a portion of healthy lung, you Avill 
 produce a resonant or hollow sound. If the lung be not there, if it be pushed aside, 
 and its place supplied by some more solid or inelastic substance, by fluid for example, 
 you will hear a dead sound. So you will if the lung be there, but has lost its spongy 
 character, is void of air, and somehow or other solidified. But you may have a 
 resonant sound, though the lung is in a state of disease ; nay though the lung is not 
 there : so that percussion alone cannot always be depended upon. I shall tell you, 
 hereafter, how to guard against being misled by it in such cases. Again, if you 
 strike over the region of the heart, you will get a positively dull sound, or at any 
 rate a much duller sound than in most other parts of the chest. 
 
 It is really a singular thing, that this method of searching for indications of disease, 
 and of health, should have been so long neglected or overlooked in .'»ur profession. 
 I am sure that I had a practical acquaintance with the princijile of percussion long 
 before I knew any thing of physic; and so, I make no doubt, have most of you. 
 ■Vlany a time, when wishing to know whereabouts I might drive a nail firmly into a 
 wall, I have tried with the hammer to find which was brickwork, and which was 
 wooden joist; and percussion is an art in daily use for similar purposes, with car- 
 penters and bricklayers. Yet it does not appear to have been thought of by physi- 
 cians till the middle of the last century, when Avenbrugger, after studying' its results 
 for seven years, as he tells us inter tcedia et laborc.s, published at Vienna his " In- 
 ventum novum, ex percussione thoracis humani, ut signo, abstrusos interni pectoris 
 
 t
 
 PHYS CAL SIGNS. 523 
 
 morbos detegendi." This ivas almost totallj' neglected however, until, as I stated 
 before, Corvisart's work on diseases of the heart brought it into general notice. 
 
 Avenbrugger and Corvisart, and indeed every body who used percussion at all, 
 until a very few years ago, employed direct percussion : that is, they struck the chest 
 with the extremities of the fingers. More recently, mediate percussion has been 
 introduced into practice, by JM. Piorry. In mediate percussion some solid substance 
 is placed upon the spot, the resonance of which is about to be explored, and the 
 blow is made upon that substance, which is called a pleximeter — a stroke-measurer. 
 A round thin plate of ivory, laid flat upon the surface, is the most common sort of 
 pleximeter ; or metal, or wood, or leather, or India rubber, may be employed. Many 
 persons, and I am one of them, use no other pleximeter than the fingers of the left 
 hand. 
 
 I shall explain, as briefly as T can, the method of employing percussion, and the 
 cautions requisite to render it an effectual and a true interpreter of the state of the 
 parts beneath the stricken surface. 
 
 The position of the patient is of some consequence. It should be one that is con- 
 venient to the examiner, and not inconvenient to himself; and it should be one 
 calculated to render the part struck as firm and tense as possible. 1 he best position 
 of all is a sitting position, on a firm chair. But you may percuss a patient very 
 effectually as he siis up in bed, or while he stands, or some parts even when he is 
 lying down. A good deal is said, — more, in my opinion, than is necessary, — about 
 the effect of curtains, and so forth, in deadening the sound. I do not believe they 
 will ever interfere with your conclusions, especially as we learn more from com- 
 paring the sounds given out upon percussing the corresponding parts of the opposite 
 sides of the chest, than from the absolute resonance or want of resonance of any 
 single part. But there are some exceptions to this ; and if your patient can be made 
 to sit on a chair in the middle of the room, so much the better. 
 
 Then, if you are about to percuss the front of his chest, make him hook his arms 
 over the corners of the back of the chair, and throw his head back. If you des.re 
 to explore in this way the lateral portion of the thorax, he must place the hand of 
 that side upon his head, and lean a hltle to the opposite side. If you would know 
 how the posterior part of the chest sounds, he must lean forwards, fold his arms 
 across his breast, and bend down his head. 
 
 Next as to the mode of percussing. For direct percussion, the ends of the fingers 
 of the right hand should be brought together, and into a line with each oiher, so that 
 no one of them may project beyond the rest ; and care should be taken, first, to 
 compare the sound produced by striking any part of the chest on one side, with that 
 produced by striking the corresponding part on the other side. It follows from this 
 rule that we should not examine all the points on one side before passing to the other, 
 because we should thus lose the remembrance of, and the power of accurately com- 
 paring, the sounds obtained from corresponding points. It is best to strike first on 
 one side of the body, and then on the corresponding spot of the other. It follows 
 also that we are not to compare the result of percussion on one of the I'ibs, with the 
 result of percussion on one of the intercostal spaces. The blow should fall upon 
 the rib, and parallel to it. 
 
 A second point requiring attention, is the state of the chest in respect to the act 
 of breathing. If one side be percussed after the movement of inspiration, and the 
 other after that of expiration, some little difference in the resulting sounds will be 
 manifest, even in the healthy condition of the thorax. And this might mislead. 
 Let corresponding spots on the two sides be therefore both struck, either while the 
 chest is expanded, or while it is collapsed, or while the patient holds his breath. 
 
 Thirdly, you must take care to strike the corresponding parts at the same angle, 
 and not with the fingers perpendicular to the surface on one side, and inclined 
 obliquely to it on the other: also to strike corresponding parts with the same degreu 
 of force. And the blow should not be hard enough to give the patient pain ; indeed 
 such a blow would not produce a good sound, it should be smart and quick ; the 
 ends of the fingers should not remain on the chest. Under some circumstances, 
 however, the patient cannot bear to be percussed at all.
 
 T '■^ 
 
 524 DISEASES OF THE THORAX. 
 
 The latter cautions are most necessary when direct percussion is employed ; over 
 which mediate percussion has, however, many advantages. Some of these are ob- 
 vious. In the first place, the space examined by mediate percussion is very exactly 
 defined and limited. Secondly, you may strike the pleximeter much more forcibly 
 than you could strike the unprotected body, and so produce a more decided sound. 
 Even when the surface is morbidly sensible, or the patient unusually irritable, so 
 that percussion in the ordinary way cannot be performed at all, it may generally be 
 done through the pleximeter. A third and very great advantage is, that mediate 
 percussion is available when made over certain parts where, even although there 
 may be no pain occasioned by i', ordinary immediate percussion is attended with 
 no useful result. Parts, I mean, where there is much fat, and parts which are fleshy, 
 or oedematous. If the pleximeter be pressed firmly upon these parts, even upon the 
 mamma in females, the hollow sound is attainable ; whereas, if they were struck by 
 the fingers, the sound would be perfectly dull. Mediate percussion may be apphed 
 also, with effect, through the clothes. 
 
 I say that a convenient way, and one which I find quite sufficient, of employing 
 mediate percussion, is by making a pleximeter of the finger or fingers, of the left 
 hand ; taking care that they are closely in contact with the subjacent parts, and si77ii- 
 larly applied to corresponding spots ; and that the backs of the fingers be outwards. 
 Piorry declares, indeed, that the resonance produced by this mode is scarcely one- 
 tenth part so great as that elicited by using a thin, solid and elastic plate. For all 
 practical purposes, however, I am certain that the finger, as it is the readiest, so also 
 it is a very satisfactory and sufficient pleximeter. It has, moreover, this positive 
 advantage, that the sound made by striking it is not loud, and does not obscure or 
 interfere with that which depends upon the condition of the chest. 
 
 Ft is right that you should be aware of differences of sound which belong to the 
 individual. Cseteris paribus, the sound given out on percussion is more resonant 
 during inspiration than during expiration ; in childhood and youth than in middle 
 age : in middle age than in old age ; in females than in males ; in thin persons than 
 in fat : and, they say, in nervous, irritable people, than in those of a contrary tem- 
 perament. 
 
 And it is still more necessary that you should be aware of differences of sound 
 given out in health, by different parts of the surface of the thorax, in the same indi- 
 vidua!. And in order to explain this more distinctly, and for the sake of refc' nee 
 hereafter, let me here exhibit to you the regions of the thorax, as they havr !'een 
 artificially mapped out for the purposes of auscultation. 
 
 It is unnecessary for me to describe particularly the method followed in this arbi- 
 trary division of the thorax into regions. I will state the names that have been com- 
 monly applied to them, and the sounds which in health they respectively yield, ac- 
 cording to their number in the diagram before you. 
 
 T\\c first region is that of the clavicles ; one, of course, on each side. Upon these 
 bones it is immaterial whether direct or mediate percussion be made. The sound 
 given out should be very clear at their sternal extremities, dull at their humeral ex- 
 tremities, and clear at their middles. The resonance diminishes from the sternal 
 towards the acromial end of the clavicle. These parts correspond to the summits 
 of the lungs. 
 
 The second region is the stibclavian. It lies between the clavicle and the fourth 
 rib on each side. Beneath this superficial region hes the upper lobe of the lung; 
 and towards the sternum large bronchi are situated. You will understand, there- 
 fore, that the sound educed by striking this part ought to be very clear, 
 
 A little lower down, number three, is the 'mammary region, extending from the 
 fourth to the seventh rib on each side, and answering to the middle lobe of the lungs. 
 Here also the resonance afforded by percussion is clear; but in the lower part of 
 this region, on the left side, we find the heart, which is more or less covered by 
 lung: and on the right side the liver begins to mount. The sound is somewhat 
 modified and deadened by these deeper-seated viscera. In women we can deter- 
 mine the degree of resonance of this region through the mammae, by mediate per 
 cussion only.
 
 PHYSICAL SIGNS. 
 
 525 
 
 The fourth is the infra-mammary region. It comprehends that part of the bony 
 compages of the thorax on each side, which Hes between the seventh rib and the 
 
 edge of the cartilages of the false nbs. Into this region, on either side, may descend 
 the thin anterior margins of the lower lobes of the lungs ; but in the same region, on 
 the right side, lies the liver, over which the sound of percussion is dull ; and on the 
 left side is placed the stomach. Hence, when the stomach is tympanitic, a preter- 
 naturally resonant sound will proceed from this part ; and when the stomach con- 
 tains no gas, the sound will be irregularly dull. 
 
 All the regions hitherto described are double. There is still the mesial part of 
 the front of the chest to be subdivided, and we may call the three regions there situ- 
 ated, and numbered 5, 6, 7, the upper sternal region, the middle sternal, and the 
 lower sternal. In all these the sound on percussion ought to be clear, except, per- 
 haps, in the inferior portion of the last, which may be rather dull, or which, from its 
 vicinity to the stomach, may be tympanitic. 
 
 The eighth region is the axillary ; the axilla above the fourth rib on each side. 
 The ninth is the lateral region, between the fourth and seventh ribs. In both these 
 regions the resonance should be distinct and clear. The tenth, which may be called 
 the lower lateral region, below the seventh rib at the sides, gives the same sounds 
 as the infra-mammary, namely, on the right side a dull sound, on the left a sound 
 which at times is preternaturally hollow : on account of the presence of the hver in 
 the former case, and of the stomach in the latter. 
 
 But we have yet to look at the hind part of the thorax. Here we have the space 
 (region eleven) which forms the top of the shoulder, and lies between the clavicle in 
 front, and the superior spine of the scapula behind ; the acromial region. Very 
 little can be made out by percussion in this spot ; the sound is dull. But the depres- 
 sion immediately above the scapula, the supra-spinal fossa, as it is called, is a space 
 which affords valuable information to the ear applied over it. 
 
 The twelfth region is the scapular. It comprises the part covered by the scapula 
 on either side. It corresponds to the posterior part of the middle lobe of the lungs, 
 but yields a dead sound, unless a pleximeter be used. 
 
 The thirteenth region is the intra-scapular. It lies between the inner edge ot 
 the scapula and the spine on each side. It corresponds to the roots of the lungs, 
 and to the middle parts of their lower lobes. You may get a good clear sound here, 
 if the patient's arms be crossed, and his head bent forwards, and his back arched, 
 60 as to stretch and tighten, and make as thin as possible, the superincumbent 
 muscles ; you will find also that the ridge of the spinal column in this part gives a 
 hollow sound.
 
 526 DISEASES OF THE THORAX. 
 
 The last region to be mentioned, number /owr/ecn, the (Zorsa/, is the loweiinost 
 part of the ribs behind. It answers to the base of the lungs, and gives a clear sound* 
 but the liver on the right side is apt to render its inferior portion dull ; and the 
 stomach on the left to make it undulj' resonant. 
 
 Now, knowmg these circumstances, if you find that a dull sound is yielded on 
 percussing a part that should render a hollow sound, you conclude that beneath the 
 pan struck there is not the natural quantity of air. But whether this arises from 
 consolidation of the lung itself, and the obhteration of its cells, or from fluid effused 
 into the cavity of the pleura, you cannot, by mere percussion, determine. So, again, 
 f the sound be unnaturally tympanitic, you cannot say whether that results from 
 what is called pneumothonLx, or from emphysema of the lung. Percussion testifies 
 that air is there ; but further this deponent sayeth not. 
 
 The information which the exercise of percussion may leave thus imperfect, aus- 
 cultation of the sounds produced by the acts of breathing, speaking, or coughing, 
 vn]\ in most cases supply. 
 
 If the ear be laid close to the surface of a healthy thorax (or if the instrument 
 called the stethoscope be interposed between that surface and the ear), the ear will 
 hear the air enter and fill the lungs, and then withdraw and leave them again, in 
 perpetual succession. The sound produced by this ingress and egress of air has 
 been called the respiratory 77nirinur. I might tell you that this sound, to my mind, 
 is rather a rustle than a murmur ; that it is hke the sighing of the wind in the 
 branches of a tree. I might say, with Laennec, that it resembles the sound made in 
 the deep inspiration of a sleeping person ; or, with Dr. Davies, that it reminds one 
 of the soft murmur of a pair of bellows, of which the valve does not click. But 
 one minute's appliance of your ear to the subclavian region in a child, or even in 
 an adult, will give you a clearer notion of the nature and character of this sound 
 than any verbal description could convey. Yet, respecting this natural respiratory 
 murmur, there are some things of which it is desirable that you should be previously 
 informed. 
 
 In the first place, the entrance of the air is much more noisy than the exit: which, 
 sometimes can scarcely be heard. You will see, by and by, the importance of 
 noticing this fact. 
 
 In the next place, the murmur of respiration is not equally audible in all persons. 
 It may differ much in intensity, though not in kind, in two persons, each of whom is 
 in perfect health. Thus it is much more loud and distinct in children than in grown 
 persons. So remarkably is this the case, that when we meet with an unusually noisy 
 respiratory murmur in an adult, we say that his breathing is puerile ; it has the cha- 
 racter of the respiration of a child. Now, I tell you before hand, that puerile respi- 
 ration in the lung of an adult is generally a sign of disease ; and it is mostly partial ; 
 heard in certain parts only of the chest. 
 
 Again, ca^teris paribus, the natural murmur of respiration is more clearly audible 
 in lean and spare persons than in such as are muscular and fat. Fat and muscle 
 are bad conductors of sound, and act as dampers. Listening to the breathing through 
 a thick layer of adipous tissue, is like hstening (as Dr. Latham says) to the respira- 
 tion of a person through his clothes. 
 
 But if you take two healthy men who are alike in respect to leaness and fatness, 
 you may often find that the respiratory murmur is very loud in the one, and very 
 feeble, or almost inaudible, in the other : but in this last it becomes audible when he 
 'akes a deep and forced inspiration. 
 
 The reason of this difference is not very well understood. The breathing may 
 be very indistinct, though the thorax be capacious, and well formed, and'heaUhy. 
 Some persons seem to require less effort than others to maintain the due equilibrium 
 between the air in the lungs, and the blood in the lungs : as if they had not only 
 pulmonary space enough, but to spare. So that the difference in the manner of 
 breathing, and in the sound occasioned by the passage of the air in and out, depends, 
 m all probability, upon individual pecuharities of the circulation. At any rate, it is 
 Tery important that you should be aware of the existence of these differences. 
 But the sounds which reach the ear applied to the chest of a breathing person will
 
 PHYSICAL SIGNS. 527 
 
 differ in different parts, and under different circumstances. The sound given out by 
 rtie air as it passes through the trachea and larger bronchi, differs from that which 
 results from its passage into and out of the smaller bronchi and air-passages. I am 
 anxious not to refine too much in these matters : and, therefore, I pass by mmuter 
 points of diff(?rence. Place the stethoscope over the trachea, and you will hear just 
 such a sound as you might expect to hear: the sound of air rushing tluough a tube 
 of considerable size, a blowing noise. We will call that sound, which you will re- 
 cognize again when you have once heard it, bronchial breathing. It accompanies 
 the outward as well as the inward passage of the breath. Again, place your ear 
 or your stethoscope upon the right mammary region ; there you shall hear that rust- 
 ling sound, which I propose to call vesicular breathing, and which is chiefly audible 
 during inspiration. We shall find these distinctions of much use in the discrimina- 
 tion of disease. We shall find, for example, that the breathing sometimes is bron- 
 chial, where it ought to be vesicular. 
 
 . Now if any part of the chest where we should hear breathing, we can hear none, 
 this may result from solidification of the subjacent portion of lung; or from some 
 obstacle in a large bronchus, preventing the air from entering that part ; or from air 
 being in any way shut up and stagnant in that part ; or from an effusion of liquid 
 into the pleura at that part. And here again percussion comes into play, and de- 
 termines for us which of these possible circumstances is the one really present. If 
 the part when struck emits a hollow sound, there is stagnant air beneath it, either in 
 the heakhy lung, or in the lung altered by disease, or in the cavity of the pleura. 
 If a flat solid sound be given out, there is sohd lung beneath, or liquid in the pleura, 
 between the ear and the lung. All these points, and the conclusions to be deduced 
 from them, will become clear to you, I trust, as we proceed. iVIinuter analysis of 
 the diagnostic signs would be premature. 
 
 A word or two preliminary I must say about the voice. 
 
 The voice passes outwardly through the mouth and nostrils into the surroundino" 
 air; it passes also inwardly through the trachea and bronchi into the lungs, and it 
 may be heard through the lungs, by the ear laid flat against the chest. Bui it gives 
 quite a different sensation to the ear in different places. If you place the stethoscope 
 on the trachea, the voice will articulate itself into your ear as if it came from and 
 through the instrument. This sound, which is natural here, would be unnatural, and 
 a mark of disease, if heard beneath the clavicles. When heard beyond its natural 
 situation, it is called pectoriloquy. A less degree of this, a sound like that of a 
 person talking into a tube, and whose words, for that reason, are muffled and indis- 
 tinct, is called bronchial voice, or bronchophony. When to this modification of the 
 voice there is added a twanging vibration, a cracked discordant tremor, resembling 
 the squeak of Punchinello, or (as some think) the bleating of a goat, oegophony 
 is said to exist. All these unnatural modifications of the voice are indicative of 
 most important changes within the thorax. I merely introduce them to you now: 
 you will become better acquainted with them in due time. 
 
 What is true of the natural voice, is true, mutatis mutandis, of that unnatural 
 vocal sound, cough. The cough may be so modified by the condition of the internal 
 parts, as to reveal that condition. 
 
 There are yet other ways in which some information can be gathered respecting 
 the interior of the chest. If you give certain patients a sudden smart jog while your 
 ear is applied to their thorax, you may hear a splashing sound, like that produced 
 by shaking a barrel or a bottle partly full of water. From this expedient you in fact 
 determine that the cavity of the pleura, or perhaps a large excavation in the lung, 
 does contain both air and a liquid. This is called the method of succussio7i. It was 
 employed long before the other forms of auscultation were thought of. Hippocrates 
 mentions it. 
 
 Again (but that is not auscultation), you may sometimes collect useful information 
 respecting the state of the chest by simply laying your open hand upon it. In most 
 persons there is a distinct vibration or thrill produced by their speaking, which thril'
 
 528 CATARRH. — BRONCHITIS. 
 
 is very sensiblj' felt by the hand. Now, this thrill may be felt on one side of the 
 chest, and not on the other. And such a difference is an unequivocal sign of 
 disease. 
 
 The positions which I described before as being the most convenient for the per- 
 'brmance of percussion, are the most convenient also for the purposes of auscultation. 
 You may listen with the unassisted ear, or you may listen through the stethoscope. 
 This, as you know, is a soUd or perforated piece of wood, of which one end is adapted 
 to the ear ; and the other, which is to be applied to the chest, is hollowed out, or 
 expanded, into the shape of a bell, or funnel. The object of the instrument is to 
 collect and convey to the ear of the observer the vibrating impulse of the air, or of 
 the solid walls of the thorax, occasioned by the motions within. The stethoscope is 
 sometimes useful for examining a circumscribed spot in the thoracic cavity. With 
 it we o-aujie, more nicely than we could do with the naked ear, the signs furnished 
 by the patient's voice. We must use it also when we would investigate the breath- 
 ing in parts to which the ear itself cannot easily be applied ; and in cases where, 
 from the filth of the patient, or because he has some infectious disorder, we desire tc 
 avoid any immediate contact with his clothes or person ; and in cases of young or 
 old ladies, to whose breasts it might not be seemly or delicate to be putting our faces. 
 But, with these exceptions, the stethoscope, in my experience, is rather a hindrance 
 than a help. Much, however, depends upon custom. I can best distinguish most 
 of the sounds to be heard within the thorax by my unassisted — perhaps I should say 
 my unimpeded — ear; and I therefore employ the stethoscope or cyhnder in such 
 cases only as I have just adverted to. I cannot do without the instrument ; but I do 
 without it as much as 1 can. Care should be taken that the end of the stethoscope 
 next to the ear be closely and comfortably fitted to that organ ; and that its other 
 extremity be blunt, so as not to hurt the patient; and further, that it be uniformly 
 and evenly applied to the surface of his chest. If these precautions be attended, to, 
 the shape and fashion of the instrument are very unimportant. 
 
 LECTURE XLVIII. 
 
 Catarrh ; its Varieties. Jicute Bronchitis. Dry Sounds attending the Respira- 
 tion ; Ehonchvs, and Sibilus ; Moist Sounds; Large and Small Crepitation; 
 how these are produced, and what they denote. Treatment of Jlcute Bronchitis. 
 Peripneumonia Notha. Sudden Infraction of a large Bronchus. 
 
 In the last lecture I described to you, in a general manner, the method of ausculta- 
 tion, or the employment of the sense of hearing in the investigation of disease ; and 
 particularly of thoracic disease. I explained, as Avell as I could, the different sounds 
 which result from percussing various parts of the chest ; and from the entrance and 
 exit of air during the several acts of breathing, speaking, and coughing. I men- 
 tioned certain conditions in which those natural sounds are abolished; but I did not 
 speak, except incidentally and very cursorily, of the altered and new sounds to 
 which the presence of disease within the thorax has been found to give rise. Nor 
 do I propose to enter now upon any formal account of these morbid sounds. I shall 
 endeavour to make you acquainted with their characters, and causes, and significa- 
 tion, as they arise in the progress of the separate thoracic diseases which I am about 
 to consider. 
 
 Before you can possibly appreciate the morbid sounds, you must make yourselves 
 familiar with the natural and healthy. You must have a standard, by which you 
 may measure the numerous deviations from the natural sound that will meet your 
 ear in disease. Listen to the voice and the breathing of healthy children, or of some 
 of your friends and fellow-students ; and you will soon recognise those respiratory 
 sounds which accompany the perfect state and working of the breath-machine.
 
 PHYSICAL SIGNS. 529 
 
 I intend to commence with those diseases of the lungs in which the imicous 7nem- 
 hrane lining the air-passages is primarily or principally involved. This membrane 
 is often affected alone. It is much exposed to known causes of disease : to alterna- 
 tions of temperature in the air which is constantly passing over it ; to the irritation 
 produced by acrid or noxious matters, solid or gaseous, which are mixed and inhaled 
 with the air. And when disease commences in other parts of the lungs, it seldom 
 fails to reach, sooner or later, the mucous membrane. In diseases also of the heart, 
 the same mucous membrane is very liable to be consecutively affected, by reason of 
 those alterations in the condition of its capillary vessels which the disorder of the 
 circulation produces. 
 
 Now I shall first point out the changes to which this mucous membrane is liable ; 
 and then describe the modifications of the natural sounds that result from such 
 changes ; and, lastly, consider the different forms of disease which these changes 
 constitute, and these altered sounds denote. 
 
 In a former part of the course, I gave you some account of the peculiarities which 
 differences of texture impress upon the phenomena and process of inflammation ; 
 and, among the rest, I spoke of the behaviour of the mucous tissue when inflamed. 
 
 The mucous membranes, in the state of health, are perpetually moist. The 
 exhalation of this moisture, to a certain amount, and not berjond a certain amount, 
 jonstitutes an essential part of their healthy functions. Now, their biflam,mation 
 (for I am atout to consider first the inflammatory affections of the membrane of the 
 nir-passages ; some of them indeed I have already discussed), I say the inflammation 
 of these mucous surfaces alters their ordinary secretion. An inflamed mucous mem- 
 brane is in the first instance dry ; its secretion is suspended. But this is not the 
 only change that takes place in it; it becomes tumid also, swollen, thicker than 
 before; it is redder than natural, and its sensibility undergoes a perceptible modifi- 
 cation. Pain, in mucous membranes, is 7iot a common phenomenon ; for their text- 
 ure enables them to expand or dilate freely, so that they escape much tension, and 
 the pain which is produced by tension ; but their natural sensations are blunted, and 
 new and uneasy sensations arise in them: sensations of heat, fullness, itching. It 
 happens that we can see a portion of the mucous membrane that belongs to the air- 
 passages ; and by noticing the changes produced in it by inflammation, we infer 
 those which are apt to take place in the parts we cannot see. We have all often 
 experienced in our own persons an inflammatory state of the membrane lining the 
 nasal cavities ; the Schneiderian membrane. At first the nostril is preternaturally 
 dry ; yet, though it is dry, you cannot breathe through it : it is stuffed up, not with 
 accumulated mucus, but by the mere swelling of the membrane : the sense of smell 
 is perverted or lost ; the part is evidently red ; it is tender, also, and irritable ; the 
 contact of atmospheric air a little colder or a little less pure than common, provokes 
 sneezing. The affection extends often into the frontal sinuses, and headach and 
 oppression ensue ; or it passes into and through the lachrymal sac, the conjunctiva 
 participates in the inflammation, the puncta lachrymalia become impervious, and the 
 tears flow over the cheek. And with all this there is sometimes shivering or chilli- 
 ness ; and the pulse, especially in ihe evening, becomes a little more frequent than 
 common. There is slight fever. After the unusual dryness, the membrane begins 
 to secrete a thin serous fluid, having acrid properties ; for it reddens and frets the 
 al?e nasi and upper lip, over which it flows. By degrees this thin serous fluid be- 
 comes thicker, and as it becomes thicker it becomes less irritating also, more viscid, 
 opaque and yellow: the swelling of the membrane diminishes; it is less raw and 
 sensitive: at length the secretion resumes its natural ^'Urt/tVy, and is reduced to its 
 natural cpumtilii again ; and the tumefaction of the membrane entirely disappears. 
 This i-s the course of what is properly called a cold in the head. When the defiuxiou 
 from the nasal membrane is considerable, systematic writers call the complaint cory- 
 za ; when it is attended with much pain and weight about the frontal sinuses, it is 
 named gravedo. It is a variety of catarrh. Iri catarrh, sometimes one part, and 
 sometimes the whole, of the mucous membrane of the air-passages suff'ers inflamma- 
 tion. If the disorder goes down into the lungs, it is said to be a cold in the chest : 
 jX, from one of the most prominent of its symptoms, a cough; in medical language, 
 iU 2 u
 
 530 CATARRH. — BRONCHITIS. 
 
 broncliilis. It sometimes travels from one part of the membrane tc another. Be 
 ginning, for example, in the nose, it oradually creeps down into the windpipe and 
 lun^^s. Sometimes the inflammatory condition passes from the throat into the Eusta 
 ch.un tubes, and produces deafness ; or down the gullet and to the stomach, causing 
 qualmish or other uneasy sensations, and loss of appetite. And occasionally this 
 order appears to be reversed. There are some persons who will tell you that when- 
 ever anything disagrees with their stomachs, whenever dyspepsia is produced by 
 some error in diet, they are sure to have catarrh. 
 
 Now I have adverted to this cold in the head, or coryza, because the phenomena 
 which are open to our inspection in the Schneiderian membrane take place also, no 
 doubt, in the bronchial. The membrane is first dry, and tumid, and irritable; fhe 
 uneasy sensations of which it is the seat prompt to the action of coughing. The 
 chest feels tight, stuffed, constricted. There is some hoarseness, and a sense of 
 roughness and soreness in the windpipe ; and a dry cough, which seems to arise 
 from some irritation about the glottis. Sometimes, with these symptoms, pains in 
 the limbs, like the pains of rheumatism, occur; the appetite is impaired ; the patient 
 IS thirsty ; and a general lassitude is felt all over the bod)'. 
 
 But what effect has the altered state of the membrane upon the sounds elicited by 
 percussion; or heard within the chest, by the ear, during respiration? AVhy it 
 brino;s us acquainted at once with two remarkable modifications of the natural sound 
 of breathing; and these I must describe and explain. 
 
 I will take this opportunity of again recommending you to read and study the 
 httle book of lectures recently published by Dr. Latham. It contains a very plain 
 and clear account of the auscultatory signs of disease Avithint he chest ; and he speaks 
 of these signs in more easy and popular language, with less of over-refinement, and 
 a less subservient adoption of the French mode of thinking and writing on these 
 subjects, than any other English author that I know of. I recommend his little 
 volume the rather also, because he uses the nomenclature which is the most familiar 
 to myself: in fact, as we some years ago saw and talked of these matters together in 
 the wards of St. Bartholomew's, we were likely to employ the same terms. 
 
 When you listen, I repeat, to the breathing of a healthy person, you hear, as the 
 breath goes in and out, but especially as it goes in, a smooth and gentle rustle — the 
 respiratory murmur, or the vesicular breathing. But when the inner surface of 
 the bronchial tubes, and of their ramifications, is preternatural ly dry, and tumid, this 
 sound is altered : you hear a hissing, or wheezing, or whistling, as the breath goes 
 in and out ; and this is technically called sibilus : or you hear a deeper note, a snoring 
 noise, as I he patient inspires or expires — a sound like the cooing of a pigeon, or the 
 bass no'.e of a violin, or the droning hum of an insect in its flight ; and this is called 
 rhonchus. These two, in their various modifications, constitute the dry sounds of 
 respiration ; and it will be worth while, once for all, to reflect upon their cause and 
 natuje, and the manner in which they are combined, and what they denote. You 
 are aware that when air is propelled through a cylindrical tube of a certain size, and 
 when that tube is narrowed in a particular way at one or more points, a musical 
 note is produced. Now this is what often happens in the larger bronchi ; this is 
 what always happens in them when rhonchus is present. Rhonchus belongs to the 
 larjrer divisions of the bronchi exclusively; and as these are often, for a time exclu- 
 sively affected, so rhonchus may exist alone. It will be grave or deep in proportion 
 to the length and diameter of the tube in which it is produced. When the sound is 
 grave and deep, the hand placed upon the chest may frequently perceive a trem- 
 bling or thrill communicated to its parietes. I believe that rhonchus is mostly occa- 
 sioned by portions of viscid half solid mucus, which adhere to the membrane and 
 cause a virtual constriction of the air-tubes, and act as vibrating tongues while the 
 air passes by them. I conclude such to be the case, because it seldom happens that 
 the rhonchus cannot be got rid of by a vigorous cough. It will soon begin again, 
 perhaps, or it will commence in some other part, but the effort of coughing, which 
 detaches and removes the adhering tough mucus, dislodges also, for the time, the 
 ihonchus. Yet, rhonchus in a given spot may be permanent : a tumour, or a tubercle, 
 may flatten one of the air-tubes, and convert it into a musical instrument. For the mosi
 
 PHYSICAL SIGNS. 531 
 
 part, you will find what I have told you holds true : you may suspend tne rhonchus by 
 getting the patient to make a hearty cough. Now in the natural state of the chest, 
 we do not, except in particular spots, hear the transit of the air through the larger 
 bronchi. Whatever sound it makes is damped by the spongy lung, or covered by the 
 vesicular breathing. But rhonchus, in its turn, may overpower the vesicular murmur, 
 and render it inaudible. It does not prevent it, but it outroars it, as it were. Yet 
 this is seldom the case : you hear the rhonchus, and, if you listen attentively, you 
 may in general hear, mingling with it, the vesicular murmur also. Recollect, then, 
 that rhonchus belongs to the larger divisions of the air-tubes ; that it denotes their 
 partial narrowing ; that it is a dry sound ; and that the condition of which it is ex- 
 pressive implies usually no danger : there is no rhaterial obstacle to the passage of 
 the air through these larger tubes to the vesicular structure beyond them. 
 
 I must further admonish you, that in your earlier essays in auscultation you will 
 De apt to deceive yourselves in respect to the exact place in the lung in which the 
 rhonchus which you hear is produced. It is so loud a sound, that when it proceeds 
 from a single bronchial tube it may be plainly audible over the whole of that side of 
 the chest ; and sometimes, more obscurely, over the other side too. 
 
 When air is driven with a certain degree of velocity through a small pipe, it 
 gives rise to a hissing noise. It is by forcing air through a cylinder perforated by a 
 slender tube, that Professor Wheatstone obtains the sound of the letter S in the 
 talking machine which he has constructed, after Kempelon's model. Precisely this 
 condition we have in the smaller bronchial ramifications, when the inflammation in 
 catarrh or bronchitis has reached ihe?7i, and rendered the membrane hning them 
 tumid. And sibilus is the result of this change. Now sibilus, like rhonchus, may 
 exist alone ; and, inasmuch as the sibilus proceeds from the smaller air-tubes, adjacent 
 to the pulmonary vesicles, it abolishes the natural respiratory murmur. It does not, 
 like simple rhonchus, merely drown it, but it takes its place. If you hear the res- 
 piratory murmur mingling with sibilus, you may be sure that some of the lesser air- 
 tubes are narrowed, and some free : you cannot have both sounds at once from the 
 same ramifications of the bronchi. Sibilus is a sound of more serious import, there- 
 fore, than rhonchus ; it bespeaks a condition of greater danger. It belongs to the 
 smaller air-tubes and vesicles, and denotes that they are in the first stage of inflam- 
 mation, which has diminished their natural cahbre, by rendering the membrane 
 tumid. It is a dry sound, but you cannot cough it away. 
 
 I say rhonchus may occur alone, and sibilus may occur alone ; but very often 
 indeed they both occur together; and maybe heard in various parts in different 
 degrees : causing a strange medley of groaning, and cooing, and chirping, and whist- 
 ling, and hissing, mixed, it may be, here and there, with the natural respiratory 
 murmur. When you hear sibilus over the entire surface of the chest, the mucous 
 membrane is universally affected, and the case is a severe one, and attended with 
 considerable hazard. 
 
 It is just possible that a sibilant sound may proceed from a large air-tube, when 
 its bore has been narrowed to a very minute slit or orifice ; but this possibility 
 does not interfere with the general distinctions that I have been endeavouring to 
 point out. 
 
 Now in these cases we neither obtain nor require any information from percus- 
 sion, except of a negative kind. Supposing the inflammation confined to the mu- 
 cous membrane, the resonance on percussion will not be sensibly diminished ; the 
 lung is everywhere spongy still, and air reaches every part of it, though not with the 
 «isual freedom. 
 
 There is one exception to this. Occasionally, though rarely, a piece of tough 
 phlegm may seal up, as it were, the very entrance of one of the principal bronchial 
 tubes, and so prevent the air from passing to or from the portion of lung to which 
 that tube conducts. When this happens, it is very likely to puzzle the auscuitator 
 for a time. There is air in the sealed-up portion of lung, therefore percussion gives 
 a natural sound ; but the air is at rest, therefore no sound of respiration is audible. 
 An effort of coughing unstops, perhaps, the bronchial tube ; and *hen the air is ao^iu
 
 532 CATARRH. 
 
 heard to enter and to depart from that portion of lung. I shall advert to this sort 
 of accident again. 
 
 Finally, I may remark, that these dry sounds, rhonchus and sibilus., are heard 
 during the breathing: they have no relation to the voice or to the cough. 
 
 After a while, the inflamed membrane begins again to pour out fluid ; but it is 
 not the thin, bland, moderate exhalation of health ; it is a glairy, saltish, transparent 
 liquid, like white of esg somewhat ; and if it be expectorated only after much cough- 
 ing, it will be frothy also, i. e., it will contain many bubbles of air entangled in it. 
 It is a stringy, tenacious fluid, and the more so in proportion to the intensity of the 
 inflammation. With this new condition of the membrane, we have new sounds — 
 sounds which result from the passage of air through a hquid ; sounds which are 
 occasioned by the formation and bursting, in rapid succession, of numerous little air- 
 bubbles. These sounds are called crepitations. This process may take place in 
 the larger air-tubes, or it may take place in the smaller, or in both. In the larger 
 tubes the bubbles will be larger, and the ear can readily distinguish this ; we have 
 large crepitation. In the smaller air-tubes, we have, in the same way, small crepi- 
 tation. There is no difference between these sounds, except in degree ; and they 
 graduate insensibly into each other. But there is a considerable difference in the 
 nature of the intimations which their well-marked varieties convey. If there be 
 merely large crepitation, without any other morbid sound, it is produced in the 
 larger tubes. Air passes, notwithstanding, into the vesicular structure beyond the 
 accumulated liquid ; and vesicular breathing exists, though perhaps it cannot be 
 heard, on account of the crepitation. But the state of the patient is not a state of 
 peril. On the other hand, small crepitation has its seat in the smaller air-tubes and 
 cells ; it supersedes the vesicular breathing, and, if extensive, it bespeaks considem- 
 ble danger. .. 
 
 Rhonchus and large crepitation are respectively the dry and moist sounds that 
 belong to the larger bronchi ; sibikis and small crepitation the dry and moist sounds 
 of the smaller branches. When the latter sounds are heard over a considerable part 
 of the chest, there is, I say, usually a good deal of distress, dyspnoea, and cough ; 
 and the fever which attends the local inflammation is at its height. By and by the 
 expectoration becomes opaque, and more consistent, and of a greenish or yellowish 
 colour; it is brought up with more ease; the crepitation, great and small, dimi- 
 nishes ; perhaps rhonchus reappears : but at last the parts return to their original 
 condition ; and the natural, smooth, equable rustle of the breathing is again every- 
 where audible. 
 
 These are all the morbid sounds to which active and recent inflammation of the 
 mucous membrane of the air-passages ever gives rise : rhonchus and sibilus ; large 
 and small crepitation. Having once described their nature and causes, I need not 
 repeat the description if we find them accompanying other diseases : but their im- 
 port may be different. I may mention here, that as crepitation results from the 
 passage of air amongst and through liquid, from the rupture of the little air-bubbles 
 so produced, the kind of liquid may vary. If the air, in going and returning, meets 
 with serum, or with pus, or with blood, it will occasion exactly the same bubbling 
 noise. Hence the French term for what I have been calling crepitation, viz., mu- 
 cous rattle, is very objectionable. From the sound itself, we cannot tell whether it 
 proceeds from mucus or from some other liquid present in the air-passages ; and 
 from this objection the word crepitation, whatever exception may be taken against 
 it on other accounts, is free. 
 
 Having thus embraced the occasion of explaining these auscultatory signs, I will 
 novv resume the history of catarrh. It implies inflammation of the mucous mem- 
 brane of the air-passages; 'and it receives different appellations, according to the dis- 
 trict of that membrane which it chiefly plagued : gravedo, in the frontal sinuses ; 
 coryza, in the Schneiderian membrane of the nose ; bronchitis in the trachea and 
 ••ungs. 
 
 Catarrh is the commonest of all disorders : — not one man in ten thousand passes 
 a winter without having a cold of some sort. And this name points to its ordinary 
 vause : cold somehow applied to the body. It does not always or often result, I
 
 CATARRH. 533 
 
 apprehend, from cold air brought into contact with the membrane iiself, in the pro- 
 cess of breathing ; but from cold, and especially from cold and wet, applied to the 
 external integument. It is unnecessary for me again to go over the circumstances 
 under which the application of cold is most likely to prove injurious. Catarrh is 
 usually a trivial disorder, and runs its course in a few days, if abstinence be observed 
 with respect to animal food and stimulating liquor, and if the patient remains in an 
 equable temperature, and avoids re-exposure to the cause of his malady. I am now 
 speaking of the milder forms of catarrh. We are not often consulted for this com- 
 plaint. Every man, in regard to a cold, thinks himself quahfied to be his own doc- 
 tor. But if you are consulted, keep your patient in the house, or even in bed ; let 
 him live upon slops ; give him a gentle aperient, and then some of those medicines 
 •w^hich are esteemed to be diaphoretic: small doses of James's powder; three drachms 
 of the liquor ammonise acetatis, with a drachm of the spiritus aetheris nitrici, and an 
 ounce of camphor mixture ; or a saline draught with an excess of alkali, and a few 
 grains of nitre, or a little antimonial wine ; three or four times a day : and let him 
 take four or five grains of Dover's powder, and put his feet and legs into a warm 
 bath, just before he goes to bed. In this way you may conduce to his recovery ; 
 and he may be simple enough to believe that you have cured him. 
 
 Yet I believe catarrhs may sometimes be cured; and the natural recovery from 
 them may be, sometimes, accelerated. If you practise the old maxim, which says, 
 " venienti occurite morbo," you may occasionally stop a cold on the threshold, as it 
 were, by an opiate. And to persons who are habitually troubled with slight catarrhs, 
 this piece of practice may prove of the greatest value. A medical man who resides 
 in this neighbourhood, and with whom I was a fellow-student, is exceedingly subject 
 to what he calls a snivelling cold. For many years he used to bear this as he best 
 might ; and that, to say the truth, was very ill and impatiently. On one occasion, 
 almost by accident, he took twenty drops of laudanum just as one of his colds was 
 beginning to torment him, and he found that the initiatory symptoms ceased. Since 
 that time he has constantly had recourse to the opiate under similar circumstances ; 
 and whereas he used formerly to be very miserable for three or four days, he now is 
 quite well and comfortable in the course of half an hour. And this is not a solitary 
 case. It is worth trying, if you experience the feelings of an incipient catarrh, to go 
 to bed, and to take a beaker of hot wine negus, with a tablespoonful of the syrup of 
 poppies in it. This will not suit every person; but if it fails on the first trial, it 
 need not be repeated, and no great harm, beyond an increase of headache, will be 
 done by it. I would not recommend this plan, however, to a plethoric person ; nor 
 to any one having a tendency to inflammatory disease ; for when it does not cure, it 
 makes the complaint worse. 
 
 There is also a period in catarrh which has gone on unchecked, when you may 
 accelerate its departure — "speed the going guest" — by a good dinner, and an extra 
 glass or two of wine. But this pleasant method is scarcely to be advised for persons 
 of delicate habits ; or in whom any pthistical tendency is suspected to exist ; or who 
 are prone to inflammation. And it is not to be tried with any one till the fever is 
 over, and the expectoration thick and loose. 
 
 t must not omit to mention the dry plan of cure ; although (I confess it with some 
 shame) I have never yet tried it either upon myself or upon others. Dr. C. J. B. 
 Williams, who invented it, I believe, has a high opinion of its efficacy. It certainly 
 has the merit of simplicity, for it consists merely in abstinence from every kind of 
 drink. No hquid, or next to none, is to be swallowed until the disorder is gone. 
 The principle here concerned is that of cutting off the supply of watery materials to 
 the blood. The wants of the system exhaust, from the circulating fluid, all that can 
 be spared for the natural evacuations ; and there is nothing left to feed the unnatural 
 secretion from the inflamed mucous membrane. Its capillary vessels cease to be 
 congested ; the morbid flux is diverted, and the inflammation starved away. Such 
 is the theory. Habitual topers might hold the remedy to be worse than the disease ; 
 but Dr. Williams assures \is that the necessary privation is not very hard to bear ; 
 and that it achieves a cure, upon an average, in forty-eight hours. He allov.-s, wiib- 
 
 2u2
 
 534 ACUTE BRONCHI ris. 
 
 out recommending, a tablespoonful of tea or milk for the morning and evening meals 
 and a wine-glass of water at bed-time. 
 
 One o-reat advantage of this plan is, that it does not require confinement to bed, or 
 to the house. The man whose business calls him abroad, ma)-, with appropriate 
 clothing, pursue his customary employment, and his cure is all the while going on. 
 fn fact, exercise, inasmuch as it promotes perspiration, helps the recovery; whereas 
 the system of warm drinks and diaphoretics renders the body more susceptible to 
 atmospheric vicissitudes ; and, to be effectual, implies restrictions which are often- 
 times extremely inconvenient. 
 
 Dr. Williams observes, that while this dry treatment is serviceable in catarrhal 
 bronchitis, it is most successful in coryza, the snivelling cold in the head. It must 
 be put in force in the very commencement of the disorder. 
 
 You may often do much by way of prevention, for persons who are unusually 
 liable to take colds. I have remarked before upon the great value of the shower- 
 bath for that purpose. I could mention several instances in which persons have got 
 rid of the tendency to catch cold by the habitual use of this aspersion. It should be 
 begun in the summer, and made tepid at first ; but in a short time quite cold water 
 may be employed ; and being once begun, the practice may be continued through 
 the Avinter. I stated formerly, that the efTect of exposure to cold was, caetcris pari- 
 bus, in proportion to the intensity and the duration of the sensation of cold that it 
 produced. The intensity of the sensation of cold under the shower-bath is consider- 
 able, but the duration of it is momentary. It operates as a prophylactic in this way : 
 it inures the surface to a lower temperature than it is likely to be subjected to at any 
 other part of the day. The lesser degrees of cold have then no injurious effect, un- 
 less they are long protracted. For those who cannot procure a shower-bath, or who 
 cannot bear its shock, cold sponging Avill be found exceedingly salutary. 
 
 But inflammation of the membrane lining the air-passages may be, and often is, a 
 very acute and dangerous disorder, i. e., the inflammation may be both intense and 
 diffused ; it may descend into the vesicular texture, and occupy the whole surface 
 of the membratie on one side of the chest, and then it may prove a very grave dis- 
 ease ; or it may involve the whole lining membrane of both lungs, and then it is 
 always attended with considerable peril. 
 
 This inflammation will sometimes, when it is thus general over the whole mem- 
 brane, linger for a considerable period in its first stage ; and it may even, after so 
 hntrering, subside asain without ever passing beyond the first stage. By the first 
 Etaee, I mean the stage of dryness. Very little notice of this modification of bron- 
 chitis has been taken by authors. Dr. Latham has given a distinct and graphic 
 description of it, to the accuracy of which I can testify from my own experience. 
 You will find cases of it detailed in his book. Since they were published, some 
 striking instances of this form of the disease have occurred to myself. One, which 
 happened lately, I will relate by way of example. I was asked by an old pupil of 
 the hospital to see a lady, his patient, in Gordon Square. I found her feverish and 
 in a state of extreme dyspnoea, sitting up in bed from inability to lie down, labouring 
 for her breath ; her face turgid and rather livid, her nostrils working, her shoulders 
 elevated. She could scarcely speak, but expressed, in what she did say, a dread of 
 imm.ediate suffocation. She had been in nearly the same state for a day or two. 
 On listening at her back I could hear the air slowly wheezing and whistling into her 
 lungs everywhere, and then leaving them still more slowly, with a prolonged growi, 
 something hke that of an angry cat. There was no true vesicular breathing ; there 
 was no crepitation ; and there was no part into which the air did not, although with 
 ditficulty, find its way. The chest was everywhere resonant on percussion. There 
 could be no doubt that the membrane throughout was tumid and dry, and in the 
 earliest stajre of inflammation. Depletion had already been employed in this case, 
 and we had recourse to the tartar emetic. This was given in free and repeated 
 doses, till it produced nausea and sickness. Whenever it did so, the pulse dimin- 
 ished in force, the face became blanched, and the breathing much easier ; and the 
 medicine was then suspended until these effects had gone off, when it was repeated 
 •V the same manner The disease was not, however, brought at once to an end by
 
 ACUTE BRONCHITIS. 53o 
 
 this treatment ; it was kept at bay for a day or two longer, and then a copious 
 secretion from the membrane took place, with great relief to all the distressing 
 symptoms. 7^hen, of coarse, crepitation became universally audible. Except 
 the debihty which it left behind, the patient soon recovered of the bronchial inflam- 
 mation. 
 
 But in the great majority of instances the inflammation does not thus linger in its 
 first stage ; the membrane soon begins to pour forth glairy mucus ; so that we do not 
 often meet with sibllus, without finding at the same time, in some part of the same 
 lung, that there is also small and large crepitation. It is of some importance to 
 attend to the characters of the mucus that is expectorated. It is transparent and 
 adhesive. If you pour it from one vessel into another, it flows out in one mass of 
 extreme tenacity ; it will draw out sometimes hke melted glass ; and the degree of 
 viscosity is a tolerably accurate measure of the degree of the existing inflammation. 
 Upon the surface of the viscid mucus there is usually more or less froth, the quantity 
 of it depending on the facility or the difliculty with which the sputa are brought up. 
 If the patient does not expectorate till after a long fit of coughing, during which air 
 has been many times inspired and expired, and has thus got intimately mingled with 
 the mucus that fills the air-passages, the expectoration will contain numerous little 
 air-bubbles ; will be very frothy. Sometimes also, during this stage of the com- 
 plaint, the sputa are marked Avith streaks of blood. 
 
 While the expectoration possesses the characters I have been describing, the 
 inflammation is still intense, and the fever and dyspnoea considerable. This cor- 
 respondence between the general symptoms and the matters spat up was well known 
 to the ancients, who said that such expectoration was still crude. But in proportion 
 as the inflammation approaches to resolution, the appearance and qualities of the 
 sputa are changed ; the mucus loses by degrees its transparency, is mixed with 
 masses that are opaque, and of a yellow, white or greenish colour : and these masses, 
 few at first, increase more and more in number, until they constitute the whole of 
 the sputa. Such expectoration as this is commonly accompanied by' a marked re- 
 mission in the different symptoms of the bronchial inflammation ; it announces that 
 the inflammation is terminating in resolution. It is such as the ancients spoke of as 
 being concocted, or ripe. However, the characters of the opaque sputa expecto- 
 rated towards the end of an attack of acute bronchitis are subject to much variety. 
 
 It will often happen that the expectoration, after having thus become opaque, and 
 parti-coloured, will go back again to its former condition of transparency, and sticki- 
 ness, and froth : and that is a very certain index of a return or increase or extension 
 of the inflammation ; so that the character of the matter expectorated exhibits, in a 
 certain degree, the progress of the inflammation ; and consequently constitutes one 
 point of guidance to our treatment. The nature of the expectoration forms also an 
 important particular in our means of distinguishing bronchitis from pneumonia; as I 
 shall further explain when I speak of the latter disease. 
 
 I have described acute bronchitis as it appears when it terminates favourably : in 
 such cases the inflammation generally begins to abate, somewhere from the fourth to 
 the eighth day of the disease. But acute bronchitis may terminate wxfavoKrably. 
 When the inflammation is universal and intense, the fever high, and the labour of 
 respiration great — if the symptoms do not yield to the treatment employed, or if judi- 
 cious treatment has not been adopted, or has been too long delayed, signs of im- 
 pending suflxjcation begin to show themselves : the lips and cheeks, and tongue, 
 assume a purplish colour; a livid paleness takes the place of the former red flush; 
 the expression becomes more and more anxious : delirium comes on, and rapid sinking. 
 These indicate, you know, the circulation of blood that is in a great measure venous 
 through the arteries ; and the venous blood acts as a poison when it so circulates 
 Profuse, cold, clammy sweats ensue ; and the patient dies of apnoc. His breathm- 
 is choked by the morbid secretion which occupies the bronchial tubes, small as wel! 
 as large, and which he has not strength enough left to cough up. 
 
 Accordingly, when we examine the thorax after death so produced, we find, ni 
 the first place, that the lungs do not collapse upon the admission of the pressure of 
 the rttmosphere to their external surface. We next find the trachea, and bronchi, and
 
 536 ACUTE BRONCHITIS. 
 
 their ramifications, blocked up by a frothy adhesive mucus, resembling that which 
 during life had been expectorated ; and the membrane which lines them is red and 
 thickened. 
 
 The treatment proper for these acute and dangerous forms of bronchitis is a matter 
 of some nicety. Blood-letting, as I formerly stated to you, has not that decided 
 power over inflammation of the mucous tissues which it possesses over the adhesive 
 inflammation that takes place in the serous membranes. If there be much fever, a 
 hard pulse, and great oppression of the breathing, and particularly if these symptoms 
 present themselves in a young, strong, and robust individual, we must bleed him 
 from the arm. And you will always find blood-letting relieve the symptoms ; even 
 when its ultimate effect may be injurious. The patient's distress arises from his 
 inability to supply air enough to arlerialize the venous blood which is transmitted to 
 his lungs ; and by diminishing the quantity of blood sent to those organs, you will, 
 pro (anto, mitigate his uneasiness. But a great part of the danger to be apprehended 
 in the advanced periods of the disease, is that the patient may not have muscular 
 power enough to disembarrass his air-passages of the phlegm that overloads them ; 
 to draw a strong breath, and to achieve a vigorous cough. We must not bleed 
 therefore to syncope, and again and again, as we are often justified in doing in cases 
 of pneumonia. Sixteen ounces will be a moderate bleeding at first for an adult, but 
 more or less than that must be taken, and the bleeding must be repeated or not, 
 according to the condition of the pulse : for the pulse affords a better measure of the 
 propriety of pushing the abstraction of blood, than is furnished by the local symp- 
 toms. 
 
 Great relief is often obtainable by topical blood-letting; by cupping over the sur- 
 face of the chest, or between the scapulae. If you distinguish sibilus in one portion 
 of the lung more than in another, take the blood rather from that part of the surface 
 which corresponds to the place of the sibilus. 
 
 After the bowels have been cleared by a mercurial purgative, calomel and jalap, 
 for example, you will find the tartar emetic a very valuable medicine in these acute 
 cases of bronchitis. It should be given in such doses as will excite nausea: and if 
 vomiting be occasioned, you may still go on with the medicine after the sickness has 
 subsided. The depression which this substance produces is great, but it is tempo- 
 rary, and it is effi'Cted without expending blood. With the antimony — I mean 
 during the same period— mercury may and ought to be given : to this combination I 
 should be inclined to trust more than to any other internal treatment. 
 
 If syraptf'iiis of sinking and debility have begun to show themselves, it \\i\l be 
 necessary to administer stimulating expectorants. I presume that the carbonate of 
 ammonia, which is often extremely useful in such cases, acts as an expectorant, by 
 giving a fillip to the muscular power. But it is supposed by some persons to exer- 
 cise some specific influence upon the bronchial membrane. However this may be, 
 five or six grains of it, given in solution every four or six hours, are often followed 
 by free expectoration and a marked improvement. 
 
 One of the circumstances of which patients are much disposed to complain, is 
 the violent or importunate cough; and another is, the want of sleep and of rest; 
 indeed, the one of these is often, in a great measure, the cause of the other ; — the 
 urgency or frequency of the cough prevents the patient from sleeping. Now there 
 is nothing so well calculated to allay cough, and to procure sleep, as opium ; and 
 you will be strongly tempted to give these patients opiates, and you will probably 
 be encouraged to do so by the success which will follow that practice in many 
 cases. The good efft'cts of a full narcotic at bed-time are sometimes very striking. 
 Patients who for previous nights have been perpetually harassed by cough, and 
 who are worn out by the disturbance of their rest, will sleep tranquilly, and in the 
 morning expectorate largely and freely, and declare themselves wonderfully the 
 better for their opiate. Yet opium is a ticklish remedy in these cases. Many a 
 patient — some within my own knowledge — labouring under general or extensive 
 broncnitis, have been put so soundly to sleep by a dose of opium on going to bed, 
 that they have not waked again. I believe you may receive it as a golden rule in 
 ih'^se case.s not to give opium — I mean in a full dose, so as to force sleep — if you see 
 
 1
 
 PERIPNEUMONIA NOTHA. 537 
 
 any venous blood mingling in the general circulation, — if the complexion be dusky, 
 and the lips in any degree blue. The circulation of half-arterialized blood through 
 the brain is in itself a powerful cause of coma ; and if you add the influence of an 
 opiate, the coma may easily be made fatal. While the cheeks and lips remain florid, 
 and when the first violence of the disease has abated, an opiate will do capital ser- 
 vice. It is a common practice to combine it with antimony or some other expecto- 
 rant. Twenty minims of laudanum, with the same quantity of the liquor antimonii 
 tartarizati ; or a third of a grain of the acetate of morphia, with a drachm of oxymel 
 of squills ; are convenient forms. 
 
 Counter-irritation is frequently of great use, as an auxiliary measure, in the treat- 
 ment of acute bronchitis. Sensible rehef of the cough, and of the oppressed breath- 
 ing, often follows the rising of a large blister laid across the front of the chest. When 
 the dyspncea is extreme, and a more speedy counter-irritant is required, you may 
 have recourse to the mustard poultice. Inhalation of the steam of hot water is also 
 very soothing and useful. It is one of the best expectorants I know of when it 
 answers at all ; but to some persons it proves irritating, and they derive no comfort 
 from it. 
 
 I have been speaking of acute bronchitis, uncombined with any other pulmonary 
 disease ; and it is curious how little disposed the inflammation often seems to be to 
 extend itself from the mucous membrane to the neighbouring tissues. The reason, 
 doubtless, is, that this membrane is furnished with a distinct set of blood-vessels, 
 the bronchial arteries, and veins : while the substance of the lungs is supplied by 
 the pulmonary. We could not tell, merely by attending to the general symptoms, 
 whether the inflammation was hmited to the inner membrane or not ; but by making 
 use of the sense of hearing, we are able to determine this. If the inflammation 
 should spread to the parenchymatous texture of the lungs, — i. e., if the bronchitis 
 should pass into pneumonia, — this circumstance would be disclosed by physical 
 signs, which I shall in due time prescribe and explain ; and it would demand certain 
 modifications of our plan of treatment. 
 
 I shall have to speak of some varieties of chronic bronchitis ; but there is a mixed 
 form of pulmonary disease that requires to be noticed, in which acute or subacute 
 inflammation engrafts itself upon changes that are chronic and abiding. Sydenham 
 calls the disorder to which I now refer peripneumonia notha — bastard peripneumony. 
 ■ Calarrhiis senilis is another of its names. It may be considered as chronic bron- 
 chitis, occurring in old persons, and very apt to be converted into pneumonia, or to 
 be greatly aggravated in degree during winter, or upon any accidental exposure. 
 This is the common complaint of persons advanced in life. I mention it here in 
 compliance with the usual custom, and because this is as convenient a place for its 
 introduction as any. But it would be an error to regard it as exclusively a disease 
 of the mucous membrane of the lungs. An habitually congested state of that mem- 
 brane, marked by some shortness of breath, and some expectoration, and by the 
 constant presence of some degree of crepitation in the lower parts of the lungs, — 
 these are circumstances which are of daily occurrence as consequences of disease 
 of the heart ^ and it is in persons whose habitual health is of this kind, that what is 
 called peripneumonia notha, which implies a diffused inflammation of the pulmonary 
 mucous membrane, with sometimes an enormous secretion from its surface, is most 
 apt to supervene. Almost all such persons will tell you that there are periods at 
 which they experience slight febrile attacks, and exacerbations of their complaints : 
 they have pain in the breast or side, headache, heat, and thirst ; and at these periods 
 the cough and expectoration are always aggravated, and continue for some time to 
 be more than commonly severe. "The disease (says CuUen, who, following Syden- 
 ham, has given a good description of its general symptoms) has often ihe appearance 
 only of a more violent catarrh ; and after the employment of some remedies, .s 
 entirely relieved by a free and copious expectoration. In other cases, however, the 
 feverish and catarrhal symptoms are at first very moderate, and even slight ; buf 
 after a few days these symptoms suddenly become considerable, and put an end to 
 the patient's Hie, when the indications of "danger were before very little evident.'
 
 538 PERIPNEUMONIA NOTIIA. 
 
 The truth is, (and we learn the truth by the evidence of auscultation,) that ia 
 these cases pneumonic inflammation is often suddenly set up. There is no security, 
 as Dr. Latham observes, that the portions of lung which yield small crepitation to- 
 day may not be solid and impervious to-morrow. Dr. Latham is of opinion that in 
 this disease the inflammation is apt to travel over the bronchial membrane from place 
 to place, as erysipelas is seen sometimes to wander over the surface of the body. I 
 know not how this may be ; but certainly death is often produced in these persons 
 by the sudden spoiling of even a moderate portion of lung. In their ordinary con- 
 dition, the patients have just enough, and no more, of the respiratory apparatus in 
 an effective stale, whereby to subsist ; and when a fresh part of it is rapidly rendered 
 solid, they quickly perish. But they die also from another cause. The nicety of 
 treatment which I spoke of as being required in certain stages of acute bronchitis, ia 
 still more apparent and necessary here. We are placed in this dilemma. If we do 
 not take biood in these attacks, we run a risk of losing our patient from the effects 
 of the unchecked inflammation ; and if we do bleed, we are in danger of losing 
 him by producing a degree of weakness which will render him unable to expecto- 
 rate the effused mucus, and so liable to perish by suffocation. Leeches and blisters, 
 and what are called expectorants, are the remedies to which we must chiefly trust. 
 Medicines, which are at the same time diuretic are also serviceable — the spiritus 
 aslheris nitrici, the preparations of squill, and of digitalis. 
 
 Even in younger patients, in whom the bronchitis is idiopathic, not engrafted upon 
 any previous disease of the chest, and in whom the disorder had not appeared severe, 
 extreme difficulty of breathing will sometimes most imexpectedly arise, and some- 
 times it will rapidly lead to the extinction of life. Now both Andral and Laennec 
 have pointed out one cause (to which, indeed, I have already adverted in the pre- 
 sent lecture) of this sudden change for the worse. It is a cause which was not 
 likely to be even guessed at before the discovery of the method of auscultation. 
 Occasionally it happens, they say, that during the course of an attack of bronchitis, 
 we cease altogether to hear, in a certain extent of the lung, either the natural respira- 
 tory murmur, or any of the modifications of rhonchus, sibilus, or crepitation, that 
 have been mentioned ; yet over this same portion of lung, in which no sound, 
 healthy or morbid, is heard by the ear apphed to the thorax, percussion gives the 
 natural hollow sound. At the same time the patient becomes affected with urgent 
 dyspnoea. This sudden suspension of all sound of respiration they attribute to the 
 temporary, or, in some cases, the permanent, obstruction of one of the bronchi, the 
 ramifications whereof are distributed to that portion of lung in which the respiration 
 is no longer audible. In such cases it generally happens that at the end of a strong 
 fit of coifo-hing — the effect of which is to expel, or at least to displace the tenacious 
 plug of mucus obstructing the bronchus — the sound of respiration is re-established 
 as suddenly as it had previously disappeared ; and the dyspnoea also ceases. In 
 some rarer cases, however, the noise of the pulmonary expansion does not return, 
 the difficulty of breathing increases, suffocation becomes imminent, and death by 
 apncea rapidly takes place. The slightest attack of bronchitis may in this way be 
 suddenly transformed into a most serious and quickly fatal malady. 
 
 Andral relates two instances of death from this cause ; one of which was the fol- 
 lowiuij. A coachman, fifty years old, had been several times a patient in La Charite, 
 for obstinate pulmonary catarrh, with slight dyspnma, and puriform expectoration. 
 Every time he went away relieved, but not cured. On both sides of his chest could 
 be heard all the varieties of rhonchus. In one spot the column of air which pene- 
 trated the bronchi imitated the snoring of one in a deep sleep ; in another spot it 
 was like a duU and prolonged groan ; in a third, a sound resembling that made by 
 bellows ; and in a fourth the cooing of a turtle-dove was exactly simulated. On the 
 last occas.on of his entering the hospital, his respiration was still tolerably free. One 
 iTiorning he was found in a state" of unusual anxiety. In the middle of the night, 
 after a violent paroxysm of cough, his breathing (he said) had suddenly become very 
 much oppressed. It was discovered, on auscultation of his chest, that no air pene- 
 trated into the upper lobe of the right lung; yet that part sounded well on percus- 
 sioi.. even louder than the corresponding part of the other side, which was morbidly
 
 INFLUENZA. 539 
 
 dull. The difficulty of breathing went on augmenting, and the man was soon 
 dead. 
 
 Besides other marks of disease in the lungs, the primary bronchus leading to the 
 upper lobe on the right side was closed up completely by tough mucus, and exhi- 
 bited the appearance of a full cylinder. 
 
 In the other case, also, the obstructed bronchial tube supplied the upper lobe of 
 the right lung. 
 
 It may seem strange that the interruption of the access of air to so small a portion 
 of the lungs should be attended with such serious consequences, when we know that 
 the greater part of each lung may be impermeable by air, and yet the patient liv^e a 
 long time, and often without any great dyspnoea. The explanation of the apparent 
 difficulty seems to be, that in the one case the prevention of the arrival of air in the 
 part afffcted is sudden, in the other gradual. Moreover, the remaining portions of 
 the lungs are performing their functions imperfectly. 
 
 When once attention has been awakened to the kind of accident just mentioned, 
 the diagnosis would not seem to be difficult. We may suspect obstruction of one of 
 the bronchi when considerable dyspnoea comes on suddenly during the continuance 
 of simple bronchitis: and our suspicion will be confirmed if at the same time respi- 
 ration ceases to be audible in a certain portion of the lung, while the sound given by 
 ])ercussion over the same part remains unaltered. Emphysema of the lung (which 
 I shall explain hereafter) is the only other condition which could give rise to a similar 
 set of symptoms. 
 
 Andral judiciously suggests the employment of emetics, and the inhalation of 
 steam, in such cases. 
 
 LECTURE XLIX. 
 
 Injliienza. Symptoms and progress. Conjectures as to its cause. Treatment. 
 Hay asthma. Chronic Bronchitis. Its varieties. Morbid anatomy of these 
 affections. 
 
 Catarrh, which was the principal subject of the last lecture, occasionally prevails 
 far and wide as an epidemic disease. I speak, indeed, (February 4, 1837,) during 
 the immediate presence of one such visitation, although the extreme violence of the 
 complaint that has been raging among us is now fast subsiding. You can hardly 
 be without curiosity to know what has been learned respecting an influence which 
 has thus, on a sudden, before your eyes, disturbed and sickened a whole community. 
 
 I have here used, without thinking of it, the very word by which, in a foreign 
 version, the disorder is denominated. It has received, however, various names ; for 
 it has been known and noticed from remote antiquity. Cullen calls it catarrhus e 
 contagio: and under that head, in his Nosology, you will find a copious reference 
 to recorded accounts of epidemic catarrh, as it has been observed to spread over 
 great portions of the world. In France the disorder thus prevailing is styled the 
 grippe. The Italians, putting the cause for the effect, called it influenza, the injlu- 
 ence: and this last term, influenza, has now become naturalized in our language. 
 Since Cullen wrote there have been four or five more of these epidemics. One in 
 1782, which extended over all Europe, visiting every country therein, affecting more 
 than one half of its inhabitants, and proving fatal to very many of them. You will 
 find, in the third volume of the Transactions of the College of Physicians, a good 
 account of the disease as it then showed itself in this country. In the spring of 1803 
 another instance of it occurred ; and of this the history, as compiled from the testi- 
 mony of a hundred and twenty-four observers, is preserved in the ninth and tenth 
 volumes of the London Medical and Physical Journal. In the month of April, in 
 the year 1833, the influenza arrain made its appearance, and prevailed extensively, 
 both here and elsewhere : and of the influenza of 1837 you have had, and you still 
 have, the opportunity of being observers. A very good and instructive sketch of
 
 540 INFLUENZA. 
 
 this epidemic malady, compiled by Dr. Hancock, is to be found in the Cyclopxdia 
 of Practical Medicine. To that article, to the publications I just now mentioned, 
 and to the works enumerated by Cullen, I may refer you for much which is curious 
 and interesting in the history of the disease ; but which would not be so well adapted 
 to our immediate purpose in this place — namely, that of seizing upon the practical 
 facts which have been ascertained respecting influenza. 
 
 One characteristic feature of this species of catarrh, as distinguished from the ordi- 
 nary sporadic disorder, is the sudden occurrence, in the outset, of more decided 
 febrile disturbance. The first two patients whom I saw in the epidemic of 1S33 had 
 just the symptoms which frequently mark the commencement of an attack of conti- 
 nued fever ; and I did not know, at my first visit, what was about to happen to them. 
 The symptoms, taking them altogether, are somewhat as follows. The patient is 
 chilly, and perhaps shivers ; presently headache occurs, and a sense of tightness 
 across the forehead, in the situation of the frontal sinuses ; the eyes become tender 
 and watery ; and sneezing and a copious defluxion from the nose ensue, followed or 
 accompanied by heat and uneasiness about the throat, hoarseness, a troublesome 
 cough, and oppression of the breathing. In short, the symptoms are the symptoms 
 of catarrh ; including in that term all the varieties thereof that are sometimes met 
 with separately — gravedo, cor}'za, bronchitis : and with these symptoms a sudden, 
 early and extraordinary subdual of the strength; and, most commonly, great depres- 
 sion of spirits. The debility which comes on at the very outset of the complaint, is 
 one of its most singular phenomena, taking place, in some cases, almost instantly, 
 and in a much greater degree than would seem proportioned to the other symptoms 
 of the malady which it thus ushers in. Indeed, this rapid and remarkable prostra- 
 tion of strength is more essentially a part of the disorder than the catarrhal affection, 
 which sometimes (though rarely) is absent, or imperceptible. It is upon the mucous 
 membranes, however, that the stress of the disease generally falls ; especially upon 
 the internal lining of the air-passages. Those of the alimentary canal seldom escape 
 entirely ; but they suffer in a less degree. The tongue is white and creamy, the 
 palate loses its sensibihty, the appetite fails, nausea and vomiting are not uncommon, 
 and sometimes there is diarrhoga. The pulse, in the uncomplicated disease, is soft, 
 and generally weak. The patients complain also of pains in the limbs and back, 
 and of much soreness, a bruised, fatigued, or tender feel, along the edges of the ribs 
 and in various parts of the body. 
 
 In its simple form and ordinary course, the disease abates of its violence after two, 
 three, or four days, and the patient is usually convalescent before the termination of 
 the week : but cough and much debilitj'- are apt to survive the other symptoms, and 
 while these continue, the complaint is very easily renewed. Pre-existing disease, 
 and peculiar constitutional habits and tendencies, modify considerably the character 
 of the influenza, as it affects different persons. I do not attempt to represent its va- 
 rious phases ; they are fit subjects of study for yourselves. 
 
 I have remarked that Cullen makes this species of catarrh to proceed from conta- 
 gion. But the visitation is a great deal too sudden and too widely spread to be 
 capable of explanation in that way. I will not say that the disease may not be iri 
 some degree infectious ; for there is reason to believe that other epidemic disorders, 
 having many points of analogy with the influenza, are somehow imparted from one 
 individual to another, akhough they are mainly produced by some influence which 
 resides in the aunosphere. There are points in the history of influenza which fur 
 nish a strong presumption that the exciting cause of the disorder is material, not a 
 mere quality of the atmosphere ; and that it is at least portable. The instances are 
 very numerous, too numerous to be attributed to mere chance, in which the com- 
 plaint has first broken out in those particular houses of a town at which travellers 
 have recently arrived from infected places. But this great and important question 
 of contagion I hope to examine with you more rigorously on a future occasion. 
 What I wish to point out now is the fact that the influenza pervades large tracts of 
 country in a manner much too sudden and simultaneous to be consistent with the 
 notion that its prevalence depends exclusively upon any contagious properties that 
 it may possess. You are aware that it has recently seized upon all parts of this
 
 INFLUENZA. 541 
 
 metropolis — and I believe I may say of nearly the whole kingdom — within the space 
 of a very few days. It has been observed to occur also, at the same time, on land, 
 and on board different ships which have had no communication with the shore, nor 
 with each other. Thus it is stated in the Transactions of the College of Physi- 
 cians, that on the 2d of May, 1782, Admiral Kempenfelt sailed from Spithead with 
 a squadron, of which the Goliah was one. The crew of that vessel were attacked 
 with influenza on the 29th of JVlay ; and the rest were at different times affected, and 
 so many of the men were rendered incapable of duty by this prevailing sickness 
 that the whole squadron was obliged to return into port about the second week in 
 June, not having had communication with any shore, but having cruised solely be- 
 tween Brest and the Lizard. This happened in one part of the fleet. In the begin- 
 ning of the same month, another large squadron sailed, all in perfect health, under 
 Lord Howe's command, for the Dutch coast. Towards the end of the month, just 
 at the time, therefore, when the Goliah became full of the disease, it appeared in the 
 Rippon, the Princess Ameha, and other ships of the last-mentioned fleet, although 
 there had been no intercourse with the land. Similar events were noticed in the 
 epidemic of 1833. One or two curious instances of the sudden sickening of consi- 
 derable bodies of men in different places at the same time, were related to me on 
 good authority. On the 3d of April in that year — the very day on which I saw the 
 first two cases that I did see of the influenza, all London being smitten with it on 
 ihat and the following day — on that same day the Stag was coming up the channel, 
 and arrived at two o'clock off" Berry Head, on the Devonshire coast, all on board 
 being at that time well. In half an hour afterwards, the breeze being easterly and 
 blowing off" the land, 40 men were down with the influenza ; by six o'clock the 
 number was increased to GO, and by two o'clock the next day to 160. On the self- 
 same evening a regiment on duty at Portsmouth was in a perfectly healthy state, 
 but by the next morning so many of the soldiers of that regiment were affected by 
 the influenza, that the garrison duty could not be performed by it. I make no doubt 
 that facts of a like nature have occurred during the present epidemic, and will be 
 made known in due time. They illustrate several important points in respect to the 
 disease : viz., the impossibility of accounting for its prevalence upon the principle 
 of mere contagion — the suddenness of its invasion — and the early and extreme pros- 
 tration of strength with which it is attended. 
 
 The occurrence of epidemic catarrh, as well as of most other epidemics, is un- 
 questionably connected with some particular state or contamination of the atmosphere. 
 What that state is, or what may be the kind of contamination, no one knows. The 
 present epidemic followed hard upon the sudden thaw that succeeded the remarka- 
 ble snow-storm of the last week of the last year. A similar coincidence between 
 the breaking out of the same disorder, and a sudden elevation of the temperature 
 of the atmosphere, happened at St. Petersburgh in the epidemic of 1782. " On a 
 cold night (Maertens says), the thermometer rose 30° of Fahrenheit ; the next morn- 
 ing 40,000 people were taken ill with the influenza." Now if every epidemic had 
 been preceded by similar changes in the weather, we might resolve the universal 
 prevalence and sudden accession of the complaint, into the effect of the cold and 
 damp state of the air, produced by the thaw. But it is not so ; for, as Dr. Hancock 
 observes, there has not been any uniform connection between any one sensible quality 
 of the atmosphere as to the heat or cold, rain or drought, wind or calm — and the 
 mvasion of the epidemic. " Et tempore frigidiori et calidiori, et flante tarn Austro 
 quam Borea, et pluvioso et sereno caelo, peragravit haSce omnes Europa} regiones, 
 et omnia loca indiscriminatim." Irregularities and great vicissitudes of weather 
 have, however, gone before the disease in very many instances : but sometimes one 
 condition of the atmosphere, and sometimes another, has been its immediate fore- 
 runner: and the epidemic has frequently been observed to fall partially and caprici- 
 ously : as a blight falls upon a field or district. Short, in his chronological history 
 of the weather, says that thick ill-smelling fogs preceded, some days, the epidemic 
 catarrh of 1557. Jussieu states that the grippe of the spring of 1733 appeared m 
 France immediately after offensive fogs, " more dense than the darkness of Egypt." 
 So also in 1775, Petit informs us that in France the disease was ushered in by thick 
 
 2v
 
 542 INFLUENZA. 
 
 noisome fogs. In the same year it visited the shire of Galloway in Scotland, where, 
 we are told, " a continual dark fog and particularly smoky smell prevailed in the 
 atmosphere for five weeks, the sun being seldom seen." Dr. Darwin has recorded 
 that, in 1783, "the sun was for many weeks obscured by a dry fog, and appeared 
 red as liirough a common mist :" and he supposes that " the materia] which thus 
 rendered the air muddy, probably caused the epidemic catarrh which prevailed in 
 that year." You will call to mind here the dark fog which brooded over this city in 
 the midst of the raging of the distemper about ten days ago, and which was repeated 
 in a less degree, on Wednesday last (Feb. 1). 
 
 It has been observed also, that shortly before, or during, or soon after, the preva- 
 lence of these epidemic catarrhs — epizootic diseases have raged ; various species 
 of brutes, and of birds, have been extensive!}'- affected with sickness : while on 
 some occasions prodigious swarms of insects have made their appearance. In 
 short, a great variet)'- of facts concur to render it probable that some pecuhar con- 
 dition of the air existed, which, though it might be favourable to the multiplication 
 of some species of living creatures, such as the insects just referred to, operated 
 as a poison upon the human body, and upon the bodies of many of the brute 
 creation. 
 
 It is a very curious circumstance in the history of epidemic catarrhs, and worthy 
 of your reflection, that they travel ; migrate as it were from one place to another: 
 and moreover, that they hold, for the most part, to certain courses, in spite even of 
 opposite winds, and of variations of temperature. It has been noticed that the influ- 
 enza generally follows a westerly direction, or one from the south towards the north- 
 west. In this remarkable properly it resembles, as you may perhaps be aware, the 
 epidemic cholera. 
 
 AUhough the general descent of the malady is, as I have said, very sudden and 
 diffused, scattered cases of it, like the first droppings of a thunder-shower, have 
 usually been remembered as having preceded it. The disorder is most violent at 
 the commencement of the visitation ; then its severity abates ; and the epidemic is 
 mostly over in about six weeks. Yet the morbific influence would seem to have a 
 longer duration. In a given place nearly all the inhabitants who are susceptibb of 
 the distemper suffer it within that period, or become proof against its power. But 
 strangers who, after that period, arrive from uninfected places, have not, apparently, 
 the same immunity. 
 
 The locality does not appear to be thoroughly cleared of the poison for some time : 
 or perhaps a more cautious statement of the fact Avould be, that the disorder generally 
 shows itself again in succeeding years, but in a milder and less general form. This 
 must depend either upon some remaining dregs, or possibly some revival, of the mju- 
 rious influence ; or else upon some abiding predisposition impressed upon the bodies 
 of men by its former visit. You may hear, every year, of Mr. So-and-so having 
 the influenza. In many instances, no doubt, common si)oradic catarrh is dignified 
 by that name ; but it is certain also that many of the colds, and bronchial disorders, 
 of the seasons which immediately follow a period of genuine influenza, are attended 
 with much more languor, debihty, muscular aching, and distress, than belong to an 
 ordinary attack of catarrh. 
 
 All this is very curious ; and very mysterious. All this, or much of it, is true 
 also of all the diseases which are known to prevail occasionally as epidemics. The 
 facts that have now been mentioned respecting the influenza, warrant, I think, the 
 conclusion that it does not depend upon any mutations in the ordinary qualities of 
 the atmospere ; upon any degrees or variations, I mean, of its temperature, its 
 motions, or its moisture ; upon what is expressed in the single word weather. Con- 
 cernmg a calamity so generafly felt, and so obscure in its origin, conjecture, you may 
 well believe, has not been idle. One hypothesis assigns the complaint to some change 
 in the electrical condition of the air : to its becoming negatively electric : or to its 
 being such as to cause an excessive accumulation of electricity in the animal econo- 
 my. The facts adduced in support of these views are of this kind. Meat, sent up 
 t»y means of a kite, high into the atmosphere, during the prevalence of the disease, 
 has returned putrid. Large heavy separate clouds, in a state of negative electricity,
 
 INFLUENZA. 543 
 
 have been observed just before the setting in of an epidemic. Thunder-storms, and 
 tumults of the atmosphere, have occurred at the same periods. During the raging 
 ^f one epidemic, 300 women engaged in coal-dredging at Newcastle, and wading al. 
 day in the sea, escaped the complaint. It has been thought that this exemption 
 might be accounted for by supposing that the almost constant immersion of the body 
 in a conducting medium prevented any undue collection of electricity. 
 
 Again, it has been fancied that the tolerably definite course of the epidemic, in its 
 migrations, might be somehow connected with magnetic currents. 
 
 Another hypothesis, more fanciful, perhaps, at first sight, than these, yet more 
 easily accommodated to the known phenomena of the distemper, attributes it to the 
 presence of innumerable minute substances, endowed with vegetable or with animal 
 life, and developed in unusual abundance under specific states of the atmosphere, in 
 which they float, and by which they are carried hither and thither. Myriads of 
 these animalcules, or of these vegetable germs, coming in contact with the mucous 
 membranes, and especially with that of the air-passages, irritate (it is imagined) these 
 surfaces, and exercise a poisonous influence upon the system. Now, the sporules 
 of certain fungi, which ruin the health, and destroy the vitality of larger plants, on 
 which they prey, are inconceivably small. I shall prove to you, presently, that 
 vegetable effluvia are capable of producing, in the human body, symptoms not very 
 dissimilar from those of influenza. Again, that the waters of this globe swarm with 
 living creatures, which are invisible by our unaided eyes, the microscope has tauo^ht 
 us. Others, too small even to be estimated by that wonder-showing instrument, in 
 all probability exist. We cannot doubt that the gaseous fluid which surrounds this 
 planet, equally teems with living atoms. We know that multitudes of insects, and 
 of cryptogamous plants, infinite in number in respect to our finite powers of compu- 
 tation, are sometimes suddenly hatched or developed, in places which were pre- 
 viously free from them. It is easy to conceive that atmospheric infusoria (so to 
 speak) may rapidly congregate, or vivify, in masses sufficient to render deleterious 
 the very air we breathe. If this be so, we can understand how such a cause of dis- 
 ease may first act here and there, and presently overspread large districts ; how it 
 may move, or be wafted from place to place, or be carried about by persons ; how 
 its course and operation may be circumscribed and definite ; and how some germs 
 or ova may remain after the visit, retaining their vitality, and ready in future seasons 
 again to start into life and activity under favouring circumstances. Taking the 
 insect hypothesis, and knowing as we do that some animal poisons (that of small-pox, 
 for example), have the singular property of multiplying themselves in the human 
 body, like yeast in beer, we may conceive that diseases, produced by animalcules, 
 may thus infect the fluids of the body, and become contagious in the fullest sense of 
 that term. Lastly, the uniform duration of these epidemics has been supposed to 
 add probability to the hypothesis that they result from the operation of some organic 
 principle, which has its definite periods of growth and of decay. All this is sheer 
 hypothesis ; but it is as good an hypothesis as I am able to offer you ; and you 
 must be content to conceive of it as being possibly the true one, until a better shall 
 be proposed. 
 
 The character of debility which is so conspicuously impressed upon this disease, 
 boars closely upon the treatment required for its cure, or its safe conduct. As in all 
 other epidemics, the severity of the complaint is extremely variable in different per- 
 sons. In some it proves a very trifling malady, Avhich soon passes off, and requires 
 httle or no assistance from medicine. In others it is a very distressing affection, and 
 lays the foundation for other and still more serious, though more chvonic diseases ; 
 and in some, and more especially in the old and the unsound, it shows itself a very 
 fatal disorder. The absolute mortality under the recent epidemic has been immense ; 
 the daily newspaper obituaries have been unusually long; and you may have re- 
 marked, that the ages of the persons whose deaths they announced were in almost 
 all cases great. The funerals have been so frequent, that difficulty has been found 
 m performing them without indecent hurry and confusion. One undertaker of whom 
 I was informed had at one time seventy-five dead bodies to inter — above ground, a* 
 he expressed it ; and mourning coaches and black horse* could not be procured in
 
 544 INFLUENZA. 
 
 sufficient numbers to meet the demand for them. The absolute mortahty, therefore, 
 I say, has been enormous ; yet the relative mortahty has been smalL You will hear 
 people comparing the ravages of the influenza with those of the cholera, and infer- 
 ring that the latter is the less dangerous complaint of the two ; but this is plainly a 
 great misapprehension. Less dangerous to the community at large (in this country 
 at least) it certainly has been; but infinitely more dangerous to the individuals 
 attacked by it. More persons have died of the influenza in the present year than 
 died of the cholera when it raged in 1S32; but then a vastly greater number have 
 been affected with the one disease than with the other. I suppose that nearly one- 
 half of those who were seized with the cholera perished ; while but a very small 
 fraction indeed of those who suffered, influenza have sunk under it. The only fatal 
 cases that I have seen have been in persons advanced in life, or in persons whose 
 lungs were previously known to be unsound. 
 
 Now, the treatment of the influenza is pretty well understood. The chief risk 
 of mistake is that of being too busy with the lancet. Certainly those affected by this 
 disorder do not well bear active depletion. Of course no one would think of blood- 
 letting except the symptoms were severe, and the distress great; but, even in such 
 cases, much caution is requisite in adopting that remedy. If you find that the in- 
 flammation has extended to the pleura, or to the substance of the lungs, it may be 
 necessary to open a vein, or to apply cupping-glasses over the chest ; but this is a 
 very unpleasant necessity. Such is the result of all that I have seen, and heard 
 from others, of the present epidemic ; and such is the result of the recorded expe- 
 rience of nearly all previous epidemics. You will find abundant evidence of this col- 
 lected into a summary view by Dr. Hancock. In 1510, Dr. Short says bleeding and 
 purging did harm. In 1557, bleeding was said to be so fatal, that in a small town 
 near Madrid, two thousand persons died after it in the month of September. In 
 1580, Sennertus, after stating that, where blood-letting was omitted, the mortality 
 was not greater than one in one thousand, adds, " Experientia enim lioc comprobavit, 
 omnes fere mortuos esse quibus vena aperiebatur." Dr. Ash observes that, in 1775, 
 it was never necessary to bleed at Birmingham ; and that, in a neighbouring town, 
 three died who were bled, and all recovered who were not bled. And a great deal 
 more evidence to the same purpose you may find in the article I have referred to. 
 
 I believe the best plan of management — as far as any general plan can be laid 
 down — is to keep the patient in bed, and, after clearing the bowels by a mild ape- 
 rient, to give a couple of grains of James's powder every six hours, with a saline 
 draught, and slops, till the first brunt of the disorder is over ; and then, if the cough 
 be troublesome, and the breathing laborious, and much rhonchus, or sibilus, or crepi- 
 tation, is audible in the chest, to apply a blister, and to give expectorants and diure- 
 tics. What I prescribed a great many times was something of this kind : half a 
 drachm of oxymel of squills, a drachm of the sweet spirit of nitre, and sometimes 
 another drachm of paregoric, in almond emulsion. With respect to full doses of 
 opium, when the feverishness is abated and the headache gone, I should recommend 
 the same practice which I described in the last lecture. If there be any lividity of 
 the skin, or of the mucous membranes, it is dangerous to give a full dose of opium. 
 On the other hand, if there be no visible indication in the complexion that venous 
 blood is circulating in the arteries, opium given at bed-time wall sometimes have a 
 magical effect in relieving distress, and (by giving rest and refreshing sleep) in 
 recruiting the strength also. In cases in which the powers of the system are pros- 
 trate, and the face and lips are livid, and the patient is tugging to expectorate the 
 mucus that is filling up his air-passages, you should have recourse to ammonia, to 
 nourishing broths, and it may be to wine and water : and when all danger from the 
 disease is over, but the patient remains feeble, languid, and out of spirits, then is the 
 fit time to administer tonic medicines; and ahhough snake-root and cascarilla are 
 well-spoken of by many practitioners, I know no tonics so good as the sulphate of 
 quina, or of iron, for such patients. 
 
 As to external applications, mustard poultices, blisters, and the like — and to the 
 mhalation of the steam of hot water, — these may each and all be very useful ; but I
 
 HAY-ASTHxMA. 545 
 
 have nothing to add concerning the time and manner of their employment lo whcit I 
 said upon the same subject in the last lecture. 
 
 There is one pomt in the treatment which I must not omit to notice, although I 
 cannot tell you much about it from my own experience. Dr. Thomas Davies, an 
 accurate observer, and one well qualified to form a judgment in the matter, slates 
 that he found a mercurial treatment answer well in severe cases, in the epidemic 
 of 1833. He perceived that active depletion was not well borne, and discovering 
 that in the bad cases there was always crepitation in the lower lobes of the lungs, 
 he thought mercury was one of the most proper remedies to subdue the inflamma- 
 tion, and to occasion absorption of the fluid eflbsed into the air-cells. He had severe 
 cases to deal with. He says that it happened to be his duty to admit the patients 
 into the London Flospiiai during the week the epidemic was at its height, and that 
 thirty-two beds which were placed at his disposal were all soon filled with individuals 
 labouring under the severe forms of influenza ; so severe, that he believed the greater 
 number of them would have perished if they had been allowed to wander about the 
 streets, or even to have remained at their own homes, with the insuflicient attention 
 they could there have obtained. Onlytjue or two of these patients were bled, but 
 they were all put under the influence of mercury. This treatment commenced on 
 Thursday, and all who, by Saturday night, were affected in the usual way by the 
 remedy, safely and gradually recovered, with the exception of two ; and one of these 
 had hypertrophy of the heart, and diseased aortic valves. His object was not to 
 salivate, but merely to make the gums tender. It was of course necessary that the 
 action of mercury should be prompt; and he found that the most quick and effica- 
 cious way of obtaining it was by rubbing in the llnimentum hydrargyri. 
 
 There is another kind of catarrh described as depending upon a peculiar local 
 cause, and therefore requiring to be briefly noticed. 1 have seen only one instance 
 of it ; but it has b.'en observed and described by several medical men. Dr. Bostock, 
 in the Medico-Chirurglcal Transactions, gives an account of this complaint as it is 
 tipt to attack himself. It is called the calarrhiis xstivm, and by some the hay-fever, 
 or the hay-asthma. In Dr. Elliotson's lectures, also, as published in the Medical 
 Gazette, there is a good deal of curious information upon this malady, contained in 
 letters addressed lo him from practitioners in various parts of the country, in conse- 
 quence of some previous remarks he had made upon it in a clinical lecture, which 
 had also been printed. Dr. Elliotson speaks of it as a combination of catarrh and 
 asthma. It consists in excessive irritation of the eyes, nose, and the whole of the 
 air-passages ; producing, in succession, itching of the eyes and nose, much sneezing 
 occurring in paroxysms, with a copious defluxion from the nostrils ; pricking sensa- 
 tions in the throat ; cough, tightness of the chest, and difficulty of breathing, with or 
 without considerable mucous expectoration. This complaint afl:ects certain persons 
 only, and in them it always takes place at ihe same period of the year, in the latter 
 end of May, or in June, when the grass comes into blossom, or when the hay-making 
 is going on. It seems, in fact, to be produced by some kind of emanation from cer- 
 tain of the grasses that are in flower at that season, of the irritating qualities of which 
 emanation some persons only, — and a very few persons in comparison with the en- 
 tire population, — are susceptible. The disorder happens only at that one particulai 
 season ; and it then attacks persons who are not remarkably subject to catarrh at 
 other times, nor from the ordinary causes of catarrh ; and if they avoid meadows and 
 hay-fields, and the neighbourhood of hay-stacks, they escape the malady. Hence 
 going to the sea-coast, and especially to those parls of the coast that are barren of 
 gia.';s, ofllers a means of protection ; and when this cannot be done, such persons ob- 
 tain refuge, in some measure, from the cause of the irritation, by remaining wiihui 
 doors, and shutting out as much as possible the external air, during the hay-crop. 
 One lady, who suffered annually from this strange aflection, states that a paroxysm 
 has been brought on by the approach of her children, who had been in a hay-field; 
 and once this happened when the hay-season had been for some time ovt-r, upon 
 iheir joining her at tea, after playing in a barn in which the hay of that yi?ar had 
 been deposited. She was in the habit of flying to Harwich, or some other pan of 
 35 2 v 3
 
 546 HAY-ASTHMA. 
 
 the coast, as the dangerous season came on. On one occasion, \vhile walkino- on the 
 shore at Harwich, she was suddenly attacked by the complaint, to her great surprise, 
 as she was not aware of any grass being in the neighbourhood ; but the next day 
 she discovered that hay-making was in progress upon the top of the cliff at the time 
 she was walking under it. In another year, she being at Cromer, and an attack that 
 she had suffered having quite subsided, and all the hay-making thereabouts being 
 over, she was suddenly visited by the well-known symptoms, and on going into her 
 bed-chamber, perceived that they were building a large stack of hay in a yard near 
 the house, having transferred it from a field five miles distant. 
 
 Very lately I was asked by Mr. Cheyne to see with him the wife of a stable-keeper 
 near Regent street. I found her suffering under what is popularly called "a crying 
 cold :" pain in the situation of the frontal sinuses, streaming eyes, sneezing and de- 
 fluxion from the nostrils, and very urgent dyspnoea, which was accompanied by loud 
 wheezing. Symptoms of this kind had come on, suddenly, some days before : and 
 her distress was then so great, that her husband proposed to drive her in a gig to 
 consult a medical friend of his who hved at Islington. On their way thither, every 
 symptom disappeared, and she felt at once^quite well. She subsequently stayed a 
 night or two, in comfort, with some relations in the city. Immediately upon her re- 
 turn homf *he same symptoms recurred, with all their former severity, and resisted 
 the means, adopted for their relief by JMr. Cheyne, who had now been called in. He 
 was soon led to suspect the cause of the attack, and of its obstinac}'. There was a 
 strong odour of hay in the house. The husband told him that his lofts were filled 
 with a lot of hay which had recently arrived, and which had an unusually powerful 
 smell. We learned that our patient was always worse at night, when the house was 
 shut up ; and better in the morning, when a free current of air blew through the 
 open windows. We advised a temporary change of residence : but our advice was 
 not followed until two days afterwards, the disorder meanwhile continuing, and in- 
 creasing in intensity. Then the patient removed to lodgings not one hundred yards 
 distant ; and immediately all the catarrh and distress again ceased, and she passed a 
 perfectly tranquil night. Afterwards she went into the country, and did not return 
 till the odoriferous parcel of hay had been consumed, and a new stock laid in. She 
 was however revisited by some slight cough, and occasional dyspnoea — neither of 
 which troubled her much or long. 
 
 Avoidance, then, of the ascertained source of the complaint is the best thing that 
 can be recommended to these persons. You may read almost every year in the 
 newspapers that one of our English dukes has gone to Brighton to escape the hay- 
 fever. But it is not in the power of every one to leave home for that purpose ; and 
 it has been found that the system is capable of being fortified in some degree against 
 the pernicious effects of these vegetable effluvia. Mr. Gordon of Welton, in York- 
 shire, had communicated some interesting observations to the profession on this 
 subject, before those of Dr. Elliotson were published. You may find Mr. Gordon's 
 paper in the fourth volume of the JMedical Gazette. He supposes that the aroma 
 of the sweet-scented vernal grass, the anthoxanthinn odoratiim, is the principal 
 exciting cause of the complaint. He found the symptoms more speedily and effectu- 
 ally removed by the tincture of lobelia inflata, than by anything else that he had tried 
 at that time; and he recommended the cold shower-bath as the best preservative 
 against the attack. But in a subsequent communication to Dr. Elliotson, he states 
 that the sulphates of quina and of iron given in combination, had proved completely 
 successful in emancipating from their tormenting disorder the two patients, from 
 whose cases he had principally drawn up his account; although they had, in spite 
 of all previous treatment, suffered an annual return of it for fifteen or twenty years. 
 
 The susceptibility of this troublesome affection of the mucous membrane, from a 
 peculiar cause, which, to most people, occasions no uneasiness, app-ears sometimes 
 to run in families : and this is nothing more than one might expect. 
 
 Dr. Elliotson, thinking it possible that the chlorides which have the power of 
 decomposing, and disarming of their noxious qualities, certain anj??Jo/ effluvia, might 
 exert a similar control over the vegetable emanations that excite the hay-catarrh, 
 ■•ug^gebted to one of the sufferers a trial of the chloride of lime or of soda. He
 
 CHRONIC BRONCHITIS. 547 
 
 desired him to have it placed in saucers about his bed-chamber : to have rags dipped 
 in it and hung about the rooms of the house; to wash his hands and face witii it 
 night and morning ; and to carry a small bottle of it with him to smell repeatedly in 
 the course of the day ; and this plan gave so much relief, — either by destroying the 
 emanations, or by lessening the irritability of the mucous membranes, — that it was 
 tried in other cases; and, though it did not succeed in all, it did in most of them. 
 Three patients out of four derived advantage from it. This expedient, therefore, is 
 worth carrying in mind. 
 
 There is another vegetable substance, better known to us, which produces in some 
 few individuals symptoms like those of the hay-asthma ; I mean the powder of ipe- 
 cacuanha. I recollect a servant employed in the laboratory of St. Bartholomew's 
 Hospital, when I was a pupil there, who had the peculiar ill luck to be liable to this 
 affection. Whenever that drug was under preparation, he was obliged to fly the 
 place. This idiosyncrasy is not very uncommon. A very small quantity of the 
 ipecacuanha dust is sufficient in such persons to bring on a paroxysm of extreme 
 dyspnoea, wheezing, and cough, with singular anxiety and great weakness. The 
 distress usually terminates by a copious expectoration of mucus. 
 
 These effects of a powdered root, and of certain emanations from grass or hay, lend 
 weight to the hypothesis which ascribes the influenza to subtle vegetable matter 
 floating in the atmosphere. 
 
 I would suggest a trial of the Respirator, as a defence against the particles of 
 ipecacuanha, and against the volatile exciting cause (whatever it may be) of hay 
 asthma. 
 
 Catarrh is very often met with in a chronic form ; in other words, the mucous 
 membrane of the air-passages is very liable to be affected with chronic inflammation. 
 The accounts which you may read of this are exceedingly puzzling. Authors have 
 endeavoured to draw nice distinctions between different species of chronic catarrh ; 
 sometimes according to varying qualities in the matter expectorated : thus you have 
 chronic mucous catarrh — /nVinVous catarrh — chronic pituitous catarrh — and dry 
 catarrh, which, after all, is not dry, but only accompanied by less expectoration than 
 some of the others ; and then again there is symptomatic catarrh. You will find all 
 these enumerated by Laennec ; and the majority of writers since his time have trod- 
 den with too submissive reverence in his footsteps. There are by no means such 
 differences in the symptoms or in the proper treatment of the several varieties of 
 chronic inflammation of the membrane in question, as to make these numerous sub- 
 divisions of any practical utility. Chronic or moderate catarrh is often a sequel of 
 acute bronchitis ; it is a very common accompaniment of disease of the heart ; it fre. 
 quently arises during the course of the febrile exanthemata; it is seldom entirely 
 absent in cases of continued fever ; and it is a form of complaint that is full of 
 interest on this account, if on no other, that it has so often been mistaken, and is so 
 liable to be mistaken still for tubercular consumption ; of which indeed it is very fre- 
 quently the companion. 
 
 The constant symptoms of chronic catarrh, or bronchitis, are cough, some short- 
 ness of breath, expectoration of altered mucus. The t^an'rti/e symptoms, those which 
 are oftentimes of the most importance, as determining the slight or the serious character 
 of the disorder, consist in the quantity and quality of the matters expectorated, and 
 the presence or absence of wasting, and of hectic "fever. 
 
 You will continually be meeting with cases of tliis kind. A person advanced in 
 years has what he calls a slight cold, in the winter. He coughs, and expectorates a 
 certain quantity of gray or transparent mucus. In the summer his cough diminishes, 
 or ceases altogether. The next winter the same thing happens again ; and each suc- 
 cessive return of the colder seasons of the year brings back in increasing seventy 
 the cough and the expectoration : and if you hsten to the breathing of such persons, 
 while the cough is on them, you will find crepitation at the lower part of their lungs. 
 Now these are examples, I beheve, of a chronic state of slight inflammation of the 
 membrane,— or it maybe of passive congestion and effusion, — depending upon
 
 1 
 
 548 CHRONIC BRONCHITIS. 
 
 slowly advancing cardiac alterations. Peripneumonia nolha is very apt to super 
 vene on this condition. 
 
 But chronic bronchitis may take place at any age, as a sequel to the acute ; just 
 as active inflammation of other parts of the body is liable lo degenerate into the 
 chronic form ; and such cases are sometimes very equivocal and deceptive. Several 
 years ago, a lady became my patient, having cough, expectoration of puriform 
 matter, night-sweats, and diarrhoea. She had had hooping-cough a short time 
 before ; but though the hooping, and other symptoms proper to that disease had 
 ceased, she continued to cough, and to waste. Gradually she got thinner and 
 weaker, her pulse became like a thread, and beat 120 times in a minute ; she took 
 to her bed, the diarrhoea was scarcely restrained b}' astringents and opiates, and I 
 thought she could not live a week. And, upon being pressed by her brother for my 
 opinion, I said so. She had scarcely allowed me to listen to the s'ounds in the 
 thorax : but I had once done so fairly, and I could find no morbid sounds, except at 
 the lower part of the lungs. If I had trusted to that circumstance alone, I should 
 have said that she had not tubercular consumption ; but I had not then so much faith 
 in the indications afforded by auscultation, nor in my accuracy of ear in such matters, 
 as I might have now; and I concluded that she teas dying of tubercular phthisis. 
 Almost on the day, however, on which I ventured to give this prognosis, some slight 
 amendment began : and she did gradually recover, and is alive and quite well at this 
 time. Now it is in cases of this kind that cures are performed by those who boast 
 of curing consumption. 
 
 In truth, chronic bronchitis is, in some cases, as incapable of recovery, and as 
 surely and progressively fatal, as tubercular phthisis itself; and even more so than 
 some of the forms of phthisis. So long, however, as no organic change has taken 
 place in the air-tubes, or in the mucous membrane lining them, these chronic forms 
 of bronchitis that simulate phthisis in their general symptoms, are within the reach 
 of cure. They are to be treated by counter-irritants to the chest — and by such 
 measures as are calculated to relieve the most urgent symptoms. Opiates for cough, 
 or for diarrhoea. Sometimes the patients bear steel well, and then it is almost sure 
 to have a beneficial effect. Sometimes sarsaparilla appears to do good ; but, as far 
 as I have observed, one of the most effectual restoratives in these cases is to be found 
 when the weather and the strength permit, in frequent change of air and place ; in 
 gentle gestation in a carriage, or in a boat ; and in a nourishing but bland and un- 
 stimulating diet. When the membrane, and the tubes which it lines, become alterca 
 in structure, and pour forth a fluid which has all the qualities of pus, hectic fever 
 generally is present, and the chronic disease tends, slowly perhaps, but surely, to 
 death. 
 
 There are certain cases af chronic bronchitis which are especially remarkable, on 
 account of the great abundance of the bronchial secretion : so great that the patients 
 appear to die principally from the daily exhausting drain thus made upon the sys- 
 tem. There are sometimes no other evident signs of inflammation; so that, as 
 Andral observes, one might be led to separate these fluxes from the truly inflamma- 
 tory afflictions. They differ from them, apparently, in their nature, and certainly in 
 the treatment which they require. Andral has detailed two or three instances of this 
 kind in his C/inique Medicale. The patients expectorated every day large quanti- 
 ties — a pint or more — of frothy fluid, resembling weak gum-water in colour and con- 
 sistence. They had no fever ; neither frequency of pulse nor heat of skin ; but they 
 were exceedingly pale, like persons blanched by hemorrhage, and their emaciation 
 and weakness were also extreme. Ver}^ little appreciable deviation from the healthy 
 state was detectible when the lungs and heart were examined after death. 
 
 It does occasionally happen that even larger quantities — three or four pints daily — 
 are, for a considerable period, spat up, without much wasting. 
 
 Andral asks, whether, in such cases as these, which certainly occur, though they 
 are not very common, the first indication of treatment should not be to check and 
 diminish the excessive bronchial secretion ; to treat it as you might treat a gleet of 
 the other mucous membranes, with balsams, administered either by the stomach, or 
 ;n the shape of vapour. He conjectures that it might have been in cases of this
 
 CHRONIC BRONCHITIS. 549 
 
 nature that the vapour of tar, and tar-water, were once thought to be so useful. 
 Probably the creasote would be well adapted to such cases. Certainly I have 
 seen the excessive expectoration diminish, and the patients gain strength, under the 
 use of the balsams ; the compound tincture of benzoes, for example ; a form of 
 medicine much emploj'ed formerly, and too much neglected, I apprehend, at present. 
 
 [Balsam Copaiba will be found a very valuable remedy in these cases. — C] 
 
 Another remedy, from which I have derived great advantage in some cases of the 
 same kind, is the sulphate of iron, given in two or three-grain doses, in the compound 
 infusion of roses, thrice daily. When there is any fever present, these remedies are 
 apt to augment it : but when the pulse is quiet, and the skin cool, 1 am quite sure 
 that they are often of the greatest service ; and this you will find to be the opinion 
 also of various practical authors. 
 
 There is another very remarkable condition of the pulmonary mucous membrane, 
 constituting also, I imagine, a species of chronic inflammation, and characterized 
 chiefly, Hke the last, by the matters expectorated. I mean that state in which a firm 
 substance, resembling a false membrane, forms in the smaller bronchi and their rami- 
 fications, and is coughed up, from time to time, in fragments. I mentioned in a 
 former lecture that the false membrane of croup sometimes descends a long way into 
 the bronchi ; even to their extremities. But I am speaking now of a different and 
 less acute form of disease, in which, the trachea being unaffected, concrete masses, 
 evidently moulded in parts of the hollow bronchial tree, are ^pat up ; somewhat like 
 bunches of worms, or the roots of a small plant. This I presume to be uncommon ; 
 for I have met with it twice only in my life. It has been described, however, by 
 several observers. The first, Dr. Warren, has a paper upon it in the first volume 
 of the Medical Transactions, where he gives representations of the substances 
 coughed up, which he calls bronchial polypi. Dr. Paris has told me that a patient 
 of his coughed up considerable qiaantities of these branching casts of the ultimate air- 
 tubes, now and then, for a long period. An interesting paper of Mr. North's, on the 
 same subject, was read at one of the evening meetings of the College of Phj'sicians. 
 That gendeman possesses some beautiful specimens of these miscalled polypi. Dr. 
 Carswell gives a figure representing them. When the affection is extensive, it is 
 attended with great distress, and dyspnoea, and violent fits of coughing; and the 
 symptoms are wonderfully calmed upon each expulsion of the solid matter. The 
 surprise is that such patients should ever recover ; but I have never heard of an 
 instance in which the complaint proved fatal. 
 
 The two examples of it which have fallen under my own observation, were 
 invested, bj'' the circumstances attending them, with a peculiar interest. They 
 occurred, within less ?han a twelvemonth of each other, in the persons of two brothers, 
 of middle age, the one a barrister, the other well known to you all as one of my most 
 valued colleagues in this place. Both of them were, and are, remarkably stout, 
 strong, and healthy men. In both cases the expulsion of the so-called polypi was 
 preceded by haemoptysis, which came in considerable gushes, and was repeated at 
 intervals of a few days, until the sohd matters began also to be expelled, and then 
 hemorrhage soon subsided. 
 
 The barrister, after having been annoyed for nearly a year by some huskiness of 
 the voice, spat up, all of a sudden, a small quantity of bright blood ; and soon after- 
 wards expectorated several ramifying masses of tolerably firm consistence, resembling 
 fibrinous coagula of blood, deprived of most of its colouring matter. Some of them, 
 which I saw and examined, were solid ; others, I understood, were hollow. I found 
 slight circumscribed crepitation in the lower and posterior part of his left lung. This 
 trivial degree of hoemoptysis, with the expulsion of what looked like casts of the inte- 
 rior of a bronchial tube, was once or twice repeated within a few days. He had no 
 fever — no dyspnoea. Mercury, inter alia, was prescribed; but as the patient did 
 not feel in any way ill, I befieve he soon became tired of physic, and of medical 
 restraint. Whenever I have since seen him, he has appeared to be in perfect 
 health. 
 
 Of the professor's illness I saw more. In the midst of health which had been
 
 ^ 
 
 550 CHRONIC BRONCHITIS 
 
 uninterrupted, save by a solitary fit of the gout some years before, he also sj/at some 
 mouthfuls of florid blocd. He had no cough, but the haemoptysis was accompanied 
 by a rattling sensation in the right side of his chest. 
 
 For about three weeks he continued, at intervals varying from three to six days, 
 to expectorate blood in gushes. The smallest quantity brought up on any one 
 occasion \vas two ounces ; the largest, eight. Just above the right nipple, the respi- 
 ratory murmur was mingled with large crepitation, Avhich was always sensiblj- 
 increased, and quite perceptible by the patient himself, during the attacks of he- 
 morrhage. In the intervals between them his breathing and his pulse were per- 
 fectly tranquil and regular. 
 
 With the florid blood came up, in general, some black coagula : and at the end 
 of three weeks, or thereabouts, in these black masses, ragged shreds of a difleren*. 
 and firmer material began to be visible : and presently afterwards, complete branch- 
 hke casts of the ramifying air-tubes were expelled ; and the bleeding ceased. 
 
 Of these casts tiiere'were two kinds; the one solid, somewhat coloured, evidently 
 fibrinous, and resembling the branching coagula that may sometimes be drawn out 
 of the arteries in the dead body ; the other white, membranous, tubular, but rami- 
 fying also. None of them were of very firm consistence. 
 
 Till these substances made their appearance, our anxiety about the patient was 
 extreme, and he underwent some rigorous discipUne at our hands. He was con- 
 fined to bed, forbidden to speak, kept strictly to the slenderest slop diet, several 
 times bled, and extensively blistered. Lumps of ice were given him to swallow, and 
 pounded ice was applied to his chest whenever the blood broke forth afresh. He 
 took mercury till his gums were tender, and afterwards the acetate of lead, and other 
 reputed styptics. 
 
 To most of this I was a consenting party ; but, looking back upon the case now 
 that its nature and resuk are known, I must confess that the treatment, though fairly 
 justifiable at the time, was unnecessarily active. 
 
 Mr. North, in the paper to which I have alluded (you may see it in the twenty- 
 second volume of the Medical Gazelle), draws a distinction, of which he gives the 
 credit to Dr. Cheyne, between the hollow, membranous concretions, expelled without 
 any blood ; and the sohd branching masses which accompany or succeed haemopty- 
 sis, and are obviously mere coagula of blood moulded in the smaller air-tubes, where 
 it had stagnated. He points out the comparatively harmless character of the cases 
 in which the first occur; and the far more serious import of the second : the hemor 
 rhage denoting the presence of some organic mischief within the thorax, and the 
 " polypous concretions" being simply an accident of the hemorrhage. 
 
 I doubt the accuracy of this distinction. The brothers of whom I have spoken 
 continue to be, as they were before, free from any symptom or suspicion, either of 
 cardiac or of pulmonary disease. Moreover, in hasmoptysis depending upon tuber- 
 cles in the lungs, or upon organic disease of the heart, these concretions are very 
 rarely observed. I have never seen them in such cases, conimon as such cases are. 
 The barrister had a husky voice, and the professor was noticed to have been often 
 " clearing his throat" for some time before the first eruption of blood : from which 
 cnxumstance I infer a previous unhealthy state of the mucous membrane. Upon the 
 whole I incline to the "iews expressed by Dr. Todd, with whom I had the advantage 
 of consulting in the latter case — that a chronic and limited inflammation of certain 
 of the bronchial tubes first occurred ; disclosing itself by no marked symptoms, but 
 leading to the formation of tubular membranes : that, after awhile, these membranes 
 began to be detached : that hemorrhage resulted, and continued till the separation 
 was complete : and that, at the same time, some of the extra vasated blood coagulated 
 in, and took the shape of, the air-tubes, and was afterwards expectorated. 
 
 I understand that the barrister has since had a recurrence of this strange complaint, 
 which he treated very lightly, and soon got rid of. 
 
 He entertained a fixed belief that his attacks were attributable to the presence of 
 v»ne of Dr. Arnott's stoves, in his chambers ; the heated atmosphere of which always 
 produced a slight feeling of constriction and distress within his chest. Whether 
 this notion be well or ill founded I cannot pretend to say : but it is curious that the
 
 MORBID ANATOMY OF THESE AFFECTIONS. 551 
 
 j>rofessor also had been using a similar stove, which, placed in his siLling-ioom, 
 warmed both it and his bed-room adjoining. 
 
 A word or two, before we separate, as to the morbid anatomy of these tissues. 
 
 Chronic inflammation of the aerial mucous membrane may lead to changes in its 
 colour; or to thickening of the membrane; or to ulceration; or to dilatation of the 
 bronchi, and their ramilications. And it is proper that you should be informed re- 
 specting these morbid conditions. 
 
 In general, when chronic inflammation has existed during life, the mucous mem- 
 brane is found to be red : but it is not a bright redness ; it is rather a livid, or violet, 
 or brownish tint. And what is very curious, in some instances in which all the 
 symptoms of inveterate bronchitis, with pwiform expectoration, had been present, 
 the inner membrane of the air-passages has been found scarcely rosy — or even per- 
 fectly white — throughout its whole extent. Of course we are not to infer from this 
 that there has not been injlummation ; for the same thing is known to occur in the 
 intestinal mucous membrane, in that of the bladder, and even in serous membranes. 
 Where pus is poured forth there must have been inflammation. 
 
 One effect of inflammation, as I formerly showed you, is a softening of the mem- 
 brane ; but this is a much less common result of inflammation in the mucous mem- 
 brane of the bronchi, than in that of the digestive organs. In regard to ulceration 
 likewise there is a great difference between the two mucous surfaces : in that of the 
 air-passages it is comparatively rare. 
 
 ■ Thickening of the mucous tissue occurs also in various degrees : but the most 
 remarkable change undergone by the membrane, and the tubes which it lines, is the 
 dilatation of those tubes, and the consequent alteration of the membrane, which 
 expands with them. 
 
 There are two or three varieties of this dilatation. In the first of them, one or 
 more of the bronchi present, throughout the whole or the greater part of their extent, 
 an increase of capacity more or less considerable : so that tubes which result from the 
 fourth or fifth, or even sixth division of the principal bronchus of each lung, may 
 equal or exceed in diameter that bronchus itself. Tubes that ought not to be bigger 
 than a crow-quill may become as large as the finger of one's glove. Sometimes this 
 kind of dilatation is seen in a single branch only, sometimes in many. It may affect 
 the bronchial ramifications of an entire lobe. It is more common in the branches of 
 a bronchus than in the bronchus itself. 
 
 It is not very easy to explain the manner in which this sort of dilatation is pro- 
 duced. We might attribute it to simple distension of the bronchial parietes, were it 
 not that these parietes are at the same time thickened, and the circular fibres hyper- 
 trophied, as you may see in this preparation, and in Dr. Carswell's plate. But there 
 is another form of bronchial dilatation to which the explanation just adverted to is 
 easily applicable. Instead of the uniform dilatation of one or more bronchial lubes, 
 throughout their whole extent, we find a bellying, or globular expansion, at the ex- 
 tremity of one of them ; and the walls of the tube, instead of being thick and hyper- 
 irophied, are wasted, and in a state of atrophy. The tissues composing the tube are 
 often so thin, that when the cavity, for such it must be called, is laid open, the colour 
 and structure of the pulmonary tissue may be seen through them. These cavities 
 are generally found filled with a thick, tenacious, straw-coloured, muco-purulent fluid. 
 Now it is easy to conceive how " the straining influence of repeated paroxysms of 
 coughing" may cause dilatation of this kind. The primary branches are more easily 
 cleared of the mucus that fills them: but the pressure which the lung undergoes 
 under a forced expiration, operating on a portion of the same kind of nmcus detained 
 in the smaller branches, may be more than the elasticity of the tube is capable of 
 resisting. And, in fact, all dilatations of the bronchial tubes must be, in part at leasl, 
 owing to the same influence of centrifugal pressure by imprisoned mucus. The) 
 are seldom met with except after those affections which are characterized Oy con 
 siderable secretion from the membrane, and by much and repeated cough : as after 
 some forms of chronic bronchitis, and after hooping-cough. 
 
 A third variety of dilatation is that in which the same bronchus bellies out in dif
 
 552 HOOPING-COUGH. 
 
 ferent plucjs ; is dilated at intervals ; so as to present in its course a series of sutccw- 
 sive enlargements and contractions. Here, again, the walls of the bronchi, thouo-h 
 they may be traced in the parts dilated, do not appear to be thickened, but rather 
 are diminished in thickness. We may suppose, therefore, that these small partial 
 dilatations of the bronchi may result from mechanical distension, by mucus, in those 
 places which offer the least resistance ; either on account of diminished elasticity, or 
 of actual thinning. This variety of dilatation is more frequent in children than ia 
 aduks. 
 
 In whatever way the dihtation may take place, one of its obvious and necessary 
 consequences is, the condensation of the pulmonary substance around the dilated 
 tube, the obliteration of some of the cells, and a proportional abridgement of the func- 
 tion of the lung. According!}^, when it is extensive, dilatation of the bronchi is 
 attended with habitual dyspnosa. 
 
 But the most important consideration arising out of this state of the bronchi, is 
 this ; that the signs, both general and physical, by which it is accompanied, are 
 apt to be exactly those which are most distinctive of phthisis. And it is on that 
 account that I have now described these changes. I shall revert to them ao-ain 
 when I come to the symptoms, revealed by auscukation, of tubercular disease of the 
 lungfs. 
 
 LECTURE L 
 
 Hooping-covgh: symptoms; duration; complications; pafhology ; treatment. 
 Fnewnonia : its stages and morbid anatomy ; auscidtatory signs. 
 
 I HAVE yet to consider one very important disorder, which is usually classed among 
 the catarrhal aflections, but which is marked by features so peculiarly its own, as to 
 distinguish it effectually from every other form of disease. I allude to hooping- 
 cough ; a remarkable complaint, well known everywhere, I believe, and much 
 dreaded by parents. It has received a variety of names : chin-cough ; kinkhoast ; 
 coqueluche ; tussis convulsiva ; tussis ferina ; and pertussis. This last name, which 
 Sydenham bestowed upon it, and which was adopted by Cullen, is the technical 
 appellation of the disease in this country, as hooping-cough is the popular. 
 
 The phenomena that characterize hooping-cough are, I say, remarkable. It begins 
 with the symptoms of an ordinarj' catarrh arising from cold. The child (for it is 
 most especially a disease of children) has coryza, and coughs ; and mothers and 
 nurses are aware that the disease commences in this way, and express their appre 
 hensions lest it may turn to the hooping-cough. After this, the catarrhal stage, has 
 lasted eight or ten days, or a fortnight, or sometimes a day or two longer, that kind 
 of cough begins to be heard which is so distinctive. It comes on in paroxysms, in 
 which a number of the crpiratory motions belonging to the act of coughing are made 
 in rapid succession, and with much violence, without any intervening inspirations; 
 till thi little patii'nt turns black in the face, and seems on the point of being suffo- 
 cated. Then one long-drawn act of i;jspiration takes place, attended with that pecu- 
 liar crowing or l)t)()[;ing noise, which denotes that the rima glottidis is partially closed, 
 and which gives tin; disease its name. As soon as this protracted inspiration has 
 been coinpleted, ilic ^^cries of short expiratory coughs, repeated one innnediaiely 
 after the other till all the air appears to be expelled from the lungs, is renewed ; and 
 then a second sonorous L:'.rk-draught occurs; and this alternation of a number of 
 expiratory coughs, with one shrill inspiration, goes on, until a quantity of glairy 
 nuicus is forced up from the lungs, or until the child vomits, or until expectoration 
 vnd vomiting both take place at once. During the urgency of the paroxysms, the 
 face becomes swelled, and red or livid, the eyes start, the httle suffi^rer stamps some- 
 times with impatience, and generally clings to the person who is nursing him for 
 support, or lays hold of a chair or table, or of whatever object may be near him. to
 
 HOOPING-COUGH. 553 
 
 diminish (as it would seem) the shock and jar by which his whole frame is shaken. 
 As soon as expectoration or vomiting have happened, the paroxysm is over. The 
 child may pant a little while, and appear fatigued ; but commonly the relief is so 
 complete, that he returns immediately to the amusements, or the occupation, which 
 the fit of coughing had interrupted, and is as gay and lively as if nothing had been 
 the matter with him. When the fit terminates by vomiting, the patient is in general 
 seized immediately after with a craving for food, asks for something to eat, and takes 
 it with some greediness. 
 
 Each paroxysm may consist of several alternations of the gasping coughs, and the 
 characteristic hoop or kink; but CuUen remarks, that the expectoration or vomiting 
 usually takes place after the second coughing, and puts an end to the fit. 
 
 The number of paroxysms that occur in the twenty-four hours is variable also; 
 and they come on at irregular intervals. When the complaint is uncomplicated, the 
 child, during the intermissions, appears to be quite well. This is another striking 
 feature of the disorder. In the earlier paroxysms the mucus expelled is scanty and 
 thin ; and in proportion as this is the case, the fits are the longer and the more violent. 
 By degrees the expectoration becomes more abundant ; and sometimes it is very 
 copious : at the same time it is thicker, and more easily brought up ; and on that 
 account the fits of coughing are less protracted. 
 
 The ordinary duration of the disease is from six weeks to three months; but it 
 ma}^ run its course, I believe, in three weeks ; and it may continue for six months, 
 or more. 
 
 In an uncomplicated case, if 3'ou listen at the chest during the intermissions, you 
 will probably hear the sounds that are proper to catarrh — some degree of rhonchus 
 or sibilus : and in many parts there may be puerile respiration ; and if you percuss 
 the thorax, you get the natural hollow sounds. But what happens when you apply 
 your ear to the chest during the paroxysms of coughing? Why, the information 
 given us in this case by auscultation is very curious. You may perhaps hear, be- 
 tween the short explosive shocks of the cough, some snatches of wheezing, or of 
 vesicular breathing ; but during the long-drawn noisy inspiration that succeeds, all 
 wllhin the chest is silent. This is supposed to result from the slow and niggardly 
 manner in which the air passes towards the lungs through the chink of the glottis, 
 which is spasmodically narrov/ed. It may also depend, in part, as Laennec sup- 
 posed, upon a spasmodic condition of the muscular or contractile fibres of the bronchi 
 and their branches. When the fit is at an end, the ordinary sounds of healthy, or 
 of catarrhal respiration, are resumed. 
 
 Children are very susceptible of this complaint ; and it is a complaint which 
 spreads by contagion. Hence it follows that kw children escape an attack of it. 
 It is also one of those contagious maladies which do not in general affect the same 
 individual twice ; and hence again it follows that it is rarely met with in adults. Such 
 is the fact ; and such, I apprehend, is the explanation of it. It is not that adults are 
 insusceptible of hooping-cough; for adults that have not had it during their child* 
 hood are readily afii^cted when exposed to the contagion. But it is that the disorder, 
 with very few exceptions, protects the system somehow from its future recurrence ; 
 and that most adults have had it when they were young, and for that reason do not 
 take it afterwards. 
 
 During the very early periods of infancy, i. e., within the first two or three months, 
 hooping-cough is said to be rare : I mentioned a case, however, before — and I have 
 read of others — in which the disorder appeared to have been contracted before the 
 patient was born. My bed maker's daughter in Cambridge had a child ill with 
 hooping-cough in the house with her during the last weeks of another pregnancy, 
 and the new-comer hooped the first day he came into the world. 
 
 As long as this disease is uncompHcated — unmixed with inflammation, and there- 
 fore unattended with fever, or only with that slight inflammatory condition proper to 
 mild catarrh — it is not at all a dangerous disease. Probably it will, under the most 
 favourable circumstances, run a certain course. By degrees the violence and the 
 frequency of the paroxysms diminish ; they occur only in the morning and the eve- 
 ning, then in the evening alone, and at length they cease altogether. But for ?orrve 
 
 2 vv
 
 554 HOOPI.XG-COJGH. 
 
 time after the disorder has apparently come to an end, if the child takes cold, and 
 gets a cough, it is apt to assume a spasmodic character, and to be attended with a 
 hooping noise in inspiration. 
 
 Unfortunately hooping-cough is, in a great many cases, not simple — not uncom- 
 plicated. It becomes mixed up with other kinds of disease in the chest, or in the 
 head. In the chest, severe bronchitis supervenes upon it, or inflammation of the 
 substance of the lungs ; and then fever is lighted up, and permanent dyspnoea is pre- 
 sent. When the disorder has been long drawn out, and has at last terminated fatally, 
 dilatation of the bronchi, such as I described in the last lecture, is often found upon 
 dissection ; or, still more commonly, I beheve, what is called emphyzema of the 
 lungs — a change which I have yet to bring before you. 
 
 That such effects should follow such violent and continued efforts of coughing, is 
 no o-reat matter for wonder. Neither can we be surprised that the disease frequently 
 leads to cerebral disorder. During the fits, there is a great and visible determination 
 of blood towards the head, or rather a detention of the blood in the veins that pro- 
 ceed from the head ; — passive mechanical congestion : the transmission of the blood 
 throun-h the lungs being obstructed, and its return from the head being interrupted. 
 Hence, the face becomes turgid, the eyes are prominent, the superficial veins full 
 and projecting, the lips and cheeks turn livid ; sometimes hemorrhage takes place 
 from the nose or ears, or the eyes become blood-shotten, or the patient actually falls 
 into convulsions ; nay, apoplexy is occasionally the result of the straining ; and when 
 life is not thus suddenly cut short, chronic mischief is apt to be set up in the brain, 
 and the child ultimately dies hydrocephalic. 
 
 All this is the more to be feared in proportion as the child is the younger. Head 
 affections are particularly to be dreaded in scrofulous children ; and in any children 
 during the first dentition. When the disease occurs within the first two years of life, 
 it is usually attended with convulsions : and many more die within that period than 
 afterwards. And CuUen's remark is undoubtedly true, that the older children are, 
 the more secure they are, cscteris paribus, against an unhappy event. 
 
 Hooping-cough may be complicated also with a disordered condition of the bowels ; 
 and with infantile remittent fever. This complication is more accidental, and less a 
 consequence of the hooping-cough than the former ; but it may very materially add 
 to its peril. 
 
 Dr. CuUen was of opinion that the complaint may exist in even a milder forn?. 
 than that which I have called simple hooping-cough. He thought he had seen " in- 
 stances of a disease, which, though evidently arising from the chin-cough contagion 
 never put on any other form than that of a common catarrh." Others again believe 
 that adulLs may have it without hooping. But all this seems to me very doubtful 
 Catarrh is an exceedingly common malady ; and I should be slow to consider any 
 case a genuine case of pertussis, unless the characteristic paroxysms of coughing, 
 and the stridulous inspiration, were present. 
 
 Divers opinions have been held respecting the seat, and respecting the nature, of 
 hooping-cough. Some supj)ose it to have its seat in the brain ; and that it is essen- 
 tially a spasmodic disease. Others maintain that it is situated in the air-passages of 
 the lungs, and that it is always an inflammatory disorder. I do not pretend to strike 
 the balance between these conflicting judgments. Certainly the simple form of the 
 disease is often unattended with any appreciable fever: and that is a strong ground 
 lor believing that its peculiar phenomena are not necessarily connected with inflam- 
 mation. They who have ascribed the complaint to a morbid condition of the brain 
 have deduced that opinion, I presume, from the cerebral symptoms that are some- 
 times so plainly marked in hooping-cough. But these symptoms are oftener, to all 
 appearance, the consequence, than the cause, of the paroxysms of coughing. I would 
 suggest it as an interesting point for your future inquiry, whether the pathology of 
 hooping-cough may not receive some elucidation from the researches of the late Dr. 
 Ley, respecting the crowing inspiration of infants. You remember his suggestion, 
 that mere inflammation of the mucous membrane of the air-passages might cause 
 swelling of the absorben" glands of the bronchi or of the neck. This is a circum- 
 iiance which I have myself long thought probable, from having found enlargement
 
 PATHOLOGY. 555 
 
 of the cervical glands springing up during the existence of pulmonary irritation. 
 Take notice that the spasmodic fits of hooping-cough are always preceded for some 
 days by mere catarrhal symptoms. Observe further how the parts supplied by the 
 pneumogastric nerve are affected in these paroxysms : the larynx, the lungs, the 
 stomach. This conjecture, that the crowing inspiration of infants, and the crowing 
 inspiration of hooping-cough — though quite distinct affections — may both depend 
 upon irritation of the recurrent nerve, or of the pneumogastric nerve generally; and 
 that even the irritation might in both cases arise out of enlargement of the glands 
 that lie in the course of that nerve: this natural conjecture had presented itself to 
 Dr. Ley's mind ; for, towards the end of his book, 1 hnd this note : — "Recently foui 
 children have been brought to my house, labouring under hooping-cough. In all, 
 ths; glandulcB concatenatas near the trachea were very considerably enlarged. Is this 
 (he says) merely an accidental combination ? or is there any essential connection 
 between the two ? May it not be that an enlargement of these glands, from a specific 
 animal poison, similar to that of the parotid glands in mumps, is, after all, the essence 
 of hooping-cough ? The subject at least deserves inquiry, and further observation." 
 In corroboration of this conjectural view of what may ultimately prove to be the 
 true pathologj' of hooping-cough, I may remark that among the morbid appearances 
 described as being met with after death from that disease, "an unusual swelling of 
 the bronchial glands" is set down. It is also stated, by some of the Germans, that 
 that portion of the pneumogastric nerve which lies in the cavity of the chest has been 
 sometimes found red. Yet I should lay no stress upon this ; for others have asserted 
 that they have looked in vain for this redness : and even supposing it to exist, it is 
 no sure or safe token that there had been inflammation of the nerve. The nerve, all 
 things considered, would be likely to become tinged of that colour soon before, or 
 even after, death, from the gorged condition of the lungs. In some cases, as you 
 may well believe, serous fluid is met with in the ventricles of the brain, or in the 
 meshes of the pia mater: in others the consequences of inflammation are traceable 
 in the bronchi, the lungs, or the pleura. Portions of what is called hepatized lung 
 are not unfrequently seen in the fatal cases. 
 
 [The leading opinions in relation to the pathoIog:y of hooping-cough, may be referred to 
 one or other of the following heads. 
 
 1st. With some the disease is essentially a spasmodic affection of the air-passages, arising 
 from a primary irritation, inllammatory or nervous, of the brain, or of one or oth'er set of the 
 respiratory nerves. This theory, variously modified, is that advocated by Hoffmann, Cullen, 
 Hufcland, Jalin, Lobel, Holzhansen. Leroy, Coitcr, Guibert, Breschet, Gardien, Bauer, Albers, 
 Clarus, Webster and Copland. Dr. Webster considers the affection of the respiratory organs 
 as secondary, and dependent on a primary inflammatory irritation of the brain or of its 
 membranes, or of both. JMost of the ailvocates of the nervous theory regard the pneumo- 
 gastric nerves as the primary seat of the aflection ; others, however, locate the irritation in 
 tbe phrenic nerves — the principal of these are Jiiger, Lobensteiii, Lobel and Leroy; others 
 again, as Albers, of Bremen, Pinel, Laennec, Blache and Roe, refer the irritation to both the 
 mucous membrane of the bronchi and the pneumogastric nerves. 
 
 2d. Others consider the disease as an inflammatory affection of some part of the mucous 
 membrane of the air-passages ; this opinion numbers among its advocates, Darwin, Watt, Mar- 
 cus Alcock, Dewees, Dawson, Pearson, Guersent, Fourcade-Prunet, Boisseau, Brpussais, 
 Rostan, and Dug^s. Dr. Watt believed it to be "in all cases, an inflammatory, whose chief 
 seat is in the mucous membrane of the larynx, trachea, bronchi, and air-cells, jjossibly at- 
 tended with a minute exanthematous eruption there.' He considers that, when mild, '-this 
 inflammation runs its course witboat materially disturbing the other functions of the body, 
 or even the functions of that very membrane in which it is seated, and that whenever 
 hooping-cough proves dangerous or fatal, it becomes so by the degree of inflammation in the 
 natural seat of the disease, or by that inflammation extending or being translated to other 
 parts.' Most advocates, however, of the inflammatory origin of the disease, limit the in- 
 flammation to the trachea and bronchi — Dawson confines it, at first, to the larynx, or. strictly- 
 speaking, to the glottis — an opinion, by the way, not widely differing from that of Astrue, 
 who of old describes the disease as an " inflammation of the superior part of the larynx nnd 
 I'harynx." 
 
 3d. Many view the complaint as at first inflammatory, and afterwards spasmodic, or a-, 
 a specific inflammation of the respiratory mucous membrane combined with irritation of th« 
 respiratory nerves, in consequence of which the muscles to which these are distributed are 
 thrown into spasmodic action, which irritation continues after the inflammation lias ceased.
 
 556 HOOPING-COUGH. 
 
 This (loctiinp, vavionsly modified, is a favourite one with the writers on hooping-cough.— 
 Desrnelles makes the di.-^ease to consist in a primary inflammation of the bronchi, compli 
 cated with a consecutive cerebral irritation, vhicli by its influence over the diaphragm and 
 other res})iratory muscles, and over those of tne larynx and glottis, changes the simple cough 
 of broncliiiis into one of a convulsive character. This opinion is the one adopted, also, by 
 Dr. C. Johnson in his able article on hooping-cough in the Cyclopxdia of Practical Medicine, 
 (^Philadelphia Editio7i, vol. 2, page 453 :) other writers who admit the occasional presence of 
 cerebral disease, consider them to be invariably secondary to the bronchial aflxjction: of thi? 
 opinion are Boisseau, Begin, Otto, and Vondembush. 
 
 4th. By not a few, especially of the older medical writers, hooping-cough is referred to an 
 irritation of the stomach and lungs. — Rosen, who supposed the disease to be produced by 
 either an insect or a morbid poison, partly inhaled into the lungs and partly swallowed with 
 the patient's saliva, considered that the stomach suffered more from the irritation than the 
 lungs. Daiiz believed that the irritation is seated primarily in the stomach and bowels, the 
 ofi'ection of the respiratory organs being secondary — this ojjinion had been previously ad- 
 vanced by StoU, and is also that advocated by Chambon in his work ^^ Des Maladies del 
 E7ifans.'" Tourtelle likewise describes the disease as a catarrhal aflection of the limgs and 
 stomach (ajjhlion piieumogastrique pituiteuse). Millot entertains a somewhat similar opinion; 
 he supposes, however, that the irritation of the stomach is secondary, and not so intense as 
 that of the lungs and larynx. Opinions somewhat similar are maintained by Mel.zer, Hoi 
 defreund. Butler, Klinge and Strack. 
 
 0th. The peculiar phenomena of the hooping-cough have been ascribed, by a few, to a 
 physical or chemical irritant introduced into the larynx, either from without or after it has 
 been engendered in the blood, or in the secretions of the respiratory organs. Under this 
 head may be arranged the opinion of Linnaeus, who referred it to the presence of minute 
 insects; that of Sydenham, who imputed it to a subtle and irritating vapour in the blood 
 which affected the lungs, — that of Bohme, and Klinge, and also, partially, that of Rosen, 
 who ascribed it to a peculiar miasm, acting chiefly on the nerves. Dr. Bland, of the Hos- 
 pital Beaucaire (Revue Medicale. March, 1S31), considers the primary cause of hooping-cough 
 to consist in an irritation, not inflammatory, of the mucous membrane of the bronchi, vmder 
 which the glands and follicles of the membrane pour forth a specific secretion saturated 
 with hydrochlorate of soda, the irritation caused by which, when it reaches the upper part 
 of the trachea and larynx, throws the muscles of the glottis and of respiration into spas- 
 modic action for its expulsion, in a manner exactly similar to any foreign body which acci- 
 dentally enters the larynx. This theory of the disease Jlr. Streeter. of London, in a paper 
 read before the Physical Society of Guy's Hospital, November, 1844, has adopted and zeal- 
 ously advocated, "as the one most consistent with the i^henomena observable in the symp- 
 toms, pathology, and successful treatment of the disease," 
 
 Mr. Streeter regards, however, the primary affection of the bronchial membranes as in- 
 flammatory, and believes that it will be found, on careful observation, to be attended by 
 more or less fever of an analogous character to that which attends the influenza. 
 
 The evidences of the truth of this theory upon which this gentleman places reliane are 
 — " the testimony of adults, who have been attacked by the disease, to the unusual and ex- 
 cessive saline taste of the expectoration so long as the paroxysms are severe — the resem- 
 blance of the expiratory eflbrts in the hooping-cough to those made by the excito-motory 
 system for the expulsion of a foreign body from the larynx — the very adequate explanation 
 it affords, both of the extraordinary and spasmodic muscular actions which accompany the 
 cough, and of its occurrence in paroxysms after intervals of uncertain duration — and, lastly, 
 the key which it furnishes to the chaotic host of apparently opposite remedies that have ob- 
 tained professional or popular reputation in its treatment. Of these remedies, we find one 
 group jidapted to lessen the original bronchial aflections, and favour the expulsion of the 
 offending mucus — as emetics, antimnnials, and counter-irritants applied over the chest; an- 
 other which acts by altering the quality of the secretion, as the alkaline carbonates, ammo- 
 nia, and sulphurct of potass, so strongly recommended by Dr. Blaud himself; another, by 
 exciting a new action in the bronchial membrane, and, by constringing the vessels, to put a 
 sto[) to the secretion, in a manner perfectly familiar to the physician in chronic bronchitis, 
 and to the surgeon in purulent ophthalmia — as the super-acetate of lead, alum, common 
 resin, tine, cantliarid., bals. copaiba, tar vapour, and even the inhalation of nitrous vapours, 
 &.O. Other?, again, as musk, both native and artificial, camphor, arsenic, conium, belladonna, 
 ojnum, and hydrocyanic acid, are more especially adapted for the nervous, lesions ; while 
 antiphlogistic measures meet the inflammatory lesions of the third or complicated stage. 
 
 "When, he remarks, the convulsive hooping is fully established, it very commonly hap 
 pens that sympioms which mark the third, or what may be appropriately termed the com. 
 plicated stage, are developed, and continue to mark the varying and formidable phases of 
 the disease which mostly attract attention in practice." These tertiary phenomena usually 
 nianifest themselves " 1st — as special lesions of the nervous and muscular systems — An 
 rxalted sensibility and morbidly susceptible state of the membrane of the larynx the pha
 
 HOOPIKG-COUGII. 557 
 
 rynx, the epiglottis, under which death from asphyxia may suddenly occur — Slorbid associa- 
 tion of the action of the muscles of the glottis and respiration, in consequence of which the 
 cough continues from mere habit, or is reproduced by the most trivial irritation of the air 
 pas.'^ages — reflex irritation often passing into inflammation of the nervous centres of the 
 pneumogastric nerves, involving those of the phrenic nerves also ; and, finally, these reflex 
 afii-'ctions may extend to the whole of the brain, or to the medulla oblongata and theil 
 meninges, and prove fatal by inducing general convulsions or hydrocephalus. All these, h^ 
 it observed, are pathological conditions of the nervous system which have been so constantly 
 put forward in high relief, by the advocates of the nervous theory, as proximate causes of 
 the disease itself" A second class of tertiary phenomena include "the various congestive 
 and inflammatory affections that result from the mechanical disturbance of respiration and 
 circulation, and the extension of the primary bronchial inflammation to the trachea, larynx 
 and pharynx, and to the tissues of the lungs themselves. Epistaxis, hasmoptysis, and fatal 
 emphysema from extensive rupture of the air-cells, have occurred within my own expe- 
 rience, and have apparently resulted from the mechanical Ariolence of the cough acting upon 
 tissues previously weakened by disease." A third class of tertiary phenomena " include 
 fever and cachexia," which are "present in individual cases in every conceivable variety of 
 combination." — " In the absence of cerebral or pulmonary inflammation, the fever of the 
 third stage is always asthenic, and oilen assumes a remittent type when the cachexia is of a 
 marasmic character." 
 
 For an account of tlie various lesions met with in the bodies of those who die of hooping- 
 cough, the reader is referred to Coiidie on Diseases of Children, page 327. — C] 
 
 The object of rational treatment in hooping-cough, supposing the disease to be 
 simple, is to kef!]) it simple : to keep it mere hooping-cough : to obviate serious 
 inflammation or mischief in the chest and head : and, if possible, to mitigate the 
 severity and shorten the duration of the fits of couohing. I have no notion that 
 anything we can do in the beginning will materially abridge the duration of the com- 
 plaint as it appears in its unmixed form. It tvi/l, I say, in all probability, run a 
 certain course ; and our business is to conduct it evenly and safely to the end of its 
 course. For this purpose the diet must, in the first place, be regulated and reduced. 
 The child should not be allowed to eat meat: the bowels should be kept moderately 
 open ; and the patient in cold weather should be confined to the equable tempera- 
 ture of the house, or protected by warm clothing. You will find different persons 
 employing and praising different plans of treatment; the object in all cases, how- 
 ever, being the same, viz., to ward cjf injlumviation and to quiet irritation. One 
 very good plan, as I believe, is that of giving a grain, or a grain and a half, of ipeca- 
 cuan, three or four times a day. This generally keeps the bowels sufficiently open, 
 and seems to have a beneficial operation on the mucous membrane of the air-pas- 
 sages also. Or a few grains of rhubarb and ipecacuan may be given every night : 
 and if the cough be very troublesome and urgent, small opiates may be administered : 
 syrup of poppies : or the extract of hyoscyamus ; as many grains per diem as the 
 child has years. There is a method recommended many years ago by a namesake 
 of mine, which some people swear by. Sir William Watson's prescription was one 
 grain of tariarized antimony and twenty drops of laudanum in an ounce of water. 
 A. teaspoonful, or a dessertspoonful, of that mixture was given every evening, or 
 every other evening. I have heard the late Dr. Gooch say that his mother became 
 famous as a village doclress by the help of that prescription. Fothergill's method 
 was to give an emetic every day ; or three or four times a week : and this j^lan 
 answers best, I believe, when the expectoration is scanty, and brought up with diffi- 
 culty, and after much coughing. The best emetic substance in such cases is, doubt- 
 less, i])ecacuan. Mr. Pearson — who has had, I fancy, many imitators — used to give, 
 after the operation of an emetic, one drop of laudanum, five drops of ipecacuan 
 wine, and two grains of carbonate of soda, in a draught, every fourth hour, for 
 several days. Under some such treatment as this, the disease will reach its termina- 
 tion in from six to twelve weeks : and it frequently happens that when the child is 
 quite well in all other respects, it still continues to cough. The cough would almost 
 seem to be kept up by the mere influence of habit. Now, under these circum- 
 stances, change of air will often remove the cough, as if by magic : and 'he shower- 
 bath, and iron in some shape, will sometimes succeed, if change of air be not 
 practicable. 
 
 2vv2
 
 558 HOOPING-COUGH. 
 
 Tliere is a great variet}' of medicines lauded as specifics against hooping-cough : 
 but they are not to be trusted to. Many persons tliink highly of the prussic acid, as 
 a remedy for the paroxysms of coughing. Others employ and laud the extract of 
 belladonna. But these are gigantic remedies to employ in such young subjects. If 
 you give them at all, you must give them in very small quantities, and watch their 
 efTects. The artificial tincture of musk is another substance which some have found 
 useful. Three or four minims of it may be given in the outset, and the dose in- 
 creased till some sensible effect is produced ; and then the dose that has been so 
 reached should be persisted in without further augmentation. I have been assured, 
 by a most intelligent practitioner, that he had got considerable credit by prescribing 
 this medicine, after other persons, with other modes of management, had failed. 
 Digitalis, and cantharipes, are other, and I think, hazardous remedies. Safer drugs 
 recommended, and, for aught I know, equally efhcacious with these poisons, are 
 cochineal, oil of amber, musk, camphor, and the meadow narcissus. Of late the 
 carbonate of iron has been greatly praised by some of the continental physicians. 
 
 [Horst recommends the flowers of sulphur as' ahnost a specific in hooping-cough. He 
 gives it throughout the disease, from its onset until its termination. Schneider, Roffy, Rand- 
 han, Riecken, and others, confine its use to the more advanced periods of the attack. Jade- 
 lot is said by Barthez and Rilliet to have derived the best effects from the sulphur as a 
 remedy in hooping-cough, as well as in bronchitis unattended with fever. The sulphur is 
 given to children between two and four years of age in the dose of from 6 to 8 grains, two 
 or three times a day, and to older children in doses of from 15 to 20 grains, — in both cases 
 the dose being gradually augmented. 
 
 Assafostida will \.^ lound a very excellent remedy in- the spasmodic stage of hooping- 
 cough. Dr. Lombard states that he has often known frictions to the spine with the tincture 
 of assafcetida of great service, and we have found a plaster of assafcetida applied to the 
 chest promptly to relieve the cough, which is liable to remain after the more acute symp- 
 toms have subsided. 
 
 It is stated that M. Berger has found the following plan of treating hooping-cough particu- 
 larly successful. In the first stage, a moderate course of antijihlogistic remedies, purgatives, 
 and repeated emetics of ipecacuanha in combination with tartar emetic. In the spasmodic 
 stage, in which the indication is to quell the existing nervous irritation, being dissatisfied 
 with the remedies ordinarily employed, he was induced to administer the nitrate of silver, 
 from which lie has obtained results singularly beneficial. He administers it in doses 
 of from a sixteenth to a twelfth of a grain, at first three times, and afterwards four times a 
 day. Of course the remedy should not be administered in cases where the state of the diges- 
 tive organs contra-indicates its employment (Annuaire de Therapeutique, 1S46). 
 
 Dr. Golding Bird remarks (^Guy's Hospital Reports, April, 1845), that, in the second or ner- 
 vous stage of pertussis,' after all infiamniatory symptoms have subsided — and when, with a 
 tolerably cool skin and clean tongue, the patient is still severely distressed by the more or 
 less copious secretion of viscid mucus from the bronchi — each attempt to get rid of which 
 produces the exhausting and characteristic cough — no remedy will be found to act so satis- 
 factorily, or to give such marked and often rapid relief to the child as alum. He has not yet 
 met with any other remedy which is equally efficacious. Dr. Bird generally gives the alum 
 in doses of from two to six grains to children of from one to tjn years of age, repeated every 
 four or six hours. For a child of two or three hours he employs generally the folloM'ing 
 formula : — 
 
 K Aluminis gr. xxv; extr. conii gr. xij ; syrup, rhsedos. ^ij ; aq. anethi ^iij. m. Dose a 
 medium sized spoonful, every sixth hour. Dr. B. has never met with any inconvenient 
 stringent effects on the bowels during its exhibition ; on the contrary, in more than one in- 
 stance it produced, he says, diarrhcea. The only obvious effects resulting from its use were, 
 diminished secrection, and of a less viscid mucus, with a marked diminution in the fre- 
 quency and severity of the spasmodic paroxysms. — C] 
 
 External applications are also much in fashion in the treatment of hooping-cough. 
 Frictions to the spine and to the chest ; and as counter-irritants, they probably are of 
 some service. The tartarized antimony is the least innocent of these applications. 
 It will often cause foul and very troublesome sores upon an adult skin : and till I am 
 better advised than 1 am at present of its certain efficacy as a remedy for hooping- 
 cough, no one (however authorized professionally liidere corio hianano), should rub 
 it upon a child of mine. Mothers are many of them fond of using Roche's Embro- 
 cation for the hooping-cough. This (Dr. Paris tells us) consists of ohve oil, mixed 
 ■with half its quantity of the oils of cloves and of amber. 
 
 Ii
 
 PNEUMONIA. 559 
 
 Such is tht plan of management which you will do well to enforce — and such are 
 the expedients which you may, if you please, make use of as auxiliaries to that 
 plan — when the disease is inere hooping-cough. But when it becomes complicated 
 with symptoms of inflammation within the chest, or with head symptoms — (and for 
 such symptoms you must jealously watch) — then you must employ antiphlogistic 
 remedies (in addiiion to the antiphlogistic regimen) adapted to the circumstances of 
 the case. Now we know that the bronchi, or the lungs, are affected with inflamma- 
 tion, when we find that the child has fever, and that there is permanent dyspnoea 
 between the paroxysms of spasmodic cough. In such a case we must have recourse 
 to the treatment required in such inflammation : leeches to the surface of the chest, 
 bleeding even from the arm, if the child's age and strength should warrant it, tartar 
 emetic, small doses of nitre, the warm bath, and blistering; and to these measures, 
 modified and combined according to the particular emergency, it will be w^ell to add 
 small and repeated doses of mercury : of the hydrargyrum cum creta, or of calomel; 
 the state of the bowels determining which. Some have recommended friction with 
 the tartar emetic ointment to the chest in such cases : but I have the same objection 
 to it there, in such young patients, as to the spine. 
 
 When any head symptoms come on, threatening hydrocephalus — such as squint- 
 ing, convulsions, stupor — those remedies must be adopted which 1 endeavoured to 
 describe to you when I spoke of that disease ; leeches to the head, cold applied 
 there, purgatives, the w'arm bath : but except in very young children, I believe there 
 is more danger of fatal pulmonary changes in this disagreeable, and sometimes in- 
 tractable disorder, than of cerebral mischief. 
 
 I might pass, by a very natural transition, from the consideration of hOoping-cough, 
 to that of spasmodic asthma. But this last complaint is found to exist in connection 
 with various organic changes within the chest, few of which have yet been treated 
 of in these lectures. I shall, therefore, postpone what I have to say respecting 
 asthma, till I have gone through some other thoracic diseases. And I now proceed 
 to pneumonia, or inflammation of the substance of the lungs. Questions have been 
 raised as to the precise part and texture in which the inflammation begins ; and to 
 these questions I may briefly advert as w^e go on: but I hold that in pneumonia all 
 the textures composing the pulmonary substance in the part inflamed are involved in 
 the inflammatory process. 
 
 Now of pneumonia it is especially true, that we ascertain its extent, its situation, 
 and every step of its progress, by means of the ear. All the symptoms that give us 
 the most sure information respecting the nature of the disease, the event to which it 
 tends, and the remedial treatment which it requires, spring out of the actual changes 
 wrought in the pulmonary substance itself; and these changes are disclosed to us by 
 the method of auscultation. It is necessary, therefore, that you should understand, 
 first of all, what those changes are which are produced by inflammation of the sub- 
 stance of the lungs : that you should know the morbid anatomy of pneumonia, as 
 an indispensable groundwork for a knowledge of its pathology. 
 
 There are three well-marked, and very constant conditions of the lung, correspond- 
 ing to different degrees and periods of its inflammation. I will describe them in 
 succession, in the order in which they take place. 
 
 The first stage or condition is that of engorgement : all modern observers agree, 
 I believe, both as to the nature and as to the name of this condition. The substance 
 of the lung is gorged with blood, or bloody serum. It is of a dark red colour ex- 
 ternally, and crepitates less under pressure than sound lung does. We feel thai 
 there is more liquid than air in its cells. It is heavier also than natural, and inelastic, 
 and retains, in some degree, the impression of the finger. When the engorged por 
 tion is cut, we find it red, and we see a great quantity of a reddish and frothy serum 
 flow from it. Its cohesion is at the same time diminished ; it is more easily torn ; 
 more, in that respect, like the spleen ; and accordingly the term splenization of the 
 lung has been given to this stage of its inflammation, as hepatization has to that 
 which succeeds it. In this state of engorgement the mucous membrane of the 
 small bronchial ramifications is of a deep red colour. The portions most engorged.
 
 560 PiNEUMOxMA. 
 
 although their specific gravity is increased, will nevertheless almost ahvaj's float on 
 water. 
 
 Now it is necessary to caution you, in the outset, against a very frequent source 
 of fallacy in respect to this condition of inflammatory engorgement. Such a state 
 of the pulmonary substance as I have been describing, you will meet with in half, 
 at least, of the dead bodies which you may have to examine ; and you must not 
 necessarily infer therefrom that the persons deceased had in/lamrnation of the lungs. 
 There is almost always some degree of mediunic.al engorgement of the back part of 
 the kings ; or of that part which has been undermost during the last hours of life, or 
 after death ; and the two kinds of engorgements can scarcely be distinguished from 
 each other by their anatomical characters alone. Andral at one time held, indeed, 
 that if the engorged part were more friable, more easily torn or broken down under 
 pressure than natural, that was a sufficient evidence of its inflammation ; but he 
 afterwards saw reason to change that opinion. We judge by the situalion of the 
 engorgement sometimes : if it be not in a depending part of the lungs, it is surely 
 inflammatory. We judge also by the antecedent symptoms. 
 
 If the inflammation continues, the lung undergoes a further alteration, and presents 
 the following characters. It is still red — externally and within : but it crepitates no 
 longer under pressure ; and it sinks in water : it contains in fact no air. Its cut 
 surface presents sometimes a uniform red colour; sometimes a slightly mottled or 
 variegated appearance, produced by intermixture of specks of the black matter of tne 
 lung, and of the interlobular areolar tissue, which is less red than the other parts, and 
 more than naturally obvious to the sight ; but the spongy character of the organ is 
 lost; it is evidently solid ; and the cut surface very much resembles the cut surface 
 of the liver. Hence Laennec, and after him most other writers, have applied to 
 this altered condition of the lung the term lupa'ization. There still flows out, 
 under pressure, from the surface, when a fresh incision is made, some red fluid, but 
 it is much less in quantity than in the former degree ; and it is not foamy ; and if 
 the surface be gently scraped with a scalpel, you may often perceive in the red fluid 
 so collected, some traces of a thicker and yellower matter, the first indication of 
 commencing suppuration. The hepalized lung is denser and more solid than before, 
 but it is also more friable ; more easily crushed and broken : and this results from 
 the softening of the areolar tissue which holds its component parts together. 
 
 If you tear a portion of hepatized lung, and examine the torn surface with a mag- 
 nifying glass, the pulmonary tissue will appear to be composed of a crowd of small 
 red granulations, lying close to each other. These are, 1 presume, the air-vesicles, 
 clogged up, thickened, and made red, by the inflammation. As no air is contained 
 in the lung in this stage of the inflammation, it follows that if the entire organ be 
 involved in the disease, it vvill not collapse when the thorax is laid open ; and will 
 therefore appear to be increased in bulk. It is swelled, in fact — ^just as other in- 
 flamed parts are swelled — by the congestion of its vessels, and by the effusion of 
 blood, or of some of the constituent parts of the blood, into its hollows and inter- 
 stices. The marks of the ribs are frequently visible on the surface of the distended 
 lung. The texture of the lung in this condition is sometimes so rotten, that a mode- 
 rate degree of pressure between the fingers will suffice to reduce it to a state of 
 pulp; and this diminution of consistence has made Andral quarrel with the term 
 hepatization : and he proposes to call this second stage of pneumonia, red softening, 
 runiol/hseiyient rouge. All this is very unimportant, provided that you recollect the 
 sense in which either nomenclature is employed. But as Laennec and Andral are 
 both great authorities, and both have their disciples in this country, it is weU thai 
 you should understand their language. 
 
 I have been speaking of pneumonia as it is apt to attack the whole, or the larger 
 portion, or a considerable portion, of the lung on one side : but it is a curious cir- 
 f-umstance that the changes I have been describing are sometimes exactly limited 
 to certain of the pulmonary lobules ; and this slate is called, accordingly, lobular 
 pneumonia. 
 
 In a degree still further advanced, the pulmonary tissue, dense, solid, and imper- 
 vious to air, as in the last stage, undergoes an alteration of colour ; it presents -i red-
 
 PNEUMONIA. 561 
 
 dish yellow, or straw, or drab, or stone colour; or it is of a grayish hue, sometimes 
 mottled with red, or with the black pulmonary matter. The little granulation? which 
 I just now mentioned are whitish or gray, instead of being red ; and the texture of 
 the lung is still more rotten and friable than before. It is full," in fact, of puriform 
 matter, which is ^metimes so abundant that it oozes out plentifully when incisions 
 are made into the lung : or it may be made to exude by gentle pressure. The gray 
 pus shows itself upon the cut surface in the form of minute drops. The more the 
 pulmonary texture is soaked or drenched with this fluid, the softer and more friable 
 it becomes. When crushed between the thumb and fingers, it is reduced to a yel- 
 lowish gray pulp, exactly hke the fluid itself, only rather more consistent. And by 
 gently forcing the finger into any part of the parenchyma in this state, a small cavity 
 may be made which soon fills with pus, and which might readily be mistaken for a 
 recently formed abscess. 
 
 Laennec has called this third stage of the process of inflammation in the lung, 
 gray hepatization, ox purulent injiltration. Andral denominates it gray softening 
 — rumolHssement gj'is. In fact, it consists in diffused suppuration of the pulmo- 
 nary texture. And it is a very remarkable circumstance, and one which the re- 
 searches of modern times have brought to light, that, in the lung, inflammation going 
 on to suppuration does not lead to the formation of a circumscribed abscess, as it 
 does when it affects the areolar tissue, or the parenchymatous tissue, in other parts 
 of the body. Abscess of the lung used to be spoken of as a very common thing; 
 but it is a very rare thing. In several hundred dissections of persons dead of pneu- 
 monia, made by Laennec during a space of more than twenty years, he only met 
 with five or six collections of pus in the inflamed lung. Once only did he find -i 
 large abscess of that sort. Once only has Andral seen a real abscess of the lung 
 form as a consequence of pneumonia. You may find collections of pus in the lungs, 
 sometimes, occurring in connection with the inflammation of veins. Several in- 
 stances of that kind have happened very recently in patients who have died in the 
 Middlesex Hospital. But these are not ordinary cases of pneumonia. I need 
 scarcely caution you not to take tubercular vomicae and cavities, containing pus, for 
 genuine abscesses of the lung. These, and the phlebitic deposits of pus, are not 
 exceptions to the general statement: they arise from different forms of disease : and 
 you will find a circumscribed collection of pus, surrounded by hepatized lung, as a 
 consequence of common pneumonia, to be an exceedingly rare event. 
 
 Can we account for this in any way ? I do not know that any satisfactory expla- 
 nation of the fact has ever been offered. But I would submit to your consideration 
 what has occurred to my mind on this subject. When I was speaking of inflamma- 
 tion in general, I pointed out to you the remarkable influence which the presence 
 of atmospheric air in contact with the inflamed part has in accelerating, or deter- 
 mining, the event of suppuration. In a recent cut, the admission or exclusion of 
 the air to the cut surface will make all the difTerence between the adhesive and the 
 suppurative inflammation ; and so in other cases which I then mentioned, and will 
 not now trouble you by repeating. Now it seems to me that the same principle 
 obtains in inflammation of the lung. First, there is an effusion of serum and blood, 
 then of lymph and blood ; but the air passing into the surrounding sounder tissue, 
 and mingling for a time even with the inflamed portion itself, causes the suppurative 
 process to supersede the adhesive ; and so no wall of circumvallation is formed by 
 the coagulable lymph, as is the case in areolar tissue which is not accessible by the 
 air. Whether this be a sufficient explanation of the/rtc/ (all explanations being the 
 resolving a given fact into a certain class of other facts more general and compre- 
 hensive); I say whether it be a reasonable and satisfactory explanation, you will 
 judge : at any rate it may serve to impress upon your memory that fact which it 
 enJeaTours to elucidate. 
 
 Gangrene is sometimes, but very seldom, the result of acute inflammation of the 
 lUng. It is almost as uncommon as the formation of an abscess. Yet it certainly 
 does now and then occur, as a consequence of acute inflammation of the pulmonary 
 substance. It is somewhat more common (though under any shape rare) as an inde- 
 pendent and primitive afTection. Sometimes it occupies a large portion of the lung, 
 36
 
 562 PNEUMONIA. 
 
 and is uncircumscrlbed ; and sometimes it is more limited. Tlie colour of the part 
 which has thus perished under inflammation is dark, of a dirty olive, or greenish-brown 
 colour. The gangrenous portion is moist and wet; sometimes of the consistence of 
 the engorged lung ; more commonly softer, and even diffluent ; and it stinks most 
 abominably. This horrible odour is in truth, during hfe, the most distinctive cha- 
 racter of gangrene of the lung. It sometimes renders the room in which the un- 
 happy patient is lying, scarcely endurable. I should have stated before that the 
 puriform infiltration of the third stage of pneumonia is attended with no fetor. 
 
 There are some other points, connected with, or learned from investigating, the 
 morbid anatomy of pneumonia, which I may as well take this opportunity of tell- 
 ing you, before we go on to consider the symptoms, ph3'sical and general, of that 
 disease. 
 
 There are two lungs, just as there are two tonsils, and two eyes ; and in the one 
 case as well as in the other, inflammation may affect both organs at once, or it may 
 affect one of them alone. Technically speaking, pneumonia may be either double 
 or single. Acain, the inflammation may occupy a part of one lung, or the whole 
 of it : in other words, it may be partial or general ; but it does not affect all parts, 
 or both sides, indifferently or capriciously. In the first place, it is (why I know not) 
 greatly more common on the right side of the body than on the left. I will give 
 you some statistical statements collected by Andral, in respect to this point. Of one 
 hundred and fifty-one cases of pneumonia, noticed at La Charite, ninety were of the 
 right lung alone ; thirty-eight only of the left alone ; seventeen of both sides at once ; 
 and in six the situation was uncertain. He was at the pains of collecting the parti- 
 culars of fifty-nine other examples of pneumonia, from different authors, so fully de- 
 scribed as to leave no doubt about the nature and situation of the disease. Among 
 these, the inflammation existed in the right lung alone in thirty-one patients ; in the 
 left alone in twenty; and in both sides at once in eight. Hence, taking both series 
 of observations together, we have two hundred and ten cases of pneumonia; and 
 there were one hundred and twenty-one in which the right side was solely the seat 
 of the disease ; fifty-eight in which the left ; twenty-five in which the pneumonia 
 was double ; and six in which the seat was uncertain. So that, at this rate, pneu- 
 monia is more than twice as common on the right side as on the left ; and does not 
 occur on both sides together so often as once in eight times. 
 
 Again, with regard to the part of the lung which is most obnoxious to inflamma- 
 tion, there are remarkable differences. It is well known, and it is a very important 
 fact in respect to diagnosis in some cases, that the lower lobes are more liable to 
 inflammation than the upper. I speak, of course, of active idiopathic inflammation. 
 But this circumstance, much insisted on by Laennec, and quite true in the main, has 
 perhaps been somewhat exaggerated. I have not had leisure to frame any numeri- 
 cal statement of the cases that have come under my own observation, but the general 
 impression which they have left upon my mind is in favour of the correctness of 
 Laennec's statement — that pneumonia generally commences in the lower lobes, and 
 spreads upwards frequently to the superior lobes. But I may adduce Andral's sta- 
 tistical representation in respect to this question also. Of eightj''-eight cases of pneu- 
 monia, he found that the inflammation affected the inferior lobe forty-seven times, the 
 superior lobe thirty, and the whole lung at once, eleven. 
 
 Inflammation of the bronchi constantly accompanies inflammation of the paren- 
 chyina. The mucous membrane presents a red colour, both in the large and in the 
 small branches of the air-passages. And when a single lobe is inflamed, it has 
 been observed that the redness of the mucous membrane existed in those bronchial 
 tubes alone which were distributed to that lobe. You may have bronchitis without 
 pneumonia ; but pneumonia without a corresponding extent of bronchitis is perhaps 
 riever seen. 
 
 The majority of cases of pneumonia are attended also with a degree of inflam- 
 mation of the investing membrane of the lung: there is some pleurisy. So fre- 
 quently indeed is this the case, that certain writers, Andral among others, call the. 
 disease by the compound name of pleuro-pneumonia. However, pneumonia may 
 and does sometimes occur without any concurrent pleurisy. Of the latter complaint
 
 PNEUMONIA 563 
 
 I must speak by itself; and I merely notice now the frequent combination of 
 the two — the occurrence of a slight degree and extent of pleuritis in most cases of 
 pneumonia — that you may the better understand some of the general symptoms of 
 pneumonia. 
 
 Now such being the changes which the lungs undergo when inflammation affects 
 the pulmonary texture, we may next inquire what signals of its existence the inflam- 
 mation holds out ; and how far we, not having the power of seeing what is going on 
 within the cavity of the thorax, may nevertheless ascertain the important processes 
 which are there transacted. 
 
 If the ear be applied to the surface of the chest, with or without the intervention 
 of the stethoscope, and the portion of lung subjacent to that surface happen to be in 
 the first stage of inflammation, that of engorgement, what does the lung, so sufl^er- 
 ing, say? what audible notice does it give of its morbid condition? Why, it speaks 
 very plainly. You hear a pecuHar crackling sound ; the smallest and finest-possible 
 kind of crepitation : which has been happily illustrated by saying that it re&emblt-s 
 the multitudinous httle crackling explosions made by salt when it is scattered over 
 red-hot coals. Andral has another resemblance for it, and not a bad one ; he says 
 the noise is often like that which is produced by rumpling a very fine piece of parch- 
 ment. Dr. Williams observes that a pretty correct idea of this sound may be 
 obtained in a ready way, by rubbing between the finger and thumb a lock of one's 
 own hair, close to the ear. Laennec calls this crepitant rhonchiis : I would speak 
 of it as minute crepitation ; or the crackling of pneumonia. This may be heard 
 in a very limited spot in the beginning. And what an important sound it is ! " It 
 is a direct symptom, having immediate reference to the structure of the part. And 
 (says Dr. Latliam) if we consider what the part is, and what the disease; the part 
 the lungs, and the disease inflammation : we cannot too highly value this single 
 symptom (simple and mean as it may seem), which gives the earliest and surest inti- 
 mation that such a disease has begun, as tends to disorganization, and the inevitable 
 loss of life, unless quickly arrested by its counteracting remedy." 
 
 At first, when you catch the inflammation in its earliest stage, this minute crepita- 
 tion, which announces commencing engorgement of the part, is heard mingled with 
 the ordinary vesicular breathing. This obscures the natural sound, though it does 
 not yet entirely cover it — but as the inflammation advances, the crackHng becomes 
 more and more pronounced, until at length it totally supersedes it. So long as the 
 natural vesicular breathing prevails over the crackling, we may conclude that the 
 inflammation is slight: and if the crackling should, in its turn, become predominant 
 if it should ultimately mask the murmur of respiration entirely, that infallibly de 
 notes the progress of the pneumonia, and teaches us that it tends to pass from the 
 first into the second degree. But the crackling sound does not long remain in any 
 part. As the case proceeds, the sound is less and less heard, and at length is not 
 heard at all, in that spot ; and it may be succeeded by one of two very different 
 things. Its place may be taken by the natural respiratory murmur again. When 
 this is so, it denotes the resolution of the inflammation. But the crackling may 
 cease, and either no sound at all be heard in its stead, or another morbid sound 
 which I shall presently describe : and this teaches us with absolute certainty, that the 
 disease is growing more severe and serious ; that the lung is becoming, or has be- 
 come, hepatized. 
 
 Let us inquire, for a moment, before we go any further, what is the nature and 
 the seat of this minute crepitation, so characteristic of the commencement of pul- 
 monic inflammation. With respect to its scat, I apprehend, there can be no question. 
 It proceeds from the very smallest ramifications of the bronchi, and the air-vesicles 
 themselves. The common opinion is, and such, I confess, is mine, that the sound is 
 the same in cause and kind, only dilTerent in degree, with the large and small crepi- 
 tation described in a previous lecture : that it results from the passage of a^r through 
 liquid ; from the formation and bursting in quick succession of a multitude of little 
 air-bubbles. The bubbles are necessarily minute, for they are formed, and they ex- 
 plode, in very slender tubes. This is Andral's view of the matter. Laennec doe.s 
 pot appear to have formed very clear notions on the subject. But a different expla
 
 564 PNEUMONIA 
 
 nation has been offered by a well-known and able writer on the auscultatory signs 
 of disease, in this country : I mean Dr. Williams. He holds t^at the distended 
 blood-vessels, and the interstitial serous effusion, press upon the minutest bronchial 
 ramifications, and obstruct, without wholly preventing, the passage of the air through 
 them : that these small tubes are lined by a viscid secretion, such as is expectoratt-d, 
 and such as I shall have to describe : that the sides of the tubes stick together in 
 consequence of the presence of this viscid matter ; and that it is the separation of 
 these adhering sides by httle portions of air which successively pass in and out, that 
 gives rise to the characteristic sound. However, what it is important to remember 
 is, that the crackling sound proceeds from the minutest divisions of the air-tubes, and 
 from the ultimate vesicles of the lungs. 
 
 Sometimes, I say, when this crackling ceases, the ear apphed to the corresponding 
 surface of the chest, feels it heave up in inspiration, but catches no sound at all. 
 Much more commonly, however, a neio sound reaches the ear. It is not the vesi- 
 cular rustle ; it is not the minute crepitation : but a whiffing sound is audible, like 
 that produced by blowing through a quill. Little gusts of air are puffed in and out ; 
 most distinct, often, at the termination of a slight cough or hem. This is the sound 
 to which the term bronchial respiration has been given : and the name expresses 
 well the fact. I mentioned before that in the healthy state we do not hear the air 
 pass through the larger bronchi during inspiration and expiration : the sound doubt- 
 less is made, but it is obscured and hidden by the smooth rustle of the vesicular 
 breathing, which comes from the spongy lung surrounding the large divisions of the 
 bronchi, and intervening between them and the ear. But that spongy structure is 
 now filled up. The hepatized lung admits air to pass through the larger bronchi, 
 which are still patent, but it admits none into the vesicles and smaller tubes. It cre- 
 pitates not when pressed between the thumb and finger: in fact, it is converted into 
 a solid substance, and conducts the sound, in the living body, as any other solid sub- 
 stance might do: and therefore the whiffing, blowing, gusty sound of the breath, 
 as it enters and departs from the larger bronchial tubes, which still remain open, is 
 conveyed to the ear, and bronchial respiration is heard. At the same time, and in 
 the same place, another auscultatory phenomenon generally arises, and admits of a 
 similar explanation. The voice of the patient descends into the pervious bronchi, 
 and is conveyed to the ear of the listener through the solid lung : and it is quite 
 altered by that circumstance. The tone of it is modified ; it sounds hke the voice 
 of one speaking through a tube. It is totally different from the same voice heard 
 through the healthy lung at the corresponding point on the other side. It approaches 
 in distinctness and qualitj% but it does not reach, the sound heard in speaking, when 
 the stethoscope is placed over the trachea. A humming and muttering are audible, 
 but the words are not distinctly articulated into the ear. It is hard to describe these 
 things in words. Three minutes, at the bedside of a patient in whom the bronchial 
 breathing and the bronchial voice were tolerably well marked, would put you in 
 possession of them for ever. They are striking sounds : requiring no fine tact to 
 distinguish : and exceedingly informing sounds. But I must resume this subject 
 when we meet again. 
 
 LECTURE LI. 
 
 Pnaimonia continued; its general symptoms; pain, dyspnoea, cough, erpectoror 
 tion. Course of the disease. Prognosis. Treatment. 
 
 1 svAS describing, at the close of the last lecture, the auscultatory signs which lead 
 us to the knowledge that the inflamed lung, in a case of pneumonia, has passed from 
 the first into the second stage of inflammation, and become solid, or hepatized. The 
 pltered condition of the organ gives rise to altered sounds. Instead of the vesicular
 
 PNEUMONIA. 565 
 
 breathing, which is the natural sound, or of the minute crepitation, which is the 
 sound belonging to the first stage of the inflammation, we either hear no sound at 
 all, although we feel the chest heave up against our ear, or we hear what I described 
 under the denomination of bronchial respiration; that is to say, a puffing sound 
 which is conveyed to the ear from the larger and still pervious branches of the bron- 
 chi, through the solid portion of the lung around them, and through the solid walls 
 of the chest. This is what the listener hears when the patient breathes. And when 
 he speaks, his voice is heard, much more resonant than is natural, much more reso- 
 nant than in the corresponding spot on the opposite side of the chest, entering the 
 same open air-tubes, and conducted to the ear by the dense and sohd lung. We thus 
 become acquainted with two entirely new sounds ; sounds which are never heard in 
 the healthy state of the lungs ; bronchial respiration, and bronchial voice, or bron- 
 chophony ; and you will do well to remember these two sounds, and to famiHarize 
 your ear to them ; for they speak a most significant language in other pulmonary 
 diseases, as well as in pneumonia. 
 
 But I say, sometimes we hear these morbid sounds, in the case in question, and 
 sometimes we hear no sound at all during the breathing. How is that? Why, the 
 existence and degree of the bronchial respiration, and bronchial voice, vary accord- 
 ing to the place and extent of the inflammation. These morbid sounds are most 
 plainly marked, where the number and size of the bronchial tubes involved in the 
 hepatization are the greater. They are most distinct, therefore, when the inflamma- 
 tion occupies the upper part of the lung ; or the central parts, what are called the 
 roots of the lungs : and when it extends thence to the surface : but when the lower 
 portions alone are inflamed, or the inflammation is merely superficial or partial, they 
 may not be heard at all. Again, if the hepatization should be so general and com- 
 plete as to prevent the chest, on the affected side, from expanding, you will, in that 
 case, hear no bronchial respiration ; for the air in the large bronchi must be stagnant. 
 Bronchophony, however, may remain. 
 
 When we have the bronchial respiration, usually also we have dullness on per- 
 cussion. The degree in which this is present will depend upon the circumstances 
 of the case. If a portion of crepitant and permeable lung, even a thin portion, should 
 intervene between the inflamed parts and the walls of the chest, there will still be 
 resonance, though it will not be exactly the natural resonance, on percussion. If the 
 hepatized part come close up to the ribs, the sound elicited by mediate percussion 
 will be flat, or dead. With all this, you will generally hear, in the sound lung, if 
 the whole of the other be engaged in the inflammation — or in those parts of the 
 inflamed lung that arc healthy — you will hear, I say, puerile respiration ; and this 
 is a strong confirming symptom that a part of the breathing apparatus is spoiled, and 
 that the remaining part is endeavouring to compensate for its deficiency. 
 
 Now, this period in pneumonia, when no sound but bronchial breathing is audible 
 during respiration, is a period of anxious and painful interest. We cannot tell whe- 
 ther the lung will revert gradually to its healthy state, or whether it is passing into 
 the third stage ; that of purulent infiltration. But taking first the most favourable 
 of these two suppositions — what happens ? Why, there, where for a while we heard 
 nothing but bronchial respiration, a slight crepitation begins again to be distinguish- 
 able, especially at the end of each act of inspiration : gradually this increases in ex- 
 tent and intensity, and, as it increases, the bronchial breathing and the bronchial 
 voice become proportionably less distinct, in consequence of the texture of the lungs 
 becoming again permeable by air, and therefore a worse conductor of sound. By 
 degrees, the bronchial breathinof and the voice disappear altogether ; the vesicular 
 murmur begins again to mix with the crepitation, and at length supersedes it ; and 
 the lung is restored to its previous fitness for the purposes of respiration. The same 
 symptoms therefore recur, over again, but in a reversed order; the returning crepi 
 tation is, however, coarser and larger, and less regularly diffused, than that of the 
 advancing pneumonia: and even when nothing is heard in the ordinary condition 
 ef the breathing but the natural vesicular rustle, some crepitation is found for some 
 little while to mingle with it, towards the end of a full inspiration. This is believea 
 to depend upon an oedematous state of the pulmonary texture, left after 'he active 
 
 2x
 
 566 PNEUMONIA. 
 
 inflammation has been displaced.* Next, let us take the worst of the two supposi- 
 tions. Auscultation has traced the disease through its stage of engorgement, and 
 into its stage of hepatization. Can it trace it further? I believe not, with any cer- 
 tainty. We cannot say whether the lung remains in the state of hepatization (as it 
 may remain), or whether it has passed into the third stage. But at last, if the struc- 
 ture of the lung breaks down, and a portion of it is expectorated, air finds its Avay 
 into the vacant spot, and gives rise to large gurgling crepitation. But the other signs 
 sometimes come to our aid when this state has been reached. 
 
 We often find, after death, the three degrees of pneumonia existing in difTerent 
 parts of the same lung; and therefore it is not to be wondered at that the different 
 parts of the chest should during life yield sounds indicative of each of those degrees, 
 or at least of the first two ; minute crepitation here, bronchial breathing, and bron- 
 chophony, and dullness on percussion tlicre, and in another spot no sound at all, or, 
 on the other hand, puerile respiration. 
 
 Again, it must be confessed — and I am desirous jf confessing it, for I am sure that 
 the method of auscultation is brought into undeseived suspicion and disrepute by 
 attempts made to assert its all-sufficiency in all cases — it must be confessed that, in 
 some instances, although pneumonia exists, the ear is able to collect nothing of it; 
 nothing indicative of its situation, or of its extent, or even of its existence. The 
 pulmonary expansion is clear, all over the thorax ; nay, much more strong than is 
 natural: and this circumstance justifies the belief that, from some cause or other, 
 not necessarily from pneumonia, a portion of the lung has ceased to discharge its 
 function, and the other portions have taken it up. This failure on the part of aus- 
 cultation happens when the inflammation occupies only a small portion of the lung, 
 and that portion central, or deeply situated — at a distance from the walls of the chest. 
 For this reason, auscultation may give little or no account of lobular pneumonia. 
 
 Such are, then, the physical signs that accompany and reveal the successive 
 changes of texture, destructive and reparatory, which take place in inflammation of 
 the lungs. I do not know whether I have made them clear to you ; but I know that 
 no very long apprenticeship, if I may so speak, in the wards of a hospital, will be 
 sufficient, Avith a little guidance, to render you master of them. There are indeed 
 varieties, and modifications, and exceptions, which nothing but such an apprentice- 
 ship can ever teach you. Of these it would be idle and unprofitable for me here to 
 speak: and I go on to consider the general SAgns of pneumonia; some of which, 
 either in themselves, or in combination with the physical signs, are of no less im 
 portance than these. 
 
 In the majority of cases the commencement of inflammation of the lung is marked 
 b)'' shivering, followed by heat and increased frequency of pulse ; in one word, by 
 inflammatory fever ; and at the same time, or presently after, a stitch in the side 
 comes on, with cough, and a sense of oppression in the chest. In other instances 
 the disease steals on more insidiously, and succeeds to bronchitis ; the inflammation 
 appearing to propagate itself by httle and little from the larger to the smaller 
 bronchi, and ultimately to reach the air vesicles themselves, and the interstitial tex- 
 tures ; and this may be accomplished with or without the sharp pain or stitch in the 
 side. At first the cough may be dry, but it soon is attended with a verj'' characteristic 
 sort of expectoration. The dyspnoea is sometimes but slight in the outset ; some- 
 times severe. 
 
 Apart, therefore, from the physical signs, we may say that the usual symptoms 
 of pneumonia are pain, more or less severe, on one side of the chest ; dyspnoea ; 
 cough ; a peculiar expectoration ; and fever. 
 
 The pain in pneumonia appears to exist only in those cases in which the inflam- 
 mation of the lung is accompanied by some degree of pleurisy. But these are the 
 most numerous cases. It is most commonly experienced on a level with, or a little 
 be.ow, one or other breast ; but it may exist in almost any other part of the thoracic 
 parictes. Generally it is most severe at the beginning, declines by degrees, and 
 ceases altogether for some time before the pnevnionia ceases. It is aggravated by 
 cough ; by a full inspiration ; often by sudden changes of posture ; by pressure made 
 upon the ribs or intercostal spaces ; or by percussion of that part. For the same
 
 PNEUMONIA. 567 
 
 reason the patients cannot lie on the painful side. Andral dec.^res that in all the 
 individuals in whom he had noticed this pain, and who died, he found the pleura 
 inflamed, and covered more or less with coagulable lymph ; and, on the other hand, 
 that he had constantly known the absence of pain coincide with a sound condition 
 of the pleura. When there is no sharp pain, there is, however, some morbid sensa- 
 tion, of trouble, or tightness, or weight, or heat on the affected side. He quotes, with 
 approbation of its justness, the ancient observation respecting pneumonia : — " Affert 
 plus periculi quam doloris." When I come to speak of pleurisy as a distinct and 
 substantial affection, I shall revert to this pain. 
 
 It is, or it was, a common doctrine, that one of the general symptoms of pneu- 
 monia relates to the posture which the patient assumes ; that the decubitus, to speak 
 technically, is on the side affected. The truth, however, is as I have just now stated 
 it. The breathing, indeed, is more oppressed when the patient lies on the sound 
 than when on the diseased side ; but, in point of fact, patients labouring under this 
 disease almost all lie upon their backs : the decubitus is dorsal. The difficulty of 
 breathing deserves some notice. In general it bears a direct proportion to the extent 
 and severity of the inflammation. But there are many exceptions to this. In some 
 persons the inflammation of even a very small portion of one lung will embarrass the 
 respiration greatly. In others, who have a much larger portion of the pulmonary 
 tissue intensely inflamed, the dyspnea is but slight. So that the degree of difficulty 
 of breathing is not a certain measure of the seriousness, or rather of the extent and 
 the degree, of the inflammation. It is probable, that if we knew of what kind was 
 the ordinary breathing of the individuals thus differently affected, we should find that 
 they whose respiration is generally indistinct, or noiseless, who do not seem to jvant 
 all their lung for the purpose of breathing, would best bear to have a part of it in- 
 fiamod ; and rice versa. Caeteris paribus, inflammation of the upper lobe causes 
 greater dyspnoea than inflammation of the lower. I may observe further with respect 
 to dyspnoea in general, that you must not trust implicitly to what patients tell you 
 on that head. They will often deny that they have any shortness of breath, when 
 one may see them respiring with unnatural rapidity, or observe that, in their dis- 
 course, they pause between every three or four words to take breath. 
 
 However, the dyspnoea produced by pneumonia varies greatly in its degree in 
 different cases. Sometimes it is so slight that the patient is not conscious of it, and 
 the physician scarcely perceives it : sometimes it is so extreme, that the patient, 
 entirely regardless of what is going on about him, seems wholly occupied with 
 respiring; is unable to lie down; can scarcely speak; his face becomes lividly red 
 or pale, and is expressive of the utmost anxiety ; his nostrils are expanded, and in 
 full action : the respiratory movements are very frequent and very short or shallow, 
 as if the air was not able to penetrate beyond the primary divisions of the bronchi. 
 From this state of extreme d3'^spnoea few patients recover : and between this, and 
 the slightest hurry or embarrassment of the breathing, there are of course many 
 degrees. 
 
 Delirium is a symptom which very frequently occurs in the course of an attack 
 of pneumonia ; and a very ugly symptom it is. It denotes that the due arterializa- 
 tion of the blood is largely interfered with by the pulmonary affection. It measures, 
 in one sense, the quantity of mischief which is going on within the thorax : and it is a 
 direct evidence that the pectoral mischief is telling, through the circulation of venous 
 blood, upon ihe brain. 
 
 The cough, in pneumonia, has no particular character, and affords but little infor- 
 mation. It does not usually take place in paroxysms; and its severity and frequency 
 are not always proportioned to the intensity and extent of the inflammation. It is 
 usually dry in the outset; but in a few hours it is accompanied by the expectoration 
 of peculiar sputa, which constitute one of the most certain indications of the pre- 
 sence of pneumonia : and as this is a symptom which every one can easily recog- 
 nize, I will describe this characteristic expectoration, and endeavour to explain the 
 cause of it. 
 
 The expectoration of pneumonia, when well marked, consists of transparent and 
 lawny or rust-coloured sputa, uniting, in the vessel containing (hem, into one jelly
 
 5G8 PNEUMONIA. 
 
 like and trembling mass , and of such viscidity that the vessel may be turned upside 
 down, and strongly shaken, without their being detached from its bottom or sides. 
 It cannot be said that when there is no such expectoration as this, there is no pneu- 
 monia : but it may be affirmed that where we do find such expectoration, there almost 
 certainly we have pneumonia. At the outset of the disease, either nothing is spat 
 up, or simply some bronchial mucus : but on the second or third day generally, the 
 matters expectorated assume the characteristic appearance : i. e., they come to be 
 composed of mucus, intimately united and combined with blood. It is not that the 
 sputa are streaked with blood, as often happens in bronchitis: nor have we the im- 
 riiixed blood of hfemoptysis. But the blood and the mucus are amalgamated toge- 
 ther ; and in proportion to the quantity of the former, the sputa become of a yellow 
 colour, or of the colour of rust, or of a decided red : and at the same time they be- 
 come glutinous and tenacious : they adhere together, so as to form one transparent 
 homogeneous mass. So long as this mass flows readily along the sides of the vessel 
 when it is tilted, so long have we reason to hope (judging from that circumstance 
 alone) that the inflammation of the lung does not pass its first degree. But, as I said 
 before, the sputa often acquire an extraordinary degree of viscidity: so as no longer 
 to separate themselves from the vessel when it is inverted : you cannot even shake 
 them out. When this happens, we are obliged to fear that the pneumonia reaches 
 its second degree. In fact, when the sputa become thus rusty and very viscid, the 
 stricken chest almost always returns a duller sound, and the vesicular breathing is 
 abolished, and bronchial respiration takes its place. The pneumonia is then at its 
 acme ; and the expectoration remains for some time stationary. At length, if the 
 inflammation recedes, the sputa become again less tenacious, less red or yellow, and 
 more like the expectoration of mere catarrh. But if the disease goes on from bad to 
 worse, the rust-coloured sputa may continue to the end. Commonly there is less 
 expectoration in that case, or even none at aU. Not that the mucus ceases to be 
 secreted, but that its ea-cretion is no longer possible : either on account of its extreme 
 tenacity, or on account of the patient's debility. The sputa then accumulate in the 
 bronchi, trachea, and larynx, in succession : they fill up the air-passages, and suffo- 
 cate the patient. In some instances the expectoration, in the advanced stages of the 
 disease, consists of a fluid having the consistence of gum-water, and of a broAvnish- 
 red colour: like (as Andral says) liquorice-water, or plum-juice. He states that the 
 mere occurrence of this kind of expectoration has led him to announce the existence 
 of the third stage of pneumonia ; and that the subsequent examination of the dead 
 body has seldom failed to justify his diagnosis. Sometimes again, during the third 
 stage, very perfect pus is excreted. 
 
 That the colour of the sputa peculiar to pneumonia depends upon an intimate 
 union of blood with the altered mucus, is perfectly obvious when that colour is deep. 
 And even when this transparent mucus is yellow, you may satisfy yourselves by the 
 following simple experiment that the source of the colour is the same, and that the 
 yellowness does not result, as some have fancied, from an admixture of bile with the 
 matter expectorated : — If to water, rendered viscid by dissolving a certain quantity 
 of gum in it, you add blood, drop by drop, you will obtain, in succession, all the 
 shades of colour that are presented by the pneumonic sputa: first a yellow tinge; 
 then a tawny yellow Vv^hich loses itself in a red, and comes to represent the colour 
 of the rust of iron ; and lastly an intense red. The sputa may indeed, sometimes, 
 but I believe that does not often happen, be coloured by bile; but bile is not the 
 source of the yellowness which they assume in cases of pneumonia. 
 
 Sputa composed of very red mucus, indicate pneumonia less sunly than such as 
 are tawny. The very red masses, in which there is more blood than mucus, often 
 belong to pulmonary apoplexy. 
 
 Although these rust or orange-coloured sputa are commonly present during ihe 
 more active period of pneumonia, and, as far as m_v experience goes, are peculiar to 
 that disease, you ought to be aware that they do not constantly accompany it. Some- 
 times the matters expectorated are like those of catarrh : and sometimes there is 
 scarcely any expectoration at all. 
 
 When the pneumonia passes into gangrene — which I repeat is an exceedingly
 
 PNEUMONIA. 569 
 
 rare consequence of inflammation in that organ, — the expectoration becomes of a 
 greenish, or reddish, or dirty gray colour ; and exhales a fetid smell, resembling that 
 which proceeds from gangrene of the external parts. 
 
 T have now described, seriatim, the main symptoms, general and physical, which 
 mark the existence and the progress of pneumonia. And in order to give you a just 
 notion of each, I have spoken of them separately. But they exist together ; and 
 they must be studied together : and some will be found to confirm or to correct the 
 indications that might be drawn from the others. I must briefly therefore run over 
 the phenomena of the disease we have been considering, as it actually presents itself 
 in most cases. 
 
 The first symptom felt is commonly pain in the side, which may or may not have 
 been preceded by rigors. At the same time the breathing is constrained ; and the 
 patient coughs without expectorating. At this period, the ear may generally detect 
 a slight degree of minute crepitation, which is not strong enough to mask entirely 
 the vesicular rustle; and the stricken thorax still sounds well : and there is fever 
 withal. This assemblage of phenomena constitutes the first period of the disease. 
 From the second to the third day, new symptoms appear. The expectoration, 
 hitherto absent, or merely catarrhal, becomes characteristic ; being at first moderately 
 viscid, and having a degree of colour proportioned to the variable quantity of blood 
 which it contains. The minute crepitation increases, and drowns or supersedes the 
 natural respiratory murmur : the clear sound produced by percussion begins to 
 diminish on that side on which the crackling is heard and the pain is felt ; and that 
 pain is commonly less sharp than in the beginning. The dyspnosa increases, as is 
 quite apparent from the short and frequent inspirations made by the patient. If the 
 pain be acute, he cannot he, on that account, on the side affected ; neither can he 
 place himself on the sound side, because in that position his respiration becomes 
 more laborious ; he remains, therefore, almost constantly, lying upon his back. 
 
 In this condition of pneumonia, though the disease may be severe, the inflamma- 
 tion is as yet in its primary stage. It often remains stationary for a while, and then 
 recedes, and terminates by resolution. The dyspncea diminishes, the slight dullness 
 of sound disappears, the crackling is gradually displaced by the natural murmur of 
 the pulmonary expansion, the sputa again become those of simple bronchitis, the 
 fever subsides, and ceases ; and all is well again. 
 
 At other times, instead of retrograding towards resolution, the pneumonia becomes 
 more intense, or rather more extensive, without passing beyond its primary stage ; 
 and the patient may die while it is still in that stage. But this is unusual. Ordina- 
 rily, if the inflammatory engorgement does not cease by resolution, and the symptoms 
 that announce it are exasperated, we must expect that the second stage will be 
 established. And we may be certain that it exists when we observe the following 
 phenomena : — the breathing becomes more and more constrained, short, accelerated; 
 the speech ceases to be free ; the patient can do no more than pronounce a few in- 
 terrupted words in a panting manner. The sputa acquire such a degree of viscidity, 
 that they can no longer be detached from the vessel by shaking it ; the sound afforded 
 by percussion, on the side affected, is decidedly dull : at first we still hear a little of 
 the minute crepitation, without the admixture of any pure vesicular breathing; then 
 that hltle crepitation ceases, and either no sound at all is perceived by the ear, or, in 
 the part where the percussion is dull, bronchial respiration is heard, and this is 
 almost always accompanied with bronchophony. The patient continues to lie on 
 his back. 
 
 In this degree of the disease the prognosis is always uncertain. The patient often 
 sinks rapidly, and dies from apnoea. Yet even in this degree resolution may still 
 take place. In that case the dullness on percussion diminishes; the bronchial 
 breathing disappears; we hear afresh the smaU crepitation, at first alone, then mixed 
 with the natural respiratory murmur, which, in its turn, becomes alone audible. The 
 sputa return to their catarrhal character. In the meanwhile the dyspnoea and fever 
 jpdiminish, and then cease entirely. 
 
 It would doubtless be very interesting to determine, in a given case, whether the 
 lung of our patient was in the second or the third stage of inflammation. But there 
 
 2x2
 
 S70 PiNEUMONIA. 
 
 are no certain means for making -this distinction. We may guess that the third 
 stage is established if the face becomes exceedingly pale and corpse-like : we may 
 be more confident of it if the prune-juice expectoration should occur; and our pre- 
 sumption will be strengthened if the disease has existed for a certain time. How- 
 ever, this last circumstance will not help us 7nnch ; for sometimes the lung has been 
 found to be in a state of suppuration on the fifth day of the disease, and sometimes 
 it has been found in a state of red hepatization after fifteen or twenty days. 
 
 Whether, when the lung has reached this third stage, it is still susceptible of 
 repair, is a question which no one can answer. We have not the materials for 
 its solution, inasmuch as we have no sure sign of the existence of this third stage 
 during life. I should think that recovery from diffused suppuration of the lung is 
 not possible. The rarer form of circumscribed abscess certainly is not of necessity 
 fatal. 
 
 The duration of pneumonia may be laid, upon an average, at ten days. In a 
 table collected by Andral for another purpose, viz., to determine whether there were 
 any fixed critical days in respect to the termination of the disease (a cjuesiion which 
 I shall not now discuss), the duration, in 112 cases, varied from four days to six 
 weeks. But one only was thus protracted ; 23 cases lasted each seven days ; and 
 only 15 of the 112 instances continued longer than a fortnight. 
 
 I have very little to add to what I have stated already of the morbid anatomy of 
 pneumonia. Of the changes which the lung itself undergoes you are now I hope 
 fully apprized. The pleurisy, which often attends the disease, is seldom accom- 
 panied by much effusion; indeed, when the whole of one lung is sohdified by in- 
 flammation, it fills the cavity of the pleui-a, and prevents much effusion. The heart 
 is found to be in that condition which I formerly described to j'ou, as being both a 
 consequence, and an index, of death by apnoea. Its right cavities especially are dis- 
 tended by black coagulated blood ; and a remarkable degree of venous congestion is 
 frequently met with in the liver, and spleen, and intestines. The amount of this 
 varies according as the process of dissolution — what the French call the agony — has 
 been more or less protracted, and the breathing more or less difficult. 
 
 Neiiher need I enter upon any formal discussion of the causes of pneumonia. 
 Sometimes no cause can be traced ; sometimes the disease is clearly the consequence 
 of exposure to cold ; especially under those circumstnces which were fonnerly de- 
 scribed as aiding the injurious operation of cold upon the human body. Why, in 
 one person, such exposure causes peritonitis, in another pleurisy, and in a third in- 
 flammation of the substance of the lungs, we can give no satisfactory account. 
 
 It remains, then, only that I should speak, first of the prognosis, and secondly of 
 the treatment, of pneumonia ; and of the first of these matters, of the prognosis, I 
 have already, incidentally, told you nearly all that is made out, or worth knowing. 
 It is almost superfluous to say that the first degree of the disease is less dangerous 
 than the second, and the second than the third. There is no doubt that pulmonary 
 inflammation may still undergo resolution, although a great part of one lung should 
 be hepatized ; but there are no facts which prove — indeed there is no possibility of 
 proving — that the lung may recover from the state of purulent infiltration — the third 
 degree. 
 
 Something will depend upon the extent of the inflammation ; I mean that pneu 
 monia in the first degree and of great extent, is generalh' as serious as pneumonia 
 in the second degree but much more circumscribed. Inflammation of the upper 
 lobes is also more perilous than inflammation, to the same extent and degree, of the 
 lower. 
 
 Of the o-e/?cra/ symptoms, those which we learn independently of auscultation, tho 
 respiration, as a prognostic sign, is the most important. Considerable dyspnoea, 
 whatever may otherwise be the condition of the lung, is alwa)'s a bad omen. We 
 get less help from the state of the pulse. If, however, a feeble pulse goes along with 
 great difficulty of breathing, and if it does not develop itself after the first bleeding, 
 we must conclude that the inflammation is intense, and form therefore an unfav^ourable 
 prognosis. The supervention of delirium is also a discouraging circumstance. You 
 will have inferred already the information which may be gleaned from the character
 
 PNEUMONIA. • 571 
 
 of the expectoration, in respect to the probable issue of the disease. Great viscidity 
 of the sputa, and a deep rusty colour, announce intensity of inflammation: their 
 return to the catarrhal condition indicates that resolution is going- on. Watery and 
 brownish sputa, more or less like plum-juice, should induce us to suspect suppura- 
 tion of the lung, and are therefore of bad augury. 
 
 The great instruments to be employed in the trccdment of inflammation of the 
 lungs, are the same which have so often been recommended by me, in other inflam- 
 matory affections, before : blood-letting, tartarized antimonj'-, mercury. Of these, 
 blood-letting is the chief. Both reason and experience attest the especial power of 
 bleeding upon acutfe pneumonia. In the first place it tends to restrain or extinguish 
 the inflammation as inflammation. But, in the next place, it has the effect of re- 
 lieving the particular y»Hc/ion of the lungs. The more blood is sent to them in 
 excess, the more dyspnoea must there be, the more venous blood passing into the 
 arteries, as well as the more risk of the effusion of lymph and the obliteration of the 
 cellular texture of the organ. When we bleed, therefore, in pneumonia, we kill 
 two birds (as a phrase is) with one stone. We do that for the lung, which we do 
 for an inflamed eye when we darken the room, or for an inflamed joint when we 
 keep it absolutely at rest ; i. c, we do all that we can to spare the exercise of the 
 organ, and to prevent aggravation of the inflammation from that cause. And the 
 result of the free abstraction of blood in this disease, fully vindicates the value of a 
 practice which has been pursued for ages. The late Dr. Gregory, of Edinburgh, 
 was in the habit of saying, in his lectures, that provided he was called early to a case 
 of pneumonia, he would be contented to dispense with all other aids than those of a 
 lancet, and water-gruel. I am far from desiring you to believe that blood-letting is 
 the only expedient required ; but certainly the amount of the best experience, ancient 
 and modern, is strongly in favour of its free, and I might almost say, prodigal, employ- 
 ment. Very lately, one most distinguished French writer, M. Louis, has endeavoured 
 to show that venesection has not much control over the progress or event of pneumonia; 
 and I advert to his opinion on this subject merely to caution you against being misled 
 by it ; as you might otherwise be, considering his well-merited reputation as an exact 
 and faithful observer. 
 
 1 can only lay down general rules and indications with respect to the manner and 
 amount of blood-letting in this disease, or in any other disease. The abstraction of 
 blood will be effectual, cxlerii paribus, in proportion as it is early ; during the first 
 stage — the stage of engorgement — and before the spongy texture of the lung has 
 been obhterated. The patient should be bled in an upright position, by a large orifice 
 and in a full stream ; and the bleeding should be continued until some sensible im- 
 pression is made upon the system: until the pjilse becomes softer ; or, if it were con- 
 tracted, until it becomes fuller ; until the sensation of constriction is abated, and the 
 dyspnoea relieved ; or until syncope appears to be at hand. 
 
 Bleeding, in this early stage, often gives very speedy relief, both to the pain and 
 to the dyspnoea. Sometimes the pain does not cease at once, but goes off a few 
 hours afterwards ; but I believe that if the breathing be not at all relieved at first, the 
 case generally (though not always) ends ill. However, you are not to expect that 
 one blood-letting will suffice, even when it is performed early in the disease. Such 
 a favourable case may happen, but not often. The patient should always be seen 
 within four or five hours from the period of the first venesection, that a timely repe- 
 tition of it may take place, if the relief has not been complete, or has not been per- 
 manent. Many fatal cases have probably been fatal from want of this attention; from 
 too long an interval having been suffered to elapse between the bleedings. A vein 
 may be opened, if necessary, two or three times in the twenty-four hours ; and 
 the ultimate loss of strength, and even loss of blood, will be less under such treatment 
 than if the blood-lettings were repeated at longer intervals ; and the necessity of the 
 repetition must be judged of from the circumstances of the case. As an auxiliary to 
 the lancet, I am much in the habit of taking blood from the surface of the chest itself, 
 by means of cupping-glasses, or of a large number of leeches. I believe that much 
 good is done by this local emptying of the blood-vessels. It is particularly indicated 
 if there be pain ; and the part to which the leeches or cupping-glasses are applied
 
 572 PxNEUMONIA. 
 
 should be determined by the situation of the inflamed portion of lung, when that 
 is ascertained bj' the ear. I scarcely need say that the Avhole of the antiphlogistic 
 regimen must be rigidly enforced ; that the patient must keep his bed ; and that all 
 superfluous exertion of his lungs in speaking must be forbidden. 
 
 When the inflammation has advanced into the second stage, we cannot expect that 
 the removal of blood will have so decided an influence upon the inflamed and solia 
 parts; but even then, if duly moderated, it will have these good consequences: it 
 will diminish the force of the heart and arteries, and so tend to prevent the exten- 
 sion of the inflammatory process ; it will lessen the whole quantity of blood circu- 
 lating through those portions of the lung which are still pervious, and thus reheve 
 dyspncea ; and it will put the system at large into the condition most favourable for 
 the reabsorption of the lymph by which the air-tubes and vesicles of the afl^ected 
 parts have been blocked up. 
 
 But a time arrives when bleeding is no longer of use, or when it is positively 
 hurtful ; when it ceases to have any good influence on the local disease, and has aa 
 injurious influence on the whole system : reducing the patient's strength, and inca- 
 pacitating him for bringing up, and ridding his lungs of, the tenacious mucus 
 exhaled by the bronchial membrane. This is what takes place in those cases in 
 which the expectoration is said to be stopped by a bleeding. I have mentioned Dr. 
 Gregory's reliance on blood-letting for the cure of pneumonia ; and I ought to tell 
 vou at the same time Avhat I have been informed respecting the result of his prac- 
 tice. He " used to bleed to the verge of convulsion. His colleague, Dr. Rutherford, 
 seldom went beyond three bleedings, and generally accomphshed his object by two, 
 judiciously timed and measured. His patients recovered quickly; Dr. Gregory's 
 very slowly." 
 
 We want some remedy, therefore, to assist the lancet, or to employ a'one when 
 the lancet can do no more ; and we have two such, in tartarized antimony, and in 
 mercury. The tartar emetic plan I believe to be the best adapted to the first degree 
 of the inflammation — that of engorgement ; and the mercurial plan to the second — 
 to that of hepatization. 
 
 I need not tell you that the tartarized antimony is not given in this disorder with 
 the object of producing vomiting.. It is a very curious thing that although, when 
 administered in a considerable dose, its first effect is usually sickness, followed, per- 
 haps, b}^ purging, a repetition of the same dose is, in the majority of cases, at length 
 borne without any further vomiting. The stomach comes to tolerate the medicine 
 as our continental brethren say ; and then its beneficial influence upon the disease 
 is no less marked than when nausea and retching take place. Some patients do not 
 vomit at all; others, the majority in fact, vomit two or three times, and then tolerance 
 is estabhshed. If the sickness and purging go on, they may be checked by adding 
 a few drops of laudanum to each dose. Dr. Thomas Davies, who had tried this 
 remedy largely, and, as he tells us, with great success, gives the following as his 
 own plan of administering it, and perhaps it is as good as any. After free bleeding, 
 he begins with one-third of a grain of tartar emetic in half a wineglassful of water, 
 with a few drops of laudanum or syrup of poppies. Two doses of this strength 
 he gives at the interval of one hour from each other. He then, if the patient does 
 not vomit, omits the opium, but continues it if he does, doubling, however, the quantity 
 of the tartar emetic, giving two-thirds of a grain for two successive hours ; and in 
 this way he goes on, adding a third of a grain every two hours, until he reaches two 
 grains every hour. This last quantity he has not exceeded, and he says that he has 
 continued it for many days without producing any injurious consequences. 
 
 Under this plan of treatment the symptoms will often undergo a marked change 
 tor the better, in three or four hours. Sometimes, however, the relief is not con- 
 spicuous for twenty-four or even for thirty-six hours. He states, and this is accordant 
 tvith my own experience of the remedy, that the tartar emetic always acts best when 
 it produces no effect except upon the inflammation itself; i. e., when it does not 
 cause vomiting, or purging, or a general depression of the powers of the system. 
 This is an important practical remark, because many persons have supposed that it 
 B'ibdues the disease only when it previously gives rise to these symptoms. I con-
 
 PNEUMONIA. 573 
 
 sider this testimony of Dr. Da vies to the power of the tartarized antimony in con- 
 trolling inflammation of the lungs the more valuable, because he informs us, that 
 before he had occasion to see its admirable effects in the first stage of pneumonia, he 
 had been in the habit of trusting to the free use of mercury, after due depletion. 
 
 When dyspnoea has been put an end to by antimony thus exhibited, the medicine 
 may be intermitted ; and if the inflammation shows any disposition to rekindle, it 
 must be again extinguished by a repetition of the tartar emetic. 
 
 When, however, the inflammation has reached the second stage, that of solidifica- 
 tion, mercury is more worthy of confidence, in my opinion, than tartarized antimony. 
 And I have little or nothing to add to what I formerly said in respect to the mode in 
 which it ought to be administered. The object of giving it is to make the gums 
 tender; and it is expedient to do this as speedily as may be. Small doses of calomel 
 repeated at short intervals — a grain every hour, or two grains every two hours, or 
 three grains every three hours — combined with so much of laudanum or ot opium 
 as may be requisite to prevent it from running off by the bowels — offer the most 
 certain way of accomplishing our object. If the bowels are irritable under the calo- 
 mel, blue-pill, or the hydrargyrum cum creta, may be substituted for it with advan- 
 tage : and if the internal use of mercury is any how contra-indicated, or if it appears 
 slow in occasioning its specific effect,, the linimentum hydrargyri may be rubbed in, 
 or the strong mercurial ointment. 
 
 Many persons, I am persuaded, are saved by treatment of this kind, pushed to 
 slight ptyalism : the effusion of lymph, tending to spoil the texture of the lung, is 
 arrested ; and the lymph already effused begins to be again absorbed : and the ease 
 and comfort of the patient, as well as the alteration for the better of the physical 
 signs, attest the healing qualities of the remedy. 
 
 After the inflamed lun'g has become solid and impermeable, the treatment must 
 be regulated rather by the state of the system at large, than by the actual or pre- 
 sumed condition of the lung : we must look more for guidance to the general symp- 
 toms than to the physical signs. If the pulse continues steady and firm, wait pa- 
 tiently the effect of the mercury. But when sunken features, a pallid face, coldness 
 of the surface or extremities, a tendency to delirium, and (above all) a feeble or 
 irregular pulse, proclaim that the vital powers are giving way, it will be requisite, 
 as in other cases where death is threatened by Asthenia, to administer cordial and 
 stimulant medicines ; the carbonate of "ammonia in a decoction of seneka ; wine : 
 and to feed the patient well on milk, or beef-tea. 
 
 Among what may be called the routine remedies of pneumonia, we must rank 
 counter-irritation by means of blisters. When one is called, in consultation, to see a 
 patient labouring under inflammation of the lungs, Ave may safely speculate upon the 
 conclusion, that bleeding and blistering, and purging by calomel, have all been duly 
 performed. And I beheve that blisters are often apphed to the chest much too early 
 in such cases. In the outset, while there is yet considerable fever present, they add 
 to the irritation, and distress the patient ; and probably tend to aggravate the existing 
 inflammation. They are also attended with this inconvenience, that they interfere 
 with the exploration of the lungs by the ear: and this is not a slight or fanciful dis- 
 advantage ; for the information we receive, by the sense of hearing, of the state of 
 the lung — whether the inflammation be making progress, or receding, or stationary 
 — is of great use in directing the remedial management of the case. But of course 
 ihis is a consideration not to be put in competition with the benefit which may be 
 expected sometimes from a blister. When the fever is no longer high, and the skin 
 no longer burning, but the expectoration is still difficult, the dyspnoea considerable, 
 and a sensation of pain, or tightness, or oppression, is experienced in the chest, then 
 a large blister is often productive of very sensible benefit ; but it should be a large 
 one. The patient should have a waistcoat almost, or at any rate a breast-plate, of 
 blistering-plaster. 1 have never seen such good effects from placing blisters upon 
 distant parts in this disease, upon the thighs or arms for instance, as would lead me 
 to plague the patient with them in those situations. 
 
 Purgatives are of less certain value in pneumonia than in many other mflamma- 
 tory diseases ; and less, especially, than in cerebral inflammation. Still, it will ahvay*
 
 574 PNEUMONIA. 
 
 be right to give an active aperient at the outset, and afterwards to take care that the 
 bowels be unloaded at least once every day. A continued drain by purgation would 
 not consist at all with the mercurial plan, which promises to be most useful when the 
 inflammation has already reached the stage of hepatization. 
 
 ^J'his, then, is the outline of the treatment which is most likely to save the life 
 of those who are afiected with acute idiopathic pneumonia. Different cases will 
 require different modifications of it ; for which, I repeat, no particular rules can bo 
 laid down. 
 
 All that I have hitherto been saying relates to acute pneumonia, occurring in a 
 previously healthy person. But pneumonia having that character, and so occurring, 
 is a much less common disorder than most persons appear to suppose, or than I for- 
 merly thought it to be. I have been surprised to find how few cases of pure idiopa- 
 thic inflammation of the lungs present themselves among my hospital patients. Five 
 or six in the year are as many as I see there. Intercurrent pneumonia, however — 
 pneumonia engrafted upon some other^re-existing disease — is abundantly frequent ; 
 and requires, in general, a much less vigorous and more wary plan of treatment. 
 Inflammation of the puhnonary substance is apt to supervene insidiously upon various 
 disorders which are of every-day occurrence: upon bronchitis, upon phthisis, upon 
 disease of the heart, and upon fevers, especially the exanthematous fevers. In these 
 cases, while the physical signs are necessarily the same as in the unmixed acute dis- 
 ease, the general symptoms are often but slightly pronounced. During the progress 
 of continued fever of a low type, inflammation may steal upon the lung, and run 
 quickly through all its stages, and spoil the organ irrecoverably, without giving any 
 notice of its presence ; unless, indeed, you suspect, and search for it with your ear 
 The pneumonia is said, in such cases, to be latent. It seldom needs, the associated 
 disorder would seldom bear, any active depletion. Much benefit often follows the 
 abstraction of small quantities of blood ; but they should be taken from the surface 
 of the chest by the cupping-glass, and not by the lancet from the arm ; and it is often 
 good practice thus to aim at reducing the local mischief with one hand, while with 
 the other we support the patient's strength by means of ammonia, wine, and nour- 
 ishing broths. Bhsters are also of service ; more so than in the sthenic forms of pure 
 pneumonia; and they may be apphed at an earlier period. In conjunction with 
 ihese remedies, I should advise the cautious employment of mercury. 
 
 When the convalescence from acute pneumonia is decided and real, it is shorter 
 -than might have been supposed. From the period when the pulmonary inflamma- 
 tion is fairly over, the strength returns with unexpected facility, even when large 
 bleedings have been practised and repeated. But we have to guard, more perhaps 
 in this disease than in most others, against false or merely apparent convalescences. 
 A patient can never be pronounced perfectly secure so long as any trace of crepita- 
 tion remains in the aff*ected lung ; and this may often continue long : nay, it not 
 unfrequently ceases only upon the supervention of another more surely fatal, though 
 less rapid disorder, viz. : tubercular consumption ; of which, however, I must treat 
 as a distinct disease. 
 
 [PxEUMOXiA IS Childrex. — Pneumonia is a very frequent disease of childhood ; and 
 as It is then marked by some very important mouifications in its general characters and 
 results, it demands a separate consideration. 
 
 The inflammation may be confined to the minute lobules of the lung, or it may attack the 
 pulmonary lobes. The first constituting lobular, and the second lobar pneumonia. In both 
 forms of the disease the inflammation may be confined to a small portion of one lung, oi 
 extend to nearly the whole of one or both. 
 
 In very young children the symptoms of pneumonia, particularly at the commencement 
 of tlie attack, are very obscure, and even when more distinctly marked, they differ but lit- 
 tle from those of bronchitis. 
 
 In infants the attack is very generally preceded by symptoms of a mild bronchitis, to 
 wnich there usually succeeds a chill, differing in its severity and duration in different cases ; 
 this is followed uy increased heat and dryness of the surface, increased frequency of pul?e, 
 accelerated respiration, dyspnoea, and a short dry cough. These symptoms quickly augment 
 in intensity — the lips become of a bright red, the tongue of a florid hue, and somewhat dry, 
 »nd coated along its centre with a thick white fur. Often there is from the commencement 
 of the attack vomiting, and, in young children, diarrhoea. In many cases there is considera-
 
 PNEUMONIA. 575 
 
 ble agitation and anxiety, in others decided drowsiness, and more rarely con-v-.;.sions ; these 
 fcre scraetimes violent and repeated, and often followed by an entire loss of consciousness. 
 Convulsions, according to the observations of Rilliet and Barthez, are confined to cases occur- 
 ring in young infants, where the inflammation is seated at the summit of the lungs. 
 
 In infants at the breast, in the early period of the attack, the breathing is no longer affected 
 solely through the nose, but the little patient lies with the mouth partly open, and drawing 
 in the air through it. The tongue becomes in consequence preternaturally dry, and the cliild 
 sucks by starts — seizing the nipple with eagerness, sucking for a few moments with greedi- 
 ness, and then suddenly dropping the nipple, and in most instances commencing to cry or 
 moan. 
 
 The inspiration in children affected with pneumonia is marked by a peculiar abruptness, 
 occurring suddenly before expiration is completed, and with a more or less dilatation of the 
 nostrils. 
 
 The frequency of the respiration is not always in proportion to the violence of the attack, 
 and does not always increase with the progress of the disease. When pneumonia occurs in 
 the course of chronic enteritis, there is often either a very slight or no acceleration of respira- 
 tion ; it rnaj', also, be masked by an accompanying atlection of the abdominal organs or of 
 the brain. In cases of broncho-pneumonia, the dyspncea is often so intense as to threaten 
 Euflbcation. The dyspncea is always proportionate to the violence and extent of the pulmo- 
 nary inflammation, and augments with the progress of the disease. It is often attended with 
 great anxiety, and a sense of impending suflbcation which renders a recumbent posture 
 insupportable. 
 
 The cough is at first frequent, short, dry, and painful, but soon becomes moist; when ex- 
 pectoration occurs, which is seldom the case in young children, it is, at first, slight, and con- 
 sists of a whitish, viscid mucus, which becomes subsequently reddish. It is rarely, however, 
 rust coloured. As the cough becomes more moist, it gradually declines in violence until 
 towards the eighth or ninth day, when it rapidly diminishes, and finally disappears. When, 
 however, the pneumonia becomes more difl'used, or occiirs in the course of some acute aflec- 
 tion, and in children not much debilitated, the cough is very frequent and intense, and is 
 rarely attended with a free expectoration. The attacks of pneumonia that so frequently 
 occur in the course of chronic enteritis, are seldom attended with much cough — occasionally, 
 indeed, it is entirely absent. There is seldom any very decided pain of the chest — when 
 present, it is generally acute, though occasionally dull, and is usually experienced at the ante 
 rior margin of the axilla — it is a/jgmented by the cough, and often disappears long before the 
 Other symptoms. 
 
 The disease in these cases is so often destitute of leading symptoms, that its existence 
 might be overlooked, were it not for the physical signs revealed by auscultation — the skin is 
 pale and cool, the pulse small, and the face and extremities cedematous. 
 
 In young children, or those under six years of age, pneumonia is frequently preceded by 
 extensive bronchial inflammation. The inflammation of the lungs, which is probably pro- 
 duced by the extension of the inflammation from the extreme branches of the bronchi to the 
 preliminary tissue, often comes on so gradually, that it is impossible to fix in most cases the 
 exact date of its occurrence. Occasionally, at the period the pneumonia supervenes, there 
 is a well-marked accession of fever and dyspncEa, and an aggravation of all the symptoms. 
 The febrile symptoms are less than in the other forms of the disease, but the dyspnea and 
 distress are usually greater, and the face presents from the first a more livid hue. The 
 cough is less hard, but often occurs in paroxysms which greatly distress the patient; th« 
 respiration is more hurried and irregular ; the irregularity coming on at an earlier period. 
 Head symptoms are more frequent, the patient's rest is disturb?d, and he often mutters in his 
 sleep, and has far more restlessness and jactitation when awake. Convulsions and coma 
 more frequently precede death, which occurs at an earlier period than in the other forms 
 of pneumonia. 
 
 Pneumonia in children is generally attended with loss of appetite and increased thirst, 
 and a torpid state of the bowels ; when the disease, however, is complicated with enteritis, 
 profuse diarrhoea may be present throughout the attack. In these cases furunculi or ecchy- 
 moses occasionally cover the skin, while the blistered surfaces are liable to become ulcerated. 
 
 In favourable cases of primitive bronchitis, the acceleration of pulse and respiration attain 
 their greatest intensity generally by the end of the fourth, fifdi, or seventh day, o:, at 
 the farthest, by the ninth day: when the heat of the skin and the frequency of the pulse 
 diminish, respiration becomes slower, and the inspiratory movement is unattended with dila- 
 tation of tlie nostrils. The cough becomes more free and moist, the fever quickly disap- 
 pears, the face becomes paler, and the expression of the countenance more natural. The 
 respiration finally assumes its normal rhythm, the cough rapidly diminishes, and in a few 
 days convalescence is fully established. 
 
 In the more severe and unfavourable cases, there is intense dyspnoea from the very com- 
 mencement of the attack — intense anxiety, a pallid hue of the face, with a violet tinge of tli« 
 lips and summits of the cheeks, an extremely small, rapid pulse, and a frequent, short.
 
 576 PNEUMONIA. 
 
 dry, painful cough. The general symptoms continue to augment in violence, and death may 
 occur on the third or fourth day. In other cases, the symptoms, from the beginning of the 
 attar k, are less intense, and do not increase in severity after the fifth or sixth day, but remain, 
 as it were, perfectly stationary. Soon, however, in addition to the cough and dyspnoea, there 
 occur pallor of the face, great emaciation, and constant diarrhoea ; and, at the termination of 
 from three to four weeks, the patient, being reduced to a state of the utmost debility, expires. 
 In other cases, again, after all the prominent symptoms have declined, and a speedy conva- 
 lescence is anticipated, from some accidental cause, the inflammatory action is re-excited in 
 the lungs, the dyspnoea, cough, acceleration of the pulse, and fever, return with increased 
 violence, and deatli speedily ensues. The fatal termination may also be hastened by the 
 occurrence of pleurisy, measles, gangrene of the mouth, &c. 
 
 Acute pneumonia, occurring in the course of some other acute disease, is generally of rapid 
 progress, and terminates either in health or fatally, within a few days. 
 
 The physical signs of pneumonia, occurring in children, are of primary importance. By 
 them alone, in many cases, can a correct diagnosis be established — while it is only by them, 
 also, that the extent and progress of the local disease can be determined. 
 
 In simple primitive pneumonia of children, if of the lobar form, there are present, from 
 the very commencement of the attack, crepitant ronchi; and often bronchial respiration on 
 one side the thorax towards its base. The crepitus is generally larger than in adults. If 
 for a short time it cannot be heard, it may be generally reproduced by causing the child to 
 cough, when it is again to be distinguished, in the strong inspiration which .-;.oceeds the 
 cough, the sound resembling the cracking of a whip. 
 
 In the lobular form of pneumonia, the subcrepitant ronchi are more generally diffused, 
 while the bronchial respiration is seldom heard. The extent of the latter increases with the 
 progress of the inflammation, while the ronchi decrease. When the acceleration of the 
 respiration and pulse has attained its maximum, the bionchial breathing is very audible, and 
 is accompanied with bronchophony, or with a resonance of the voice and extensive dulness 
 of the chest. As the general symptoms decline, and the cough becomes more moist, the 
 subcrepitant ronchi are very abundant, antl the resonance of the voice extends over a greater 
 space ; the bronchial breathing continues, but the dulness of the chest diminishes. Even after 
 convalescence is established, a slight prolongation, as well as a different resonance of the 
 voice, is still perceptible. The respiration continues feeble for several days, and only slowly 
 recovers its proper vesicular tones. 
 
 In more violent cases, humid ronchi are heard throughout the chest, intermixed with others 
 of a drier character, or with bronchial expiration and a diflused resonance of the voice. 
 Bronchial breathing is ahvays a very grave sign. In eleven out of twenty cases in which 
 it was detected by Dr. West of London, the disease had a fatal termination. 
 
 The mucous ronchus is heard in most cases of broncho-pneumonia in children, and in 
 cases of lobar pneumonia, in the neighbourhood of the subcrepitant ronchus, and occasionally 
 wheru distinct bronchial respiration exists. It often persists for a long time after every other 
 sign of disease has disappeared. 
 
 In the lobular pneumonia of young children, the physical signs are at first limited to the 
 mucous and subcrepitant ronchi, dependent upon the increased secretion of mucus in the 
 bronchi. The subcrepitant ronchi are frequently continued throughout the attack, being often 
 the only stethoscopic signs present. They are rarely replaced by the fine crepitant ronchi, as 
 in the pneumonia of adults. Bronchial respiration becomes developed when induration has 
 extended to a considerable portion of the texture of the lungs. It is chiefly heard at the 
 upper and middle portions of their posterior parts — it is rarely heard in the lower lobe, from 
 the comparative smallness of the bronchi, and their early obliteration by the progress of tlie 
 inflammation. The respiratory sounds are very peculiar — the inspiratory murmur, in place 
 of being full and expansive, as in a healthy chikl, is short, obscure, and almost without the 
 vesicular murmur, and may or may not be accompanied with the mucous or subcrepitant 
 ronchus; the expiration is rarely distinct, unless the bronchial respiration is fully developed, 
 when it is usually louder than the inspiration. The sounds indicative of inflammation of 
 tlie texture of the lung are often entirely obscured by the mucous ronchi of bronchitis. 
 
 The anatomical lesions in the pneumonia of children differ very materially, according as 
 the inflammation is lobular or lobar, and according to the period of the disease when death 
 takes place. 
 
 In lobular pneumonia the lung is usually soft and flaccid, of a mottled appearance exter- 
 nally; patches of a deep red or violet colour, generally distinctly circumscribed, of a circular or 
 ovai form, hard to the touch, and slightly projecting, being interspersed in the midst of the 
 natural grayish red tint. They are commonly situated at the inferior edge of the lung, bii4 
 may occupy other portions of its surface. The part occupied by these patches does not col- 
 lapse upon the chest being opened. 
 
 lu some cases this marbled appearance of the lung is absent; but spots of induration, more 
 01 less deeply seated, may be detected by the fingers, giving to the lung an uneven or knotted 
 i"eel.
 
 PNEUMONIA. 577 
 
 The same marbled appearance is presented by a section of the lung. The dark patches 
 aie more or less accurately circumscrilicd in the first stage of the disease; they are firmer 
 than the surrounding tissue, swim when thrown into water, crepitate beneath the finger, and. 
 however carefully separated from the sound portion of the lung, yield upon pressure a red- 
 dish fluid intimately mixed with air. In the second stage the dark patches form nodules of 
 a firmer and more compact consistence. Tlieir cut surface is smooth, and when carefully 
 detached from the surrounding parts, they crepitate none or but slightly, and sink rapidly 
 when thrown into water. When the central portion alone of the nodule is subjected to 
 pressure,- a red sanious fluid escapes without any admixture of air. It is seldom that single 
 lobules are found affected, the induration usually comprising four or five, forming a mass of 
 the size of an almond. If the patient lives for some time, the intervening substance usually 
 becomes affected, and the lobular is converted into lobar pneumonia, and the inflammation 
 runs its course, as in the ordinary cases of this latter form of the disease. 
 
 In the third stage of the disease, the section of the lung presents a grayish colour, inclining 
 more or less to yellow in diflerent cases. The pulmonary tissue is friable, and when pressed 
 gives discharge to a purulent fluid, its texture being infiltrated with pus. Upon minute 
 examination, some of the lobides will be found more projecting than others, their vesicles 
 not being compressed, as in the less projecting parts. 
 
 According to Barthez and Rilliet, there are two forms of lobular pneumonia. In the first, 
 which they denominate tlie mammelonated, is marked by nodules of hepatization, comprising 
 one or more lobules, differing but little in colour and appearance from the surrounding tissue. 
 Their limits are well defined, even when the neighbouring tissue is engorged. They are 
 frequently surrounded by a layer, of about half a line in thickness, white, firm, and of a 
 fibrous appearance. The hepatized portions slightly project above the surface of the incised 
 lung, from the collaiise of the surrounding air-cells. They vary in size from that of a hemp- 
 seed to that of a pigeon's egg. They are of a spheroidal form, and have usually a regular 
 surface. But a single nodule may exist in one lung,'or there may be from twenty to thirty 
 or more. They are almost invariably surrounded by a circle of pulmonary tissue in a state 
 of engorgement. The diseased portions generally attain the third stage of pneumonic hepa- 
 tization, which terminates in the formation of an abscess. 
 
 In the same lung there may exist nodules of hepatization in the first and second stages, 
 and also rounded masses of a straw colour, very humid when cut into. At a more advanced 
 stage, the pus, which is at first deposited in the interstices of the pulmonary tissue, becomes 
 collected in the centre of the nodules. This minute collection of pus is surrounded by two 
 concentric zones, the internal one yellow — hepatization of the third degree; — the external 
 one red — hepatization of the second degree. At a later period, the size of the abscess is 
 increased at the expense of the inner zone, the outer zone at the same time passing into sup- 
 puration. At a still later period, an incision through the diseased portion of the lung reveals 
 cavities varying in size from a few lines to four or five. These cavities are in general round, 
 more rarely oval, and contain usually a thick tenacious yellow or greenish pus, perfectly free 
 from any admixture of air. Sometimes small coagula of blood are mixed with the pus 
 These cavities are at first formed by a layer of hepatization, lined with a layer of concrete 
 pus, or with a false membrane, yellow, soft, and easily detached. Subsequently, this mem- 
 brane becomes changed into a thin, smooth, polished tissue, analogous to a serous membrane. 
 The abscesses sometimes communicate freely with each other, and at the point where the 
 bronchi penetrate their cavity, its mucous menrbrane presents a true solution of continuity. 
 When the inflammation invades separately several neighbouring lobules, the cavity of the 
 abscess is multilocular, each cell being isolated by a lamina of the hepatized tissue, upon 
 the rupture of which the different abscesses communicate with each other. These abscesses 
 have usually a tendency to approach the surface of the lung. An adhesion often takes place 
 between the opposing surfaces of the pleura, or the pleura of the lungs becomes gradually 
 thinned and finally perforated, giving rise to a true pneumo-thorax. It has hai)pened, that 
 an adhesion has formed between the lung and diaphragm, and the abscess of tne lung has 
 thus communicated with the peritoneal cavity. These abscesses are often completely iso 
 lated, and, with the exception of the thin layer of hepatization in their immediate vicinity, 
 are surrounded with a perfectly healthy pulmonary tissue. Occasionally, liowevor, they per- 
 vade the great portion of the whole of one of the lobes. Their size is ordinarily in inverse 
 proportion to their numbers. In the greater number of cases, they are confined to one lung, 
 and are more frequent in the left than the right. They are met with most frequently in chil 
 dren imder six years of age. 
 
 Partial, which is the second form of lobular pneumonia, is much less circumscribed than 
 the preceding. Indistinct limits exist between the healthy and diseased portions, and the 
 disease occupies a larger portion of the lungs. The diseased portions may throughout havo 
 reached the second stage, or at the centre alone, the circumference being still in the first 
 stage, nn<' this being in contact with several other portions of the lung, in a similarly dis- 
 eased condition: nearly the whole of an entire lobe may present an admixture of the c'laiac, 
 
 37 2y
 
 578 PNEUMONIA. 
 
 teristics of pneumonia in the first and second stages, and when the disease has reached the 
 .hird degree, it is strictly lobar. 
 
 In the major part of the cases, lobular pneumonia is double — the disease, however, being 
 frequently much more extensive on one side than the other. A union of the three forms of 
 pneumonia — mammelonated, partial, and general — is often met with in the same patient. 
 The lirst is equally frequent in every portion of both lungs, while general pneumonia is far 
 more frequent in the inferior lobes. Partial pneumonia is often disseminated throughout the 
 three lobes — it is.more frequent, however, in the inferior. Mammelonated pneumonia is of 
 much more :are occurrence beyond the sixth year than partial pneumonia, while general 
 pneumonia is still more rare than the former between the sixth and fifteenth years. (Se« 
 Barthez and Rilliet — Maladies des Evfants, t. i., p. 61.) 
 
 borne doubts have been suggested as to all the changes in the texture of the lungs, de- 
 scribed as characteristic of lobular pneumonia, being actually the result of inflammation. 
 For the investigation of this subject, the reader is referred to the Editor's Treatise on the Dis 
 eases of Children, 2d edit., p. 282. 
 
 The anatomical characters of lobular pneumonia in children are the same with those met 
 with in the pneitmonia of adults. 
 
 .Inflammation of the bronchi, particularly of tlie smaller bronchial ramifications, pleurisy, 
 and emjihysema of the lungs, are common complications of pneumonia in children. 
 
 The lobular form of pneumonia is the most frequent during childhood — it is also the most 
 serious at that age. 
 
 Lobar pneumonia occupying only one lung, when it occurs in children between six and 
 fifteen years of age, whose health has not been impaired by previous disease, unless compli- 
 cated by some secondary affection is not a very fatal disease, if judiciously treated from its 
 commencement. Its serious character is however greatly enhanced by its being complicated 
 with other diseases. The most common of these are measles, hooping-cough, chronic ente- 
 ritis, and small-jiox. 
 
 Pneumonia in children is produced by the same general causes, as give rise to it in adults. 
 It is common to both sexes, but more frequent iu boys. It is particularly liable to occur in 
 the same child after a shorter or longer interval. 
 
 In the treatment of the pneumonia of children, bleeding will very generally be demanded 
 in the commencement of the attack. In young children leeches or cups should be applied 
 to the anterior parietes of the chest, beneath the clavicles, or between the shoulders. Their 
 number should be proportioned to the violence of the symptoms, and to the age and strength 
 of the patient. In older children, however, bleeding from the arm should be preferred. The 
 amount of blood drawn must be proportioned to the extent of the disease. The propriety 
 of repeating the bleeding will depend upon circumstances. When the first bleeding has 
 been well timed and carried to a sufficient extent, a second will seldom be required ; when- 
 ever, however, the leading symptoms, particularly the dyspnoea, continue with little abate- 
 ment, we should never hesitate to repeat the bleeding, either from the arm, or by leeches or 
 cups, according to the violence of the remaining symptoms, the age of the patient, and the 
 amount of strength remaining. It is, however, in the early period of the attack alone, that 
 any very decided advantage is to be expected from blood-letting; in the more advanced 
 stages of the disease, it will seldom be beneficial or admissible ; though cases may occasion- 
 ally occur, when the cautious application of leeches or cups to the chest or between the shoul- 
 ders will be attended with marked relief, even after the disease has existed for several 
 days. 
 
 In the commencement of the attack, if the bowels are active or torpid it will be proper to 
 administer a full dose of calomel, to be followed in a few hours, by a dose of castor oil, or 
 in robust children, over three years of age, a mixture of equal parts of magnesia and epsom 
 salts. Subsequently the bowels should be kept regularly open by enemata, or occasional 
 doses of some mild purgative ; a grain of calomel, with half a grain each, of ipecacuanha 
 and extract of hyosciamus, administered twice or thrice a day, will usually effect this object. 
 Costiveness is not, however, very common in the pneumonia of infants; an opposite state of 
 ihc bowels is a more frequent and troublesome symptom. 
 
 Subsequent to blood-letting, in robust children over three years of age, tartarized antimony, 
 jijven in small doses during the day, will be found highly beneficial. But in younger chil- 
 dren antimony in any form is a dangerous remedy, more particularly when there is any 
 tendency to disease of the alimentary canal. Small doses of ipecacuanha and calomel will 
 be found very generally to act beneficia'.Iy in allaying the cough, dyspnffia, and general 
 restlessness, and may be given to the youngest patient without any inconvenience resulting; 
 adding to each dose a minute portion of powdered digitalis will in most cases be found ad- 
 vantageous. Occasionally the calomel will purge; should this be the case it will be neces- 
 sary to add to it a grain or two of Dover's powder. After the violence of the disease has 
 been considerably abated, we have found advantage from the administration, every three 
 hours, of small doses of calomel, ipecacuanha and hyosciamus. Under the same circum- 
 stances the compound honey of squill may be given. To children over three years of age it
 
 PLEURISY. 579 
 
 Is well adapted to allay the cough and dyspncea: to the dose given in the evening a few cirops 
 of paregoric may be added. 
 
 Blisters to the chest are certainly very important remedies in the pneumonia of children. 
 In violent cases occurring in patients over five years of age, particularly when attended with 
 much febrile excitement, they should not be applied imtil the violence of the symptoms have 
 been abated by direct depletion ; they should be kept on no longer than is necessary to pro- 
 duce, a decided redness of the skin; they should be then removed and the reddened surface 
 covered with a soft emollient poultice. In infants, as well as in slight cases, and in those 
 occurring in children of a delicate frame or who are much debilitated, in place of a blister a 
 thick slice of bread, dipped in vinegar and lightly sprinkled with powdered mustard, should 
 be applied to the chest, and removed as soon as it has reddened the skin. 
 
 Warm sinapired pediluvia, or a sinapired hip-bath, will often produce a favourable revul- 
 sion from the -'ungs, and may be frequently repeated. 
 
 In stubbon; cares Dr. West speaks highly of mercurial inunction; under its employment, 
 he has seen vecoveiy to take place even where the circumstances had seemed to warrant 
 a more unfavourable prognosis. The full value of mercurial inunction is seen in cases which 
 have been neglected until c!ie time for depletion has gone by, the patient having becoifie 
 exhausted, and the employmeni, oi calomel is forbid by the presence of diarrhcea. Dr. West 
 employs it in the proportion of oris drachm, rubbed into the thighs and axilla every four 
 hours, in children of four years of age. He has never seen salivation to be induced by it, 
 but he has observed the disease gradually to diminish in severity during its employment, 
 and the solid lung, to become once more permeable to air. 
 
 When in the advanced stage of the disease there is great exhaustion, with symptoms of 
 impending suffocation, the use of carbonate of ammonia has been strongly recommended — 
 but under such circumstances, there can be but little hope of the patient's recovery. 
 
 In chronic cases, our chief dependence is upon revulsives, applied either upon the chest, 
 or upon the surface generally, and perhaps upon a judicious mercurial course, particularly 
 by inunction. 
 
 In all cases of pneumonia, the exhibition of some mucilaginous drink, in small portions, 
 and at short intervals, will be found to abate, very sensibly, tlie cough, and relieve the dry- 
 ness of the fauces, which, in the early stage of the disease, is often a harassing symptom. 
 A solution of gum acacia, or the mucilage of the elm bark, or pith of sassafras, sweetened, 
 will be the best we can employ. 
 
 The diet of the patient, in the earlier period of the more acute cases, should be confined, 
 almost exclusively, to these mucilaginous fluids — after the violence of the disease has been 
 subdued, plain water gruel, arrow-root, or tapioca, may be allowed. When the disease oc- 
 curs in young infants, they should be taken from the breast — the mother's milk being given 
 to them in moderate quantities by means of a spoon, as well to prevent their stomach from 
 being overloaded, as to guard against the mischievous effects of the violent exertion of the 
 respiratory organs in sucking. 
 
 The patient should be kept in a clean, well ventilated, and moderately warm apartment. 
 It is all-important to guard him from cold and dampness, and from sudden transitions of 
 temperature. He should be placed upon his bed or couch in a half-recumbent position, in 
 order to render the respiration more easy, and to prevent the injurious consequences resulting 
 from the stasis of fluids in the posterior portion of the lungs. 
 
 AVhen the disease has arrived at an advanced stage, or involves a considerable extent of 
 the lungs, the patient should be moved with the greatest care and gentleness, lest convulsions 
 be induced. 
 
 After convalescence is fully established, gentle exercise in the open air, in mild, dry wea- 
 tlier, may be taken ; but, for a long period, the utmost care should be observed to guard against 
 exposure to cold and dampness ; and while a gradual improvement is made in the diet — if 
 the child be weaned — all rich, stimulative, and indigestible food must be avoided, as well as 
 the slightest excess in the use of those articles that are allowed. See Condie on Diseases of 
 Children, 2d ed., page 274, et seq. — C] 
 
 In the next lecture I shall speak of pleurisy. 
 
 LECTURE LII. 
 
 Pleurisy. Its anatomical chtiraders ; false membranes; liquid effusion ; effects 
 of these tipon the shape and contents of the chest, and upon its healthy sounds. 
 Symptoms of Pleurisy. 
 
 I PROCEED this afternoon to the subject of pleurisy, having in the last lecture con- 
 cluded 'what I had to say on that of pneumonia ; that is. I pass from inflammation
 
 580 PLEURISY. 
 
 of the substance of the lung, to inflammation of its investing membrane. The two 
 frequently exist together ; but, when that is the case, the one predominates greatly- 
 over the other. Pleurisy, however, without pneumonia, is much more common than 
 pneumonia without pleurisy. When both are present, and the pneumonia predomi- 
 nates, the term pi euro-pneumonia is applied to the compound disease. The whole 
 interest of such a case merges in the pneumonic inflammation. Again, when both 
 are present, and the pleurisy predominates, the compound affection is sometimes 
 called pncumo-pleuritis. 
 
 The pleura, as you know, is one of the serous membranes. Its inflammation is 
 attended, therefore, with those events which I formerly took some pains to describe 
 as belonging especially to that particular tissue. The inflammation is of the adhe- 
 sive kind : it is accompanied by pain, by the pouring out of serum, of coagulabla 
 lymph, of pus, or of blood, I think it will be best, in this instance, also, to lay 
 before you some account of the morbid anatomy of the disease, before I consider it's 
 symptoms. 
 
 The alterations that take place in the inflamed membrane itself are not very 
 striking or important. Experiments upon living animals, made by introducing some 
 foreign substance, or injecting some slightly irritating liquid, into the cavity of the 
 pleura, have proved that, as in other cases, inflammation is attended with redness of 
 the part affected. But it is scarcely ever that we observe this effect alo7ie of inflam- 
 mation, in the pleura of a dead person ; unless, indeed, he has died of some other 
 Complaint while he happened to have incipient pleurisy. The pleura has been said 
 to be thickened by inflammation ; but that I apprehend to be, a mistake. It often 
 appears to be thickened, in consequence of the superposition of a false membrane — 
 a layer, or several layers, of plastic lymph. But actual thickening of the pleura 
 itself seldom or never happens. Neither does the pleura easily soften, or readily 
 ulcerate, under inflammation. It peels off", in some cases, from the lung, or from the 
 ribs, with more facility than in the sound state. 
 
 The most remarkable effects of pleurisy result from the effusion of coagulable 
 lymph, or of serous fluid, or of both, into a shut sac, having peculiar anatomical 
 relations. One part of the membrane lines the firm walls of the chest ; the other 
 part envelops the soft and compressible lung. The opposed surfaces of this closed 
 and empty bag being opposed also, but freely movable one upon the other, very dif 
 ferent, and even contrary, effects may be produced by its inflammation. The pul 
 monary pleura may be glued to the costal pleura, so as to prevent all lateral move 
 ment between them, and to obliterate the pleural cavity ; or the two surfaces of the 
 membrane which are naturally in contact, may be forced unnaturally apart by a 
 pouring forth of serum between them ; or the opposite surfaces of the pleurae may 
 be united by coagulable lymph in some places, and separated by effused fluid in 
 others. And great difl^erences will arise in the symptoms, and in the gravity and 
 tendency of the complaint, according as one onanother of these different conditions 
 of the contents of the thorax is established. 
 
 Let us first consider the effect of the throwing out of coagulable lymph only ; or, 
 of what comes to the same thing, the effusion of coagulable lymph with a small 
 quantity of serum, which last is soon reabsorbed. 
 
 One consequence of this is the formation of false membranes. These, indeed, 
 are formed whether there be much or little serum poured out. We continually meet 
 with them, sometimes when we least expect to do so, in the dead body. They vary 
 greatly, in different cases, in respect to their thickness, situation, extent, organization 
 and effects. 
 
 When the lymph is first deposited upon the free surface of the inflamed pleura, 
 it is soft, and of a grayish-white colour, like paste somewhat. It soon, however, 
 acquires an increase of consistence, and shows marks of vitality ; becomes, in short, 
 organized. Red points begin to appear in it, few in number and widely separated, 
 at first ; but they presently multiply, and lengthen into reddish streaks, which run 
 aiong the surface of the efllised matter. Soon these red streaks may be perceived 
 to be slen-ler vascular canals ; and at length they inosculate with the vessels of the 
 pleura, and the lymph, converted into a false membrane, becomes a constituent par* 
 nf tne livinp- frame.
 
 PLEURISY. 581 
 
 It is curious, and useful too, to know how rapidly this work of organization may 
 go on. 
 
 Andral made experiments upon the pleuroe of rabbits, by injecting acetic acid into 
 them. He sometimes found, at the end of nineteen hours, soft and thin false mem- 
 brane, traversed by numerous anastomosing red lines. In other rabbits, placed 
 under circumstances which appeared to be exactly similar, no such result had taken 
 place at the end of a much longer period ; but the pleura contained only a serous or 
 puriform liquid, mixed with unorganized flakes of lymph. Now similar differences 
 have been remarked in the human subject, under disease. False membranes, 
 already vascular, have been found in the bodies of persons who died of pleurisy 
 after a very few days' illness : while in other patients, who had lived for many 
 months after the invasion of the disease, there has been no trace of such vascular 
 membranes. It is clear, therefore, that the organization of the lymph does not de- 
 pend solely upon the length of time that has elapsed from the period at which it was 
 poured forth. It has much more to do with the previous state and habit of the 
 patient. Cseteris paribus, plastic lymph and early adhesion are more to be expected 
 in young, strong and healthy persons ; curdy unorganized lymph, granular deposits, 
 with copious and abiding serous effusion tending to become puriform, in such as are 
 old, feeble, cachectic, and scrofulous. 
 
 The extent of these false membranes varies according to the extent of the inflam- 
 mation which has produced them. When that has been general, they cover the 
 whole lung, and line the whole costal surface, and spread themselves over the 
 diaphragm and mediastinum of the same side. Supposing that there is no serous 
 liquid effused, or that it is absorbed, the lung then becomes everj'where adherent 
 to the sides of the cavity which contains it. The medium of adhesion, which is soft 
 and tender while it is recent, grows firm, and assumes the characters of areolar tissue, 
 when the union is of old standing. 
 
 The thickness of the false membranes is also extremely variable. Sometimes it 1 
 not more than that of the pleura itself, and the lymph might then, in the absence ot 
 adhesion, be almost overlooked. But in the majority of cases their thickness is much 
 greater than this. Frequently several distinct layers or strata are seen, superposed 
 one upon another, to a considerable depth. 
 
 Are there any auscultatory signs of this process of adhesion when it occurs? Yes. 
 There is a morbid sound not hitherto mentioned by me, whereby it is sometimes dis- 
 closed : the sound, namely, oi friction ; the sound produced by the rubbing together 
 of the dry, or inflamed and roughened surfaces. You doubtless are aware that every 
 time a tolerably deep inspiration takes place, the relation between the ribs and the 
 lung undergoes a change. While the ribs are elevated, the lung descends a little : 
 and consequently any given point of the surface of the lung is no longer in contact 
 with the same point as before of the thoracic parietes. You may convince yourselves 
 of this fact by carefully making a small incision through an intercostal space, in a 
 living animal. Now the pulmonary pleura, when that membrane is inflamed, does 
 not slip and glide over the costal in its usual smooth and noiseless manner ; but it 
 makes a creaking or rubbing sound, which the ear, applied to the corresponding sur 
 face of the chest, readily catches. I have many times heard this; yet it is not 
 at all a common sound : indeed I had heard it, in one instance, some time before I 
 knew what the noise meant. The sound has, mostlj^ an interrupted character, 
 occurring in a series of three or four jerks. The patient is often made aware of the 
 harsh movement, by some internal sensation ; and a bystander, who places his hand 
 flat upon the corresponding surface of the thorax, may sometimes feel this grating of 
 the membrane upon itself. You may wonder, as adhesions are so common, that this 
 sound, and these sensations are not oftener heard, and felt. In truth, they are tran 
 sitory phenomena, and cease, of necessit}', as soon as adhesion prevents any further 
 motion of the opposed pleurfe upon each other. If we do not happen to listen during 
 that period, usually a short one, in which the pleurcc, roughened by inilaiamntiou 
 and effused lymph, but not separated by liquid, still chafe against each other, we 
 lOse the opportunity of hearing the sound at all. This rubbing sound, this noise of 
 fiiciion, we shall find to be of greater importance in relation to certain diseases of 
 
 2y2
 
 582 PLEURISY. 
 
 the heart, than m cases of acute pleurisy. In pleurisy the liquid matters poured 
 into the membranous sac have far more interesting consequences : and to these I now 
 beg your attention. 
 
 In some instances we find, after death, a clear serous, or watery fluid, without 
 colour, or of a pale lemon colour, and perfectly limpid and transparent. This may 
 occur independently of inflammation of the pleura ; from some mechanical obstacle 
 to the circulation. It then constitutes a species of dropsy; a true hydrothorax : 
 and this, though less common than ascites, is by no means an uncomxnon conse- 
 quence of disease of the heart. When the efflision does not proceed from a cause 
 of that kind, it is always, probably, the result of inflammation of the pleura itself, 
 although we may find only a slight degree of redness upon its surface, or a few 
 patches of coagulable Ij'mph. More frequently, besides this clear hquid, with flakes 
 of albuminous matter floating in it, there is also a coating of lymph on the inflamed 
 membrane. Very often the thinner fluid is turbid, or whitish, like whey ; sometimes 
 it is distinctly puriform ; sometimes it is tinged more or less deeply with blood ; 
 sometimes it consists of nothing else but blood, which has separated into the serum 
 and crassamentum. There being no wound, nor visible rupture, of large or of small 
 vessels, we conclude, in such cases, that the blood has exuded, or been exhaled, from 
 the membrane. 
 
 The different kinds of fluid effused into the pleurce are alwa)'s, or almost always, 
 without smell ; — provided that it has remained a closed bag : I mean when no com- 
 munication has been established between the cavity of the pleura and the external 
 air, either through an opening in the walls of the chest, or through a pulmonary 
 fistula leading to the trachea, or through some breach of the oesophagus. I have 
 met with but one exception, and that a doubtful one, to this rule. A patient died in 
 the hospital, who, some years before, had nearly killed himself by swallowing, in 
 mistake for beer, a solution of caustic potass. The result of this had been ulceration, 
 and subsequently stricture, of the gullet. His left pleura was perfectly full of most 
 stinking pus ; and we were unable to detect any channel of communication with the 
 outward air, although the circumstances of the case rendered it not improbable that 
 such a channel might have existed. 
 
 Sometimes air, or gas, is found in the cavity of the inflamed pleuia; either alone, 
 or (what is much more common) together with a liquid. We ascertain this fact, in 
 the dead bod3% by the hissing sound that takes place as soon as a penetrating inci- 
 sion is made between the ribs ; or by opening the thorax under water, and noticing 
 the escape of air in the form of bubbles. It is probable that these gases are some- 
 limes secreted or exhaled from the diseased membrane ; sometimes they are the pro- 
 duct of decomposition within the cavity; but, for the most part, they are met with 
 only when the sac of the pleura communicates somehow with the external air. 
 
 Such being the fluid matters that frequently occupy the cavity of the pleura when 
 that membrane has undergone inflammation, let us next examine the necessary effects 
 of their being collected in that part. These efl^ects \\'\\\ obviously vary considerably 
 according to the quantity of the fluid that accumulates. 
 
 Now the quantity of fluid may vary from less than an ounce to several pints. At 
 first it is lodged in the cavity of the pleura solely at the expense of the yielding lung, 
 which is compressed to make room for it. But if the quantitj'- continues to augment, 
 other parts at length displaced by the increasing pressure, the boundaries of the chest 
 on that side are stretched, and even the abdominal viscera are thrust out of their 
 natural position. The lung is pushed back towards the mediastinum and vertebral 
 column, and flattened, and brought to lie in the smallest possible compass ; the 
 diaphragm is forced downwards, which sometimes gives rise to a considerable promi- 
 nence of one or the other hypochondrium, the spleen and stomach being displaced 
 on the left side, or the liver on the right. The ribs are separated too; the intercostal 
 spaces become wider, and are pushed out to the level of the bones, and the whole of 
 the afiected side is smooth and obviously larger than the other. The mediastinum 
 also undergoes some chansre of position, being driven more or less towards the side 
 opposite to that on which the effusion exists. If the liquid happens to fill and distend 
 the left side of the thorax, the heart may be moved out of its natural place, and be
 
 PLEURISY. 583 
 
 heard, and felt, and seen to beat on the right of the sternum. Andral mentions 
 having met with only one instance of that kind. I suppose that I cannot have wit- 
 nessed less than a dozen such. So again the heart may be carried beyond its proper 
 place, to the left, by a large effusion into the right pleural cavity. 
 
 I say when the liquid is accumulated in very considerable quantity, the luno- is 
 pressed into the form of a thin cake, which occupies a very small space alono^side 
 the vertebral column : and if it happens to be covered over and concealed, as it often 
 'is, by a strong layer of adventitious membrane, we might fancy, at first examination, 
 that it had completely disappeared. It was in cases of this kind— especially whea 
 the effused fluid consisted of pus — that the lung was erroneously represented by the 
 older observers as having been destroyed by suppuration. However, you will always 
 find the lung there if you take the pains to look for it, and to divide the false mem- 
 branes that bind it down : and, in many instances, it is sound also. Its surface may, 
 indeed, be wrinkled, but the lung itself is capable of being restored to nearly its 
 former volume by insufflation, as- it is called; by blowing air into it through the 
 principal bronchus of that side. In this compressed state the lung does not crepitate- 
 under the finger : it is dense, and sinks in water ; in fact it is wholly void of air, 
 and has been brought, by the pressure of the fluid around and upon it, into nearly 
 the condition of the lung of the fcelus that has never breathed. But its firmness, its 
 resistance to being torn, and its capability of being again inflated, prevent our con- 
 founding it with hepatized lung. Sometimes its cellular texture is obliterated ; the 
 opposite surfaces of the vesicles and smaller air-tubes adhere together; the luno- will 
 aot admit air ; it looks like a piece of muscle, and is then said to be carni/ied. 
 
 Such is the general account of the anatomical characters of pleurisy, as they are 
 lisclosed to us by an examination of the body after death. We may now inquire 
 what effect these changes are capable of producing on the sounds which are heard 
 when the heahhy chest is percussed, or listened at. We shall then be the better 
 prepared to appreciate the several symptoms, general and physical, which are known 
 actually to occur in pleurisy. Now it is clear that when the lung is pushed away 
 from the walls of the thorax by fluid between the pleurae, it will be compressed also ; 
 its capacity must be reduced ; less air will be able to enter it. There will conse- 
 quently be a proportional diminution in the intensity of the respiratory murmur , 
 and this murmur will, moreover, be less audible in consequence of the distance, from 
 the ear, of the structure in which it takes place. The lung is attached by its roots 
 (so anatomists speak) to the spinal column. A moderate amount of effusion will, 
 therefore, cause it to recede upwards and inwards ; and a certain quantity of the 
 liquid will ascend between the lung and the ribs, compressing the spongy pulmonary 
 tissue around the larger and more resisting bronchial tubes. We might expect, in 
 this condition of things, that the passing breath and the voice, would be audible in 
 those tubes, through the partially condensed lung, and through the circumfused layer 
 of liquid: and it is so. We do hear bronchial respiration, and bronchial voice and 
 cough ; with some modification, indeed, to be noticed presently. In this respect 
 therefore, you will observe that pneumonia, which solidifies the spongy texture of 
 lung around the bronchial tubes by filhng it with blood, has the same effect, so fai 
 as acoustic principles are concerned, as pleurisy, which solidifies a portion of the 
 lung by expressing air from it, and pours round the bronchial tubes a fluid which 
 readily transmits sound. Hence bronchial respiration and bronchophony are not 
 always indicative of the same condition of parts within the chest, but derive their 
 true value and meaning from the context, if I may so say ; from the circumstances 
 under which they occur, and with which they are associated. 
 
 When the eflusion is so copious as to squeeze aU the air out of the spongy part ot 
 the lung, to pack the organ up along the vertebral column, to distend the thorax, and 
 to compress strongly the bronchial tubes themselves, no respiratory murmur ccri 
 then be heard, nor any tubular breathing; for the dilated chest can neither expanJ 
 nor collapse, and, therefore, no air can pass along even the larger air-tubes ; neithei 
 can these compressed tubes vibrate with the patient's voice , wherelorc Lrfonchophony 
 also ceases, or is but faintly audible. 
 
 Again, if percussion be made over a portion of the chest, where there is inr.onv
 
 584 PLEURISY 
 
 pressible serous fluid beneath, in the stead of healthy and spongy luncr, a dull flal 
 sound will be rendered. But a dull sound is rendered also when percussion is made 
 over a solidified lung. Hence the mere dullness of the part struck does not inform 
 us whether Ave have pneumonia or pleurisy tn deal with, or some other disease that 
 has the effect of making the lung solid, without plugging up the larger bronchi. 
 
 But an expedient presents itself, by which we may, in some cases, render this 
 experiment of percussion conclusive. The dull sound occasioned by hepatization or 
 other solidification of the lung occupies the same spot in every position of the patient. 
 Not so, necessarily, the dull sound produced by the presence of liquid in the cavity 
 of the pleura. The liquid will gravitate to the lowest part of that cavity, and will 
 carry with it the dull sound. We place the patient, therefore, in different altitudes ; 
 and if we find that the chest, when struck, is always resonant in the higher, and 
 always dull in the lower portions of the thorax, whatever the posture may be, then 
 we may be sure that the cavity of the pleura contains liquid. In such a case, when 
 the patient sits up, the dull sound will be elicited from the lower part of the chest, 
 on one side, from the spine round to the sternum. When he hes on his back, the 
 anterior of the thorax sounds hollow ; the posterior dull : and when he reverses that 
 position, and lies with his face downwards, these sounds change places also ; the 
 hollow sound is still uppermost, in the posterior part of the cavity ; the dull sound 
 still undermost, in its anterior portion. 
 
 There are just two states which may interfere with the true interpretation of the 
 sounds produced by percussion in the manner now described ; and these are, first, 
 partial adhesions of the pleurae, which may confine and isolate the effused liquid, 
 and prevent its sinking from one part of the chest to another under the influence of 
 gravity : and, secondly, so large an amount of effusion as to fill entirely the cavity, 
 and fix the compressed and empty lung in one position ; for it is necessary, in order 
 to obtain the shifting sounds in different attitudes of the bod}^ that there should be 
 light spongy lung to ascend, as well as heavier fluid to sink down, according to 
 the posture of the patient. In this last case, that of excessive effusion, the whole 
 surface of the affected side will yield a dull sound. It is seldom so in pneumonia; 
 it is seldom that the entire lung on one side is so blocked up, in consequence of in- 
 flammation, as to give rise to universal dullness on percussion. But the diagnosis 
 of these two conditions is an important one, and apt to puzzle a student. I hope to 
 elucidate it as we go on. 
 
 We may now consider, with a better chance of understanding some of them, the 
 s-ymploms which are generally met with in a case of pleurisy under its ordinary 
 form and progress. The general signs, then, of that complaint are rigors, pain in 
 the chest, dyspnoea, cough, difliculty or impossibility of assuming certain postures, 
 and fever. Very much the same, therefore, (as Cullen truly stated) with those of 
 pneumonia, and, it may be added, with those of pericarditis : but auscultation dif- 
 ferentiates these diseases. The physical signs I will examine presently. The general 
 symptoms will bear, each of them, a short comment. 
 
 The pain which the patient feels — or the stitch in the side, as it is expressively 
 called — is one of the most striking and characteristic signs of the disease. Point de 
 cote, the French name it. It occupies a point or spot ; and patients feel as if some 
 sharp stabbing instrumen* were driven in at that spot every time that the act of inspi- 
 ration goes beyond a certain limit. The Latin medical writers, attending chiefly to 
 this prominent syuiptom, call pleurisy *' morbus lateris." 
 
 This pleuritic stitch is subject to considerable variety in regard to its situation, its 
 severity, and its dura ion. Most commonly it is felt on a level with or just beneath 
 one or other of the breasts, in the part corresponding to the lateral attachments of 
 the diaphragm : and this, even when the inflammation which occasions it is of much 
 greater extent. 'Why is this? What is the cause of the pain ? Wherefore should 
 it bo restricted to one small spot, when the inflammation perhaps pervades the whole 
 of the pleura? Pathologists have made attempts to explain these matters; but per- 
 haps tht'ir explanations are not very much to be trusted to. They say that there is 
 a larger degree of motion at the lower part of the thorax, of the pulmonary over the 
 costal pleura ; and that the pain resulting from that friction, when the membranes
 
 PLEURISY. 585 
 
 are inflamed, is therefore felt where the friction is the greatest. However the pain 
 is not always confined to that spot. It is occasionally I'elt in other places, as in the 
 shoulder ; in the hollow of the axilla ; beneath the clavicle ; along the sternum : and 
 sometimes it is complained of as extending over the whole of one side of the thorax. 
 Andral states that he has observed the pain to prevail especially along the cartilao-in- 
 ous border of the false ribs, when the inflammation has attacked that portion of the 
 pleura which covers the upper surface of the diaphragm. He says, too, that in such 
 cases, the pain often affects the hypochondrium, and even extends as far as the flank, 
 so that it might be mistaken for a symptom of abdominal inflammation. This ob- 
 servation is Avorth remembering. Sliarp pain, occupying the right hypochondrium, 
 belongs oftener to the pleura than to the peritoneum. I have known several instances 
 m which such pain was erroneously supposed to be a sign of hepatitis, when in truth 
 It resulted from inflammation of the pleura. Cruveilhier observes, also, that he has 
 known the pain afiect the loins, and simulate lumbago. 
 
 Whatever may be the situation of the pleuritic pain, it is generally increased by 
 percussion, by intercostal pressure, by lying on the aflected side, by a deep inspira- 
 tion, by cough, and by diflerent movements of the body. 
 
 In many patients the pain is exceedingly sharp, whether it be continued, or whe- 
 ther it occur only at intervals : the more circumscribed it is, generally the more acute 
 it is. The patients are then in a state of great anxiety: they make very short and 
 imperfect inspirations, through fear of aggravating the pain ; they dread the least 
 effort of coughing, or of sneezing, and suppress the desire to cough which the dis- 
 ease may occasion. There are other patients in whom the pain is moderate, is felt 
 only when a deep inspiration is made, and is scarcely augmented by pressure or per- 
 cussion. And there are even some cases of pleurisy which are unattended with pain 
 from first to last. 
 
 The pain commonly exists from the very outset of the pleurisy. It is sometimes 
 vague and fugitive at first, and becomes fixed and permanent after a day or two. In 
 that case it may be mistaken for a simple rheumatic pain ; for pleurodyne ; or for 
 what is thought to be merely a nervous pain. When the pain is increased by shght 
 pressure made upon the ribs as weU as between them ; when it extends over a laree 
 space ; Avhen it is unattended with fever ; when it is inconstant or fugitive — we may 
 suspect that it is situated in the fibrous and muscular tissue ; but these circumstances 
 do not afford any certainty that such is the case. In fact, I have long been of opi- 
 nion that some at least of the cases which pass under the name of pleurodyne, are 
 really instances of what has been called dry pleurisy. You are aware perhaps that 
 adhesions are very constantly found to exist between the lungs and the ribs in per- 
 sons dead of pulmonary consumption. Such persons are liable to pains in the chest, 
 beneath the clavicles, in the axilla, between the shoulders, at the upper part of the 
 dorsal region : in short, in those situations where the adhesions are found after death 
 most frequently and in the greatest number. The pains indicated, it may be pre- 
 sumed, the periods at which the shghter forms of circumscribed pleurisy, attended 
 with no other effusion than that of coagulable lymph, took place. And it is probable 
 that many cases of pleurodyne are really instances of the same kind of pleuritic 
 inflammation. How often do we find, even when there are no tubercles in the luno-s, 
 firm adhesions between the pulmonary and costal pleura3, in the bodies of persons 
 who were never known to have had any pectoral disease ! The pain alone marks 
 the inflammation in those cases ; adhesion presently ensues ; there is no fever per- 
 haps, or none that attracts much notice ; the pain soon subsides, and is soon foro-otten ; 
 but the adhesion, the consequence of inflammation, remains : and this is a morbid 
 condition which is neither revealed to the sense of hearing, nor in any other way. J 
 am much disposed therefore to agree with Cruveilhier in thinking that ''pleurodyne 
 is nothing else (in many cases at least) than adhesive pleurisy.'' 
 
 I need scarcely repeat the fact which has so many times before been mentioned 
 in these lectures, viz., that the inflammation of membranous parts, and especially 
 of serous membranes, is attended with much more pain than inflammation of paren- 
 chymatous parts. We cannot have a better example of it than is afforded in most 
 Cases of pneumonia. Most cases of pneumonia are accompanied in the begiiuiing
 
 586 PLEURISY. 
 
 with a stitch in the side ; some cases are not. In those cases in which the stitch 
 happens, tiie pleura also is inflamed to a certain degree, and the pain depends 
 upon the coexistence of the pleurisy : they are cases of pleuro-pneumonia. In 
 pure pneumonia, on the contrary, the pleurisy being wanting, the sharp pain is 
 wanting also. 
 
 The respiration in pleuris}, at its outset especially, and while there is still pain, 
 is considerably embarrassed ; the movements of inspiration in particular are short, 
 hurried, and often interrupted or jerking. And this depends evidendy upon the pain, 
 which forbids the free contraction of the muscles that dilate the thorax ; and you may 
 often observe that the dilatation is sensibly less on the affected side than on the other. 
 Cruveilhier indeed denies this ; or rather he states that he has never observed it: 
 but it certainly is not an uncommon phenomenon, I have noticed it, and drawn the 
 attention of others to it, again and again. 
 
 When effusion has taken place — that, one can easily understand, will be likely 
 to aggravate the dyspnoea; and it will aggravate it in a greater degree, or in a less, 
 according to circumstances. Thus, if the other lung happens to be a diseased lung, 
 then the compression of that which is on the side of the pleurisy will have a more 
 injurious effect upon the breathing. The dyspnoea arising from the effusion and con- 
 sequent pressure upon the lung will also be in proportion, first to the amount of the 
 efTusion ; and, secondly, to the rapidi/y Avith which it has taken place. When 
 the effusion has been slow — or when it has long existed, and the case has become 
 chronic — the circulation through the lung has had time to accommodate itself to the 
 altered condition of the parts, the disturbed equilibrium bt?tween the quantit)'- of air 
 and the quantity of blood in the lung is restored, and the dyspncca is consequently 
 shght. 
 
 But there are very singular exceptions met with to all this. Andral states (and 1 
 have seen more than one instance confirmatory to his statement') that there are per- 
 sons with pleuritic effusion enough not merel\^ to fill but to dilate that side of the 
 chest on which it exists, (and you will observe that we cannot doubt about the pre- 
 sence of the effusion in such a case,) who appear nevertheless to be quite free from 
 dyspncea; and that, not while they are at rest merely, for the}'- talk, get up, walk 
 about, even take long journeys, without their respiration becoming so short as to 
 make them complain of it. Now this is conceivable enough in old and chronic cases ; 
 but Andral further affirms that this absence of dyspnea is not restricted to those 
 cases in which the collection of fluid has taken place slowly ; but sometimes happens, 
 even in patients in whom pleurisy has Ld to abundant effiision in a few days. He 
 gives a case of this kind, in which the patient was not prevented by an enormous 
 pleuritic effusion from carrying on, without fatigue, in the streets of Paris, his busi- 
 ness as a carter. I remember having a butcher in the Middlesex Hospital in ex- 
 actly the same predicament ; and nothing could persuade him that he was otherwise 
 than well, and fit to go out ; and out accordingly he went. Remember, therefore, 
 that there are great varieties in this respect. In some patients the dyspnoea never 
 ceases to be urgent from first to last ; and these are apt to prove fatal cases. In others 
 the respiration is very much impeded at first ; then the difficulty of breathing di- 
 minishes ; and at length it ceases long before, the fluid is reabsorbed. In others 
 again, by some unaccountable idiosyncrasy, the respiration remains at all times very 
 facile, both at the outset and during the progress of the disease. 
 
 Cough is another of the ordinary symptoms of pleurisy. It does not occur in 
 paroxysms. It is small, half-suppressed, ineffectual. In some few cases this symp- 
 tom also is entirely absent, even though the inflammation is intense, and the efllusion 
 into the pleura considerable. When cough does exist, it is dry ; or it is accompanied 
 by the expectoration of slight catarrh. If much frothy mucus should be expectorated, 
 the pleurisy is complicated with bronchitis: if rust-coloured sputa be brought up, it 
 is complicated with pneumonia: and in each case other signs, proper respectively to , 
 those iwo diseases, will be present. 
 
 A good deal has been said and written respecting the position which a patient 
 assumes who is labouring under pleurisy. The manner of the decubitus has even 
 beeii regarded as one of the pathognomonic signs of the disease. Yet, strange to
 
 PLEURISY. 587 
 
 say, observers are much at variance with each other in respect to this so-called 
 pathognomonic symptom. Some affirm that the patient hes on the side affected ; 
 others that he can He only on the sound side ; others ajjain that he lies neither on 
 the one side nor on the other; or even that he lies indifferently in any posture. But 
 this dispute is an exact counterpart of that celebrated quarrel which took place about 
 the colour of the chameleon: "they all are right, and all are wrong." I believe 
 that, if you narrowly inquire into the facts, they will be found to be somewhat as 
 follows : — In the outset of the disease, while there is yet pain, the patient cannot he 
 on the affected side on account of the pain, which that position exasperates ; he lies 
 therefore on the sound side, or on his back ; sometimes he is obliged to sit up. At 
 a more advanced period of the disease, when the pain has ceased, and considerable 
 effusion has taken place, he cannot lie on the sound side, because of dyspnoea : the 
 dilatation of the chest on that side would be impeded by such a posture ; and what 
 is more, the effusion, lying uppermost, would press upon the mediastinum, and so 
 further tend to restrain the expansion of the sound lung. But he is no longer pre- 
 vented by pain from tying on the diseased side, and consequently he does, in some 
 instances, take that position: but more commonly still he lies in what Andral calls a 
 diagonal posture ; i. e., the patient is not on his back, nor on his side, but between 
 the two ; on his back, we may say, but inclining towards the affected side. Again, 
 however the fact maybe explained, it is certain that there are some few persons who 
 lie indifferently on the back or on either side without augmentation of the dyspnoea 
 in any of these positions, though one side is choke-full of liquid. 
 
 Now of the symptoms that we have hitherto been considering, the pain, the 
 dyspncEa, the cough, the accommodation of position, there is not one which, taken 
 alone, can be said to be strictly or absolutely pathognomonic; or which indicates in 
 a positive and certain manner the existence of pleurisy, or of pleuritic efflision. Yet 
 when all, or several of them, occur together, they afford a degree of probability on 
 these points almost equivalent to certainty. There are yet some other, and more 
 conclusive signs, which either in themselves, or taken in conjunction with those 
 already mentioned, render the diagnosis of pleurisy easy and sure. These signs are 
 furnished by the size of the thorax on the affected side ; by its form and motions ; 
 and above all, as you will have anticipated, by percussion and auscultation. 
 
 I have already stated that in some cases, that side of the chest which contains the 
 effused fluid becomes evidently larger than the opposite side. The ribs and their 
 cartilages present that position which they assume during a deep inspiration : the 
 intercostal spaces are pushed outwards and brought up to the level of the ribs ; and 
 occasionally fluctuation may be perceived in those spaces, through the muscles. 
 When these appearances are observable, no doubt (or scarcely a doubt) can remain 
 concerning the nature of the disease. This dilatation of the thorax on the diseased 
 side is more common in old chronic cases than in the earlier periods of acute pleu- 
 risy ; yet it may take place in a very short time. Andral declares that he has known 
 it sometimes reach a great degree by the fourth or fifth day of the acute disease. 
 You may satisfy yourselves that the side is dilated, by measuring it with a string. 
 Carry a string round the chest, upon a level with the extremity of the xyphoid 
 cartilage, then fold it upon itself, and you will find that the half of it will more than 
 encompass the sound moiety of the chest, and will not reach round the disease. The 
 diseased side may measure an inch, or an inch and a half, or even sometimes two 
 inches, more than the other. But this measurement by a string is seldom necessary. 
 The eye takes a very accurate estimate of the comparative volume of the two sides ; 
 and the obliteration of the intercostal spaces can only be ascertained by seeing or 
 feehng them. It is necessary to remember that, in most persons, the right side is 
 naturally somewhat the larger of the two. 
 
 I say when this dilatation is noticed, scarcehj a doubt can exist of the true nature 
 of the case. Some time ago I should have said no doubt : but having myself mis- 
 taken such a case, and seen others mistake it, I introduce this slight qualification, 
 although it is a thousand to one against another such instance occurring to puzzle or 
 mislead the observer. My colleague Dr. Hawkins had a patient in the hospital, in 
 whom this dilatation of one side of the chest was exceedingly well marked. It was
 
 588 PLEURISY 
 
 the left side that was enlarged ; the heart was evidently pushed over to the right of 
 the sternum. This is another circumstance strongly corroborating our conclusion in 
 such cases. The intercostal spaces were effaced, and the whole of that side was 
 perfi ctly dull on percussion. The poor fellow had a very unhealthy aspect ; — and 
 he had, some time before, suffered ampatation of a leg, for what was understood to 
 have been scrofulous disease of the knee-joint. It was not unnatural, therefore, that 
 every one who saw him should have come to the conclusion that this was a case of 
 empyema ; of fluid, and most likely of pus, collected in the pleura, and very proba- 
 bly the result of the extension of scrofulous disease from the lungs. Under these 
 circumstances, and inasmuch as his dyspnoea was not urgent, it was not thought 
 right to take any steps for evacuating the presumed fluid. The case was pointed, 
 out to ihe pupils as a capital example of empyema. At length the patient died ; and 
 when his body was examined we discovered — what think you ? not pus, nor serum, 
 but a larire red solid mass, in the centre of which, when it was divided, was still a 
 red, but softer, pultaceous, half-fluid substance. At first it was thought to be can- 
 cerous degeneration of the lung; but it was soon noticed that the solider part was 
 arranged in concentric layers, like those which are often seen in aneurismal tumours ; 
 and further research showed that the effusion had indeed once been liquid, for it 
 consisted entirely of blood, which had coagulated in the manner I have just described. 
 And the source of the blood was detected. A portion of two of the ribs had been 
 destroyed by ulceration, and one of the intercostal arteries had thus been laid open. 
 The lung was found uninjured, but totally empty of air, and pressed flat up against 
 the mediastinum. 
 
 No precaution could guard against such a source of fallacy ; and you are not 
 likely ever to meet with just such another case: yet I have thought it sufficiently 
 interesting to relate, in illustration of the subject immediately before us. 
 
 It is unfortunate, as far as the diagnosis is concerned (but not in any other sense), 
 that dilatation of the thorax is far from being a constant symptom, even in cases in 
 ■which the effusion is verj^ considerable. 
 
 There is still a condition of the thorax to be described, which is the very opposite 
 to this. When the effused fluid begins to be reabsorbed — and when some cause or 
 other, generally the formation of adventitious membranes, prevents the lung from 
 re-expanding, and approaching the ribs in proportion as the fluid is removed — then 
 of course the ribs jjiust sink in, and approach the lung, to prevent that void which 
 would otherwise exist between the ribs and the lung. Consequently that side of the 
 chest on which the fluid has existed becomes narrower than the sound side. And 
 the actual diflerence between the two will be augmented by the circumstance that, 
 in such cases, an amphfication of the sound lung, and of the cavity in which it is 
 lodged, a true compensatory hypertrophj', commonly takes place. 
 
 This partial or general retraction of one side of the chest is not so much a sign of 
 disease actually in progress, as of disease gone by ; and it may exist without evident 
 disturbance of the health of any kind. 
 
 Persons who are thus affected have the appearance of being inclined towards the 
 diseased side, even when they endeavour to hold themselves upright: and the de- 
 formity, for such it is, becomes manifest to the eye when the chest is uncovered. 
 You see that the side is narrowed and shrunken. All its dimensions are contracted. 
 It measures less, in circumference, by an inch or more, than the other side. The 
 shoulder is depressed ; the hypochondrium is tucked up ; and the libs are drawn 
 close together. A patient of mine, whose chest had been punctured (a remedial 
 procedure to be spoken of presently), and who drew off daily, with a syphon, pus 
 which did not otherwise find vent, had such difficulty at last in introducing the tube 
 between his ribs, that excision of a piece of the bone was contemplated by the emi- 
 nent surgeon who had performed the operation. The effect of the atmospheric 
 pressure is sometimes so great as to crook the vertebral column, and produce lateral 
 curvature of the spine. This I have myself witnessed. And as one of the unseen 
 walls of the cavity, viz., a part of the diaphragm, is carried permanently up under 
 tne ribs, so another of the unseen walls, the mediastinum, is liable to be influenced 
 by the tendency to contraction. The heart w4iich, when the left pleura is distended,
 
 PLEURISY. 589 
 
 IS apt to be thrust over, beyond the sternum on the right, may thus, when the nght 
 pleura is contracted, be dragged into the same position. In the former case, the 
 dull sound given out by the diseased side when struck, will transgress the mesial 
 line, and encroach a hltle upon the healthy side : in the latter, the resonance yielded 
 by the healthy will transgress the mesial line, and encroach a little upon the diseased 
 side. 
 
 The difference of the two sides is so striking, that, at first sight, an observer sup- 
 poses it to be even greater than it is actually found to be by admeasurement. Yet 
 Laennec tells us that he had met with this deformity in persons who were not them- 
 selves aware of its existence. But all such persons had suffered some long disease, 
 which appeared to be shuated chiefly in the thorax. 
 
 The conditions I have just been describing are physical conditions ; and the signs 
 they furnish are physical signs. I have still to speak of the remaining physical 
 signs, which are also auscultatory signs. What I have already said upon this sub- 
 ject in the present lecture will, I trust, enable you almost to foresee the kind of 
 information which these signs afford in actual practice. 
 
 As soon as even a slight amount of effusion commences in the pleura, it is an- 
 nounced by a diminution of the hollow sound which percussion elicits in the healthy 
 state. In proportion as the effusion becomes more considerable, the chest, when 
 struck, gives a sound more and more dull. At first, this flat sound is rendered oppo- 
 site the lowermost, depending part only of the cavity ; and this, as I showed you 
 before, forms one ground of distinction between the dullness on percussion in pleu- 
 risy, and in pneumonia. However, at length, the effusion augmenting, the dead flat 
 sound may proceed from the whole of the affected side ; and this forms another 
 ground of distinction ; for it is very seldom that the whole lung becomes so solid in 
 pneumonia as to yield a uniform dead sound over the whole of one side of the chest. 
 Either the dull sound is universal on one side, or it is not. If universal, it is not 
 likely to be the result of solidification by pneumonia; or, I may add, by tubercles : 
 if not universal, the dull sound will (except in some rare cases), shift its place as the 
 patient alters his posture. 
 
 I may mention another ground of diagnosis, which may be of great assistance 
 when the case is seen from the beginning. The dullness comes on much more 
 quickly in pleurisy than in pneumonia. It has been noticed within twelve hours 
 from the invasion of the disease. In living animals, a considerable quantity of serous 
 effusion has often been very rapidly produced by injecting some slightly irritant 
 matter into the cavity of the pleura. In pneumonia, the dullness is commonly later 
 in its appearance. The induration of the lung is gradual; and so is the pneumonic 
 dullness on percussion : the effusion of serous fluid is early and rapid ; and so also 
 is the coming on of the pleuritic dullness. Moreover, as I have just shown you, 
 pleurisy may displace the mediastinum, and cause the whole sternum to give a dull 
 sound. A hepatized lung will render one-half on]y of it dull. 
 
 The intensity, or completeness too of the dull sound is generally greater in pleurisy 
 than in pneumonia. In two days, or even in twenty-four hours the whole cavity of 
 the pleura on one side may be filled quite full ; and the whole of the corresponding 
 surface of the chest, from its base to its summit, will yield a sound (to use one of 
 Avenbrugger's strong expressions) tanquam percussi femoris. It is very uncommon 
 for such total and universal matite, as the French call it, to result from inflammation 
 of the lung. 
 
 Again, in the outset of the disease, while there is yet little or no effusion, but 
 when the pain is acute, the vesicular breathing is heard more faintly and feebly on 
 the painful side than on the other. On that side also the walls of the chest are less 
 forcibly expanded. But percussion, when the pain will permit of its being practised, 
 gives the same sound on each side. It is clear that the sharpness of the pain causes 
 the patient instinctively to expand the chest on that side as little as possible, and 
 consequently the quantity of air that penetrates the lung in a given time is diminished, 
 and the respiratory murmur is feeble. 
 
 As soon as efliision commences, the vesicular rustle is heard still less plainly on 
 the affected side ; and in proportion as the fluid increases, that rustle or murmur be- 
 
 2z
 
 590 PLEURISY. 
 
 comes more faint ; and at the same time it becomes more distinct and noisy than 
 natural — puerile, in fact — on the sound side. And while the respiratory murmur is 
 disappearing on the diseased side, and the spongy lung is becoming empty of air 
 from the pressure of the augmenting fluid, and the larger bronchi are surrounded by 
 con)pressed lung and by incompressible liquid, the bronchial sounds begin to be 
 heard, which I formerly described — the bronchial voice, the bronchial respiration. 
 But the sounds are not exactly the same as those which are heard in pneumonia. 
 They are modified by the nature of the substances through which they pass. The 
 voice, for example, is still bronchial, still the voice of a person talking into a tube : 
 but it has a superadded character ; it is trembling, quivering, thrilling, cracked, dis- 
 cordant. I strive in vain to convey to you by these epithets a notion of this remark- 
 able modification of the voice. Laennec's happy similitudes may enable you to 
 form a more exact conception of it. It is hke (he says) the bleating of a goat; or, 
 happier still, it resembles the voice of Punch. But when once you have heard the 
 sound, you will never forget it again. I presume that this modification of broncho- 
 phony (for such it is, and such I would have you consider it), is caused by the rapid 
 undulations communicated to the effused liquid by the vibrations of the bronchi and 
 condensed pulmonary tissue. This sound is usually most distinctly heard near the 
 inferior angle of the scapula, the patient being in a sitting position. It disappeai-s, 
 or merges into pure and distant bronchophony, when the liquid exceeds a certain 
 amount, so as to compress the bronchial tubes themselves, and to dcimji their 
 vibration. 
 
 I would have you recollect, therefore, that jegophony, which is the technical ap- 
 pellation of the sound I have just been describing (goat-voice), — aegophony is nothing 
 more than a species or variety of bronchophony; and the two run each into the other 
 by such fine gradations, that it is sometimes difficult to say which it is we are listen 
 ing to. When the quivering is strongly marked, we may be certain that it denotes 
 effusion into the pleura ; when bronchophony only is heard, we cannot be sure, froir 
 that sound alone, whether there be indurated lung between the ear and the bronchi 
 or a liquid, and a portion of compressed and condensed lung: but other phenomena 
 complete the diagnosis. 
 
 Do not forget that when any modification of the voice is heard, or thought to be 
 heard, on the suspected side, the sound of the voice in the corresponding part of the 
 other side of the chest must be ascertained also. It is only by a comparison of the 
 two sides that we can come to any safe conclusion ; and that comparison becomes 
 often a striking and most instructive contrast. 
 
 LECTURE LIIl. 
 
 Pleurisy continued. Recapitulation of Symptoms ; of Diagnostic Signs. Causes 
 of Pleurisy. Pneumothorax; its Conditions and Signs. Treatment of Pleu- 
 risy. JSmpyema. Paracentesis Thoracis. 
 
 In the last lecture I enumerated the symptoms, general and physical, which are 
 met with, more of them or fewer, in cases of acute pleurisy. I then considered them 
 singly : it may be well to take a rapid recapitulatory view of them as they exist 
 together or in succession, and compose the actual disease. 
 
 The outset, then, of pleurisy is marked by sharp stabbing pain, most commonly 
 situated beneath one of the breasts, and preceded or accompanied by rigors. These 
 two signs, the stitch and the shivering, are sufficient of themselves to awaken a 
 strong suspicion that pleuritis has set in. At the same time there are usually a dry 
 cough; a dread of breathing; a check or catch in the inspiration, which is curbed, 
 so to speak, by the pain ; fever ; often a comparatively feeble respiratory murmur 
 on that side on which the pain is felt ; and the patient cannot lie on that side. If no
 
 PLEURISY. 591 
 
 liquid effusion takes place, these symptoms ordinarily disappear at the end of a few 
 days, and the patient recovers. The case has been a case of dry pleurisy ; and the 
 chances are much in favour of the lung having become permanently adherent to the 
 ribs. 
 
 I should have said, with respect to the fever, that at the outset of the pleurisy it 
 is often high. And it was matter of observation long before the method of ausculta- 
 tion was thought of, as well as since, that in the acute period of the disease the pulse 
 is remarkable for its hardness, and forms a contrast with the soft pulse of pneumonia, 
 and with the small and contracted pulse of inflammation of the serous membranes 
 of the abdomen. Indeed, the older physicians laid great stress upon the quality of 
 the pulse, in their endeavours to distinguish pleurisy from pneumonia. 
 
 But to resume the description of the symptoms of pleuritis. Where effusion 
 takes place (and it does so very early, so as to form a part of the complaint, just in 
 the same sense in which expectoration forms a part of catarrh), the sound elicited by 
 percussion becomes dull on the side on which the effusion exists. While the effu- 
 sion is moderate, the dullness shifts its place according to the posture of the patient, 
 and is heaid only when the lowermost part of the chest is struck. But the fluid 
 may soon increase so much as completely to fill the pleura ; and then the whole of 
 that side is dull. Meanwhile the murmur of respiration becomes feeble and faint, 
 and at length, as the effusion augments, ceases altogether; while on the sound side 
 it grows noisy and puerile. Tubular breathing, and that modification of the bron- 
 chial voice which medical men have agreed to call aegophony, become audible during 
 the early periods of the effusion, ^gophony is heard, however, only so long as the 
 quantity of liquid poured out observes a specific limit. There must be a certain 
 amount of effusion — and there must not be more than a certain amount. I have 
 sometimes thought that the peculiar sound depended on the undulations produced in 
 the surface of the liquid by the bronchial vibrations. It certainly is somehow con- 
 nected with the presence of a stratum of liquid between the lung and the ear. When 
 the lung is strongly compressed, and especially when the cavity is stretched and dis- 
 tended by the enclosed fluid, the side is necessarily motionless ; no tubular or other 
 breathing can any longer be heard, or even occur : nor is the voice conducted, except 
 perhaps very faintly, to the listening ear of the physician. 
 
 When the effiasion is great, that side of the thorax on which it has taken place 
 becomes, often, more or less dilated ; and I should add, that the integuments on the 
 same side are frequently cedematous. The patient now cannot lie on the sound 
 side ; and the most common posture is that which is intermediate between the 
 supine position and the lateral ; he lies towards, but not, in general, on, the affected 
 side. 
 
 I observed, in the last lecture, that this inabihty, after the effusion has reached a 
 certain point, to lie on the sound side, might be accounted for in two ways. Partly 
 it rnay be owing to the impediment which lying on the sound side offers to that side's 
 expansion. The muscles which dilate the healthy side have then to lift, as it were, 
 the weight of the body, and are, some of them, pressed upon and encumbered in 
 their action by that posture. But the inability in question is chiefly attributable to 
 another circumstance, viz., the pressure exercised by the efftised fluid downwards, 
 through the mediastinum, upon the only lung that is left to perform the function of 
 breathing. Now, disputes or differences of opinion have arisen as to which of these 
 two circumstances is the most efficient cause in this matter ; and therefore it may not 
 be amiss to provide you with the facts which prove that the last-mentioned cause is, 
 in reality, the most operative — I mean the weight of the superincumbent liquid, in 
 the supposed position, upon the mediastinum and upon the healthy lung below it. 
 This is shown by the fact that patients, to whom the decubitus on the sound side 
 had previously been impossible, on account of dyspncea, have been able to rest in 
 that position hnmediutdy cfler the artificial evacuation of the fluid. Now, in such 
 a case, the obstruction to the dilatation of the heahhy side, produced by placing it 
 under the weight of the body, would remain the same as before, or nearly so. A 
 hospital patient of mine, named Coggs, could not breathe if he attempted to lie on 
 hi" right side. His left pleura was distended by liquid effusion. I thought fit to
 
 / 
 
 592 PLEURISY. 
 
 have paracentesis performed ; and the poor man was greatly delighted to find him 
 self at once enabled by it to assume the posture which his weariness had long made 
 him wish for, but which he had not been capable of enduring. We found by per- 
 cussion that the diseased side was now filled with air ; the compressed lung had not 
 risen at all; so that the necessity for the free expansion of the sound side was just 
 as great as before the operation. You may find a precisely similar consequence of 
 the same operation related in the fifth volume of the Dublin Transactions. 
 
 The cede ma that is sometimes observed on the diseased side is more or less con- 
 nected, probably, with the habitual position of the patient. 
 
 There is yet another sign of pleuritic effusion, M-hich, as it is very simple, and 
 readily perceived by even the least instructed observer, is too valuable to be neglect- 
 ed. In most persons, one's open hand, laid flat upon the surface of the chest, feels 
 the vibration or thrill which the voice occasions when the person speaks. Now, in 
 a case of pleurisy with effusion, you will generally find a remarkable contrast be- 
 tween the two sides in this respect ; {. e., the thrill is strong and evident on the sound 
 side, and not perceptible at all on the other. Whereas, when the whole side is dull 
 in consequence of solidity of the lung, the thrill is much augmented on that side. 
 But this thrill is not always present in the healthy state, and then we can infer 
 nothing from its absence on the diseased side. 
 
 After a while, when the fever has ceased, the liquid begins to be reabsorbed : but 
 as, in many cases, the lung is more or less bound down by adhesions, or overlaid by 
 a membranous stratum of lymph, it cannot expand in proportion as the liquid is re 
 moved : and the necessary consequence is, that shrinking of the affected side in all 
 its dimensions, which I fully described yesterday. 
 
 Let me now briefly re-state the points of distinction between pleuritic effusion and 
 pneumonic consolidation, when the one or the other of these two morbid conditions 
 is proved to exist by dullness on percussion, extending over the whole of one side 
 of the chest. The question is one which frequently arises ; and it is one of much 
 interest and importance. 
 
 First, then, we distinguish these different conditions, having some physical signs 
 in common, by their history. In pleurisy, sharp pain, and a dry cough, or perhaps 
 no cough, precede the dullness : and we have not the crepitation, nor the rust- 
 coloured sputa, which are antecedent to the dullness of pneumonia. 
 
 We cannot, however, always learn the previous history of a given case. 
 
 Secondly, a lung rendered solid by inflammation does not distend the cavity. 
 Copious pleuritic effusion most frequently does. In the first case, therefore, we 
 have not that separation of the ribs, that obliteration of the intercostal depressions, 
 that protrusion of the corresponding hypochondrium, that mensurable enlargement 
 of the side, that extension of the dull sound beyond the middle of the sternum, or 
 that displacement of the heart, which are, some or all of them, apt to result from a 
 collection of liquid in the pleura. 
 
 Thirdly, the solid lung transmits the voice from the pervious bronchi to the sur- 
 face of the thorax ; and if any motion of the affected side remains, it transmits also 
 the sound made by the passage of the air through them. These phenomena are 
 wanting when the pleura is so stretched by its hquid contents as to make the side 
 everywhere dull to percussion. 
 
 Fourthly, the vibration of the thoracic parietes, caused by the patient's voice, is 
 augmented by consolidation of the lung ; prevented when it is strongly compressed 
 by imprisoned liquid. The increase of this thrill can be felt therefore in the one 
 case ; its diminution in the other. 
 
 The simple test fails to be applicable when, from the feebleness, or the high pitch, 
 of the person's voice, no thrill is perceptible on either side in the healthy state. 
 
 Fifthly, a patient having one lung solid, is generally indifferent as to posture. A 
 patient having one pleura quite full of liquid, lies (usually) on or towards that side ; 
 and is distressed and suffers dyspnoea if he attempts to lie on the other. 
 
 It 's of more importance that we should inquire into the exciting causes of pleu 
 risy than ii.to those which give rise to pneumonia. They are more numerous and
 
 PLEURISY. 593 
 
 complicated, and have a more direct bearing upon the prognosis and treatment in the 
 one case than in the other. I do not desire to refine too much ; and therefore I shall 
 restrict myself to those causes which are obvious, and which you are likely to meet 
 with in practice. 
 
 1 merely say of exposure to cold, as an exciting cause of pleurisy, that it is a very 
 common — the most common — cause. You know already all that I can tell you of 
 the circumstances that are likely to render that cause effectual in producing internal 
 inflammations, and, among the rest, pleuritic inflammation. 
 
 But pleurisy is often occasioned by mechanical violence; or by the accidental 
 extension of disease from other parts ; and the course, and the event of the disease, 
 are liable to be considerably modified by the nature of its cause in such cases. 
 
 Pleurisy may be excited by the splintered ends of a broken rib ; and if the pul- 
 monary pleura be wounded in that manner, air may get into the pleural cavity, as 
 well as into the areolar tissue beneath the skin ; constituting the true and genuine 
 emphysema of our forefathers. Pleurisy may be determined also by a penetrating 
 wound of the thorax ; or by a perforating ulcer of the pulmonary pleura, the exten- 
 sion of a tubercular excavation. In the one case air vi^ill enter from without, if the 
 aperture be sufficiently large ; in the other, air will pass from the lung into the cavity 
 of the pleura. In all of these cases of air finding its way into this serous sac while 
 in a state of inflammation, the event of that inflammation is much more likely to be 
 the effusion of pi(S, than w'hen no communication exists between the inflamed mem- 
 brane and the atmosphe-re. This I have mentioned, and offered some explanation 
 of, before. But another very curious consequence results from the admission of the 
 air, and its coexistence with puriform or other liquids in the sac of the pleura. New 
 auscultatory signs arise, very easily appreciated, very instructive, and therefore very 
 necessary for you to be acquainted with. 
 
 You must know that when the pleura contains air alone, the patient is said to 
 have pneumothorax ; and when (what is infinitely more common) the air is there in 
 company with liquid, he is said to have pneumothorax with effusion. This is the 
 name given to that condition of the chest by Laennec ; and it serves its purpose 
 sufficiently well. I shall take leave to employ the simple term pneumothorax, in 
 speaking of either condition ; whether there be liquid also in the pleural cavity or 
 not. Pneumothorax, then, often proceeds from one or other of those causes of pleu- 
 risy just mentioned. It is sometimes produced by the operation of paracentesis tho- 
 racis ; by the opening made into the thorax by the trocar of the surgeon, in order to 
 let out its fluid contents; in plain English, by tapping the chest. The modifications 
 of sound that resuh are particularly curious. Of course the air occupies the higher 
 portion of the cavity and the liquid the lower, in whatever position the patient may 
 be placed. And this being the case, percussion will give a remarkably hollow 
 sound when made upon the uppermost part, and a totally dull and flat sound when 
 made upon the lowermost part: and the change from the hollow to the dull sound 
 will often take place quite abruptly, so that you may trace out the exact level at 
 which the surface of the effused liquid stands. And if you reverse the posture of 
 the patient, the resonant and the dull sounds will interchange their respective places : 
 the uppermost part always yielding the clear, and the undermost the flat sound. 
 This is just what you would expect. The result of the experiment is the same 
 whether you make it upon the human thorax, or upon a beer-barrel. The resonant 
 part, you are to observe, will'be much more resonant than it would be in health — 
 more resonant (you have always the other lung to test it by) than the corresponding 
 portion of the opposite side of the chest — tympanitic, drum-like : for the air is not 
 involved in spongy lung, but contained in a free space ; and the sound is not damped, 
 as in a heahhy chest it is damped somewhat, by the presence of the lung. More- 
 over no respiratory murmur can be heard where this tympanitic resonance occurs: 
 nor can any thrill be felt. Now I say all this is no more than you must have fore- 
 seen. But the sounds detected in this new condition of things by the ear applied to 
 the chest, as the patient breathes, or speaks, or coughs, you would not, I think, have 
 anticipated. You hear then a sound which I must endeavour to descrbe in words, 
 but which you will scarcely form a right conception of till you have heard it. and 
 38 2z2
 
 594 PLEURISY. 
 
 then all further verbal description will be needless. I can describe it by simihtudes 
 only. The patient's breathing is like the noise produced by blowing obliquely into 
 an empty flask ; and so the French have given the sound the somewhat magnificent 
 title of '• amphoric resonance." I have heard, fifty times over, exactly the sound in 
 question when I have been out shooting in a rough day, and the wind has blown 
 sidewa3's into the gun-barrel. It is a ringing metallic sound. When this is present 
 during the breathing, the voice also has, even more strongly in general, this metallic 
 character ; and so has the cough ; and each of them is apt to be succeeded by a 
 tinkling echo. The voice and cough resemble those of a person who speaks or 
 coughs into a deep well : or with his head bent over an empty copper boiler. The 
 same ringing quality is often heard when one speaks in a large vaulted room ; or 
 beneath the arch of a stone bridge. You may perhaps now have some idea of what 
 these metallic sounds are. They are very singular : and they are perfectly decisive 
 (as far as my experience has gone) of the presence of air in a considerable cavity, 
 within the thorax ; which cavity mostly contains liquid also : and of the presence 
 of air and liquid in the cavity of the pleura in particular. I do not know that the 
 liquid is essential : I do not believe it is ; but commonly there is some liquid, and a 
 good deal of air. Almost always too — but that is not indispensable — the cavity 
 communicates with the external air, either through the walls of the chest, or through 
 the bronchi. Neither is it necessary that the cavity should be in the pleura, for it 
 may be in the lung: and when we come to speak of phthisis I shall point out the 
 circumstances which will enable you to determine whether the sounds proceed from 
 a tubercular cavity, or from the sac of the pleura. What you will please to remem- 
 ber is, that in actual practice, in ninety-nine cases out of a hundred, these sounds 
 will be found to denote the presence of both air and liquid in the cavity of the pleura ; 
 and the probable existence of some passage of communication between that cavity 
 and the external air: in a single w'ord, they will reveal the existence of pneumo- 
 thorax. The voice reverberates in the little cavern just as it does in a large empty 
 room with a stone roof; and this is the best explanation I can give you of the phe- 
 Tiomenon. Sometimes, as you are listening, especially if the patient has recently 
 changed his posture, you will hear a sound just like that occasioned by dropping a 
 p n's head into a glass vase, or into a metal basin; and to this sound the name of 
 metallic tirihling has been given. It really often closely resembles the distant 
 tinkling of a sheep-bell. This is supposed to result from the dropping of the liquid 
 from the upper part of the cavity ; or sometimes from the bursting of a bubble on 
 the surface of the liquid during respiration. You may succeed now and then in 
 hearing a species of the same metallic tinkling by applying the stethoscope over the 
 stomach, when percussion has already taught j-ou that it is distended with gas, and 
 by getting the patient to swallow some drink in successive teaspoonfuls. 
 
 Another auscultatory sound, arising out of the same condition, viz., the presence 
 of both air and liquid in the cavity of the pleura, and known even as early as the 
 time of Hippocrates, is rendered audible by siiccussion of the patient's body. You 
 lay your ear upon his side, and get him to give his body a sudden jerk or jog ; or 
 you get some one else to take him by the shoulders and shake him ; and you hear 
 the liquid splashing within : just as you hear it when you shake a cask that is 
 neither full nor empty of water. This is an unequivocal indication of pneumo- 
 thorax; and demonstrates beyond a doubt that there are both air and liquid in the 
 pleural sac ; for no sound would arise if there was liquid only. A moderate quan- 
 tity of liquid will make a greater squash than a large quantity. Unequivocal I say 
 it is, because one coulJ scarcely be misled by the splashing which may sometimes 
 arise from wind and water mingling in the stomach. I wish that a patient, who 
 was under my observation for some months last year in the Middlesex Hospital, and 
 could produce this splashing noise at will, were there now; for he was not a little 
 proud of his fatal gift, and I should have brought him down here to-day, and given 
 you an opportunity of hearing this sound for yourselves, worth a dozen descriptions 
 of it. 
 
 It is surprising how long this state of things within the thorax may last, without 
 Any great declension of the patient's general heahh and strength, even when the
 
 PLEURISY. 595 
 
 disease is (as it mostly is) incurable. Two men, patients of mine, both of whom had 
 well-marked pneumothorax in connection with tubercular phthisis, remained in the 
 hospital for several months ; till, in fact, I could conscientiously keep them there no 
 longer : and each of them went away in very tolerable plight. 1 was unable to 
 trace them afterwards, for they returned to their homes, the one in Ireland, and the 
 other in the north of Scotland. 
 
 You see, then, that the conditions of pleurisy, and the symptoms of those condi- 
 tions, ma)' be modified by its causes. All those causes that imply the introduction 
 of air into the cavity of the pleura, imply also a more serious state of disease than 
 results from most other causes. The perforation of the pleura, by the extension oi 
 a vomica, I have mentioned as one of those causes. But tubercles in the lungs are 
 frequently, very frequently, the cause of pleurisy, when no such perforation has 
 taken place. A tuhercle, or a group of tubercles, approaches the surface of the 
 lung, but does not break through. Generally the pleurisy so produced is slight and 
 partial, and ends in the formation of adhesions : it is dry pleurisy. And this very 
 common occurrence of adhesions between the costal and pulmonary pleurae, in the 
 course of tubercular disease of the luugs, is, in truth, one reason why perforation of 
 the pleura, and pneumothorax from that cause, is comparatively so rare. The part 
 where the perforation is hkely to take place has generally, though not always, been 
 secured and clouted, as it were, by previous adhesion. So that even here we find 
 that inflammation has a conservative tendency, and helps to postpone the fatal ending 
 of the specific disease. 
 
 Pleurisy may terminate in resolution and complete recovery; or in adhesion, 
 which is its next best termination, and which obtains for the patient, at the expense 
 of some trifling embarrassment of his breathing, complete security for the future 
 against the dangers of pleuritic efTusion. Again, acute pleurisy may end in chronic 
 disease of the pleural cavity: i. e., in a shrinking inwards of the walls of the chest, 
 attended with total uselessness, or a very imperfect and limited use, of the corres- 
 ponding lung. Lastly, pleurisy may terminate in death. It may cause efTusion so 
 copious, that the patient will die of actual suffocation, unless the fluid be removed by 
 art. On the other hand, he may die worn out and exhausted by the disease, espe- 
 cially if it be attended with suppuration. In that case he will suffer hectic fever, 
 and all its wasting and mournful accompaniments; and death ultimately by asthenia. 
 It is seldom that simple idiopathic pleurisy proves fatal. 
 
 As the matter from a tubercular cavity may break in tipon the pleural sac, and 
 lead to the admission of air, and the establishment of pneumothorax ; so the puriform 
 fluid which has resulted from inflammation of the pleura, and was for some time 
 imprisoned in its sac, may also break out, and the result will still be the admission 
 of air, and pneumothorax. This is not a very frequent result of pleurisy, however. 
 When it occurs, an abscess forms externally, generally in front of the chest ; and 
 either the abscess bursts, or it is opened by the surgeon, and then it is found to com- 
 municate with the cavity of the pleura. 
 
 Sometimes air is eflused into the sac of the pleura, in consequence of the rupture 
 of dilated air-cells on the surface of the lung: sometimes gas is generated there from 
 the decomposition of effused liquids ; and in such cases the gas has a strong odour, 
 like that of sulphuretted hydrogen : sometimes, again, gas appears to be secreted 
 from the membrane itself. All these events are, however, uticommon. When air, 
 from whatever source, is shut up in the cavity of the pleura, and goes on accumu- 
 lating there, it will compress the lung, just as certainly and efTeciually as if there 
 were a liquid extravasated. And such compression, if suddenly brought about, may 
 cause speedy death by apnoea : and this is more apt to occur from a puncture of ihe 
 pulmonary pleura by the extremity of a fractured rib, than from any other cause. 
 
 As to the treatment of pleurisy, you will have anticipated that in the outset of the 
 disease we must have recourse to the lancet. I have stated, more than once, that 
 blood-letting tells more, and is better borne, in inflammation of serous membranes, 
 than in any other case. If you see the patient while the stitch in the side, and the 
 restrained and cautious respiration are present, you will bleed him, in the upright
 
 596 PLEURISY. 
 
 posture, from a large orifice, until the pain is relieved, and he can draw a full breath 
 again with ease and satisfaction ; or until he is about to faint. And if the pain and 
 catch in the breathing should return, and the pulse continue firm and hard, you will 
 bleed again in the same way ; or cover the painful side with leeches ; or abstract 
 blood by the cupping-glass and scarificator. It is best to bleed fearlessly at first ; 
 and in proportion as you do so, the chance will be diminished of a repetition of the 
 blood-letting being needed. The blood, in pleuritis, is always deeply buffed and 
 cupped. 
 
 Tartar emetic, which is so useful when the mucous membrane of the air-passages 
 is inflamed, is not adapted to inflammation of the pleura. On the other hand, mer- 
 cury, from its well-known power to check the effusion of coagulable lymph, is espe- 
 cially indicated. Of course it is to be given with a view to its specific effect on the 
 system ; i. e., in equal doses, repeated at frequent and equal intervals, and guarded 
 by a small quantity of opium. And in very severe cases, or when the internal^ 
 employment of mercury is in any way contra-indicated, recourse must be had to 
 inunction of the linimentum hydrargyri, or of the strong mercurial ointment. 
 
 By the early and vigorous adoption of these measures, the inflammation may 
 generally be subdued in no long time. If, though the fever diminish, there still be 
 pain in any part of the chest, leeches may be again applied, or the part may be 
 covered with a blister. I do not think a blister does any good, — on the contrary, it 
 is likely, by the additional irritation it causes, to do harm — while the inflammation is 
 yet recent and active. 
 
 But though pain may have ceased, and no fever remains, and the patient is not 
 conscious of much dyspnoea, there may be, and there often will be evidence, not to 
 be mistaken, of effusion into the cavity of the pleura. Dullness, I mean, on percus- 
 sion, bronchial respiration, segophony ; and the object of our treatment is now to get 
 rid of the fluid. We seek to do so by keeping the patient on low diet. The more 
 (says Broussais, with some quaintness), the more the patient eats, the sooner he will 
 die. We pursue the same object by keeping his gums tender with mercury ; by 
 applying blisters one after another to the affected side ; and by purgatives, and 
 diuretics. By keeping the vessels empty we facilitate as much as in us lies, the 
 absorption of the liquid contents of the pleura. A very good form of diuretic for 
 this state of matters is a combination of squills, digitalis, and mercury. Half a grain 
 of digitalis, one grain of squills, and three or five grains of blue pill, repeated and 
 continued according to the state of the mouth. 
 
 Under this kind of treatment the effused fluid will often be completely removed ; 
 and the chest restored to its former state. I last week dismissed a lad from the 
 hospital in whom all this was accomplished. 
 
 But in other cases, though the fever and the inflammation are at an end, and ab- 
 sorption of the liquid takes place, the parts within the thorax do 7iot revert to their 
 original condition. This we know by that shrinking of its dimensions on the side 
 affected, which was described in the last lecture. This shrinking and narrowing arc 
 the necessary consequence of the absorption of the liquid, unless the compressed 
 luno- dilates a^ain in proportion as the fluid is taken up. In most cases of this kind 
 the lung cannot rise ; being bound down by thick and firm false membranes : and 
 then the deformity is irremediable, and lasts for life. If the lung is completely 
 emptied of air, and enveloped by strong bands of lymph, so that it is permanently 
 unable to admit air again — in that case, as the bony framework of the thorax can 
 yield to a certain extent only, there will always remain, I presume, some liquid in 
 the pleural cavity. If, again, the lung recovers a part of its lost volume, and nieets 
 the contracting parietes of the chest, adhesion may take place : and the cavity of the 
 pleura be obhterated by thick layers of false membrane. And other changes t.re 
 apt to arise in the lymph which is adherent to the pleura in these cases of imperfect 
 repair. Sometimes tubercles form in it. Sometimes ossific matter is deposited, I 
 show you a fine specimen of this kind of ossification of the pleura. There is yet 
 another supposable case : the investing adventitious membrane may be thin and 
 weak, and yielding; and though the lung may not expand to its full dimensions at 
 Srst it may gradually force its way against the binding power of the coagulable
 
 PLEURISY. 597 
 
 lymph, and then the external configuration of the chest may be restored, and the 
 symmetry between the two sides return. That this sometimes takes place I cannot 
 doubt: but I have only once met with a case in which the dwindling- of the side 
 was entirely recovered from. In May, 1834, I was asked to see a child four )'ears 
 old, who had had cough, and had wasted to mere skin and bone, after scarlet fever. 
 I found the whole of the right side of the chest perfectly dull on percussion, and no 
 respiration could be heard on that side. He was taken by his parents into the 
 country, and I did not see him again for some weeks. He then had ceased to cough, 
 and, in a great measure, had regained his strength ; but he presented, on the side 
 which had been dull, the most marked and complete example I ever saw of the 
 sinking in of the ribs, flattening and contraction of the chest, and depression of the 
 shoulder, which denote bygone pleurisy and diminished size of the lung. About a 
 year from the occurrence of the original disease his father brought him to my house, 
 that I might see the change which had again taken place. The boy was plump and 
 rosy, and in perfect health ; the right side of the chest was as full and round as the 
 other ; the symmetry of the two sides was completely restored ; the breathing natural 
 and perfect ; and the sound on percussion hollow. His father, to whom the former 
 shrunk state of the side had been pointed out, told me that he had watched, with 
 deep interest, the process of recovery, and that it had been very gradual. Whether 
 after once having sunk in, the ribs ever quite return to their natural position in the 
 adult subject, I do not know. I have never seen that happen. 
 
 There are yet other cases in which the effusion continues and increases, and the 
 side, instead of shrinking, enlarges ; the functions of the lung on that side are en- 
 tirely abolished ; nay, the use of the remaining lung is greatly interfered with, by 
 the pushing over of the mediastinum ; and the patient is in imminent danger of 
 suffocation. In such cases, whether the effusion has taken place rapidly or slowly 
 — whether the disease has been acute or chronic pleurisy — we must reheve the op- 
 pressed lung by letting the fluid out — by tapping the thorax ; and the sooner that 
 is done, when such a state of things exists, the belter. 
 
 The operation is not difficult, nor formidable ; but a mistafte in the diagnosis may 
 be very formidable. I have heard of two instances, one in Scotland, and one in this 
 town, in which the operation of paracentesis thoracis was determined on, to relieve 
 the oppression caused by empyema : but the opening was made on the wrong side ; 
 and the patient in three minutes was, in each case, a corpse. There was effusion, 
 which had already put a stop to the play of one lung ; and upon air being admitted 
 to the surface of the other, it collapsed also, ond immediate suffocation took place. 
 I do not mention these mishaps to deter you irom performing the operation. They 
 both took place some years ago. Such a mistake would be unpardonable now. But 
 I mention them to show the necessity of our being sure of our ground before we 
 proceed to open the thorax of a living person. A surgeon told me very recently 
 that with the sanction, and at the suggestion, of a physician, who understands aus- 
 cultation exceedingly well I believe, he passed a trocar into the chest of a patient ; 
 but no fluid followed, to the no small mortification of the physician. This proved to 
 be a case of malignant disease of the lung; and fluid was let out afterwards by 
 puncturing the thorax in another place, and much relief afforded ; although of course 
 the disease proved ultimately fatal. The surgeon informed me that he had suspected 
 the true nature of the case, from observing a livid protrusion in front ; which was in 
 fact, the specific disease making its way through. 
 
 You will take care, then, to survey the chest narrowly before you plunge a trocar 
 into it. If you see by your eye, and ascertain by measurement, that one side is 
 larger than the other ; if the intercostal depressions be effaced on that side ; if the 
 whole surface affords a dull sound when percussed ; if the side does not move at ali. 
 or scarcely moves during respiration ; if no vibration can be felt on that side when 
 the patient speaks ; if no breathing can be heard in the corresponding lung ; if tht 
 heart be found beating in an unnatural place, down towards the left hypochondriuni, 
 or in the other direction on the right of the sternum ; and if, at the same time, the 
 other side of the chest moves freely, sounds resonantly, communicates a thrill to the
 
 598 PLEURISY. 
 
 hand while the patient converses, and is full of puerile respiration ; then you may 
 be sure that the larrrer side is distended with fluid. 
 
 But it does not follow that you should, therefore, open that side. The propriety 
 of doing so will depend upon circumstances. 
 
 In my judgment, that operation ought never to be performed unless the hfe of the 
 patient is, or seems to be, in jeopardy, from the continued presence of the liquid 
 within the thorax. 
 
 Now, life is plainly in jeopardy when the vital functions of the lungs, or of the 
 heart, are greatly hindered ; when symptoms present themselves of approaching 
 death by apnoea, or by syncope. If we discover no cause for those symptoms, 
 except the increasing pressure of liquid pent up in the pleura, we are warranted in 
 ascribing them to such pressure, and bound to act upon that persuasion. When- 
 ever, with the physical signs of abundant effusion, we have great labour and dis- 
 tress of breathing; an anxious and livid aspect; a tendency to delirium — or extreme 
 faintness, and a vanishing pulse — there is no time to be lost : it is our duty to pro- 
 pose and to urge the mechanical removal of the pressure, which must else be fatal. 
 
 Again, when the patient, without suffering much dyspncea while he lies quiet, is 
 yet evidently losing ground from day to day, and early death by asthenia appears to 
 be inevitable, without the operation ; and when all other means for getting rid of the 
 imprisoned liquid have failed ; and when no other condition of disease, or of advanced 
 age, exists to account for the progressive sinking ; then also, in my opinion, the 
 patient should not be denied the chance which the operation may afford. 
 
 Thirdly, whenever (no matter how we ascertain the fact) the effused liquid con- 
 sists of jms, it should be let out. 
 
 In either of these three predicaments, and in no other, should we be justified (as 
 I think) in making an opening into the living thorax. 
 
 But I wish to be understood as giving you simply the impression which my own 
 experience has made upon my own mind. I know that some practitioners recom- 
 mend the early employment of the trocar ; while (they say) the false membranes, 
 which are apt to prevent the compressed lung from expanding again, are yet tender 
 and unorganized. But surely we should risk much, and gain nothing, by admitting 
 air into the pleura while the inflammation is still in progress. Most cases of mere 
 pleurisy with effusion do well. The mortality from uncomplicated pleurisy is ex- 
 ceedingly small. It would, I fear, be vastly augmented if every patient having mani- 
 fest effusion were to be tapped. The danger of the operation is this ; — that it may, 
 and probably will, induce suppuration, or cause the elfused liquid to become putrid. 
 Generally the effusion consists of serous fluid, which is at length spontaneously re- 
 absorbed ; the lung expands again, or the walls of the chest shrink inwards : and 
 the ultimate state of such a patient is as good as it probably would have been after 
 a successful tapping. 
 
 To make assurance doubly sure, it is always right, before proceeding to the ope- 
 ration of paracentesis, to adopt the expedient first suggested and used, I believe, by 
 Dr. Thomas Davies, of trying the chest by means of a grooved needle ; making a 
 tentative exploration of the nature of its contents in that manner. The passage of 
 this little instrument — like the dismissal of a pilot balloon — affords information 
 which is useful in guiding the particulars of the subsequent process. It not only 
 ascertains that there really is liquid within the pleura, but it discovers the kind and 
 quality, and exact place, of the liquid. If it be serous, it will flow readily along the 
 groove, and trickle down the patient's side. \i it be puriform and thick, it will not 
 exude so freely, but a drop or two will probably be visible at the external orifice; 
 and when the needle is withdrawn, its groove will be found to contain pus. In the 
 former case, it is possible that there may be no false membranes ; in the latter, they 
 are likely to be thick. You would use a larger trocar to evacuate the thicker fluid. 
 
 The puncture thus made is quite harmless, and inflicts very trifling pain. Dr. 
 Davies gives this useful piece of advice in respect to the trocar, that its point should 
 be sharp ; for otherwise, after the serous membrane has been penetrated, if there 
 happen to be thick tough layers of coagulable lymph, not very closely attached to
 
 PLEURISY. 599 
 
 the costal pleura, they may be driven before the instrunaent, and so the liquid will 
 not be reached, but the operator will be perplexed and baffled. 
 
 Connected with the operation itself there are some questions concerning which 
 medical opinions and medical practice are not yet settled. I do not pretend to decide 
 these questions ; yet I cannot pass them by — I must point them out to you ; and I 
 shall, at the same time, state what my own observation has suggest d in regard to 
 \hem. 
 
 1. Should all the liquid be let out at once ? 
 
 Some say yes : some say no. If we appeal to experience on this point, we obtaia 
 no satisfactory answer. I have known patients get rapidly and perfectly well, after 
 as complete an evacuation of the liquid as was possible. On the other hand, I have 
 heard of speedy recovery when, by a sort of accident, very little had been with- 
 drawn ; enough to relieve the pressing distress ; but much less than the operator 
 intended. 
 
 We must try the matter, therefore, by our reason. 
 
 I think it very probable that when the serous membrane is stretched by the pres- 
 sure of its contents, its natural absorbing power may be lessened. But we have no 
 reason to suppose that the mere relief of this tension will often suffice to renew the 
 process of absorption, and to enable the flattened lung to re-expand. 
 
 The theoretic objection to the thorough emptying of the thorax in such cases is (1 
 conceivej, that the introduction of air is likely to be hurtful, by converting the adhe- 
 sive into the suppurative form of inflammation, and by promoting decomposition of 
 the extravasated fluids. No doubt there is this risk ; but, in general, it cannot be 
 avoided. Unless the lung freely rises at once, the liquid cannot all, nor even much 
 of it, come out, without air getting in. Some attempts have indeed been made, of 
 late, to draw the water into an exhausted bag, by the help of a pipe and stop-cocks. 
 But it is obvious that, in most cases, very little can be so abstracted. The mere 
 admission of air to the pleura does not necessarily create inflammation of the mem- 
 brane. This we know from what happens sometimes in emphysema produced by 
 a fractured rib. In the only instance of pure pneumothorax which I ever saw, the 
 sac of the pleura had become half-filled with air, through a very minute opening in 
 the pulmonary membrane, communicating with the air-passages. There was no 
 mflammation of the pleura in that case. Except that it was preternaturally dry, it 
 seemed perfectly healthy. Neither does the access of air necessarily superinduce 
 suppuration in the membrane already inflamed. Certainly, if pus follows the passage 
 of the instrument, as much should be removed as we can get. And, for my own 
 part, I should take away as much as would come, if the inclosed liquid proved to 
 be serous. • 
 
 2dly. Is the orifice to be healed up, or to be kept open ? 
 
 Here, also, practical men differ. I should say, if pus comes out, by all means 
 keep the aperture open ; and inasmuch as detention of the pus would be injurious, 
 and the depending point is difficult to hit, and the orifice is apt to clog, I would do 
 more than leave it open : I would draw the puriform fluid ofT twice a day by a 
 syphon. 
 
 If serum is let out, by all means close and heal the wound. Then, if all goes on 
 well, our object is achieved. But should the condition of the patient fail to improve ; 
 should hectic fever, after a day or two, set in or even continue ; should much consti- 
 tutional distress or disturbance arise ; — under such circumstances, I would re-open 
 the wound. There was mere serum, or liquor sanguinis : there now is, in all pro- 
 bability, puriform matter pent up in the pleura, and even stinking and poisonous 
 gases. 
 
 On six occasions I have myself witnessed the evacuation, by puncture, from the 
 human pleura, of a clear transparent liquid. Some of the patients were under my 
 own charge, some under the charge of others. Of these six patients, one died the 
 day after the operation ; I can scarcely say why. She was an extremely timid and 
 susceptible J'eung woman ; and I am inclined to attribute her death to the shock pro- 
 duced, by apprehension of the operation, upon her sensitive nervous syste n. Two 
 others recovered forthwith, and perfectly. The wound presently healed in the threr.
 
 600 PLEURISY. 
 
 remaining cases also ; but in one of the three it soon broke out again, and a quantity 
 of h-althy pus was discharged daily. After some time, the expedient of keeping 
 the cavity free from accumulated pus by the use of a syphon was resorted to. Under 
 this plan the discharge became gradually less and less, and at the end of many 
 months it finally ceased. The patient has a contracted chest, but his general health 
 is quite re-established. He was on the brink of sufTocation when the operation was 
 performed. I have been told of a man who, for the last fifteen years, has had a 
 similar thoracic fistula, and who has nevertheless, during nearly the whole of that 
 period, being actively engaged in the various labours of a farm-servant. 
 
 I have still two of the six patients to account for. They were both much reheved 
 by the operation for a while ; but after a few days they again fell off; and after 
 many more days of gradual sinking and distress, they died. The cavity of the 
 pleura contained, in both cases, much puriform liquid, and a quantity of most offensive 
 gas, consisting in great part, as I judged from its odour, of sulphuretted hydrogen. I 
 have since thought that both these patients would have had a much better chance for 
 life, if this corrupt and corrupting mass had been duly removed. 
 
 Again, I have twice seen pus let out, by the primary puncture of the chest. One 
 of these two patients sunk, exhausted, some months after the opening, which never 
 healed, was made. The empyema of the other had been occasioned by fracture of 
 a rib. The discharge continued for a short time, then ceased, the orifice closed, and 
 the lad got well. 
 
 This constitutes the amount, or nearly so, of my personal experience of the ope- 
 ration of paracentesis thoracis. You will see, in the statement I have been making, 
 the grounds of those opinions which I have formed and expressed respecting it. A 
 full and final solution of the grave and difficult questions that it involves would re- 
 quire a much wider field of observation than any one individual is likely to command. 
 Dr. Thomas Davies has published a tabular account of the several cases of operation 
 which he had then superintended. In sixteen cases of empyema, so treated, there 
 were twelve recoveries ; that is, the operation was successful in three-fourths of the 
 whole number of cases : a very encouraging result. In three of the less fortunate 
 cases, the lung could not expand after the evacuation of the fluid, in consequence of 
 the thickness of the false membranes covering it. 
 
 The value of Dr. Davies' table would have been greater, if it had shown in each 
 case the time, after the commencement of the disease, at which the operation was 
 performed ; the symptoms that called for its performance ; the nature of the liquid 
 evacuated ; and whether the orifice made by the trocar was closed or not. 
 
 The quantity of liquid which the distended pleura is capable of holding is enor- 
 mous. I have seen upwards of a gallon let out at once. Dr. Townsend mentions 
 the case of a patient of Dr. Croker's, in Dublin, from whose left pleura Mr. Cramp- 
 ton drew off the almost incredible quantity of fourteen imperial pints of pus. Of 
 course this could not have accumulated there without making injurious pressure in 
 all directions : upon the ribs, upon the heart and mediastinum, upon the diaphragm, 
 and the abdominal viscera beneath it. It is interesting to know with what rapidity 
 the capacity of the diseased side of the thorax will, in favourable cases, diminish. 
 The same writer gives the history of a boy, 12 years old, in whom the circumference 
 of the diseased side was sixteen inches and six lines, while that of the sound side 
 was fourteen inches and one line. JNine days after the operation the circumference 
 of the diseased side had decreased nearly three inches: it measured thirteen inches 
 and nine lines ; that is, rather less than the circumference of the healthy side. The 
 side had shrunk somev.-hat within its natural size. This is common in such cases. 
 
 There is yet a third question of some importance. Whereabouts should the 
 opening be made ? 
 
 If any soft inelastic tumour has appeared, marking a tendency in the effused liquid 
 to make its own way outwards, that tumour should be punctured without loss of 
 time ; for there will be no chance of the reabsorption of the pus ; and if the swelling 
 be left to itsflf, troublesome, burrowing sinuses will be apt to form in the thoracic 
 and abdominal parietes. As we have no choice in such a case about the place 
 where the aperture is to be made, authors have termed the operation the operation
 
 PLEURISY. bUl 
 
 of necessity ; and they distinguish the case in which the surgeon is at liberty to m 
 troduce his trocar whenever he pleases ; they say that then the operation of election 
 takes place. Now the question is, what spot is the best for this operation of election ? 
 
 If there be any part of the surface which is resonant on percussion, or which 
 affords any sound of respiration, that part must be avoided. It is probable thai the 
 lung, in that place, is fastened by adhesions to the costal pleura. Of course you 
 would not thrust in a trocar where you saw or felt that the heart was beating. 
 
 The object to be kept in view is that of making the opening in the situation which 
 will allow the most free and perfect vent for the liquid. The intercostal space 
 between the sixth and seventh true ribs, where the digitations of the serratus major 
 meet those of the obliquus externus muscle, is the place usually recommended. 
 Laennec prefers the space between the fifth and sixth ribs. He observes that, on 
 the right side, an enlarged liver frequently reaches as high as the sixth, or even as 
 the fifth rib. When the diaphragm is pushed as high as this (and I believe that 
 Dr. Edwin Harrison, who has paid much attention to this point, will tell you that 
 it is often pushed up even higher) there is an obvious risk of penetrating it with 
 the trocar. In fact, Laennec committed that error himself. After making an in- 
 cision between the fifth and sixth ribs, he thrust the instrument, as he supposed, 
 into the thorax; and was a good deal surprised to find that no gush of liquid fol- 
 lowed its introduction. The patient died ; and dissection showed that the trocar had 
 entered the cavity of the abdomen after transfixing the diaphragm, which, having 
 been forced upwards by a large liver, had contracted firm adhesions to the seventh 
 rib. I have myself witnessed a similar mischance, on the other side of the chest. 
 The integuments of the side were csdematous ; and it was thought that a little serum 
 issued upon the passage of the grooved needle. The serum must have come from 
 the infiltrated areolar tissue. No liquid was evacuated by the trocar. The patient 
 died a day or two afterwards of peritonitis. The instrument had perforated the 
 diaphragm, and entered the spleen, which was unusually large. 
 
 I am tempted to relate the particulars of one of the prosperous cases that I 
 before briefly adverted to. It occurred in a lad of nineteen ; a patient of my col- 
 league, Dr. Wilson. On his admission into the hospital he bore all the marks of 
 copious effusion into the left pleura ; the side enlarged and motionless, and dull on 
 ..percussion ; the intercostal spaces tense, and even with the ribs ; the heart beating 
 to the right of the sternum; respiration puerile on the right side, inaudible on the 
 left ; urgent dyspnosa ; a tendency to coma, marked by drowsiness and blueness 
 of the cheeks and lips. In short, the boy was on the very verge of suffocation. 
 He had been ill about a month : and had been bled, and cupped, and brought under 
 vhe specific influence of mercury. Dr. Wilson judiciously directed that the liquid 
 should be let out. 
 
 A grooved needle was first passed between the fifth and sixth ribs ; and some 
 serum following the puncture, a trocar was then introduced by Mr. Tuson, and 
 nine pints of a clear fluid were drawn off. During the operation the patient became 
 faintish at times, and then the orifice in the canula was stopped for a moment by 
 the finger. The immediate effect of the tapping was most interesting and grati- 
 fying. Even while the liquid was flowing, the heart was observed gradually to 
 move over from beneath the right mamma towards its natural situation ; and his 
 difficulty of breathing was signally relieved. At the beginning of the operation he 
 respired fifty times in a minute ; at its conclusion thirty-eight times only. A good 
 deal of air entered while the liquid vvas escaping: and for some days after the 
 operation a splashing sound vvas audible on succussion of the chest : and one part 
 of that side was unnaturally resonant, when struck, and another part unnaturally 
 dull ; and whatever was the posture of the patient, the hollow sound was uppermost, 
 and the dull sound was undermost ; and when he sat up and spoke, or coughed, a 
 brazen resonance was heard by the ear applied to the scapular region. This lad 
 got quite well, without the recurrence of a single bad symptom. He afterwards 
 presented himself at the hospital ; and I understand that the left side was found to bo 
 in a very slight degree smaller than the right. 
 
 The liquid evacuated in this case was clear and transparent. It separated, on 
 
 3a
 
 G02 PLEURISY. 
 
 cooling, into three parts : one of quite water)- consistence, one more viscid, and a 
 third which constituted a soft, transparent, jelly-like mass of fibrin. 
 
 In this instance no injurious consequences resulted from the free admission of air 
 
 It may sometimes be necessary to puncture the cavity for mere pneumothorax : 
 when, for instance, the pulmonary pleura has been pricked by a fractured rib, and 
 air passes from the lung into the pleural sac faster than it can be absorbed ; fast 
 enough to compress the lung, and to threaten death by apnosa. The diagnosis of ' 
 such a state cannot be difficult. The existence of the fracture, the t3'mpanitic sound 
 yielded by the chest on the injured side, the absence of respiratory murmur in the 
 tympanitic part, and the increasing dyspnoea, all point to the same conclusion. Now 
 a trocar of the smallest size — or even an acupuncture needle — maj- suffice to give 
 vent to the imprisoned air, which will escape with an audible hissing noise. In 
 some cases it must have existed in a very large quantity, for the stream of issuing 
 air has been strong enough to blow out a candle several times in succession ; the 
 flame being each time immediately re-lighted. 
 
 The same necessity for puncturing the cavity of the pleura from without may 
 arise in cases of pneumothorax depending on specific disease in the lungs : but we 
 cannot regard the operation as curative in such peases. Its value is very different 
 from that which experience has shown to belong to it in empj^ema from acute or 
 chronic (but simple) pleurisy. Yet if it saves life for the time, if it prevents im- 
 pending suffocation, and relieves existing distress, and postpones the fatal event, it is 
 not ivithout its value ; and it has many times been done, and been followed by very 
 gratifying results ; but it has never, that I knoAV of, been followed by entire recovery. 
 Dr. Davies had superintended the operation in nine instances of pneumothorax with 
 efi'lision : and all the patients died from tubercular complications. 
 
 There are, indeed, on record examples of recovery after the operation, when 
 pneumothorax had existed, and under very unpromising circumstances. I should 
 have stated before, that as the pus, in empyema, sometimes finds its way outwardly, 
 penetrating between the ribs, and forming an external swelhng, which, if not opened 
 by the scalpel, will at length burst ; so it also, sometimes, escapes bj^ making a road 
 into some part of the air-passages, and being expectorated. Now the operation of 
 paracentesis, in such a case, there being no tv.l'erciilar disease, has been successi'ul. 
 Le Dran relates an instance in which he operated for empyema, where " the injec- 
 tion of a small quantity of mel rosarum and barley-water through the wound excited 
 coughing, and part of it was coughed up through the mouth, mixed Avith pus ;" thus 
 clearly proving the existence of a fistulous passage through the lung ; notwithstand- 
 ing which the patient recoA^ered completely. The effusion Avas probably circum- 
 scribed. But you Avill find other cases of a similar kind referred to by Dr. ToAvnsend, 
 in the Cyclopxdia of Practical Medicine. 
 
 This concludes Avhat I have to say, not only of pleurisy, but also of pneumothorax, 
 and of empyema, Avhich are often treated of as separate and independent disorders. 
 They are more frequently connected Avith pleurisy than Avith any other form of dis- 
 ease, and they are almost always consequences of disease or of injury. But I believe 
 I have omitted nothing of importance in respect to either of them. 
 
 [Typhoid Pneumonia. — A state of conptestion, or of inflammation, more or less intense, 
 of the lungs, accompanied by that impairment of the sensorial powers, and morbid condi- 
 tion of the circulation and of the organism generally, which characterize the more grave 
 forms of typhus fever, iias repeatedly prevailed in diflerent portions of the United States, as 
 an epidemic, often of Avide extent, and, in its earlier, visitations, producing an amount of 
 mortality truly appalling. 
 
 The first notice we have of the appearance of this form of disease, remarks Dr. Dickson, 
 (Essay on Pathology and Therapeutics, vol. i. 435), "was in the year 1S06, in Medfield, a 
 town of tlie ^tate of ^Massachusetts, whence it spread gradually — extending itself, iv-nter 
 after winter, throughout New England, into Canada, and the ^Middle States, progressing 
 fiom A'illage to village, and from one portion of the country to another, until, in 1S13, it had 
 reached Philadelphia. In the winter of 1S15 it first prevailed in South Carolina, and was 
 then, .and more A\-idely in ] SIC, epidemic ; since Avhich time its raA'ages in this s'ate ha'.w 
 'been slight. It continues to show itself, sporadically, everywhere, I believe, wheie it has 
 oace found footing In South Carolina we scarcely pass a winter without meeting with 
 iastances of it, espi>cially among the blacks."'
 
 PLEURISY. 603 
 
 The disease Is of frequent occurrence in other portions of the United States, and may be 
 considered, to a certain extent, as endemic in several localities. 
 
 We are informed by Dr. Gibbes, (jlmericati Journal of the Medical Sciences, Oct., 1842.) that 
 it prevails extensively during the winter months, on the rivers, svv^ampy plantations, in the 
 neighbourhood of Columbia, South Carolina, and destroys more negroes than all the other 
 maladies combined to which they are ordinarily liable. 
 
 According tu Dr. Dickson, it has not been observed farther south than the State of Georgia, 
 nor is it of very frequent occurrence beyond the latitude of Charleston. 
 
 Typhus pneumonia, as it prevails in the United States, is very similar in character to, and 
 is probably the same affection as that described by Sydenham, Huxham, and others of the 
 older writers, as peripneumonia notha. Sauvages has very accurately portrayed the disease 
 under the denomination of peripneumonia typhcides. An account is given by the late Dr. 
 John Bard, of New York, of an epidemic that prevailed on Long Island, in the winter of 
 1749, which he terms a malignant pleurisy, that in all its essential features corresponds ex- 
 actly M'ith the disease under consideration; a similar ailectior is also noticed by Dr. Hugh 
 Williamson, as prevailing in North Carolina in 1792. 
 
 Typhoid pneumonia is described by Dr. Stokes as not uncommon in Ireland, while Dr. 
 Burne, of the Westminster Hospital, mentions that a great number of cases of what he calls 
 "the spotted fever," were brought into that institution in the year 1838. He describes the 
 affection as "an adynamic or typhus fever, combined with a latent and dangerous pneumonia, 
 and exhibiting on the surface a very regular and uniform spotted eruption — not petechiaj." 
 This is evidently the same disease as the typhus pneumonia of this country, which, when'it 
 first attracted attention, was so frequently attended with an eruption upon the skin, that it 
 was very generally designated by the popular name of spotted fever. The eruption, how- 
 ever, soon ceased to attract attention ; it was seldom observed as a phenomenon of the dis- 
 ease south of the Potomac, and even in the northern and middle portions of the United States, 
 the eruption ceased early to present itself 
 
 Dr. Mackintosh, of Edinburgh, describes a forni of pneumonic inflammation, attended by 
 symptoms that are generally denominated t3^phoid, and which, in consequence, has obtained 
 the name of pneumonia typhoides, as very prevalent among the British troops stationed in 
 exposed situations along the coast, and in large garrisons where the duty is severe. Dr. 
 Mackintosh, however, objects to the adjunct typhoides, as expressing erroneous ideas of the 
 pathological condition of the body; — and the objection is not without foundation — for although 
 that peculiar form of pulmonary engorgement quickly followed by inflammation aiid hepa- 
 tization, to which the term typhoid pneumonia has been applied, does very frequently occur 
 in connection with genuine typhus, it is likewise a very common complication in certain 
 seasons and localities of the bilious remittent fever, while it is also met with in cases of 
 gastro-enteritis, of ambnlent and erratic erysipelas, of diffuse cellular inflammation, and of 
 other diseases by which the thoracic affection is more or less modified, and often completely 
 masked; hence to denominate the pneumonic disease as essentially and invariably typhoid 
 in its character is evidently a misnomer, and very liable to lead to serious errors in practice. 
 
 In the United States the disease is known by various names, according to the predomi- 
 nance of particular symptoms. In the more violent cases, the patient being suddenly seized 
 with a very severe chill, accompanied with marked coldness of tlie surface, it is, according 
 to Dr. Gibbes, frequently denominated the cold plague. The head being almost invariably 
 affected, before the pneumonic symptoms are developed, it is often called head pleurisy. In 
 tlie autumn or spring, when, in particular districts of country, it is frequently attended by the 
 symptoms of ordinary bilious fevers, it is called bilious pleurisy. From the symptoms of pros- 
 tration by which the disease is so generally attended throughout its whole course, and the 
 rapidity with which the patient sinks in the more violent cases, the term typhoid pneumonia 
 has become, however, the one by which it is most frequently designated. 
 
 In its mode of attack, and the general symjitoms by which typhoid pneumonia is ordinarily 
 attended, there is no uniformity. Usually, however, the disease is ushered in by a chill, 
 which is often of great severity and long continuance — the heat of the whole surface being 
 to the touch much below the standard of health. The cold stage is not unfrequently so in- 
 tense as to destroy the patient before the slightest reaction occurs. Where the disease is vio- 
 lent in its attack. Dr. Gibbes states, that the patient may suddenly become cold and pulseless, 
 lethargic, and often insensible without previous complaint ; he has known instances in which 
 the patient was foimd dead, or died within three or four hours after being apparently well 
 
 During the cold stage, the respiration is short and oppressed, and a pain on one or othei 
 side of the chest is generally complained of; pain of the head is also present in most cases; 
 and not unfrequently the patients experience severe pains in the back, limbs, and other parts 
 of the body — similar occasionally to those of rheumatism. The muscular strength is greatly 
 prostrated, and there is a sense of general uneasiness and great rest.'pssness. .Vfier a period. 
 longer or shorter in different cases, but usually protracted, reaction ensues, and the heat of 
 the surface is restored — it is seldom, however, increased much above the ordinary standard 
 of health. The heat is often unequally ditfused over the surface — portions being decidedly
 
 604 PLEURISY. 
 
 hot while others arc comparatively cool. Occasionally, the skin hecornes hot, dry and harsh, 
 while, at other times, it is relaxed, cool, and clammy. The pulse, when reaction ensues, 
 becomes somewhat fuller, and more quick and frequent, but in very few cases does it acquire 
 any degree of tensioii, excepting, perhaps, when the disease attacks young subjects and those 
 who retain some degree of vigour. Most commonly the pulse is soft, or it yields to the 
 slightest pressure. During the febrile stage, the pain, oppression of the chest, and difficulty 
 of respiration are increased, and, very generally, a cough comes on within the first twenty- 
 four hours, by which the pain in the thorax is greatly aggravated. When the cough is at- 
 tended with expectoration, the pain in the side is considerably relieved, and the oppression 
 of respiration diminished. When, however, the cough continues dry, or the expectoration is 
 slight, all the more serious symptoms become aggravated. The matter expectorated is a 
 thick, tenacious mucus, often tinged with blood, but at other times of an ash or dark-brown 
 colour. The respiration besides being oppressed is usually hurried, and irregular — the pa- 
 tient's spirits are greatly depressed — he often utters deep and heavy sighs, and complains 
 of a sense of weight, or of constriction at the prsecordia ; he is often affected with nausea, 
 and occasionally with vomiting. 
 
 Dr. JNIann (il/erf. Sketches, page 308), notices, as a common symptom of the disease, a re- 
 markable pink-coloured suffusion over the whole face, distinct from the usual febrile redness 
 of the cheeks — the face becoming, at the same time, puffed or bloated. This appearance is 
 most conspicuous in individuals of a light complexion j it is present, also, upon the body, but 
 to a less extent. In nrany cases it is not observed even on the face, or in a very slight 
 degree, and for a short period. 
 
 The tongue, in the first period of the disease, is often clean but red, particularly at its 
 edges ; in other cases, and perhaps most commonly, it is thickly coated with a yellowish 
 mucus, which, in the progress of tlie disease, changes to a dark-brown — the tongue becoming, 
 at tlie same time, dry, hard, and rough — often chapped. Upon the separation of the crust, 
 the tongue presents, not unfrequently, a bright-red colour, which colour occasionally pervades 
 also the fauces. 
 
 In many cases, the patient exhibits from the very commencement of the attack, particularly 
 where there is much pain of the head, more or less delirium, and great restlessness. 
 
 As the disease advances, the teeth and the whole interior of the mouth become coated 
 with a dark-coloured sordes ; the breathing becomes shorter and more oppressed — the 
 strength more prostrated, the pulse smaller and weaker — the patient sinks into a state of low 
 muttering delirium or of coma, more or less complete, and the fatal event takes place as in 
 the ordinary cases of typhus fever. 
 
 The duration of the disease is very variable. Death, as we have seen, may occur within 
 a very few hours from the commencement of the attack. Dr. Mackintosh has seen the dis- 
 ease, in the strongest subjects, run its course to a fatal termination in from forty-eight to sixty 
 hours j while Dr. Gibbes has known patients to be destroyed by it in from three to twenty 
 hours. In other cases, the disease may continue for several days before a fatal event occurs. 
 
 In cases where, under an ajjpropriate treatment early commenced with, the nervous power 
 is quickly aroused, the activity of the circulation is excited and a free action of the peripheral 
 capillaries restored, according to Dr. Gibbes, the attack may be cut short, without the occur- 
 rence of any symptoms of pneumonic disease. 
 
 When symptoms of pneumonia become developed, these will often yield to a proper treat- 
 ment, within the first thirty-six or forty-eight hours, though they will occasionally continue 
 for six or seven days, or even longer. The pulse increasing in volume and in firmness, the 
 surface becoming, throughout, warm, soft, and moist, the tongue cleaner and less red. the 
 delirium diminishing, the expectoration becoming more free and copious, the cough less fre- 
 quent and annoying, the pain of the thorax less intense, the respiration more full and easy, 
 and the occurrence of a quiet sleep, from which the patient awakes refreshed and with 
 greater cheerfulness, are the certain indications of amendment — recovery, however, is in 
 general very slow — tlie period of convalescence being protracted, while relapses readily 
 occur from slight exposure or the least imprudence of any kind. 
 
 Dr. Gibbes states, that he has frequently known patients who were convalescent and able 
 to walk about, complaining, in fact, of nothing but debility, to "yield suddenly to a cold 
 change of weather, and die in a few hours, or linger several days with pneumonic symp- 
 toms." Symptoms that were before mild and favourable, will often become aggravated 
 upon a change in the atmosphere to cold and damp. If a patient has been much enfeebled 
 by a first attack, a second is very likely to prove fatal. 
 
 In many cases of pneumonia typhoides, instead of a gradual decline of the symptoms of 
 thoracic disease taking place, these cease suddenly, and a severe pain is immediately expe- 
 r'enced in some other and perhaps remote part of the body, as in the region of the liver, in 
 the bowels, or in the head, attended with the other symptoms of inflammation in these 
 ports. According to Dr. Gibbes, when upon the cessation of the thoracic symptoms, a he- 
 inoiThage from the bowels ensues, it is generally critical — when inflammation of the brain 
 or peritoneum takes place, the case usually terminates fatally.
 
 PLEURISY. 605 
 
 The foregoing is the description of pneumonia typhoides as it most frequently presents 
 itself. In the different epidemical visitations of the disease, at different seasons, and in dif 
 ferent localities, or even during the same periods and in the same places, it not unfrequently, 
 however, assumes a very ditferent form. Thus, in some cases, the only symptoms which 
 the patient exhibits are extreme prostration and wandering pains of the back, loins, shoul- 
 ders or legs. In other cases, after a severe and protracted chill, the patient is seized with 
 severe pain of the head and back, and great gastric distress — delirium soon sets in, which 
 quickly gives place to coma, and death ensues within a few hours. 
 
 " Occasionally," remarks Dr. Gibbes, " an acute pain in the back part of the eye, in the 
 ears, or side of the neck, with stiffness of the muscles, is present. In severe cases the ton- 
 sils, the submaxillary and sublingual glands are swollen, with acute pain in swallowing ; 
 these are usually the worst cases." In a few instances the symptoms of genuine erysipelas 
 present themselves on some portion of the skin, and invade successively almost every part 
 of it. 
 
 In these irregular forms of the disease, the symptoms of the thoracic affection are often 
 very slight, or they may be entirely absent. There is usually, however, some sense of 
 tightness about the chest, some difficulty of respiration, and a slight occasional cough — with 
 or without expectoration ; and it is remarked by Dr. Stokes, that the physical signs of pneu- 
 monia may frequently be detected in cases unattended with dyspnoea, pain, cough, or 
 expectoration. 
 
 A very common form of the disease under consideration — and which at certain seasons, 
 and in particular districts, is even more prevalent than that to which the appellation typhoid 
 is ordinarily applied — is the one usually known as bilious pleurisy or bilious pneumonia. 
 
 In this, the attack commences with symptoms differing but little from those which usually 
 usher in an ordinary case of bilious remittent fever — there is, perhaps, in general, a more 
 severe and protracted chill, and a sense of distress and oppression about the chest, which is 
 not usually observed in the latter disease. Occasionally, the attack is preceded, for a day or 
 two, by a sense of fulness and weight in the right hypochondrium, and, in a few cases, by 
 symptoms of a dysenteric character. Very generally there is severe pain of the back and 
 extremities, and often of the head also. Almost invariably, the attack is accompanied by 
 an acute pain of the forehead — well-marked febrile symptoms, with, usually, decided exa- 
 cerbations in the morning and remissions towards evening. — During the exacerbations the 
 face is flushed, and as the skin, from the commencement of the disease is more or less tinged 
 with bile, the mixture of red and yellow gives to the countenance a very peculiar, sickly 
 aspect. The eyes are red and watery, the conjunctiva having often a deep yellow hue. In 
 many instances, it is only after the fever has continued for several days that pain in the 
 chest is complained of: this is sometimes very severe and acute, more commonly, however, 
 it is obtuse — of an aching rather than of a lancinating character — there is, at the same time, 
 a sense of weight and oppression of the chest, with more or less difficulty of respiration and 
 cough. The cough is at first dry, and its repeated paroxysms cause an increase of the pain 
 in the thorax and head. The expectorated matter is frothy and of a yellowish colour, often 
 streaked with blood, and of variable consistence. The tongue is, at first, coated on its sides 
 with a whitish mucus, while at the centre it is covered by a dark-yellow or brownish crust 
 — the edges of the tongue are ordinarily of a decided red. As the disease advances, the 
 tongue becomes dark-brown, dry, and hard. The pulse is usually small, frequent, and quick, 
 with a slight degree of tension. 
 
 There is always more or less gastric distress, and very commonly vomiting, the matter 
 discharged from the stomach being often bile or a thick ropy mucus mixed with bile. In 
 many cases the epigastrium is hot, and painful upon the slightest pressure. The urine is 
 always of a deep yellow colour from the presence in it of the colouring matter of the bile. 
 
 The stage of excitement in bilious pneumonia is ordinarily of short duration, and, unless 
 the disease is arrested by an appropriate treatment, great muscular prostration speedily 
 supervenes, and the same train of symptoms ensue as in the tyj)hoid form of the disease. 
 
 In the affection we have described, under whatever form it may present itself, the periou 
 of convalescence is always slow, irregular, and for a long while in)perfect. "Chronic hepa- 
 tization, with or without hectic fever, or a lurking congestion, may continue for weeks ; and 
 although, under appropriate management, the disease may be ultimately removed, atrophy 
 of the lungs, with or without ulcerative disease, is often established. In certain cases, months 
 may elapse before the respiratory murmur is heard, and, in many instances, it is never re- 
 established. On the other hand, it has been known to cease in a single day, on the super- 
 vention of an attack of gastritis or enteritis." (^Dnnglison' s Practice of Medicine, vol. i. 313.) 
 The principal exciting cause of pneumonia typhoides is unquestionably protracted expo- 
 sure to a damp and cold atmosi)here, while the predisposition to its attacks is promoted by 
 all those causes which tend to reduce the vital energies of the system — as bodily or menta' 
 fatigue, intemperance, improper or deficient diet, insufficient clothing, mental distress or 
 anxiety, long watching, previous disease, &c. Nothing, remarks Dr. Mann, predisposes to its 
 attack in So high a degree as an intemperate use of intoxicating drinks. The soldiers, sayi 
 
 3 a2
 
 606 PLEURISY. 
 
 Dr. Mackintosh, were often seized with the disease who were exposed at night as sentinels — 
 "instead of walking; about they frequently stand shivering in their sentry-boxes, the surface 
 continues long chilled, and with a view to fortify themselves, and to produce warmth, the/ 
 are in the habit of drinking ardent spirits in considerable quantity." 
 
 It is a common complaint among the poor and labouring classes in many parts of thla 
 country, during the prevalence of long-continued cold and damp weather, such as frequently 
 occurs during the spring and autumn, in the more northern states, as well as during the open 
 winter of the middle states. In the south, according to Dr. Gibbes, it is rarely met with on 
 highland plantations, and if at all, is confined to such negroes as are more or less exposed 
 to work on low or wet ground. On the swamp plantations the disease is endemic. 
 
 As we have already stated, the disease occasionally occurs as an epidemic, but generally, 
 during seasons when the temperature of those districts in which it prevails is marked by 
 sudden and considerable vicissitudes from heat to cold, and by extreme and long-continued 
 moisture. 
 
 Typhus pneumonia more frequently attacks males than females, and aduhs than children — • 
 this is a statement in which nearly all who have written upon the disease concur. The pre- 
 disposition of adult males to its attacks, is very readily explained by the axuount of exposure 
 and fatigue to which they are usually subjected being much greater than that of females and 
 children — and probably, also, from the fact that their habits, geiaerally speaking, are much 
 less temperate. The disease is not, however, confined to any age, nor are females and chil- 
 dren entirely exempt from it, particularly when it prevails as an epidemic. It is usually, 
 however, most severe in individuals over fifty years of age, and is very seldom seen in chil- 
 dren under ten years. The negro race is particularly liable to its attacks. 
 
 In the treatment of pneumonia typhoides much must necessarily be left to the judgment 
 of the practitioner. In the selection of his remedies, more perhaps than in any other disease, 
 must he be guided by the particular character of the symptoms present in each case. It is 
 all important that the true nature of the disease be carefully investigated in its earliest 
 stages — it being then, in its ordinary form, readily controlled by an appropriate treatment, 
 and, even when marked at its onset by symptoms of very considerable severity, it may often 
 be arrested by prompt and judicious management. 
 
 In this disease, Dr. Gibbes remarks, and a similar observation is made by others," if the 
 cases are immediately attended to, it is found quite manageable, as much so as an ordinary 
 catarrh; but when neglected for twelve or twenty-four hours, and the symptoms are at all 
 aggravated, the patients are very apt to die." 
 
 We shall often succeed, when the patient is seen during the first period of the attack, or 
 diuing the cold stage, as it is not improperly termed, in rousing the nervous energy — pro- 
 ducing a free and equable circulation, and a due degree of heat and moisture upon the sur- 
 face, by resorting at once to moderate doses of opium, cainphor, calomel, and ipecacuanha, 
 in conjunction M'ith the milder class of diffusible stimulants internally, and the application 
 of heat and rubefacients externally. By this treatment, early and judiciously pursued, and 
 carefully watched so as to prevent a state of over-excitement being produced by it, the en- 
 gorgement of the lungs may often be prevented or removed, and a speedy restoration of 
 health secured to the patient. 
 
 In the more open form of the disease, known as bilious pneumonia, the early administra- 
 tion of an emetic will often be found beneficial. Richter states, that in the bilious form of 
 the disease, emetics will often remove the pain and aflection of the chest as by a charm, and 
 Stoll makes the same observation {Ratio Meden., i.). In the few cases Dr. Eberle had seen 
 of bilious pneumonia, he states that the utility of emetics in its treatment was strikingly 
 evinced. They, in general, bring on an uniform diaphoresis, promote expectoration, and 
 allay the pain in the thorax, often almost immediately. Dr. Dickson also remarks, that he 
 has been much pleased with the effects of the early administration of an emetic, or an 
 emetico-cathartic. A combination of ipecacuanha and calomel may be given, or the sulphate 
 of magnesia dissolved in a strong infusion of seneka or serpentaria, with the addition of 
 twenty grains of ipecacuanha. Dr. Mann, likewise, speaks favourably of the effects of an 
 emetic of ipecacuanha. In the more decidedly inflammatory cases, the emetic was not ad- 
 ministered by him until after bleeding and cathartics had been employed ; especially where 
 the head or chest was affected with severe pain : — when after the occurrence of expectora- 
 tion, this had become arrested from any cause, small emetics, he states, were found benefi- 
 cial, and in many cases had to be frequently repeated. The emetico-cathartic or even the 
 emetic alone, is, however, a remedy of very doubtful propriety in cases attended with early 
 symptoms of prostration and extreme muscular debility. 
 
 The propriety of blood-letting in any of the forms of typhus pneumonia, has excited not a 
 little controversy. By some practitioners, the use of the lancet is condemned in every case, 
 as a remedy fraught with danger, from its liability to induce speedily a state of prostration 
 fiom which the patient is witli difl5culty roused; while others of equal celebrity insist upon 
 ihe necessity of full and even repeated venesection — considering it to be an important, if not 
 an mdjspeiisable remedy in the treatment of the form of pneumonia under consideration.
 
 PLEURISY. • 607 
 
 This discrepancy of opinion is satisfactorily accounted for by the very different characters 
 under which the disease presents itself in different localities, and at different periods — often, 
 indeed, during the same epidemic visitation ; south of the Potomac, we are informed by Pro- 
 fessor Potter, that the disease is seldom so inflammatory as along the shores of New Jersey 
 Delaware, and Maryland; and the farther south, the more it is said to assume a middle ty- 
 jihoid complexion. In the winter epidemic of 1815-16, along the northern frontier of the 
 United States, we are assured by Dr. IVIann, that in many districts " the disease was highly 
 inflammatory from its commencement to its final resolution," and that, " it was as idle to 
 administer stimulants for its cure, as it would have been to have poured oil on fire to extin- 
 guish the flame." "Its cure," ho adds, "depended upon the assiduous administration of the 
 antiphlogistic regimen: evacuants, expectorants, and diaphoretics, with the aid of blisters." 
 It is very certain that in the ordinary cases of typhoid pneumonia, the use of the lancet 
 will seldom be demanded, and in many, would be altogether inadmissible. Cases, it is 
 true, will not unfrequently occur, in which the detraction of a moderate quantity of blood 
 from the arm, during the early period of the febrile stage, will be productive of the best 
 effects. General blood-letting, however, should always be resorted to with the utmost cau- 
 tion — perhaps it would be better, in every instance where symptoms of a typhoid character 
 early set in, and the loss of blood is considered advisable, to apply cups to the chest in pre- 
 ference to resorting to the lancet. In cases of bilious pneumonia, blood-letting will be much 
 more frequently demanded than in the typhoid form of the disease ; but even in these it 
 should be resorted to only in the early period of the attack, and it is more safe to take away 
 a sufficient amount at the first bleeding, than to trust to small and repeated bleedings. In 
 the bilious form of the disease, when much pain or tenderness of the epigastrium is present, 
 leeches or cups to this part are always proper, and will often be found to afford very decided 
 relief. 
 
 The bowels should be early evacuated by some mild but effective laxative — the best is 
 unquestionably calomel in moderate doses, followed by castor oil or magnesia — active or 
 "A-atery purging should always be cautiously avoided. 
 
 In the cases marked by early prostration, and extreme muscular debility, we should resort 
 at once to moderately stimulating diaphoretics ; of these, according to Dr. Dickson, camphor, 
 nitrous ether, the carbonate and acetate of ammonia are the best ; and they are rendered 
 more beneficial by combining them with Dover's powder. " The efiicacy of all these," he 
 adds, " will be much aided by the pediluvium, and by the application of warm fomentations, 
 poultices, and heat in various forms to the surface of the patient. Cataplasms with mustard 
 must be laid over the chest, if pain or dyspnoea is present, and applied also to the wrists and 
 insteps. Epispastics are also of use, by their double power of stimulants and revulsives 
 tlie back of the neck, if the head be affected, the sternum and the epigastric region, if the 
 lungs or heart or stomach suffer, should be selected for their application. There has been 
 some dispute as to the preference due to the dry or moist form of heat, as the best to be re- 
 sorted to in this disease. It is, I think, easy to decide. If the skin be dry, I prefer fomen- 
 tations, or even the vapour-bath ; if moist, I prefer bottles of hot water, heated bricks, bags 
 of hot salt, chaff, &c. Sweating will in the greater number of cases, come on readily, but 
 must be regulated. If too profuse, and kept up for too long a time, it may prove injurious 
 and debilitating. You restrain it by substituting dry for moist applications, and removing 
 some of the bed-clothes, and changing cautiously the body linen of the patient; dry garments 
 carefully and well aired, being put on in the place of those moistened by the cutaneous 
 discharge." 
 
 In cases where a tendency to sinking is early evinced. Dr. Gibbes recommends sma.l doses 
 of calomel as a general excitant of the secretions, with camphor, opium, carbonate of am- 
 monia, and free vesication. 
 
 In nearly every form of the disease, whether typhoid, bilious, or more openly intlam- 
 matory, the effects of small doses of calomel, combined with ipecacuanha and opium are 
 spoken of as particularly beneficial. Large blisters over the chest will also, in most cases, 
 be found of the highest importance, from the very commencement of die attack. In obstinate 
 cases. Dr. Mann directs them to be renewed daily until the pain of the chest is removed. 
 
 Where the patient's strength rapidly fails, and he is sinking into diat low typhoid condi- 
 tion which marks the second period of die disease, stimulants must be freely resorted to : of 
 these Dr. Dickson prefers " the volatile alkali in large doses, from five to ten grains every 
 half hour or hour, widi wine whey or brandy toddy; spts. nit. dulc., spts. of turpentine, the 
 tincture of cantharides." "I can set," he remarks, "no limit to the administration of this 
 class of remedies, but the excitement of a notable degree of reaction, which being observed, 
 will guide you in the future quantities to be exhibited ; taking care, however, that the patient 
 shall not suffer by dieir timid or ineflicient amount, nor be allowed to retrograde by any sud- 
 den subtraction of dose." 
 
 " It is well to be reminded," observes the same writer, " that in this strange disease it ia 
 never permitted to despair of your patients, recoveries being in considerable number recorded
 
 608 PULMONARY HEMORRHAGE. 
 
 fiom circumstances the most deplorable, and, indeed, to all reasonable anticipations, abso 
 lutely hopeless." 
 
 During the whole period of convalescence the patient will require to be watched with 
 care. — - You must abstract gradually from the amount of stimulants which have been given 
 him, and substitute in their stead the more permanent tonics. Of these each practitioner has 
 his favourite. Arsenic is preferred by many of the New England physicians, and is, accord- 
 ing to Dr. Dickson, without doubt, highly serviceable." The muriate of iron is also spoken 
 of as well adapted to this period of the disease — and is certainly preferable in all respects 
 to the arsenic. Dr. Mann states, that the only stimulant employed by him in the convales- 
 cent state, was a mixture of spts. nit. dulc, and aqua ammoniae ; a teaspoonful of this proved 
 a cordial and expectorant, at the termination of the disease, when repeated every two or 
 three hours; as did, also, a mixture of equal parts of the camphorated tincture of opium and 
 antimonial wine, where the cough was troublesome. Other practitioners prefer, as a tonic, 
 at the close of the disease and during the period of convalescence, the cinchona or the sul- 
 phate or muriate of quinia. Dr. Dickson gives the bark in infusion, combining it with ser- 
 pentaria, adding to each dose a small proportion of carbonate of potass, and camphorated 
 tincture of opium. The patient should be supplied with a light diet of nourishing and easily 
 digested food — and should be guarded sedulously from the slightest amount of exposure to 
 cold or damp, and should be guarded from sudden alternations of temperature for a con- 
 siderable time after recovery • — he should to that end vi^ear flannel next his skin, and adapt 
 his clothing not only to the season, but to the temperature of each day and each portion of 
 the day. — C] 
 
 LECTURE LIV. 
 
 Pulmonary Hemorrhage ; its varieties ; its connection with pulmonary consump- 
 tion, and with disease of the heart. Pulmonary apoplexy. Prognosis in 
 Hxmoptysis. Symptoms. Treatment. 
 
 Having gone over the inflammatory affections of the organ of respiration ; having 
 brought before you inflammation of the membrane which lines the air-passages, or 
 bronchitis ; inflammation of the membrane which invests the lungs, or pleurisy ; 
 and inflammation of the ichole substance of those organs, or pneumonia ; I proceed 
 next to the subject of pulmonary hemorrhage. 
 
 You may remember that, in an early part of the course, I drew your attention to 
 some general facts respecting internal hemorrhages. I showed you that the blood 
 does sometimes proceed from visibly ruptured vessels, but that it is much oftener 
 poured forth from unbroken surfaces, in the way of exhalation ; and that hemorrhage 
 of this kind takes place from the mucous membranes far more frequently than from 
 any other natural surface of the body. I observed also that such hemorrhage is 
 almost always preceded by congestion ; either by active congestion, which is less 
 common, or by passive and mechanical, which is extremely common : and we speak, 
 accordingly, of active and passive hemorrhage. Hemorrhage is also sometimes 
 primary, or idiopathic, and then constitutes the whole disease ; while at other times 
 it is merely a symptom, direct or indirect, of some other disorder, in which case we 
 call it secondary. 
 
 Now in the lunsfs we find examples of all these varieties of internal bleeding; but 
 pulmonary hemorrhage is secondary much more often than it is primary. 
 
 In speaking, therefore, of some forms of pulmonary haemorrhage, I must touch 
 upon certain diseases of which the bleeding is a symptom : but I shall not go further 
 into the consideration of those diseases at present, than may be necessary to elucidate 
 the hemorrhage. Bleeding from the lungs is a thing of most fearful interest ; and 
 It will be useful to take a general view of that phenomenon, whether it be a substan- 
 tial disease in itself, or merely a sign of other pre-existing diseases. 
 
 Tne blood, then, in pulmonary, as in all other hemorrhages, may issue through a 
 breach in the walls of some considerable blood-vessel ; or it may proceed from innu- 
 merable points in the mucous membrane of the lungs, by the process of exhalation : 
 «nd the latter mode of hemorrhage is much the more common of the two, although
 
 PULMONARY HEMORRHAGE. 609 
 
 it is the popular belief tfiat the "breaking a blood-vessel in the lungs" is of very- 
 frequent occurrence. 
 
 The particular vessels injured in the first class of cases, and the nature and origin 
 of the breach made in their sides, are matters of infinite variety. Sometimes the 
 blood is extravasated through apertures, the results of a disorg:mizing process which 
 has commenced in the coa-ts of the vessels themselves ; as when, for example, aneu- 
 risms of the thoracic aorta, or of its primary divisions, burst, and pour their contents 
 into the air-tubes. Having pointed out this accidental and hopeless form of pulmo- 
 nary hemorrhage, I shall postpone any further account of the disease that gives rise 
 to it, to a future lecture. 
 
 Sometimes, again, a large blood-vessel is laid open by the encroachment and ex- 
 tension of disease from contiguous structures. Here is represented (Carswell, fasc, 
 vi. plate iii. fig. 5) the perforation of a large branch of the pulmonary artery, and of 
 a neio-hbouring bronchial tube, by the extension of tubercular ulceration. The blood 
 escaped so abundantly in this case, that the patient was dead in less than a quarter 
 of an hour. And here I show you a preserved specimen of a similar opening made 
 in the pulmonary vein. 
 
 It will be necessary that T should anticipate somewhat ; and in order to include in 
 one view all that relates to p'llmonary hemorrhage, that I should speak cursorily of 
 Us connect'on with tubercular phthisis. No one here can be ignorant that in that 
 terrible disease portions of the lung are liable to be hollowed out by the softening 
 and expulison of tubercular matter, into what are called vomicx. Now seeing that 
 hsemoptysis occurs very frequently in persons labouring under consumption, and 
 that the expectoration of blood is often copious, and takes place when it is evident 
 that there are tubercular excavations in the lung, it would be vevy natural for you 
 lo suppose that the bleeding in such cases proceeded from large vessels which had 
 been laid open during the softening of the tubercles, or by the subseq.isnt extension 
 jf the ulcerating cavities. But in point of fact, this is very rarcbj iho case. I shall 
 explain to you hereafter how it happens that this hemorrhage from the larger vessels 
 is generally prevented ; still it does sometimes happen. 
 
 But in a far greater number of instances the blood in haemoptysis is exhaled from 
 the mucous membrane that lines the air-passages. For when this surface is examined 
 in the dead body, and immediately after the occurrence of pulmonary hemorrhage, 
 it is very often found to be perfectly entire, from the commencement of the trachea 
 10 the remotest divisions of the bronchial tubes ; as far, at least, as minute dissection 
 can follow them. The membrane in these cases is usually red, as in simple bron- 
 chitis ; but it is sometimes pale, or with scarcely any traces of vascularity. The 
 former of these appearances results from the continued turgescence of the capillary 
 vessels ; the ktter is the consequence of their having been completely emptied of 
 blood by the last hemorrhage. We shall meet with analogous conditions when we 
 come to examine the hemorrhages that proceed from other mucous surfaces ; and 
 especially from that of the alimentary canal. 
 
 When blood is thus exhaled from the mucous membrane of the air-passages, the 
 hemorrhage may be strictly primary or idiopathic; i. e., it may be independent of 
 any discoverable alteration of texture, either in the mucous surface itself, or in any 
 other part which, by reason of some intelligible connection of structure or relation, 
 seems capable of influencing the capillary circulation of the membrane. But the 
 occurrence of pulmonary hemorrhage strictly idiopathic has been more frequently 
 affirmed than proved. Active hemorrhage from the lungs is stated by systematic 
 writers to be the hemorrhage of adolescence, as epistaxis is that of childhood. I 
 believe, however, that idiopathic active hemorrhage from these organs is very rare 
 indeed ; unless we may consider as such, certain forms o^ vicarious bleeding, which 
 I shall presently advert to. Andral tells us that in one instance only, in whicn 
 hemorrhage from the surface of the air-passages had been the immediate and appa- 
 rently the sole cause of death, had he ever found the substance of the lungs free 
 from tubercles, and perfectly healthy. He does not, however, state whether in this 
 one instance the heart also was in its natural condition : an important omission, as 
 we shall hereafter perceive. He relates, indeed, as an examnle, of idiopathic 
 39
 
 ()I0 PULMONARY HE3I0RRHAGE. 
 
 hccmoptysis, the case of a young man who suffered profuse hemorrhage from the 
 luntrs on four several occasions, between the ages of twelve and eighteen, without 
 any apparent detriment to his health, which remained excellent. It is consistent, 
 however, with much experience to suppose that crude tubercles might have been 
 scattered in the lungs of this person, and have sufficed, on the application of some 
 exciting cause, to determine the hemorrharje, although as j'et their presence was not 
 indicated by any other sign. Almost every systematic writer quotes, as an example 
 of idiopatliic hemorrhage from the lungs, the story of the Roman governor, men- 
 tioned by Pliny, who lived to the age of r 'nety, though he was afflicted with habitual 
 hajmoptj'sis. Now the frequent citatiot of this supposed instance is of itself a suffi- 
 cient proof that spontaneous pulmonary jemorrhage is far from being common. 
 
 Cscteris paribus, the disposition to pulmonary hemorrhage is increased by what- 
 ever tends to diminish the capacity of the thorax, and to compress the lungs, or the 
 heart and great blood-vessels. The "lechanical congestion thus produced may be- 
 come a very intelligible cause of the '.xhalation of blood from the mucous membrane. 
 And it is partly on this principle that Ave may account for the frequency of hae- 
 moptysis in persons with crooked spines ; in tailors, who sit continually in a stooping 
 posture : in young women who lace their stays too tightly ; and even in those who 
 labour under dropsy, or other cause of distension of the belly. Haemoptysis accom- 
 panying ascites has been known to cease at once upon the performance of the 
 operation of tapping, and to recur upon the reaccumulation of the dropsical fluid ; 
 and this is not on one occasion only, but so often and regularly as to preclude all 
 notion of accidental coincidence. There can be little doubt, however, that in this 
 class of cases,' or at least in a vast majoritj'^ of them, the haemoptysis is mainly to be 
 ascribed to organic disease of the heart or of the lungs ; and that the pressure which 
 precedes and determines the bleeding is simply a concurrent cause. 
 
 If we cannot properly rank that pulmonary hemorrhage as idiopathic, which is 
 constitutional and vicarious of some other natural or morbid discharge, — and most 
 frequently of all of the menstrual discharge in females, — it may be considered as 
 forming a link of connection ; as lying midway between secondary and primary 
 hemorrhages. There are a great number of very curious and well-authenticated 
 facts upon record concerning this singular form of hemorrhage by deviation. . will 
 give you one history of the kind by w^ay of sample; it is related by Pinel, who held 
 that there was no supplemental hemorrhage more common than the haemoptysis that 
 is vicarious menstruation. 
 
 A female, 58 years old, born of healthy and robust parents, of strong constitution, 
 of a sanguine and plethoric temperament, and of great sensibility, lived in the Sal- 
 petriere, and was therefore, under constant observation from the age of 14. She 
 enjoyed excellent health till she was 1(> years old. In her IGth year the menstrual 
 discharge commenced without mishap or difficulty ; but this, \\ex first menstruation, 
 was suddenly suppressed, in consequence of the fright and agitation produced by the 
 eight of an epileptic patient in strong convulsions. From that time the catamenia 
 never reappeared, nor did any kind of discharge take place from the genital organs , 
 but at the next period, when regular menstruation ought again to have come on, the 
 girl was attacked with violent hcemoptysis. The hemorrhage was preceded by vague 
 pains in the uterus and loins, and by other symptoms which frequently announce the 
 catamenia. It lasted two days, during which time the girl expectorated nearly a 
 quart of blood. With one interval of exception only, this female continued to men- 
 struate through her lungs at each monthly period, from her IGth to her 5Sth year, 
 t. c., during 42 years of her life. The coming on of the hemorrhage was sometimes 
 a little accelerated by strong mental excitement ; sometimes a little retarded by 
 causes of a contrary nature. It was suspended during one whole year, without any 
 serious impairment of the general health, or the occurrence of any other hemor- 
 rhage : during this interval, however, the patient suffere'? most severe headaches. 
 Occasionally the hremojotysis was complicated with ha^mateinesis. The symptoms 
 by which the pulmonary hemorrhage in this instance was generally preceded or 
 accompanied were the following : — a sensation of weight and uneasiness in the loins 
 and in the .situation of the uterus, soon followed by chilliness of the surface, general
 
 PULMONARY HEMORRHAGE. 611 
 
 lassitude, and a feeling of oppression and heat in the chest, with some dyspnoea. 
 The face became red, and she had intense headache. Then she began to have a 
 distinct sensation of pricking, and of a sort of bubbhng, in the trachea and about the 
 commencement of the bronchi ; then followed sharp cough, and the expectoration 
 of blood, often bright-coloured and frothy, sometimes of a darker hue. The dura- 
 tion of the haemoptysis was generally confined to a single day, and it never exceeded 
 three days. It recurred with tolerable exactness at monthly periods ; sometimes the 
 interval was longer, and then the hemorrhage continued longer, but was less abun- 
 dant ; and upon the whole, about the same quantity of blood was lost on each occa- 
 sion. This woman continued plump, and otherwise healthy, though liable to some 
 thickness of the breath upon unusual exertion. 
 
 Cases of this kind are not at all uncommon ; although the vicarious hemorrhage 
 seldom persists so long and so steadily. They are not usually attended with any 
 peril to life. 
 
 It is, however, a melancholy truth, that the hemorrhage, which takes place by 
 exhalation from the mucous membrane of the air-passages, is dependent, in a very 
 large proportion of instances, upon incurable disease. The hemorrhage is secondar}^; 
 and the clisease of which it is symptomatic is usually a fatal disease. And the com- 
 plaint of which hcsmoptysis is by far the most frequentli/ symptoma.tic, is tubercular 
 phthisis. When the tubercles are found upon dissection to be yet crude and entire, 
 and no breach can be detected in the membrane, then no doubt can be entertained 
 about the source and manner of the bleeding; and even when cavities exist, espe- 
 cially if they are found to contain no blood, it is probable that, in most cases, the 
 hemorrhage has had a similar origin. 
 
 When haemoptysis is thus actually symptomatic of tubercular disease of the longs, 
 it is liable to considerable variety in regard to the period of its first occurrence, and 
 the symptoms by which it is succeeded. There are many persons in whom the first 
 attack of htcmoptysis precedes, even for years, the primary symptoms of unequivo- 
 cal phthisis. There are others in whom the iirst attack of haemoptysis is imincul- 
 atclij followed by all the signs which announce vhe presence of tubercles in the lungs. 
 Man}', again, do not spit blood until the tubercles have acquired a considerable 
 degree of development, and the phthisical symptoms have been for some time clearly 
 marked ; and occasionally, in these cases, the first hemorrhage proves fatal. Lastly, 
 it is far from being an uncommon thing to see pulmonary consumption run its 
 whole course, and terminate in death, without having been attended with any spitting 
 of blood. 
 
 Andral gives the following statement as the result of his own observation, in re- 
 gard to the relative frequency of these several modes of connection between haemo- 
 ptysis and consumption. 
 
 Of the persons whom he had known to die of that disease, one in six never spat 
 blood at all. Three in six (or one half of the whole number) did not spit blood 
 until the existence of tubercles in the lungs was already made certain by unequi- 
 vocal symptoms. In the remaining two-sixths the haemoptysis preceded the 
 other symptoms of tubercular disease, and seemed to mark the period of its com- 
 mence-menl. 
 
 By this comparative statement you will see how very frequently hosmoptysis 
 occurs as one of the symptoms connected with tubercular phthisis. Under this 
 physician's observation it happened in live cases out of six. In the experience, 
 however, of M. Louis, the proportion, though very large, is not quite so great as 
 Andral found it. Among eighty-seven instances of consumption, there were fifty- 
 seven, or four in every six, in which hcemoplysis had been present. 
 
 It has, however, been made a question, whether the spitting of blood which thus 
 occurs in connection with tubercular phthisis, is always to be considered as indica- 
 tive of the existence already of tubercles in the lungs ; or whether it may not some- 
 times precede, and give occasion to, their formation in those organs. This question 
 has evidently been suggested by those cases (constituting, according to Andral, one 
 third of all that happen) in which the ordinary signs of phthisis begin to manifest 
 their»seives immediately upon the occurrence of the first haemoptysis, or within a
 
 612 PULMONARY HE3I0RRHAGE. 
 
 short time afterwards. Morton, who has noticed this kind of pulmonary hemorrhajje, 
 includes among his species of phthisis, the " phthisis ab hcemoptoe ;" and Cullen 
 held that spilling of blood was oflen the cause of pulmonary consumption. It is a 
 very important question, and I shall revert to it again hereafter. 
 
 Next to tubercular disorganization of the lungs, the most frequent source of pul- 
 monary hemorrhage is to be found in the organic disease of the heart. It has been 
 stated by Chomel, Bouiilaud, and others, both in this country and abroad, that the 
 disease in these cases is most commonly situated in the I'ight chambers of the heart. 
 But certainly this is a mistake. The error has arisen from arguing upon erroneous 
 analogies, instead of attending to matters of fact. However, the statement is just as 
 httle supported by reason as it is by the result of general experience. The only 
 alteration in the right cavities of the heart which we could suppose likely, a priori, 
 to cause pulmonary congestion, and thereby haemoptysis, would be increased strength 
 and thickness of their muscular parietes : hypertrophy ; a morbid condition which 
 is comparativily rare on that side of the heart, and which, perhaps, would not suffice 
 for the production of haemoptysis, even if it did oftener exist. The direct effect, on 
 the other hand, of any obstacle to the free passage of the blood in the right cham- 
 bers of the heart, would be to gorge the liver, and the system of the vena portse ; 
 and to prevent the lungs from receiving their due proportion of blood. But any 
 material obstruction existing in the left auricle or ventricle will impede the return 
 of blood from the lungs, lead to its accumulation in those organs, give rise to me- 
 chanical congestion, and so dispose strongly to pulmonary hemorrhage. And, in 
 point of fact, we find that haemoptysis is very frequently the result of disease in the 
 left side of the heart ; and this leads me to speak here of one very remarkable morbid 
 condition of the lungs, which is often directly connected both with pulmonary he- 
 morrhage and with cardiac disease ; though it is not always, or necessarily, associated 
 with either. 
 
 The morbid state to which I allude is far from being infrequent ; yet it had been 
 scarcely noticed by or known to pathologists, until Laennec described it under the 
 title of pulmonary apoplexy. It appears under two forms. In the one form we 
 find an uncertain number of hard knobs, or compact masses, situated here and there 
 in the substance of the lungs, chiefly in their lower lobes, and towards their posterior 
 surface. Their size varies from that of a marble to that of a hen's egg. When 
 cut through they are seen to be very exactly circumscribed, the cut surface being 
 more or less circular, of a uniform and very dark colour throughout, and exhibiting 
 a strong contrast with the surrounding tissue. Careful examination shows that these 
 masses are composed of blood that has coagulated in the pulmonary vesicles. Occa- 
 sionally the pulmonary substance seems broken down, or torn, by the extravasated 
 blood ; and in these cases, perhaps, the resemblance between the injury done to the 
 lung, and that which is inflicted on the substance of the brain in cerebral hemorrhage, 
 is tolerably close. Generally, however, there is no such laceration of the pulmonary 
 tissues ; but one, or more, of the lobules of the lungs are gorged and crammed with 
 blood, which has been poured out from the surface of the mucous membrane. These 
 lobules, it is weU known, have no direct communication with each other ; but are 
 isolated (except where they severally open into the bronchial tubes from which they 
 spring) by a distinct investment of areolar tissue ; and it is to this peculiarity in 
 their structure and disposition, that the exact circumscription of the dark-red indu- 
 rated masses is to be attributed. 
 
 In the other form of pulmonary apoplexy, there are fewer of these solid spots; 
 perhaps one only, large, diffused, occupying sometimes nearly the whole of one 
 lobe, its limits obscurely defined, and its colour gradually deepening to the centre, 
 which is obviously formed by little else than a black clot of blood. 
 
 Now the principal symptom attendingthe formation of these masses is hasmoptysis; 
 and the principal, though not the only cause is disease of the heart. The hemor 
 rhage is often severe and copious in the first, or circumscribed form : sometimes 
 shght and scanty, but commonly slow, oozing, and persistent, in the second or uncir- 
 oumscribed form. The heart disease is in its left chambers, and very often consists 
 <n contraction of the mitral orifice. No example of pulmonary apoplexy, or of
 
 PULMONARY HEMORRHAGE. i t)l3 
 
 pulmonary hemorrhage, even apparently dependent upon hypertrophy of the right 
 side of the heart, has ever fallen under my notice. 
 
 In truth the morbid condition of the lungs which I am now speaking of, has been 
 badly named. The application, by Laennec, of the term apoplexy to \.\\q lungs was 
 singularly unfortunate : for it suggests an analogy between two things, which, though 
 resembling each other in the appearances which they leave behind them in the organ 
 affected, are yet, essentially, unlike. I have shown you, in a previous part of the 
 course, that cerebral hemorrhage depends almost always upon the giving way of a 
 blood-vessel, in consequence of the morbid brittleness of its coats ; while what is 
 called pulmonary apoplexy can very seldom indeed be so caused. The notions which 
 I have been led to form upon this subject differ materially from those which you 
 will find expressed in the works of almost every writer on pulmonary apoplexy. 
 The opinions I entertain were stated several years ago, in some lectures which I 
 was appointed to deliver before the College of Physicians ; and I have constantly 
 been in the habit of mentioning them to the pupils of the Middlesex Hospital, and 
 to my medical friends. It is a matter of satisfaction to me to find that they are 
 esteemed to be correct by so sound a pathologist as Dr. Carswell, who has alluded 
 to them in one of his fascicuh on the Elementary Forms of Disease. Laennec 
 speaks of the pulmonary apoplexy, as if it were the cause of the haemoptysis. But 
 ihis is surely a very incorrect view of the matter. The partial engorgement, and 
 ihe haemoptysis, are not mutually connected with each other as cause and effect, but 
 they are concurrent effects of the same cause ; of that cause which gives rise to the 
 extravasation or exhalation of the blood in the first instance. A part of the blood so 
 extravasated passes outwards by the trachea and mouth ; while a part is forced in 
 the contrary direction, into the ultimate divisions of the bronchi, so as to fill and 
 block up the whole tissue of a single lobule, or of a bunch of contiguous lobules, 
 and thus arises the circumscribed variety. Andral conceives that the sanguine effu- 
 sion takes place in the ultimate air-cells ; and he applies to this form of disease the 
 term pneumo-hemorrhage, to distinguish it from ordinary haemoptysis, which he calls 
 6ronc/jo-hemorrhage ; and this I believe to be the true pathology of the wicircum- 
 scribed variety. But it seems to me vastly more probable, that in the other form of 
 the complaint the seat of the effusion is in one or more of the larger branches of the 
 air-tubes; and that the blood, a part of it at least, is driven backwards into certain, 
 of the pulmonary lobules, by the convulsive efforts to respire w^iich the patient 
 makes when threatened with suffocation by the copious explosion of blood, or by a 
 paroxysm of cough and extreme dyspnoea : especially if the blood is poured out from 
 the membrane while the chest is in the state of ea;piration. It is easy to understand 
 how certain portions of the lungs, without undergoing any actual change of texture, 
 may in this manner be so choked up, and crammed with blood, which afterwards 
 coagulates, as to preclude any subsequent admission of air. 
 
 This view of the formation of circumscribed pulmonary apoplexy affords an easy- 
 explanation of some of the phenomena attending it, which it would be difficult to 
 account for on any other supposition : I mean, first, the occurrence of several of the 
 clots or masses of blood, in different, and sometimes in distant parts of the lung at the 
 same time; and secondly, the exact manner in which they are commonly bounded 
 and hmited to certain lobules. And if (as is sometimes, though seldom, the case), 
 even the texture of the lung be lacerated, it is easier to conceive that this may happen 
 in consequence of the violence of regurgitation during the struggle of impending suf- 
 focation, and that the mere impulsion of a thickened muscle at the centre of the cir- 
 culation should be capable of driving the blood through the walls of an artery with 
 sufficient force to tear and break down the substance of the lung around it. 
 
 In the didused or uncircumscribed form of pulmonary apoplexy, the congested 
 lung is not relieved by a sudden and copious gush of hemorrhage, but the impeded 
 and stagnating blood oozes slowly through the vessels containing it into the neigh- 
 bouring interstitial and vesicular tissues, clogs up a larger and larger space, and is 
 partly expectorated in separate dark-red sputa, combined with a certain quantity of 
 mucus, A similar condition of the lung sometimes occurs in purpura hccuiurrnngira
 
 014 PULMONARY HEMORRHAGE. 
 
 without any mechanical impediment to the passage of the blood into and through the 
 heart. 
 
 The belief that the dark-coloured, circumscribed spots seen in the lungs, and 
 spoken of as pulmonary apoplexy, are often, if not always, produced in the manner 
 1 have just been describing, was suggested to me by the observation of a case, in 
 which these appearances existed, and in which they certainly were so occasioned. I 
 tokl j'ou, when speaking of cynanche tonsillaris, that I had seen one person, and one 
 only, die in consequence of that complaint; and that his death was occasioned by the 
 laying open of the lingual branch of the carotid artery in the progress of ulceration. 
 The phenomena attending that patient's dissokition were of deep, though of painful 
 interest. I described them to you before. He had been taken out of bed, and laid 
 upon a table in the ward, in the middle of the night, in order that Mr. Mayo might 
 more conveniently place a ligature upon the carotid. Suddenly the bleeding burst 
 forth afresh: and he expired, before our eyes, in the course of two minutes: not 
 from syncope or exhaustion, but evidently suffocated. The blood entered and choked 
 up the trachea, and ho had not strength enough left to expel it by coughing, i (Vlt 
 his heart and the artery at his wrist pulsate firmly for some little time after the last 
 attempt to dilate the chest had been made. This you know is what always hap;)ens 
 Vv-hen death takes place from the sudden denial of air to the lungs. We found the 
 upper surface o"f the glottis covered by a clot of blood. There was blood also in the 
 windpipe ; and scattered through the substance of the lungs there were numerous 
 hard, and dark, but not ver)'' large masses, precisely resembling those described by 
 Laennec as constituting pulmonary apoplexy. This man had shown no symptoms 
 of any pulmonary complaint ; nor was thevre any morbid appearance in his lungs 
 except those which resulted from the presence of the blood that had been poured into 
 them through the trachea, and rammed home into some of the air-cells, in his con- 
 vulsive attempts to breathe. All that I have observed since this case happened, has 
 tended to confirm my belief, that what has been erected into a distinct form of dis- 
 ease, under the objectionable name o^ puhnonary apoplexy, is simply an accident of 
 pulmonary hemorrhage. When haemoptysis has occurred, to any amount, in con- 
 sumption, it is by no means uncommon to find pulmonary apoplexy after death ; and 
 Dr. Latham has mentioned to me, in conversation, one remarkable instance of that 
 disease, strongly corroborative of the doctrine I have been endeavouring to support. 
 A young female patient of his, labouring under confirmed phthisis, was attacked, for 
 the first time, with haemoptysis. The bleeding was so profuse as to cause almost 
 immediate death by suffocation. IJer lungs were found riddled with small tubercu- 
 lous cavities ; and each of these little cavities contained a little clot of blood. Surely 
 It is more credible that the blood should have reached each cavity by regurgitation 
 from the larger air-tubes, than that each should have been the seat of an independent 
 hemorrhage at the same moment. It is by a similar reflux of blood that the ap- 
 pearances are produced which characterize the circumscribed form of pulmonary 
 apoplexy. 
 
 Upon the whole, the occurrence of hsemoplysis, considered in reference to the 
 probable duration of life in those who are the subjects of it, is of melancholj^ omen. 
 
 I have long arrived at this conclusion : — that if from any given number of persons 
 who have been known to spit blood, we subtract those in whom that symptom was 
 connected with irregularity in the uterine functions, there will remain but few in 
 whom the haemoptysis did not depend upon disease, incurable and progressive in its 
 nature, of the lungs, or of the heart ; and that if w^e still further subtract those per- 
 sons in whom the hemorrhage was symptomatic of cardiac disease, there will be 
 very few indeed deft, in whose lungs the existence of tubercles may not be confi- 
 dently predicated. 
 
 Among these few may be reckoned persons who have suffered hasmoptysis de- 
 pendent upon the detachment and expulsion of " bronchial polypi;" and who exhioit 
 no other indication of cardiac or pulmonary disease. 
 
 You vvill, of course, understand that 1 do not include in this estimate of hgemo- 
 ptysis a? a prognostic symptom, those cases in which (as in simple bronchitis) the 
 expectoration is merely s/rer//c«Z with blood: — nor those in which small quantities
 
 r 
 
 ULMONARY HEMORRHAGE. ' 615 
 
 of blood are intimately combined and amalgamated with the bronchial mucus, and 
 form the rust-coloured sputa so indicative of the presence of pneumonia : — nor those 
 in which the hemorrhage is a consequence of mechanical injury to the chest. 
 
 Of those individuals whom Andral had known to spit blood at some period or other 
 of their hves, there was only one in five whom he did not also know t-o have tuber- 
 cular pthisis. On the other hand, Louis states that for three years he asked all the 
 patients who came before him, in the practice of a large hospital, and who were not 
 affected with pthisis, whether they had ever spat blood; and the answer was always 
 in the negative, excepting only a few instances in which the patients had received 
 violent blows upon the thorax; and the cases of females in whom the menstrual dis- 
 charge had been suddenly suppressed. 
 
 The quantity of blood which is brought up in different cases of pulmonary hemor- 
 rhage, is extremely variable. Sometimes it is so copious and overwhelming that the 
 patient either dies suffocated, or he dies of syncope, outright : but this is not very 
 common. Sometimes, on the other hand, a small quantity of blood finds its way into 
 the mouth, the patient scarcely knows how. And between these two extremes there 
 is every gradation in respect to quantity. 
 
 " When blood is thrown out by the mouth (says Cullen), it is not always easy to 
 determine from what internal part it proceeds; whether from the internal surface of 
 the mouth itself, from the fauces, or adjoining cavities of the nose, from the stomach, 
 or from the lungs. It is, however, very necessary to distinguish the different cases." 
 
 Now the diagnosis between hemorrhage from the lungs and hemorrhage from the 
 stomach, in other words between hxmoptysis and hscmatemesis, I shall not enter 
 upon, until I have described the latter disease. And the diagnosis between hemor- 
 rhage from the fauces or cavity of the mouth, and hemorrhage from the luno-s, can 
 never be very difficult, if once the doubt suggests itself, and the necessary examina- 
 tion of the mouth be made. And 1 would advise you not to omit that inspection. I 
 could tell you of cases in which the neglect of this simple precaution has led to 
 needless activity of treatment, and to the ukimate discredit and disadvantage of the 
 practitioner. Blood may ooze into the mouth from spongy gums, or drip from the 
 posterior nasal orifices, and be at length spat out in considerable quantity. Etymo- 
 logically speaking, these are cases of hsemoptysis ; but they do not constitute the 
 particular disease or symptom to which alone nosologists have agreed to restrict that 
 term. The sources of the bleeding are manifest as soon as they are carefully looked 
 for. 
 
 Patients who are subject to hjEmoptysis generally know by experience when it is 
 about to happen. It is frequently preceded by some uneasy feeling within the 
 thorax — pain, or a sense of weight, or of heat or of pricking, beneath the sternum, 
 with anxiety ; and they tell you that they taste the blood in their mouths before it 
 comes up, i. e., they perceive a saltish taste ; and just before the blood appears, a 
 tickling sensation is experienced about the top of the larynx. To relieve this sensa- 
 tion, the patient coughs or hawks a little, and a certain quantity of frothy and florid 
 blood is expectorated. 
 
 In a person disposed to pulmonary hemorrhage, the bleeding may be determined 
 by a variety of causes ; which ought to be pointed out to him, in order that he may 
 avoid them. Any thing which hurries the circulation will, of course, have a ten- 
 dency to excite the hermorrhage. Straining of any kind ; great efforts of the body; 
 active exercise ; much talking; and more especially public speaking, or singing, or 
 playing on wind instruments. A diminution in the superincumbent weight of the 
 atmosphere is supposed to be, in some cases, sufficient to bring on. hcemoptysis ; iind 
 blood is said to have been forced even from sound lungs, in persons vi'ho have 
 ascended very high mountains, where the atmosphere is rare, and where the pres 
 sure upon the surface of the body is sensibly lessened. Perhaps the labour of th<. 
 ascent may have shared in the production of the hemorrhage ; for I am not awaro 
 that any such efl^ect has ever occurred to persons who have much more rapidly 
 readied a very great altitude in balloons. 
 
 Auscultation and percussion do not stand us in much stead in cases of hajmoptysib.
 
 016 PULMONARY HEMORRHAGE. 
 
 so far as that symptom itself is concerned. Indeed, if they were capable of affording 
 us information, it would in most cases be superfluous ; for we see the blood, and we 
 can generally satisfy ourselves that it comes from the lungs. 
 
 But pulmonary hemorrhage may occur without hocmoptysis. In what is called 
 pulmonary apoplexy there is extravasation of blood : and it is not always attended 
 with the expulision of a portion of the extravasated fluid through the mouth. Laennec 
 and others pretend to say, that when there is blo;d in the bronchi, they can dislin 
 guish, by the peculiar character of the crepitation to which it gives rise, that it is 
 blood, and not mucus ; that the bubbles, passing through a thinner liquid, are 
 larger, and break oftener, than those produced by the passage of air through viscid 
 mucus. This distinction is too subtle for me. If, indeed, there has been hsemoptj'sis 
 and especially if the hosmoptysis has been sudden and copious, and if, after it, j'ou 
 hear a large crepitation in one or more isolated parts of the lung, it will be reasonable 
 to conclude that the air-tubes contain blood in those parts. Those lobules that are 
 plugged up with blood, to the entire exclusion of air, will not, of course, be the seat 
 of any sound during respiration ; but this limited absence of sound will be scarcely 
 appreciable unless the infracted portion lies near the surface of the lung. Around 
 the spot thus rendered solid the sound of crepitation may be audible. 
 
 Yet, although the method of auscultation furnishes but little help towards the 
 detection of pulmonarj'' hemorrhage, it will often afford us most precise and valuable 
 information respecting the disease of which the hemorrhage is a consequence, and 
 an index. Thus, it will frequently teach us, with absolute certainty, that the heart 
 is diseased, or that the lungs are occupied by tubercles. The precise sounds, or de- 
 ficiencies of sound, which supply the key to this knowledge, I shall describe when I 
 come to th6se disorders. 
 
 Whatever may be the source and organic cause of the hcemoptj'sis, the bleeding 
 should be stopped as soon as possible : not, however, merely by suppressing it, but 
 by relieving the necessity on which it depends. The longer it is sufl^ered to con- 
 tinue, the more likely is it to add to the damage which already, in too many cases, 
 exists in the lungs. If it leads to the formation of blocks of pulmonary apoplexy, the 
 portions of lung so filled up are rendered useless for a long period, and probably for 
 ever. Now as in most cases the hemorrhage is a hemorrhage by exhalation, and 
 depends upon congestion, active or mechanical, we shall stay the hemorrhage if we 
 remove the congestion. , 
 
 The congestion may be either mechanical or active when it results from the pre- 
 sence of tubercles in the lungs ; it is almost always mechanical when it depends 
 upon disease of the heart. The tubercles may press upon the blood-vessels, and 
 so lead to mechanical engorgement ; or they may provoke by their presence an 
 active determination of blood to those organs, just as we know that they often 
 provoke inflammation, Avhich is congestion and something more; and just as any 
 foreign body lodged in the lung may cause either the one or the other of these 
 conditions. 
 
 Frequently there is a distinct febrile movement accompanying the hemorrhage : 
 the heart beats with increased force and frequency, the cheeks are flushed, and the 
 skin is hot ; sometimes the pulse is quite hard, and full, and bounding, and people 
 speak of such a pulse as a Itcmorrhagic pulse. Now I mentioned in a former part 
 of the course, that hemorrhage occurring under such circumstances as these, often 
 works its own cure ; but it is belter, when an organ so vital and important as the lung 
 is the seat of the effusion of blood, that tve should cure the bleeding than that it 
 should cure itself — that we should diminish the congestion with which it is linked, 
 through the safer channel afforded by the veins of the arm. The patient is to be 
 surrounded with cool fresh air. His head and shoulders should be elevated. He 
 should b'> restricted to the most meagre diet; and be forbidden to exert himself, or to 
 speak more than is absolutely necessary. His bowt-ls should be freeljf^ purged, in 
 the first instance, and then kept lax and open, both with the view of deriving (as it is 
 ".alied) from the thorax, and of preventing costiveness and straining. And, in con- 
 junction with these measures, he should lose blood from the arm. The amount and 
 il-e repetition of the'bleedmg must be determined by the circumstances of the case 

 
 PULMONARY HEMORRHAGE. ' 617 
 
 {. e., by the cessation or continuance of the hemorrhage, and especially by the con- 
 dition of the pulse. It would be idle to attempt to lay down precise rules on this 
 matter. We do not bleed, however, so resolutely and perseveringly in haemoptysis 
 as we are often obliged to do in acute inflammation. 
 
 A prejudice has been taken (such, at least, I think it) against local blood-kfling 
 in pulmonary hemorrhage. Inasmuch as leeches applied to the groins in amenorrhosa 
 appear sometimes to restore the catamenia, so they have been thought hkely, when 
 appUed over the surface of the chest, to attract the blood somehow to that part of 
 the body, and even to cause hemorrhage when none before existed. Now I have so 
 many times taken blood from some part or other of the exterior of the thorax by 
 leeches, or cupping-glasses, without observing any such effect, of causing hemoptysis, 
 or of increasing it while already present, that I cannot help considering the objection 
 rather a fanciful one. 
 
 When the fever or congestion are abated ; or when there has been no constitu- 
 tional disturbance, and the hemorrhage has shown a passive character from the 
 beginning, and when a continuance of it, so far from being curative in its nature, is 
 hkely to be injurious ; then we are to employ those remedies which have been found 
 efficacious in restraining and suppressing hemorrhages. 
 
 Now of the substances which are held to possess more or less of a specific virtue, 
 when taken internally, in arresting the efflux of blood, the sugar of lead, the phimbi 
 acetas, enjoys in this country the highest reputation. And it certainly is a very 
 serviceable remedy. Dr. Paris speaks of it as one of the most valuable resources of 
 physic : and says that in respect to its power over internal hemorrhage there is 
 nothing simile aiit secundum. He states also that its use is equally safe and 
 manageable. There is, in fact, no doubt of its efficacy : but most other writers use 
 very cautious language in recommending its employment. Physicians have been 
 deterred from giving it by the fear of its poisonous qualities ; by the dread of pro- 
 ducing the disease called coUca pictonum. Cullen observes, that the preparations 
 of lead are certainly powerful in controlling hemorrhage, but that they are otherwise 
 of a character so pernicious as to forbid their use except in cases of the utmost dan- 
 ger. Of late years this drug has usually been administered in small doses, and 
 guarded by opium ; and it is to this combination that Dr. Paris refers when he de- 
 clares it to be a safe and manageable remedy. More recently, however, a statement 
 has be«n made by Dr. A. T. Thomson, which must be considered of much impor- 
 tance if further experience shall show it to be well founded. He was led, it seems, 
 by some accidental circumstance, to suspect that lead acted as a poison upon the 
 animal body, only in the shape of its carbonate. And the result of a series of expe- 
 riments upon brutes satisfied him of the correctness of this notion. He holds, that 
 when the acetate of lead produces the well-known symptoms of the painter's colic, 
 it does so in consequence of its being somehow converted, after its reception into the 
 body, into the carbonate ; that the conversion may be obviated by a very simple ex- 
 pedient; and that the remedy may then be given with perfect safety in large and 
 efficient doses. The expedient is merely that of administering the lead in draughts 
 containing some dilute acetic acid, which prevents the decomposition of the acetate 
 by any carbonic acid that happens to be present in the intestinal canal. In this way 
 he tells me he has given as much as fifteen grains daily for ton days together, with- 
 out any inconvenience, and with most excellent effect upon the hemorrhage. I have 
 often exhibited lead in this manner; and I have never known it to give rise to any 
 unpleasant consequences. At any rate this method of administering it deserves 
 further and careful inquiry. 
 
 [We liave also administered acetate of lead very extensively in cases of hremoptysis, and 
 in tolerably large doses, continued, at short intervals, for one or two days, and have neve* 
 known any injurious or even unpleasant effects to be produced by it. As a means of con- 
 trolling the hemorrhage from the lungs we know of no remedy so certain in its effectb. In 
 the disease under consideration, we have very generally combined a small portion of ipeca- 
 cuanha with the acetate of lead. — C] 
 
 In slight cases of hfemoptysis, the mineral acids, with or without alum, are oftoi 
 insufficient ; or, if there be feverishness, the saline draught with nitre and digitalis. 
 
 3b2
 
 618 PULMONARY EMPHYSEMA. 
 
 Of the numberless r/iher drugs which have been vaunted as specific in hemorrhage 
 I have very little personal experience ; at least in pulmonary hemorrhage. In cer- 
 tain other ibrms or' internal bleeding there are some of them that are worth trying. 
 But in haemoptysis there are none I can venture to recommend out such as I have 
 now mentioned.' You may sometimes be urged to give a celebrated quack medicine 
 — JRuspi)u''s styptic, which has obtained a high repute, and sells at a high price. 
 This nostrum seems for a long while to have baffled analysis. The late Dr. Wol- 
 laston told Dr. Maton that it contained no metaUic substance ; Dr. Thomson has 
 .since announced that it mainly consists of a solution of gallic acid in alcohol diluted 
 with rose-water. But I believe that all the remedial agents which contain gallic 
 acid are more effectual in another form of internal hemorrhage, to be considered 
 hereafter. 
 
 Of mercury, as a remedy for pulmonary hemorrhage, I have already mentioned 
 both my own insufficient experience, and the very favourable report of some excel- 
 lent judges who have much employed it. • 
 
 LECTURE LV. 
 
 Pulmonary Emphysema ; vesicular and interlobular. Jinatomical characters of 
 vesicidar emphysema ; physical signs ; general symptoms ; causes; treatment. 
 Interlobular emphysema : its o.natomical characters, symptoms, cause, and cure. 
 (Edema of the lungs. Phthisis Pulmonalis. 
 
 T HAVE yet one or two morbid conditions of the lungs to consider and to describe, 
 before I go to that which is the most common and most extensively fatal of all its 
 morbid cond'tions — tubercular phthisis. 
 
 There is a slate of the lung, or rather there are two or three different states, to 
 which Laennec has applied the name emphysema. A very injudicious name it was 
 for him so to impose. We are infinitely'- indebted to Laennec for the entirely new 
 light which his able researches have thrown upon the morbid anatomy and tl^ pa- 
 thology of the lungs : but we have to regret that he should have employed, in several 
 instances, a vicious nomenclature. Emphysema is a term that had long been fa- 
 miliar among medical men in a certain sense. It was used to express the indation 
 of the areolar tissue of the body with air; and surgeons still make much of it as an 
 indication, in cases of fractured rib, that tlie bone has grazed the pleura, and allowed 
 air to pass into the areolar tissue, and to diffuse itself over the chest and neck, and 
 other parts ; so that these parts, when pressed, convey a curious sense of crackling 
 to the finder. But emphysema of the lung, as that term is employed by -Laennec, 
 includes dilatation of the air-cells of the lungs, and rupture of the partitions which 
 separate them from each other; and also the infiltration of air into the interlobular 
 areolar tissue, or into the subpleural areolar tissue. In strictness of language these 
 last conditions alone should have been called emphysema of the lung. Laennec has 
 distinguished the two species in this way. To the dilatation of the air-cells, with or 
 without a breach of their partitions, he gives the name of vesicular emphysema: 
 "the vesicular (I quote the words of Dr. Forbes' translation), or pulmonary, properly 
 so called." Now in truth this is emphysema improperly so called. To the infiltra- 
 tion of the areolar tissue in or around the lung with air, i. e., to emphysema of the 
 ungin the old sense of that word, he applies the title of interlobular emphysema. 
 We cannot change these denominations now. They have fastened themselves upon 
 medical language. But it is very fit that you should be aware of their inconsistency 
 with the ancient signification of the same Avord, and have clear notions of what, in 
 Laenncc's nomenclatun-, they are intended to express. 
 
 The change called vesicular emphysema was not vnknoivn, as a mere morbid 
 :-ondition. before the time of Laennec ; but it had been noticed by vriry few writers,
 
 PULMONARY EMPHYSEMA. 619 
 
 and practically, it was lohoUy unattended to. Yet it is extremely common ; much 
 more so than you would suppose : and when rightly studied it is of great inieres;:. 
 too, in relation to the general pathology of the chest. But it is still so new, aucl 
 may so readily escape observation, both in the dead and in the living body, if it be 
 not looked for, thai I shall devote a somewhat more minute attention to it, on those 
 accounts. 
 
 Laennec was undoubtedly the first to put emphysema pulmonum upon the list 
 of definite and cognizable diseases; to point out its frequency; and to collect its 
 symptoms. But when he affirms that, before his time, the pulmonary change which 
 constitutes the disorder was misunderstood by nearly all those persons who had no- 
 ticed it, he scarcely does them justice. "All of them (says he) seem to have thought 
 that the derangement in question consisted in the infiUration of the cellular substance 
 of the lungs with air." He inconsistently adds, " Ruysch and Valsalva are the only 
 authors, as far as I know, who have observed in individual cases, the dilatation of 
 the cells ;" and with still greater inconsistency he proceeds to quote, from Morgagni, 
 the following passage, in which this dilatation is very clearly described : " Sinistri 
 pulmonis lobus superior, qua claviculam spectabat, vesicidas ex quibus constat 
 minim in modum auctas habebat ; ut nonnullre avellanse magnitudinem sequarent; 
 easterns multo minores erant." You will find the same change noted by Dr. Baillie, 
 in his Morbid Anatomy : and by earher writers than he. 
 
 Vesicular emphysema, then (to adopt Laennec's phraseology), consists in dilata- 
 tion of the air-cells. The enlarged cells become misshapen also in many cases. 
 They vary in magnitude from that of a millet-seed to that of a swan-shot: nay, the 
 cavities may even reach the size of a nutmeg, or of a hen's eg^: but when they are 
 as big as this — and a fortiori if they, are still bigger — the distension and vacuity are, 
 no doubt, the result of the union of several air-cells, broken into one, by the stretch- 
 ing or destruction of the partitions that naturally divide and isolate them. You may 
 see the dilated vesicles very plainly through the pleura, if you carefully examine the 
 surface of the lung. They appear to the naked eye as the healthy vesicles appear 
 when seen through a magnifying-glass. Sometimes all the vesicles belonging to one 
 lobule are enlarged, while those of the adjoining lobules are of the natural size. In 
 that case, the emphysematous lobule is conspicuous both by its peculiar colour, and 
 by its protrusion. The surface of the lung is often rendered quite irregular and ^ 
 unevei* by projections of this kind. Sometimes one large globular prominence is 
 seen, like a bubble on the water, or like a little bladder springing from a footstalk; 
 but if you examine it closely, you will generally find that the footstalk is merely a 
 constriction at the surface, and that there is as large a cavity beyond it, in the lutig, 
 as there is without. These bullce you cannot slip about by pressure from one part 
 of the pleura to another. 
 
 The unevenness produced by vesicular emphysema upon the outside of the lung 
 IS manifest enough, when looked for; but the same condition of the air-cells exists 
 also within, and 7/?ere it is wo/ so readily perceptible. The fluids which the lung 
 "ontains obscure all distinction of parts when the organ is cut. The best way of 
 getting a fair view of the dilated cells as they appear in the substance of the lung, 
 is to inflate the emphysematous portion, by blowing air in at the bronchial trunk 
 which belongs to it, and then tying that trunk to prevent the escape of the air. The 
 inflated lung should be hung up in a current of wind, so that it may quickly dry, 
 and, during the drying process, it should, from time to time, be reinflaled ; for else 
 the included air gets out somehow, and the piece of lung shrinks and shrivels up. 
 When it is quite dry, if a section of it be made with a thin sharp knife, the altered 
 state of the air-cells, some of which are more and some le^s dilated, will be very 
 conspicuous. 
 
 No part of the lung is exempt from liability to these morbid changes ; but gene 
 rally they are limited to certain portions of the organ ; and they are much more 
 common and more pronounced at its loose anterior borders, and near its summit, 
 than anywhere else. Both lungs appear to be alike obnoxious to the disease, which 
 seldom affects the one without affecting, in a greater or less degree, the other also. 
 The parts that are emphysematous are usually paler than the rest, and sometim»-a
 
 620 PULMOxVARY EMPHYSEMA. 
 
 they are quite white. In extreme cases, the surface of the lung presents a sort of 
 piebald appearance ; large patches of it looking as if they had been bleached. Thii 
 pale colour is oftenest seen towards the free edges of the lung. Sometimes those 
 edges are rounded and thick; sometimes thinner, and folded back; while sometimes 
 the margin is blown out, as it were, into an irregular fringe ; some of the inflated 
 portions remaining connected with the lung by slender pedicles, and thus forming 
 appendices to it of a light yellow colour. I presume that what was thought and 
 called a fringe of fat, garnishing the edges of the lung, in the body of King George 
 IV., was of this kind. At least I have never seen nor heard of any other example 
 of fat deposited in those organs. If you hold the emphysematous border between 
 your eye and the light, you perceive that it is translucent : if you prick it with a 
 pin, the pufty part surrounding the puncture collapses ; which shows that the dilated 
 vesicles communicate together. 
 
 An emphysematous lung is not only paler, but drier also, than ordinary ; and for 
 the same reason. It possesses fewer capillary blood-vessels, less blood, and conse- 
 quently less moisture. It is dry and Hght, and floats high upon water, like a bladder 
 filled with air. 
 
 If )'0U take such a lung out of the body, having its surface embossed with irre- 
 gular groups of enlarged air-cells — and if you inflate that lung, by blowing into the 
 bronchi — the emphysematous portions will seem to sink in, and flatten, and return 
 to the ordinary level as the lung becomes distended. In point of fact, however, these 
 portions remain permanently dilated, and the other parts of the surface rise, as the 
 air enters them, until the whole is smooth and even. Air is shut up in the emphy- 
 sematous portions, which do not subside, as the adjoining portions do, when left to 
 the agency of their proper elasticity. Hence you will see how it is that, when the 
 vesicular emphysema is extensive, so as to occupy nearly the whole of the lung, the 
 lung becomes apparently too big for the case in which it is contained. Not only 
 does it not collapse when the sternum is raised, and the pressure of the atmosphere 
 is admitted to its external surface, but it even protrudes, the moment that the open 
 ing is made. When you handle such a lung, it gives a very difl^erent sensation tr 
 the fingers from that produced by pressing a healthy lung. It feels like a down 
 pillow. It crepitates less ; the air is less easily forced out of it, and escapes slowly, 
 with a slight hissing noise. 
 
 Such being the state of the lung, as discovered after death, you will naturally be 
 inquisitive to know by what signs the existence of a condition so remarkable is re- 
 vealed during life. First, then, when the emphysematous distension is considerable 
 in amount, and extensive, it produces alterations in the shape and movements of the 
 chest. The lung, having lost much of its elasticity, does not subside as a healthy 
 lung does. The act of expiration is arrested and incomplete. Consequendy, the 
 thorax remains nearly in that position which it assumes after inspiring. It is promi- 
 nent and rounder on the diseased side, or on both sides, if both lungs be affected; 
 but it is apt to be irregularly prominent, and unsymmetrical ; to bulge here and 
 there in correspondence with the bulging of the lung within. The ribs are less 
 oblique than they should be, and the chest is, therefore, more cylindrical. The cla- 
 vicles are ill-defined in such persons. They are so, as you know, in fat persons ; 
 wherefore this aid to the diagnosis is of most value in those who are spare. In them 
 it is a valuable sign, for it is simple and obvious. The distended lung presses up- 
 wards, as well as in other directions, and tends to efface the depressions which natu- 
 rally exist both above and below the collar-bone. This symptom is the more to be 
 depended on if it presents itself on one side only. The manner of breathing is 
 instructive also. The rihp, never receding within their proper limits after w.pira- 
 tion, can move but little during j^ispiration ; and the breathing is in a great measure 
 abdominal. 
 
 Now, all these signs are physical signs. But what, in the second place, are the 
 anscidiutory physical signs ? Why, in the emphysematous regions, which com- 
 itionly are also the most bulging, percussion yields an unnaturally clear and resonant 
 »nund, while auscultation discovers a very indistinct vesicular murmur. The two 
 modes check and explain each the information afforded by the other. Percussion
 
 PULMONARY EMPHYSEMA. 621 
 
 ascertains that there is air beneath the part struck : auscultation ascertains that there 
 is little or no air in motion beneath that part. It follows, therefore, that there is 
 stagnant air; air shut up in the enlarged air-cells, or air interposed between the ear 
 and the lung in the cavity of the pleura: air at rest, in fact. I say the respiratory 
 murmur is very feeble. This partly depends upon the limited play of the ribs, partly 
 and chiefly upon the circumstance that the air is imprisoned in the dilated cells. 
 When none enters or leaves them during respiration, no vesicular breathing can be 
 heard ; and then we must call in the aid of other considerations to determine whe- 
 ther the air be contained in the cavity of the pleura, or in the emphysematous lung. 
 
 Pure pneumothorax is extremely rare. Pneumothorax with liquid effusion is 
 easily recognised by its proper signs. If these be absent, we conclude that the 
 stagnant air occupies the lung, and not the pleura ; and this conclusion is strength- 
 ened if the unduly resonant part be prominent also. Almost all writers on this 
 subject follow Laennec in stating that dry crepitation may be heard in the emphy- 
 sematous parts. It may be so; but, if so, I cannot distinguish it. I mean that I 
 know no crepitation but that which is moist, and which proceeds from the formation 
 and rupture of bubbles, as air passes through liquids in the bronchial tubes. But 
 other people believe that they can hear a dry crackling, such as may be produced 
 by inflating a portion of dry areolar tissue out of the body, or a dry bladder. You 
 will try this by your own experience. I do not deny that such a sound exists : I 
 only say that if it does exist, I cannot tell when I hear it, and when I hear largo 
 moist crepitation. But I more than suspect that no such sound is given out by an 
 emphysematous lung, and that the sound heard is really large crepitation in tho 
 neio-hbourhood of the dilated cells ; for emphysema is very often accompanied b}' 
 catarrh ; and the sounds in question, authors agree, are not permanently audible. 
 
 So much for the physical signs of emphysema pulmonum. The general signs, 
 when the change is extensive, are an habitual shortness of breath, with occasional 
 paroxysms of extreme dyspnoea; cough which, however, is far from being a 
 constant symptom : palpitation in most instances as the disease advances, and more 
 or less oedema of the ankles. Usually the appetite remains unimpaired, and the 
 patient does not lose flesh. The disorder is unattended with fever ; and is essen- 
 tially chronic. 
 
 The paroxysms of urgent dyspnoea are frequently concurrent with, and apparently 
 excited by attacks of smart bronchial catarrh ; but they sometimes arise without any 
 obvious cause. They are apt to come on suddenly, in the night, and the patient is 
 obliged immediately to sit up, and even to open the doors and windows of his bed- 
 room, that he may breathe more freely. In one word, he undergoes a paroxysm of 
 asthma. These attacks become more frequent and more severe as the patient and 
 the disorder grow older. They are attended with much wheezing ; and in the lower 
 posterior part of the lungs crepitation is generally audible. At first the palpitation 
 of the heart, and oedema of the feet, abate and cease as the violent dyspnoea goes off: 
 but at length these symptoms become permanent. 
 
 We see a reason, in the physical condition of the thorax, why the breathing should 
 be more oppressed, and why the paroxysms of orthopnoea should occur more fre- 
 quently in the night. Whenever the respiration is principally abdominal it is apt to 
 be embarrassed by the recumbent posture, which throws a j)art of the weight of the 
 viscera of the belly upon the diaphragm. The horizontal position is always ill borne 
 by these patients ; and, for similar reasons, flatulence or fulness of the stomach, how- 
 ever caused, distresses them. 
 
 Cough, as I observed before, is an occasional, but by no means an essential accom- 
 paniment of vesicular emphysema: the expectoration, where there is any, is thin- 
 nish, like gum-water, and full of foam. 
 
 Louis, who has analyzed, with his accustomed care and exactness, a considerable 
 number of cases of emphysema, states that the disease is seldom complicated with 
 tubercles in the lungs. We may suspect that complication, if haemoptysis, or ema 
 ciation, occur ; which are otherwise rare symptoms. 
 
 To what cause can we ascribe this dilatation of the pulmonary vesicles, whereby 
 the proper function of the lung, in the part affected, is impaired, or annulled '
 
 C22 PULMONARY EMPHYSEMA. 
 
 Mainly, I think, in the outset at least, to the imprisonment of air within them, undei 
 circumstances of disease. You may often trace back ihe shortness of breath to the 
 period of inilmcy. Patients will tell you that from their earliest recollection they 
 have been easily put out of breath: that they never were able to engage heartily, 
 and to the same degree with their companions, in the active sports of childhood, "it 
 is easily to conceive that under chronic inflammation, or other disease of the mucous 
 membrane, air may enter the vesicles more readily than it can escape from them 
 again. The act of inspiration is voluntaiy and strong ; the tubes are made patent 
 by it, and air rushes in and finds its way to their extremities. But the act of expi- 
 ration is passive, and comparatively feeble. Slight tumefaction of the membrane, 
 or a little plug of viscid mucus, may so close up a small bronchial ramification, that 
 the air cannot pass through it in expiration : and more and more air may thus be 
 accumulated and incarcerated in certain air-cells, which yield to its distending force, 
 and losing their elasticity become permanently large. And this process will be acce- 
 lerated if the original disorder which gives rise to it is attended with violent cough ; 
 wiih forcible efforts, that is, of expiration. Etnphj'sema is always (in my opinion) 
 a consequence of pre-existing disease or disorder of the chest. There are some who 
 believe it to be occasionally a congenital and idiopathic affection. They build this 
 notion upon the fact that the complaint is traceable, from one generation to another, 
 in certain families; and as it often is present at an early age in children born of 
 emphysematous parents, they conclude that the emphysema, in such cases, is a vice 
 of the original bodily formation. I am not convinced by this mode of reasoning. 
 The facts upon which it rests show simply that the disorder runs much in families, 
 and that the tendency to it is sometimes inherited. The lax or weak fabric, which 
 favoured the production of the disease in the parent, is repealed in the offspring, and 
 imparts the same predisposition. Children are very liable to severe coughs, such as 
 are calculated to strain and overstretch the cells of their delicate lungs. What can 
 be more likely to do so than the reiterated and violent paroxysms of coughing which 
 occur in pertussis ? After the cough has ceased, however, the shortness of breath 
 which it leaves behind is easily overlooked, until with the increase of the emphysema, 
 it forces itself into notice. For when once the morbid process has begun it tends, 
 slowly often, but surely, to its own augmentation. As the cells dilate, the capillary 
 blood-vessels distributed over their parietes are gradually compressed and emptied : 
 and many of them are, at length, completely obliterated. Hence, not only an ex- 
 sanguine condition of the pulmonary tissue, but atrophy also of the intervesicular 
 partitions, which become first thin, then tattered and imperfect. In dried specimens 
 of emphysema you see wexy plainly the remains of the former walls of separation 
 between the vesicles. 
 
 It is this interference with the nutrition of the lung which causes vesicular em- 
 physema to be always a progressive disease. We see why it is that, speaking gene- 
 rally, the extent of the morbid change is proportioned to the age of the patient : 
 why paroxysms of severe d3'spncea at length supervene ; and become more and 
 more frequent and trying. The function of the lung becomes year by year more 
 limited ; until it can no longer bear, without a struggle of distress, that further en- 
 croachment upon its office and capability which a slight catarrh, rapid movements of 
 the body, a distended abdomen, or even the recumbent posture, may be sufficient to 
 produce. 
 
 Laennec attributes the dilatation of the air-cells, in the first instance, to what (with 
 a curious infelicity of diction) he terms dry catarrh, which is characterized by its 
 tendency to recur, and by the expectoration of small pieces of hard, pearly phlegm. 
 But doubtless the disorder may be produced, and aggravated when produced, by any 
 cause that impedes the free exit of the air from the lungs during expiration : by 
 blowing on wind instruments of music, by pressure made on parts of the lung ; bj 
 tumours therefore in the thorax, a large heart, aneurism of the thoracic aorta, de- 
 formity of the chest from crookedness of the spine, tight lacing, and even the pre- 
 sence of tubercles ; although lungs that are full of tubercles are not, in general, much 
 affected by emphj-sema. This last fact has led to the absurd project of attempting 
 «o present phthisis by producing emphysema. It is the same disease which exists
 
 
 PULMONARY EMPHYSEMA. 623 
 
 in broken-Avinded horses ; and Sir John Floyer, in his Treatise of the Jlsthma, pub- 
 lished in 1()!)8, sets forth, in the quaint language of that olden time, both the altera- 
 tion which Laennec thought he had been the first to describe, and the mode in which 
 it takes place. His observation respecting the lungs of horses are equally applica- 
 ble — and he no doubt intended to apply them — to the hnman lungs. After speaking 
 of "the broken wind, from the rupture or dilatation of the bladders of the lungs, by 
 which the air is too much retained in the bladders or their interstices, and thereby 
 produces a permanent flatulent tumour" — and stating that " these horses «'heeze 
 much after filling their stomach, by water or food, because that keeps up the dia- 
 phragm" — he goes on thus. "As it happens in external flatulent tumours, they at 
 first go off and return, but at last fix in permanent flatulent tumours ; so it is in the 
 flatulent asthma, the frequent nervous inflations induced at last a constant windy 
 tumour or inflation ; and it ought to be considered how far holding the breath in 
 hysteric fits, or the violent coughing in long catarrhs, or the great distension of the 
 lungs by an inflammation in the peripneumonia, may strain the bladders and their 
 muscular fibres, and thereby produce the same rupture or dilatation or hernia as hap- 
 pens in the broken-winded. This must be observed by the help of the microscope; 
 and if the air blown into any lobe will not be expelled thence by the natural lone or 
 muscle of the bladders, that the lobe may again subside of itself, 'tis certain some 
 injury is done to the ventiducts ; the bladders are either broken, and admit the air 
 into the membranous interstices, or else they are over-distended like a hernia in the 
 peritoneum ; and this will produce an inflation of the whole substance of the lungs, 
 and that a continual compression of the air and blood-vessels, which will produce 
 a constant asthma." Really this is a capital piece of pathology for the seventeenth 
 century. 
 
 It is, at first sight, a matter of surprise that vesicular emphysema of the lung, and 
 dilatation of the bronchi, do not more often go together. Sometimes, indeed, the 
 smaller branches of the air-tubes do partake of the dilatation of the cells : but this is 
 not commonly the case. Still the mechanism of both diseases appears to be, in the 
 first instance, the same. The detention of mucus in them leads to dilatation of the 
 bronchial tubes: the incarceration of air in them to enlargement of the pulmonary 
 vesiiles. 
 
 Vesicular emphysema may arise then, and receive increase from, various disor- 
 dered conditions that precede or accompany it, and of which it is the effect. On 
 the other hand, it is often itself the cause of subsequent disease, not merely in the 
 lung, but in other parts ; and above all, of disease in the right chambers of the heart. 
 The smaller blood-vessels, as I have shown you, are gradually effaced as the dilata- 
 tion of the air-cells proceeds: the emphysematous lung is evidently in a state of 
 comparative anaemia, and incapable of admitting all the blood which is due to it 
 from the pulmonary artery. In other words, the right side of the heart does not 
 empty itself with its accustomed ease. Hence increased muscular contractions of 
 the right ventricle: and a yielding of its walls to the augmenting pressure of the 
 contained blood. And this embarrassment of the circulation in the right side of the 
 heart is aggravated at those periods when the paroxysms of urgent dyspnoea occur. 
 Now nothing is a more sure cause of anasarca than a permanent dilatation of the 
 right cavities of the heart: and this influence of the emphysematous lung upon that 
 organ is clearly seen in the palpitations to which such patients are liable, and in tho 
 oedema of the feet and anlcles which often becomes manifest at the same time. 
 
 I must beg you to bear in mind that emphysema of the lung is one, and a very 
 common, cause of a.sthmn. The asthma so arising is less perilous than that which 
 l)roceeds from certain other organic changes, to be described hereafter. Vesicular 
 emphysema, indeed, in its simple uncomplicated form, is seldom attended with much 
 danger. When it proves fatal, it is so in consequence of the superaddition of some 
 other disease. Laennec states very truly, that of all the varieties of asthma, this is 
 the one which affords the patient the best hope of a long life. 
 
 The condition that I have been describing, when once it has fairly been establish- 
 ed, can scarcely admit of a cure. We shall do our patients good, not by any treatment 
 addressed to the existing emphysema itself, but by guarding them ao-ainst those f-jr-
 
 C24 INTERLOBULAR EMPHYSEMA. 
 
 cumstances which are likely to aggravate it ; and by miligatinor or removing those 
 other disorders with which the emphysema is apt to be combined. Whatever is 
 calculated to put the patient out of breath is bad for him. It is observed that they 
 who, having emphysema, are obnoxious also to catarrhs, during which the dyspnoea 
 is singularly increased, are much more free from such attacks in the warm weather 
 of summer, than in the winter. This explains the beneficial influence of a judicious 
 change of climate upon such persons, and it points to the necessity of warm clothing 
 m the colder seasons for those who are obliged to remain in this country. The feet 
 especially should be kept dr}'' and warm ; and the liability to catarrh may be some- 
 times diminished by the use of the cold shower-bath, in the way I formerly recom- 
 mended. During the fits of extreme dyspncea, you may hear the expiratory wheeze 
 remarkably loud and protracted ; and if, withal, you hear any small crepitation, in- 
 dicative of pneumonic inflammation, you will do well to cup the patient between his 
 shoulders. This will always give relief to loaded lungs, whether there be inflam- 
 mation present or not. But the great assuager of the dyspncea in this disorder is 
 opium; and especially opium combined with aether. Haifa drachm of Hofl^man's 
 anodyne, with a third of a grain of the acetate or muriate of morphia, in camphor 
 julep, will operate like a charm often, in quieting the whole system, and removing 
 the difficulty of breathing. This circumstance would lead us to suppose that the 
 access depended, in part at least, upon a spasmodic state of some of the muscles 
 concerned in respiration. To this question I shall revert when I speak of asthma 
 as a separate disease. At any rate you will find that some such formula as I have 
 just mentioned will stand you in good slead when you have to deal with asthma 
 engrafted on emphysema. And I may add, that this is a case of exception to a rule 
 I formerly laid down. You need not be deterred from giving a full dose of opium 
 by the blueness, which is temporary, of the patient's lips and countenance. 
 
 The interlobular and suh-pleural emphysema of the lungs is a species of trut 
 emphysema, the air being contained in the meshes of the common areolar tissue. 
 When it appeai-s on the surface of the lung, it may be distinguished from the bladder- 
 like prominences which sometimes form there by the dilatation of the air-cells, in 
 this waj^ : the bullae which are situated in the areolar tissue connecting the pleura 
 with the lung, may be made to move hither and thither under pressure; whereaa 
 those which result from the protrusion of an enlarged cell or cells cannot be madfe 
 thus to change their place. This sub-pleural efTusion of air is sometimes enormous. 
 I have seen it as large as a hen's cg2,' Bouillaud mentions a case in which the 
 bladder or pouch was equal to the size of a stomach of ordinary dimensions. It 
 proceeds, I presume, from the rupture of a superficial air-vesicle. Sometimes, as I 
 mentioned before, the pleura also gives way, and air is poured into the cavity of 
 the thorax. More commonly the membrane remains entire, and then these large 
 bubbles of air may be seen upon the surface of the lung. 
 
 Of interlobular emphysema I can give you but little account except from the ob- 
 servations of others. I have never seen more than one well-marked example of it. 
 The lobules of the lungs cohere together by means of areolar tissue, which is dense 
 and close in the natural state, but which admits of considerable expansion when it is 
 inflated with air. If the emphysema be slight in degree, the lozenge-shaped spaces 
 visible on the surface of the lung are defined by little bubbles of air, that look like 
 beads strung upon a thread But in extreme cases the lobules are fairly blown 
 asunder bv the air ; the partitions between them increase in width, and are said to 
 be sometimes as much as an inch broad. They are broadest towards the surface of 
 the lung, and narrower towards its roots ; and exhibit somewhat of the arrangement 
 seen m the section of an orange, the septa radiating and diverging from a centre. 
 If the areolar tissue could be taken out, there would be left cracks and clefts in the 
 lung. When the interlobular emphysema penetrates to the roots of the lung, the 
 air readily passes into the areolar tissue of the mediastinum, and thence to the sub- 
 cutaneous tissue of the neck and chest — and then we have the genuine emphysema 
 ui authors who wrote prior to Laennec. 
 
 There is this material difference between vesicular and interlobular emphysema;
 
 INTERLOBULAR EMPHYSEMA. 625 
 
 that the one is slow and gradual in its formation, the other sudden. The permanent 
 dilatation of the air-vesicles is the work of time. They yield, and lose their elasti- 
 city, and break into one another, only by degrees. The interlobular effusion of air 
 may be effected in a few minutes or seconds. It is caused by violent straining 
 effbris ; such as those made by a woman in childbirth, or by any one who exerts 
 himself to lift a weight which is too much for hiin. A deep inspiration is taken ; 
 then the glottis is voluntarily closed, and a strong expiratory effort is made. Some 
 rupture must take place and form a communication between the air-vesicles and 
 the areolar tissue ; but such rupture has never been traced, nor is it hkely that it 
 should be. 
 
 They say that this form of emphysema is revealed also by large dry crepitation ; 
 why it should, is not evident. 1 can only say of that sound, as I said before : it 
 may exist, and it may be distinguishable from large moist crepitation, but my ear is 
 not delicate enough to distinguish it : and to speak the truth, I doubt exceedingly 
 whether any such sound really occurs at any time. But do not let my doubts infect 
 you : try for yourselves ; and till you have had opportunities of investigating this 
 point, consider it as adhuc sub judice. 
 
 Again, they say that the noise of friction denotes the existence of interlobular and 
 subpleural emphysema. On this point I can give you no information of my own 
 knowledge. That you may sometimes hear the costal pleura rub against the pul- 
 monary during inspiration and expiration, I know ; I have often heard that sound 
 (as I mentioned to you before) when the membrane has been roughened by pleurisy; 
 but that a soft, smooth, moist lung, though embossed by emphysema, will give rise 
 to a rubbing sound, I do 7iot know. It may be so, but it has never occurred to me 
 to hear it. 
 
 We may be more certain that interlobular emphysema has arisen when, im- 
 mediately after some violent straining effort, considerable dyspncea and oppression 
 ensue, and presently the subcutaneous areolar tissue becomes emphysematous. 
 You will understand how rapidly the inflation of the areolar tissue may take 
 place if you ever saw a butcher blow up that of a calf which he is in the act of 
 skinning. 
 
 As interlobular emphysema differs from vesicular emphysema in its seat, and in 
 the suddenness of its formation, and in some sort also in its cause, so does it differ in 
 its curability. Under favourable circumstances it will soon cure itself — the air will 
 be reabsorbed, and the dyspnoea cease. I do not know that we can do much by art 
 to accelerate that process. If the dyspnoea be extreme, it will be relieved by blood- 
 letting ; and if the air makes its appearance, and can be felt, crackling, beneath the 
 skin, you may let it out by making a few punctures with a lancet, and the deeper- 
 seated emphysema will be lessened as the air escapes. I believe that this inter- 
 lobular emphysema is more common in infancy than in any other part of life ; 
 on account, I suppose, of the greater dehcacy and tenderness of all the tissues at 
 that age. 
 
 The interstitial areolar tissue of the lungs, as well as the air-cells, is liable to be 
 filled not only with air, but with serous fluid ; and this constitutes adenia of the 
 lungs ; a condition which is by no means uncommon, and one of which you ought 
 therefore to be aware ; but it need not long occupy our attention at present. When 
 a lung, or a portion of a lung, is anasarcous (and you will often find that the oedema 
 is limited to the most depending part of those organs), it is generally of a pale gray 
 or yellowish tint; is heavier than healthy lung, and less crepitant; and pits more 
 on pressure — is doughy. And if the cedema is extensive, the lung does not collapse 
 when the chest is laid open. When incisions are made into the lung in this state, a 
 thin wati'ry fluid flows out, more or less spumous ; and if the lung be well squeezed, 
 the vvhole of the liquid may be expressed; and then it will be obvious that the tex- 
 ture of the organ is sound, but that it had previously contained less air than usual. 
 in consequence of the presence of the watery fluid. " 
 
 Tliis condition of the lung seldom takes place except as a part of general anasarca 
 and we may discover its existence, first by noticing that there is dropsy of the areola/ 
 40 3c
 
 G2G PHTHISIS PULMONALIS. 
 
 tissue in other parts ; secondly, that the patient has dyspncea ; and thirdl}', by hearing 
 crepitation, produced by large bubbles, at the lowermost portions only of the lungs. 
 Into those portions the liquid gravitates ; just as it sinks into the ankles when the 
 patient sits up or walks about. There is still air in the osdeniatous portion ; so that 
 percussion still gives a hollow sound : as hollow at least on the one side as on the 
 other. With the air there is also liquid, which transudes, I suppose, from the areolar 
 tissue, or is exhaled from the surface of the membrane : and the liquid is from time to 
 time coughed up and expectorated. Sometimes, however, there is but little expecto- 
 ration. What does come up is chiefly aqueous, witli occasionally a piece or two of 
 mucus floating upon it; and it is somewhat foamy also. 
 
 This CEdema or anasarca of the lung is symptomatic of other disease ; generally 
 of disease of the heart or great blood-vessels : and it is capable of no other rational 
 treatment than such as is suited to the original disorder : and therefore I have nothing 
 further to say about it now. 
 
 I proceed, in the next place, to that most prevalent and lamentable disease of the 
 lungs, which is well known to everybody, under the titles of pulmonary consump- 
 tion, and tubercular phthisis. And without pausing to make any general reflec- 
 tions, respecting facts which must be familiar to you all — the fatal and almost 
 hopeless character of the disease, and the havoc it produces among the young, the 
 most gifted, and the most beautiful, of the human race — I shall commence by 
 inquiring into the morbid anatomy of tubercular phthisis: which will naturally 
 introduce us to the consideration of its symptoms, causes, treatment, and general 
 history. 
 
 Phthisis, you know, means a wasting away, or a consuming ; but of late years 
 the term has been restricted to that species of wasting disease, which consists in the 
 occupation of the lungs by tubercular matter, and the changes which that matter 
 sujjh's and works. But it would be an error to suppose that the disease is restricted 
 to the lungs in these cases. The lung disease would be sufficient at leng<.n to destroy 
 hfe ; but its mortal tendency is aided and accelerated, in most instances, by disease 
 of a similar character, situated in other organs. " The pulmonary consumption (as 
 Dr. Latham justly observes) is no more than a fragment of a great constitutional 
 malady." But that malady plays its part most conspicuously in the lungs. 1 shall 
 notice its complications as I go on ; but I am desirous of cautioning you in the outset 
 against supposing that tubercular phthisis is exclusively a pulmonary disease. 
 
 Before I proceed to a more particular description of the changes that, in the pro- 
 gress of consumption, are wrought in the lungs, I must briefly recall to your recol- 
 lection certain points, relating to tubercular disease in general, which were brought 
 before you in an earlier part of the course. The formation of tubercles is closely 
 linked with the existence of the scrofulous diathesis. Tubercles themselves are com- 
 posed of unorganized matter, deposited from the blood, of a yellowish colour, opaque, 
 friable, and of about the firmness and consistence of cheese. This is what all 
 pathologists agree in regarding as the true tubercular matter. It is most commonly 
 deposited on the free surface of mucous membranes ; and not unfrequently amidst 
 areolar tissue. You will remember that tubercles are not necessarily, as some have 
 supposed, of a round shape. Their form depends upon the nature of the tissue in 
 which the tubercular matter is deposited. Wherever it is laid down, it is liable to 
 increase m quantity by the continual accretion of fresh matter of the same kind. 
 Hence, when a speck of this peculiar matter is deposited in any soft uniform tissue — 
 such as tiie brain, or the areolar membrane — there being no inequality of pressure 
 from any quarter, it preserves a spherical or globular form as it grows larger. But 
 taking the lung, with which we are at present chiefly concerned, the round form is 
 •sometimes real, sometimes apparent only. It is real when the tubercular matter fills 
 up, or fines, and therefore takes the shape of, the pulmonary vesicles. So it is when 
 a number of these, contiguous to each other, coalesce by the increase of deposit and 
 compose one large globular mass. And you may often catch the tubercles, if I may 
 so say, in the process of forming these large rounded masses ; i. e., you may see 
 liiem arranged in circular groups or clusters, tbj interstices between them beconting
 
 PHTHISIS PULMONALIS. 627 
 
 gradually smaller and smaller. But when, as is often the case, the tubercular matter 
 is laid down in the smaller ramifications of the bronchi, it assumes a cylindrical 
 shape. This you may ascertain by carefully following the branching of the air- 
 tubes : but in the manner in which the lung is usually divided by the scalpel, you 
 see merely sections of these cylinders; and then the round form is apparent c.nly. 
 If the tubercular matter comes to fill one of these smaller air-tubes, and also all the 
 vesicles to which that tube conducts, then the new substance, when fairly displayed, 
 represents a branch, with a cauhflower termination ; hke a twig with a bunch of 
 leaves at its extremity. You may see these appearances dehneated, from nature, in 
 Dr. Carswell's admirable lithographic drawings. 
 
 If this account of the formation of tubercles, as explained by Dr. Carswell, be the 
 true one ; — of which [ entertain little doubt ; — it will follow, as a matter of necessity, 
 that no alteration ccm take place in the tubercular matter, after it has once assumed 
 the solid form, except through the agency of the parts around and in contact with it. 
 No change can originate in the organic tubercle itself. 
 
 Besides this true and undisputed species of tubercle, you will often find the lungs 
 more or lt>ss thickly studded with a number of small granules, of firmer consistence, 
 almost as hard as cartilage, semi-transparent, and of a bluish gray colour. Respect- 
 ing the nature of these granules — which are sometimes called miliary tubercles, 
 sometimes the granulations of Bayle, who first described them — many difl'erent 
 opinions are entertained. Laennec considered them to represent the incipient stage 
 of the opaque yellow substance ; and he calls them accordingly nascent tubercles. 
 Andral believes that they are simply some of the pulmonary vesicles rendered solid 
 and hard by chronic inflammation. Dr. Carswell explains their formation in this 
 way. The membrane lining the air-passages secretes from the blood, not only the 
 matter of tubercle, but its own proper fluid ; whence it sometimes happens that a 
 dull j'ellowish point of tubercular matter becomes enclosed and set, as it were, in a 
 small pallet of gray, tough, semi-transparent mucus. Whatever may be the true 
 theory respecting these little bodies, it is certain that they acknowledge some intimate 
 connection with the true cheesy tubercle. They both occur in the same persons, in 
 the same lungs, in the same parts of the lung. One very seldom occurs without the 
 other. They both belong essentially to the disease we are considering — pulmonary 
 pthisis. Louis, a minute and faithful observer, states that the granules present, at a 
 certain period of their development, a central opacity. Upon the whole, it seems 
 probable, that Lacnnec's doctrine, in regard to the relation subsisting between the 
 gray semi-transparent granule and the yellow opaque tubercle, was well founded. 
 
 He was wrong, however, in some other points, especially in his statement that the 
 softening of tubercles begins in their centres. Dr. Carswell has shown how the ap- 
 pearance of a central softening arises, first, in the smaller tubercles; secondly, in the 
 larger agglomerated tubercular masses. The morbid secretion is deposited, princi- 
 pally, upon the mucous surface — upon the inner lining of the air-cells, and of the 
 bronchial tubes communicating with them. Now it may so accumulate as to Jili 
 those cavities ; and then, sections of them will represent the crude tubercles of 
 Laennec. But it may only line the cavities : it may leave a central vacuity, con 
 taining mucus or other secreted fluids ; and if the lung be cut across under these 
 circumstances, the divided air-cells will look like rings of tubercular matter grouped 
 together ; and so also will the divided bronchial tubes. We then have the appear- 
 ance of tubercles, with central depressions, or soft central points ; and Laennec was 
 deceived by those appearances. 
 
 But the larger masses begin also, he says, to soften at the centre. True : we do 
 find the process of softening going on at several points within them at the same time. 
 The masses, you must bear in mind, are formed by the growing together of many 
 smaller tubercles; and the areolar tissue, with the other tissues which originally 
 separated these tubercles, still exists, though it ceases to be visible. At length, under 
 the augmenting pressure, or some other influence, it suppurates; and in this way the 
 tubercular mass is broken down. Now this is the very process by which the tubercles 
 are at length, often, expelled from the body. They increase till the surrounding parLs 
 take on inflammation, either from the increasing pressure, or from some accidental
 
 628 PHTHISIS PULMONALIS. 
 
 cause. The inflammation thus excite:>(l, occurring in scrofulous persons, has the 
 scrofulous character. The thin pus which it throws out pervades and loosens the 
 tubercular deposit; a process of ulceration goes on in the surrounding textures ; and, 
 at last, the softened scrofulous matter is graduailj?- coughed up and expectorated. 
 
 This explanation of the mode in which the tubercles are formed, and increase, and 
 soften, and are removed, has been given to the Avorld within the last few years, by 
 Dr. Carswell ; and it is much the most simple and probable of any that I have seen. 
 It is moreover, perfectly consistent with the best ascertained facts concerning the 
 progress of tubercular disease. You will find numberless theories broached by dif 
 ferent authors on this subject, if you like to look for them ; but I do not think you 
 will find any so satisfactory as Dr. Carswell's. And having recalled these things to 
 your memor)" (for it is some time now since I mentioned them before) we may go 
 on to the further consideration of the morbid anatomy and pathology of tubercular 
 phthisis. 
 
 It is a remarkable and very important fact, that tubercles, when they affect th& 
 lungs, are not deposited at random, or indifferently in all parts of those organs. It is 
 in the upper lobes, and in the upper and back parts of those lobes, that, in nineteen 
 cases Out of twenty, and in more than that proportion, we meet with tubercles when 
 they are few. It is in the same part that they are largest, and most numerous, when 
 they are scattered throughout the whole lung. It is here, also, that they first ripen, 
 and grow soft, and become ready for expulsion through the bronchi and trachea : 
 consequently, it is here, that we have the most frequent, the most numerous, and the 
 largest excavations in the lung — what are technically called vomiar. And the 
 iiumber and magnitude of the tubercles and of the vomicas gradually diminish from 
 ■ he summit of the lungs downwards. 
 
 Now these are not merely curious facts: they have a most important bearing 
 upon the diagnosis, in cases that might otherwise be doubtful. It is a rule which 
 has but few exceptions — ^just enough to establish its claim to be a rule — that the 
 favourite habitat of pulmonary tubercles is the upper part of the superior lobes of the 
 lungs ; and I may remind you that the converse of this is true (though with more 
 numerous exceptions) of common inflammation of the lungs. Pneumonia affects by 
 preference the lower lobes; it does sometimes commence in the up])er, but that is 
 comparatively rare. When it occupies the superior lobes it generally has arrived 
 there by travelling upwards from the inferior. You Avill at once perceive the prac- 
 tical advantage of knowing these points of contrast. 
 
 It is a curious fact also — less practically useful, perhaps, than the former, but still 
 a valuable fact — that the left lung is much more obnoxious to tubercular disease than 
 the right. Modern observers have collected numerical statements showing that this 
 really is so. Why it should be so, I know not. Thus Louis, whose volume is tho 
 result of immense labour in observing, and is full of the most instructive matter, had 
 met with seven cases in which tubercles were confined to a single lung: in tivo of 
 the seven cases it was the right lung that was thus exclusively affected, in Jive it was 
 the left. Of 08 instances in which the upper lobe was totally disorganized by the 
 disease on one side, 28 were of the left, and only 10 of the right. Eight times he 
 had known the pleura perforated by the extension of tubercular disease ; and seven 
 times out of the eight the perforation happened on the left side of the chest. So also 
 Reynard met with 27 cases of pneumothorax on the left side, to 13 on the right. No 
 less curious is it that here also the facts ascertained with respect to pneumonia are 
 just the contrary of those which belong to phthisis. I mentioned, in a former lecture, 
 Andral's conclusion, derived from the observation and collation of 210 examples, that 
 pneumonia is more than twice as common on the right side as on the left. M. Lom- 
 bard, of Geneva, found the ratio somewhat less than this, but still great. Of 8(58 in- 
 stances of pneumonia, 413 occurred on the right side alone, 2(i0 on the left alone, 
 and }9o on both sides at once. That is, there were three on the right side alone, for 
 every two on the left alone. 
 
 The tubercular matter, then, being deposited on the mucous surface of the vesi- 
 cles, and of the small bronchial tubes that conduct to them — groups of these diseased 
 nir-cells, lvi/ig contiguous to each other, become, more or fewer of them, amalga-
 
 PHTHISIS. 629 
 
 mated, or fused, as it were, into one large mass : and generally there are tuberclea 
 of various sizes, from that of a pin's head, to that of a pigeon's egg, in the same 
 lung. And there is yet another disposition which the tubercular matter is apt to 
 take : it sometimes is diffused uniformly over a considerable space, occupying all the 
 areolar and interstitial portions of the part affected, and having no distinct circum- 
 scribing boundary. The part looks as if fluid tubercular matter had been poured 
 into it, and there had hardened. This is what the French call tubercular infiltration 
 of the lung. 
 
 The tubercular matter, once deposited, may remain for a longer or shorter time in 
 what is called the crude state ; surrounded by perfectly healthy lung, undergoinp- 
 no increase in quantity, and no alteration of consistence. But in a vast majority of 
 cases, scrofulous inflammation is sooner or later set up around the tubercles — or in 
 the areolar tisssue imprisoned within the agglomerated masses — and then the whole 
 breaks down in the way I mentioned before ; and the detritus is conveyed through 
 one or more tubes into the primary divisions of the bronchi, and thence to the 
 mouth, to be expectorated. Of course there is an excavation, cavity, cavern, or 
 vomica, left. All these names are given to the void space which the tubercular 
 matter previously occupied. Now there are some curious particulars to be men- 
 tioned respecting these cavities ; but I must postpone them till our next meeting. 
 
 LECTURE LVI. 
 
 Phthisis, continued. Vomicae; adhesions of the pleurae ; ulceration of the larynx 
 and trachea — of the intestines ; fatty liver ; auscultatory signs of a vomica : 
 gurgling, cavernous respiration, pectoriloquy : general symptoms of phthisis : 
 cough, expectoration, dyspnoea, pain, hectic fever, diarrhoea, wasting, oedema, 
 aphthae. 
 
 We were engaged, when we separated yesterday, in investigating the morbid 
 anatomy of consumption. Bear in mind how and where the tubercular matter, 
 which is the essence of that disease, is deposited in the lungs : that it occupies, by 
 preference, their upper lobes, and the upper part of those lobes ; invading gradually 
 the lower lobes, from above downwards, as the disease advances. Both lungs are, 
 commonly, affected at the same time, though in unequal degrees. Among one 
 hundred and twenty-three instances of phthisis, Louis found that the tubercles were 
 limited five times to the left lung, and twice to the right. The tubercular matter, 
 once deposited, may remain quiet and unchanged for some time; but in general it 
 increases in quantity, until at length inflammation of a low and scrofulous character 
 arises in the pulmonary substance in immediate contact with the tubercles — or in the 
 areolar tissue involved in the larger agglomerated masses — in consequence of which 
 inflammation a sort of suppuration takes place ; the tubercular matter becomes soft, 
 and breaks down, and is ultimately expelled through the bronchi, trachea, and 
 mouth. The vacuities left in the lung after this process of expulsion are called cavi- 
 ties, excavations, caverns, vomicce. And I go on to consider certain points of prac- 
 tical interest connected with these vomicas. 
 
 In the first place, as j'-ou may see by the specimens upon the table, they vary 
 greaiiy in size. They may be m* bigger than, or not so big as a pea : or they ...ci) 
 be large enough to contain a pint or more of fluid. Sometimes the whole of the 
 upper lobe is converted into a bag of this kind. These large cavities are never mel 
 with in the lower lobes. They are formed by the union of several that are smaller; 
 so that they are often of very irregular shajje, and divided, as it were, into chain 
 bers, by imperfect partitions, or by bands Avhich cross them in various direction* 
 Opening into the cavity there is always one, and there are generally several, per 
 
 3c2
 
 G30 PHTHISIS. 
 
 vious bronchial tubes, which seem as if they had been cut off just wliere they enter 
 the cavity. But you never, or very seldom, indeed, find a hlood-vessfl thus opening 
 into the cavity. And the reason of these differences is plain enough. ]t is not, as 
 some modern authors have fancied, that the arterial or venous tissue possesses a low 
 degree of vitality, and therefore resists or avoids the destruction in which the sur- 
 rounding tissues are involved. That principle may be applicable to other cases, but 
 it is not applicable to this. The opinion I am now referring to proceeds on the sup- 
 j)Osilion that the bands which sometimes cross the cavities are really blood-vessels 
 that have escaped the disorganizing process. Such seems to have been the nouon 
 entertained by Bayle ; and it has been more recently and more expressly advanced 
 by Cruveilhier. But the truth is, that these bands rarel_v contain blood-vessels: and 
 when they do contain them, the blood-vessels are mostly impervious. In one \iun- 
 dred and twenty-three cases, Louis found pervious blood-vessels in the bandb no 
 oftener than five times. 
 
 The true reason why bronchial tubes open into these cavities, and blood-vecsels 
 do not, is to be found in the natural differences between the two sets of vesseL. in 
 respect to their structure, and in respect to the fluids that pass through them. The 
 blood-tubes yield readily to external pressure. Many of them are pushed aside and 
 flattened by the progressive increase of the tubercular matter around them ; s&me, 
 probably, are obstructed by its gradual accumulation within. In either case the 
 stagnant blood coagulates, and the vessel is obliterated to some distance from the 
 place of the original obstacle ; just as you know a clot forms, and seals up an artery, 
 which has been tied during life, for some Httle way anterior to the ligature. But 
 the bronchial tubes are neither so easily compressed, nor do they carry any coagu- 
 lablc fluid. In the agglomeration of the tubercular masses, by the softening of which 
 the cavities are formed,.the air-tubes included within the mass are filled up by it; 
 and when the whole breaks down in scrofulous suppuration, they are expectorated 
 with the rest of the detritus. Meanwhile, their open mouths, on the hither side 
 of the point where the tubercular matter stopped, remain, and afford a channel 
 through which the same matter, after it has become soft, finds its way towards the 
 trachea. Occasionally, indeed — but that, I repeat, is a rare occurrence — a con- 
 siderable blood-vessel does get laid open during the formation of a vomica, and then 
 copious and fatal hemorrhage ensues. Occasionally,' also, an oozing or exhalation 
 of small quantities of blood takes place from the inner surface of the cavity, tinging 
 the matter expectorated. 
 
 AVhen the vomica is first formed, by the expulsion of the tubercular matter, its 
 inner surface is soft and ragged ; and if other softening tubercles are in the imme- 
 diate neighbourhood, the cavity goes on enlarging; that is, two or more vo micas 
 coalesce. If, however, there happen to be no more tubercles thereabouts, the cavity 
 may remain stationary. Its inner surface then becomes smoother ; and something 
 like a membrane forms upon it: and sometimes a puriform fluid is poured out by 
 this surface, and sometimes not. G' r^ralljMhe pulmonar)' tissue around such a 
 cavity is condensed and solidified ; par / perhaps by crude tubercular matter which 
 it contains, partly in consequence of the inflammatory process of which it has been 
 the seat during the softening of the tubercles. It is important to bear in mind this 
 fact of the condensed, solid state of the lung immediately surrounding a vomica; for 
 it explains certain peculiarities met with in the symptoms. 
 
 There is another point of much interest connected with these vomicae. When 
 they occur singly, without other tubercles or cavities (which, though a very rare 
 thing, does sometimes) ; and when occurring thus singly they have been completely 
 *?mptied of the tubercular matter; they may gradually contract, and ultimately be- 
 come obliterated. This approach of their sides Ic^ds to a puckering of the pleura 
 on the surface of the lung; and, on the other hand, a puckering of the surface indi- 
 cates that beneath it there is probably a collapsed vomica. Its inner surface becomes 
 converted in that case into a substance resembling cartilage ; and the appearance it 
 presents is called a cicatrix ; and really it deserves that name. The process which 
 lias gone on is a process of natural recovery ; and the recover}^ would be complete, 
 kC nc fresh deposit of tubercular matter took place. Too often, however, the tuber-
 
 PHTHISIS. 631 
 
 cles multiply, until at length their number, or size, or effects, become inconr palible 
 with the further continuance of Jife. 
 
 This, then, is one way in which tubercular disease, limited to one small portion 
 of the lung, may be eliminated, and the part which it occupied undergo a kind of 
 repair. But the disease, lohen so limited, maij cease in another way. The more 
 watery parts of the morbid secretion may be absorbed, and the earthy salts it con- 
 tains may concrete, and the whole be converted into a shrivelled, hard, chalky mass, 
 which somcumes is coughed up ; sometimes, in favourable cases, remains for years 
 in the lung, an inert and almost harmless body. 
 
 Let me smte, while I think of it, that the expectoration of these chalk-like concre- 
 tions, denoting, as it usually does, the existence of pulmonary consumption, marks 
 at the same time the chronic character of the case. I am acquainted with a gentle- 
 man who, though delicate, enjoys a very fair share of health, and who has for years 
 been coughing up, at intervals, little branching fragments, like bits of white coral, 
 consisting principally of carbonate and phosphate of lime, and evidently moulded in 
 the smaller bronchial tubes. 
 
 When the tubercles are numerous — or rather when they lie near to the surface 
 of the lung, as, of course, they are likely to do when thej-- are numerous — they very 
 generally give rise to dry or adhesive pleurisy. So that, in a person dead of con- 
 sumption, it is a very rare thing to find the lungs free from adhesions to the ribs. I 
 mentioned before that this attachment of the lung to the walls of the chest affords a 
 protection against a much more formidable condition; namely, perforation of the pul- 
 monary pleura, and the escape of tubercular matter and air into the serous cavity; 
 producing that worst kind of pleurisy which constitutes pneumothorax. That the 
 pleurisy and adhesion are consequences of the presence and irritation of the tuber- 
 cles, appears from this : — that, for the most part, the extent and the situation of the 
 adhesions correspond with the extent and situation of the tubercular disease. Thus, 
 a single spot of adhesion has been seen to unite the costal and pulmonary pleurae 
 exactly opposite a solitary tubercle which lay near the surface of the lung. As the 
 summit and back part of the upper lobes are most thickly set with tubercles, so 
 here also is the adhesion the most constant, and the most firm. You will often find 
 the upper part of the lung invested with a thick cap of false membrane ; and the 
 connection between the pleural so tough, that the lung breaks down in the attempt to 
 separate them. 
 
 To show you that these statements — which have long been familiar to those much 
 conversant with disease and with morbid anatomy — to convince you that they are 
 strictly borne out by numerical or tabular facts, I may again have recourse to Louis. 
 He tells us that in 112 cases which he himself examined of persons dead of con- 
 sumption, and having therefore tubercles in their lungs, there was but one in which 
 both lungs were free from adhesions. In eight cases the right lung was exempt 
 from them, and in seven cases the left. Again, in twenty-five other instances, there 
 were either no cavities, or very little ones ; and the adhesions were accordingly of 
 small extent, and easily broken down. In the remainder there were large vomicae, 
 and the adhesions were extensive, dense, and firm. 
 
 Such is a sketch of the changes which take place in the lungs, in consequence 
 of the deposition of tubercular matter in them, and of the changes which that matter 
 undergoes. But the air-passages that lead to the lungs are very liable to become 
 implicated as the disease proceeds. The mucous membrane of the larynx and tra- 
 chea ulcerate ; and when the morbid condition of the larynx gives rise to prominent 
 symptoms, and especially (as it is apt to do) to hoarseness and loss of voice, the dis- 
 ease is sometimes called laryngeal phlhisis. But there is no such disease, that f 
 know of, existing by itself. I mean, that scrnfalous ulceration of the larynx anu 
 trachea occurs only when the lungs are affected -with tubercles. It is curious thai 
 when ulcers are met with in the trachea, they are often found on one side of it onlv : 
 on the side, viz., which corresponds with the diseased lung, or with that lung which 
 is most diseased. In like manner, when some of the bronchi are found red inter- 
 nally, and even ulcerated, these appearances are confined to those bronchi which 
 CO nmunicate with cavities ; and do not occur in the bronchial canals leading to
 
 C32 PHTHISIS. 
 
 crude tubercles. It is towards the back part also of the trachea that the ulcers, espe 
 cially when large, are most commonly observed ; the floor of that channel when the 
 patient lies supine. And when the epiglottis is involved in the mischief, the ulcers 
 are situated, almost always, on its larjmgeal surface alone. We have strong reasons, 
 therefore, for believing that their formation is influenced by the contact of the matter 
 which is expectorated, in its frequent passage over the mucous membrane. More- 
 over, the little mucous glands wherewith the membrane is provided, are most num*'- 
 rous at the posterior part of the trachea and bronchi ; and these glands are especially 
 prone to ulcerate. 
 
 In respect to these points, also, Louis has made comparative observations. Among 
 180 persons who died of some chronic disorder, not phthisical, he once onlj'- met 
 with ulceration of the larynx ; whereas, of those who perished with consumption, 
 nearly one in even/ five had ulceration of the epiglottis and larynx, and nearly one 
 in three had ulceration of the windpipe. Hence it would appear that, if we except 
 the eflxxts of the syphilitic poison upon the larynx, ulceration of that part is almost 
 peculiar to phthisis pulmonalis. 
 
 I have told you that consumption is not merely a lung disease. Its local ravages 
 are most obvious, indeed, in the thorax ; but it leaves in the abdomen, also, traces of 
 its destructive agency, not less definite and scarcely less constant. You know that 
 the surface of the intestinal canal is strewed throughout with separate mucous folli- 
 cles, and that the lower portion of the ileum is furnished with other follicles, collected 
 together in oval or circular groups. When I come to speak of continued fever, I 
 shall have much to say about the changes which these little glandular bodies undergo, 
 in one form at least of that disease. These same glands are the frequent seat ol 
 tubercular deposit in phthisis. Here and there you may see a solitary yellow tumour, 
 not larger than a hemp-seed, projecting from the surface of the bowel. In other 
 places the ripened little tumour has burst, the tubercular matter is gone, and a ragged 
 roundish ulcer remains. More frequently the aggregated glands are afl^cted ; and 
 the ulceration, in them, varies much in form and extent. It often involves the whole 
 patch, and then the shape of the ulcer is more or less elliptical. Louis met with 
 ulceration of these glandulse agminatte in five-sixths of all the fatal cases of phthisis 
 that he examined. Ulcers of greater magnitude were very nearly as common in the 
 large intestines. And it is worthy of notice that, the disorganizing process being in 
 these cases slow, nature has time (if I may use such metaphorical language) to pro- 
 vide against the threatened perforation of the gut. The tissue that forms the base 
 of the ulcer, whether it be the muscular or the peritoneal coat, is thickened and 
 vamped ; or the bowel becomes adherent to some contiguous surface. Once only in 
 my life have I known scrofulous ulceration, in phthisis, penetrate the serous tunic, 
 and allow the contents of the intestine to escape into the sac of the peritoneum. 
 
 It is fitting you should know — although the facts possess, as yet, no practical value 
 — that the stomach is often much enlarged and thinned in those who die of consump- 
 tion ; and that the liver is ver3''apt to undergo a remarkable change, almost peculiar, 
 i believe, to that disease. It, too, enlarges, and becomes full of adipose matter, 
 greasing the hands and scalpel of the anatomist, and yielding, when heated, an oily 
 substance, which makes a grease-spot on paper placed in contact with it. The 
 whole gland partakes in the alteration, is of soft consistence, loses its natural red tint, 
 and assumes a pale fawn colour. No profession contributes so much as ours to the 
 introduction of new, barbarous, and dissonant words into the English language. We 
 have accordingly invented an epithet for this kind of liver. We call it (not they«/, 
 bui) ihefatti/ liver. In three years, Louis met with this fatty liver forty-nine times; 
 and forty-seven of the patients died phthisical. It occurred in one-third of the whole 
 number of the victims to consumption ; whereas, among two hundred and twenty- 
 three cases, not phthisical, there were two examples only of this hepatic change. 
 Its presence is revealed during life by no symptoms, except that the enlargement 
 belonging to it may sometimes be ascertained by percussion and pressure with the 
 u nge rs. 
 
 Let us now mquire Avhat modifications of the healthy sounds arise from the 
 "tiiered conditions of the lungs in phthisis. Most of them are such as you would
 
 PHTHISIS. G33 
 
 naturally expect. Whether a portion of lung be rendered solid by comn.on inflam- 
 mation, or by the presence of tubercles in it, the result, so far as the ascultatory signs 
 are concerned, will be the same. In such a piece of lung, supposing the solidifica- 
 tion complete, no vesicular breathing can be heard ; but bronchial breathino- and 
 bronchophony will be audible, in each case, if the solidified portion encloses a con- 
 siderable bronchus, and comes near the surface of the chest. And percussion will 
 give a dull sound, whether the lung lying beneath the part struck be hepatized, or 
 blocked up by tubercular matter. On these points, therefore, after what was said in 
 a preceding lecture, I need not dwell. But the excavations, the empty or half-empty 
 vomicae — these are something new. We have hitherto met with no condition ex- 
 actly similar to that of a large cavity. And accordingly I have to make you 
 acquainted with two or three new sounds : or sounds which are modifications of 
 those formerly described, and in most instances sufficiently distinct from them to 
 have acquired peculiar names. You will remember that what we have called laro-e 
 crepitation depends upon the passage of air through liquids ; the liquids being con- 
 tained in tubes ; those tubes the bronchi and their ramifications. But when pus or 
 vitiated mucus, or liquid of any kind, is collected in a vomica, which communicates 
 freely with the trachea through pervious bronchi, the bubbles produced by the 
 entrance and exit of air will be still more numerous and large ; and a sound is then 
 produced which the word gurgling expresses well. Laennec calls it gargouille- 
 ment. This sound is heard, too, in a circumscribed space ; and not diffused, as laro^e 
 crepitation usually is. Whenever, therefore, we hear gurgling during respiration, 
 or during the act of coughing, there, we conclude, exists a cavity. But the cavity 
 is not necessarily a vomica. In ninety-nine cases out of a hundred, it will be so ; 
 but in the hundredth case perhaps it will not. Bear in mind what was formerly 
 stated of dilatation of the bronchi : how sometimes they terminate in a considerable 
 globular expansion ; sometimes belly out and contract again several times alternately: 
 and you will see that cavities containing liquid, or liable to contain hquid, belono-ino- 
 equally to the one condition and to the other, and the sound in question dependino- 
 solely on the intermixture and agitation of air with liquid in a cavity, we cannot be 
 sure from mere gurgling respiration, or gurgling cough, that we have a tubercular 
 excavation beneath our ear; or that the case is one of consumption. Gurgling may 
 also proceed from that very rare morbid condition, abscess, the result of common 
 inflammation of the lung. These constitute the only sources of fallacy in the matter. 
 The fallacy seldom interposes ; but it does sometimes interpose ; and therefore it 
 must qualify om conclusion from this symptomof gurgling, in respect to cases other- 
 wise doubtful. 
 
 Again, the vomica may be empty of liquid ; and then we hear, as the patient re- 
 spires, not vesicular breathing of course, nor yet exactly bronchial breathing ; it is 
 something more than that when the cavity is large, something different in character 
 from it when the cavity is small: but whatever the character of the sound, as ws 
 believe it to take place in a vomica or cavern, we call it cavernous respiration. It is 
 a hollow sound, especially when the cavity is of considerable size ; an exaggeration 
 of mere bronchial respiration. But the cavity may be small. The moment a por- 
 tion of tubercular matter is separated and discharged through a neighbouring bron- 
 chial tube, the cavity has commenced ; and the sound produced through these little 
 cavities during the breathing may be of various kinds. It may be, and it often is, a 
 click, hke the opening and shutting of a valve ; or a chirp ; or a creaking; or like 
 many other well-known sounds: but, as all these sounds, under certain circum- 
 stances, denote the formation of a vomica, it is best for simphciiy's sake, to call them 
 all by the same name — cavernous respiration. 
 
 Dr. Latham explains in a few words the causes of these differences. "Th(! vari- 
 eties of cavernous breathing are doubtless owing to different sizes, and forms, and 
 situations of cavities, and to different conditions of the surrounding lun^. A cavity 
 may be very large or very small. Several bronchi may open into it, or only one. It 
 may be a simple cavity, or it may have many chambers. Its sides may be con- 
 densed and equal, or rough and ragged. The lung around it may be solid and m 
 durated, or pervious and vesicular." It may be near the ribs, or far from them
 
 634 PHTHISIS. 
 
 adherent to, or separate from the pleura. It is quite obvious that these different cir- 
 cumstances are calculated to modify the sound, which will, nevertheless, be always 
 such as indicates a cavity." 
 
 A tubercular cavity may be so large, and of such a kind, as to yield the metallic 
 sounds which are apt to be heard in pneumothorax. I show you a cavity in which 
 those sounds were actually heard, most distinctly, by many persons, during the 
 patient's life while he was under my care in the Middlesex Hospital. I was certain 
 beforehand that these sounds proceeded, not from the cavity of the pleura, but from a 
 tubercular excavation. Once subsequently, in a patient who was dying of phthisis 
 and diabetes, I have heard the same sounds ; also, I am sure, in a tubercular cavity. 
 The patient insisted on leaving the hospital, and I lost sight of him before he died. 
 
 I promised, when speaking of these metallic sounds as arising (as they much 
 more commonly do) from pneumothorax — a collection of air, or of air and fluid, in 
 the sac of the pleura — I promised to point out the circumstances whereby you may 
 tell which of the two conditions in question the sounds denote. Both of the conditions 
 imply, in general, the existence of tubercular phthisis ; and therefore the observation 
 of the ordinary symptoms of phthisis will not help us much. 
 
 Now, in the cases seen by me, there were two circumstances that stamped them 
 as beino- cases in which the sound proceeded from a cavity in the lung, and not 
 exterior to it. One was the situaiion in which the sound was invariably heard. 
 The other was, the absence of excessive resonance when that part was percussed. 
 You know that when air is contained within the pleura itself, the sound yielded on 
 percussing the chest in the corresponding spot is quite tympanitic, like that of a 
 drum. But it is a well-ascertained fact, (though contrary perhaps to what you would 
 suppose,) that the sound is duller over tubercular cavities, in nine cases out of ten, 
 than over sound lung. The explanation of this fact is simple enough. It is that the 
 layer of lung which still remains in such cases, thick or thin, is dense and solid, and 
 damps the sound which the vomica might otherwise make resonant. But then again 
 the situation of the metallic sounds was a guide. They occupied the upper part of 
 the chest; the very part where vomicae are wont to be the most common, and the 
 iaro-est : and moreover a part where pneumothorax seldom or never exists. The 
 summit of the lung is generally covered in phthisis with a cap of false membrane, 
 which binds it to the ribs : and this, as I observed before, is the main reason why 
 perforation of the pleura pulmonalis is so rare in that disease ; and it is also the reason 
 why, when it does take place, it seldom takes place at or near the apex of the lung. 
 In truth it is found by experience that (though the rupture of the pleura maij hap- 
 pen in any part) the place where it usually occurs is in the lower and back part of 
 the upper lobe of the lung, opposite the angle of the third or fourth rib ; that is, just 
 beneath the edge of the false membrane by which the summit of the lung is gene- 
 rally adherent. But the sound, in the cases I refer to, was invariably heard at the 
 very top of the chest. It did not shift, as that of pneumothorax may often be made to 
 shift, when the patient changed his posture. Attention to these points will always 
 lead you to an exact diagnosis. You may say, perhaps, " The complaint being in 
 each case a mortal one, what is the use of so much refinement?" Why, there is 
 this utility in it. We may sometimes, as I stated before, give great relief to the 
 patient, and save his life for a time, by tapping the chest of pneumothorax. The air 
 mav^et in with each inspiration, and threaten immediate suffocation ; and the thorax 
 being^puncmrcd it will issue in a blast. But no one would think of tapping a tuber- 
 cular cavity. 
 
 To giveout the amphoric resonance and the metallic sounds, the vomica must, I 
 presume, be a large one. That which is before you, the only one I ever saiv in 
 which those sounds had-been heard, is very large. Its inner surface is smooth : it 
 adheres to the ribs externally by at least two-thirds of its circumference : and the 
 medium of aflhesion is very thin. Quite low down, a single bronchial tnbe, of about 
 the third division, may be seen to enter it. 
 
 So much, then, lor the modification by a tubercular cavity, of the sounds heard 
 dunng respiration. But the voice will also be modified, if the cavity be of consi- 
 derabfe size, and near the surface, and have dense walls, and be empty. Then we
 
 PHTHISIS. 635 
 
 hear, in that part, when the patient speaks, the sound which is called pectoriloquy: 
 as if the voice proceeded from the chest. The words are distinctly articulated into 
 the ear oi the listener. But 1 need not trouble myself or you by attempting to de- 
 scribe pectoriloquy. You may any day hear the exact sound that word is intended 
 to denote, by placing a stethoscope over the trachea of one of your friends, aj)plying 
 your ear to the other end of it, and getting him to speak : just as you may obtain an 
 exact notion of bronchial respiration by listening then to his breathing. 
 
 For some time after the first appearance of Laennec's great and original work on 
 the diseases of the chest, pectoriloquy was deemed to be the pathognomonic and 
 infallible sign of a vomica. "Oh," the young auscultator would say, "I detect pec- 
 toriloquy beneath the clavicle. There can be no further doubt about the nature of 
 the disease. My patient has not only tubercles, but a cavity, in his lung." So I 
 long thought ; and so some, I fancy, think still. Yet the evidence afforded by mere 
 pectoriloquy of the presence of a vomica, or even of the presence of tubercles, is far 
 from being certain or trustworthy. Experience ha'd taught me this before I knew 
 that many others, studying under the same schoolmaster, had learned the same truth. 
 Among my hospital patients some years ago was a man who laboured under phthisis. 
 Percussion gave a dull sound under his right collar-bone, and in the same spot loud 
 and distinct pectoriloquy Avas audible. I well recollect inviting the particular atten- 
 tion of the pupils to this case, as affording an exquisite specimen of pectoriloquy ; 
 and I predicted very confidently that after the patient's death, v/hich was obviously 
 at hand, a large excavation would be found in the summit of his right lung. My 
 prediction did me no credit. The left lung indeed was hollowed by cavities, but 
 there was nothing like a cavity in the right. The upper part of the lung was tho- 
 roughly and uniformly solid ; filled with hard, gray, tubercular matter. The large 
 bronchial tubes were pervious, and the voice descending into them had been con- 
 ducted by the solid lung with perfect and almost painful distinctness to the listener's 
 ear. This was a useful lesson to me : and I mention it that it may be a lesson to 
 you. Remember that solidification of the summit of the lung will modify the sound 
 of the patient's voice, very much in the same manner as a large vomica there situ- 
 ated. It is stated, indeed, and perhaps truly, that a practised ear can discriminate 
 between the loud, diffused, though articulate, resonance of the voice produced by 
 solid lung, and the circumscribed, whiffing, pectoriloquy of a cavity. But the dis- 
 tinction is too nice for the average of practitioners. Piow since the pulmonary tissue 
 may be rendered dense and solid by other causes than tubercles, pectoriloquy does 
 not a]wa3's indicate the existence of consumption. The fallacious condition does not 
 often occur; for common inflammation is seldom hmited to the upper part of the 
 lung ; and the whole of that part is seldom completely hardened by crude tubercles. 
 But" whenever it does occur, it is apt to mislead or puzzle. I was consulted last year 
 about a gentleman in whom this phenomenon of pectoriloquy was strono-ly marked. 
 Two excellent auscultators had been led, by this symptom, to the belief that a cavity 
 existed in the lung. Remembering the case I have just mentioned, and learning that 
 the patient had been ill for a few days only, and had not previously suffered cough, 
 nor any apparent pectoral complaint, I was of opinion that the summit of his right 
 lung had become hepatized by acute pneumonia. And it was so. The patient died; 
 and the diagnosis I had formed was verified upon the inspection of the lung. Dr. 
 Latham relates one or two examples to the same purpose. Dr. Stokes goes so far 
 as to consider pectoriloquy the least important and most fallacious of all the physical 
 signs of phthisis. Taken alone (he says) it is absolutely without value. Dr. Forbes 
 has come to similar conclusions. Certainly cavernous respiration is a much more 
 alarming sound. 
 
 Wherever actual pectoriloquy from a cavity is heard, there also will be heard 
 cavernous res])iration. But the converse of this is not necessarily true. There may 
 be, and there often is, cavernous respiration and a cavity, yet no peclcri^loquy. Tho 
 cavity is not large enough, or not near enough to the surface of the chest, or not of 
 such a kind as to reverberate the voice. 
 
 C^flen when pectoriloquy is absent, and cavernous respiration is doubtful, and gurg- 
 ung even cannot be heard (because the communication with the bronchi is not free).
 
 636 PHTHISIS. 
 
 a slight splashing sound will occur when the patient coughs : nay, you niay some- 
 times hear it, if he holds his breath, with every beat of his heart, which causes a 
 little succussion in the cavity : but its contents must then be ihin. 
 
 Now when the sounds I have been engaged in describing are well marked, they 
 denote the existence of a vomica. The only source of fallacy is that which I formerly 
 mentioned: the same sounds may arise from a cavity in the lung, whatever be its 
 nature ; and therefore they may arise when the bronchi are expanded into cavities. 
 But I repeat that this is a deceptive condition which you cannot calculate upon meet- 
 ing with often. "" 
 
 When the sounds are not w^ell marked, take time before you pronounce a decided 
 opinion respecting them. Strong bronchophony comes very near to weak pectorilo- 
 quy : bronchial respiration may closeJy resemble some varieties of cavernous breath- 
 ing : large crepitation, confined to a small spot, may simulate gurgling. It is better, 
 when the sounds are thus equivocal, and when they may denote conditions so very 
 different in their nature and tendency, to suspend one's judgment, and to give a 
 guarded opinion. A httle time in such cases will clear away the doubt. 
 
 I am afraid of being tedious about these sounds ; but really they are of immense 
 importance. Upon their exact appreciation, and correct interpretation, will depend 
 the opinion you will be culled upon to express : and that opinion will, in many cases, 
 be a sentence of fife or death in respect to the dearest friends of those who hear it. 
 A correct diagnosis is also very important, in early periods of the disease especially, 
 for another reason. It is in those early periods alone that we can hope to arrest the 
 progress of the complaint by art, or by change of climate. 
 
 I must now consider the general symptoms of this most afflicting disease: and 
 while doing so, I shall point out how the physical signs confirm or confute their lan- 
 guage, in cases which might otherwise be doubtful. 
 
 The general symptoms of phthisis are cough, dyspnoea, expectoration, haemo- 
 ptysis, wasting, hectic fever, hoarseness, or loss of voice, diarrhosa ; and there are 
 some other symptoms which mark often some of its stages, and to which I shall 
 incidentally advert. I shall speak of them all as briefly as is consistent with 
 clearniess. 
 
 Cough is one of the earliest symptoms of consumption ; and it is that which com- 
 monly "first attracts the attention, and awakens the fears of the patient, or the patient's 
 friends. Generally at first it is slight, occasional, and dry : it occurs upon the 
 patient's getting out of bed in the morning ; or if he makes any unusual exertion in 
 the course of the day. It feels to him as if it was caused by irritation about the 
 throat. Sometimes it \\\\\ cease for a while, as in the w^arm w^eatlier of summer, 
 and recur in winter when the external temperature is lower. By degrees it begins 
 to be troublesome in the night : and to be attended with more or less mucous ex- 
 pectoration. 
 
 Now when such a cough steals upon a person gradually, and when no reason can 
 be assigned for its occurrence, that circumstance alone is enough to excite suspicion 
 as to its true nature and cause. But chronic cough may exist without any tubercular 
 disease of the lungs ; as you well know. It may depend upon a disordered state of 
 the stomach; the pneumogastric nerve may be irritated there. It may be the 
 cough of chronic catarrh; it may result from disease of the heart ; it may be the 
 nervous, barking, importunate cough which I formerly mentioned as of frequent oc- 
 currence in hysterical girls. And bearing these circumstances in your mind, you 
 will inquire and you will generafly make out without much ditliculty, whether there 
 be any unnatural or deranged stale of the digestive organs ; or chronic catarrh ; or 
 cardiac disease ; or hysteria. These are points on which I need not further insist. 
 
 I may obuerve, here, that as chronic cough may exist when there is no consump- 
 tion ; so consumption may sometimes exist, and even prove fatal, and large portions 
 at the lungs may be disorganized, without there having been any cough ; or at least 
 without the occurrence of cough enough to draw the notice of the patient or his 
 friends to it. This is not common, howe^^er : cough is usually present more or less, 
 during al.' the stages of phthisis, and it is often that symptom which most distresses 
 •md iiarasses both the patient and his family.
 
 PHTHISIS. 637 
 
 Great a tention used to be paid to the expectoration in cases of suspected phthisis. 
 It was thought that if a patient spat pus, he was in a state of confirmed consump- 
 tion : and whole volumes have been written, and prizes awarded to their authors, 
 respecting the means of distinguishing pus from mucus. But we now know that, 
 so far as the diagnosis of phthisis is concerned, this is a very idle inquiry. The 
 inflamed bronchial membrane may secrete pus ; so that the presence or absence of 
 pus in the sputa is no test at all of the presence or absence of tubercles in the lungs. 
 If you are, nevertheless, curious to know how pus may be recognized, one easy 
 criterion is that proposed by the late Dr. Young. You are aware that pus, like the 
 blood, contains globules ; and these globules, when examined through transmitted 
 light, will exhibit prismatic colours ; appear surrounded by rings of colours, some- 
 what resembling those of the rainbow, but differently arranged, and often beautifully 
 brilhant. Mucus having no such globules, affords no such coloured rings. The 
 way to make the examination is, to put a minute quantity of the fluid between two 
 small pieces of plate glass ; to hold the glass close to the eye ; and to look through 
 it at a distant candle, having a dark object behind it. A yet readier, and I believe a 
 better test is furnished by the liquor potassx, which converts pus into a viscid stringy 
 mass, while it liquefies mucus. 
 
 Whether the expectoration be puriform or not, has ceased, however, to be a ques- 
 tion of much importance as regards the diagnosis of phthisis. A portion of the 
 matter expectorated comes from the surface of the bronchi, and consists of altered 
 mucus : and therefore the sputa brought up in phthisis, and the sputa brought up in 
 bronchitis are, in a great degree, the same. These are partly composed of a stringy 
 transparent fluid, in which opaque masses of a yellow or greenish colour are seen to 
 float ; and intermixed also with which there may be a good deal of froth. The 
 froth is a measure of the difficulty with which the mucus is brought up : and it is 
 usually less abundant and conspicuous in phthisis than in bronchitis. The heavy 
 sage-leaf sputa that we sometimes see, belong to both diseases. 
 
 You may occasionally find portions of tubercular matter in the expectoration; a 
 circumstance quite decisive, when we are sure of it, of the nature of the case : dull 
 yellow streaks, or little curd-like fragments involved in the mucus. But smaU opaque 
 specks of that character are sometimes formed in the follicles of the tonsils ; and 
 this makes the appearance more equivocal. The sputa most characteristic of tuber- 
 cular disease consist of globular flocculent masses, which look like little portions of 
 wool more than any thing else. Nummular sputa the French call these, because 
 when spat into a vessel not containing water, they assume a flat circular form, hke a 
 piece of money, and remain separate and distinct from each other. When they are 
 spat into a glass of water, you perceive that some of them subside to the bottom — 
 some float on the top, suspended, apparently, by healthier mucus in which they are 
 entangled, or by bubbles of air — and some remain stationary at different depths. 
 When stirred and agitated in the water, they render it shghtly milky. This kind 
 of expectoration commonly marks a confirmed and advanced state of the disease; 
 but it will continue for weeks sometimes. It is not perfectly pathognomonic, but 
 nearly so. On one occasion I found expectoration of this nature from a man whom 
 I did not very diligently examine by my ear ; and I set the case down as one of 
 phthisis chiefly on the observation of that symptom. The patient evidently had not 
 long to live. Our apothecary at the hospital, Mr. Corfe, had more time to explore 
 trhe condition of the chest: and he came to the conclusion, that the disease was not 
 tubercular phthisis, but extensive chronic bronchitis : and sure enough he was right. 
 When we came to examine the lungs after the patient's death, not a tubercle could 
 be foimd. I am satisfied that there is no kind of expectoration which indicates 
 phthisis with perfect certainty ; but that which I have just been describing very 
 seldom occurs except there is phthisis. Louis appears to have noticed these round 
 separated, woolly masses twice only unconnected with tubercles ; and once the same 
 thing has occurred to Chomel : so that, when the other symptoms are obscure and 
 doubtful, this will materially augment the gravity of the prognosis. Fiies appear to 
 be more attracted by the sputa of phthisis than by any other. 
 
 Haemoptysis is a kind of expectoration; the expectoration of Hood. I hava 
 
 3i>
 
 638 PHTHISIS. 
 
 already spoken of this symptom as connected with phthisis, and have stated my 
 belief on that subject; viz., that if a person spits blood who has received no injury 
 of the chest, in whom the uterine functions are healthy and right, and who has no 
 disease of the heart, the odds that there are tubercles in the lungs of that person are 
 fearfully high. Excluding cases of amenorrhcea, and of mechanical injury to the 
 thorax, Louis did not meet with a single example of haemoptysis among twelve hun- 
 dred patients, except in such as were phthisical. 
 
 I touched, at the same time, upon the question, whether haemoptysis, which some- 
 times precedes for a while the manifestation of any other symptoms of consumption, 
 is ever really the cause of it, as the old authors maintained. You will understand 
 iny persuasion to be that, occurring in connection with tubercles, pulmonary hemor- 
 rhage is always the consequence, and never the cause, of their presence in the lung. 
 Andral relates a curious case, from which the contrary opinion might be argued. 
 "A man, ill of chronic peritonitis, had been for nearly two months in La Charite, 
 and had never presented any morbid symptom which had relation to the organs of 
 respiration. He had no cough, and he breathed easily. One evening, for the first 
 time, he sufl~ered some dyspnoea ; and in the course of that night he spat up a large 
 quantity of florid and frothy blood. For the five following days the hasmoptysis 
 continued abundant, then it diminished by degrees, and at length stopped. But the 
 patient continued to cough, and to breathe with difficulty, and at length he died. In 
 the right lung there were found several masses of a brownish-red colour, exactly 
 circumscribed, and constituting, in short, that condition w^iich Laennec has called 
 * pulmonary apoplexy.' One of these masses contained a considerable number of 
 granulations of a yellowish-white colour, and having all the characters of minute 
 tubercles in an early state. Two other of the red masses contained each a very 
 small number of these white granules ; and in the remaining masses no tubercles at 
 all could be discovered, nor was there any trace of them in other parts of the lungs ; 
 but they were numerous in the false membranes of the peritoneum. 
 
 Andral argues, that in this case the partial collections of blood that were found in 
 the lung could not have been occasioned by the presence of tubercles, because in 
 the majority of these masses no traces of tubercular matter could be perceived. On 
 the other hand, their existence appears connected with that of the apoplectic masses, 
 because, except in the midst of some of these, no pulmonary tubercles could be seen. 
 But such a case as this hardly bears out the conclusion that pulmonary hemorrhage 
 is ever the cause of tubercles. There were tubercles in the abdomen before ; there- 
 fore, the disposition to tubercular disease pre-existed in this individual ; and then 
 tubercular matter was deposited in the places where blood was extravasated ; just as 
 we know it is deposited in the blood itself, in the spleen sometimes ; or, what 1 think 
 more probable still, the cluster of granulations provoked the hemorrhage from the 
 spot they occupied, and other lobules of the same lung became blocked up by the 
 reflux of blood in the manner formerly explained. 
 
 Prior to the age of fifteen, haemoptysis, even in phthisical children, is extremely 
 uncommon. 
 
 Dijspnira is not a very important symptom in phthisis. It is seldom extreme till 
 towards the termination of the disease, and not always then. Patients who fear, and 
 yet are unwilling to believe, that they are consumptive, will fetch a deep breath, and 
 Did you remark how thoroughly they can distend their lungs ; and they expect you 
 to say that there can be no disease in those organs. I have been told that the late 
 Dr. Baillie died of pulmonary phthisis ; and that even he was accustomed to delude 
 himself by this test. However, though phthisical persons do not in general suiTer 
 much from dyspnoea, their breathing, though they may not bo aware of it, or choose 
 10 acknowledge it, is generally, in some degree or other, short, or hurried. You 
 may wonder that a disorder in which so large a portion of the breathing apparatus is 
 often effectually spoiled, should be attended by so little distress in respiration ; so 
 liitie dyspnoea : but your surprise will be diminished if you consider the insufficient 
 manner in which consumptive patients are nourished, in consequence of abdominal 
 •- isease ; and the extent to which their blood is wasted by diarrhoea, and by perspi- 
 ration Thc^ mass of blood is thus kept down to that measure which, passing through
 
 ■^ PHTHISIS. 639 
 
 the still pervious portions of the lungs, is capable of being arterialized without any 
 great deviation from the ordinary mode and frequency of breathing. 
 
 Neither is pain of the chest a very important symptom in consumption. In some 
 cases severe pains are complained of, resembling those of rheumatism, in the sides, 
 or beneath the clavicles. In others, no pain at all is experienced. When sharp 
 pain occurs, it may be supposed that the pleura is inflamed and beginning to adhere 
 in the painful part. 
 
 There is, however, one contingency of which the two symptoms last mentioned are 
 sometimes very significant. When, during the progress of phthisis, violent pain of 
 the side, and extreme dyspnoea and anxiety, set in suddenly, they denote, with much 
 certainty, perforation of the pleura, and its serious consequences. 
 
 The hectic fever which accompanies phthisis is of much greater moment. It often 
 creeps upon the patient insidiously. He feels chilly, perhaps, towards evening; 
 and in the night his hands and feet are dry and burning; and in the morning he 
 perspires. The most marked symptoms of the hectic are to be found in the perspi- 
 ration, and in the state of the pulse. The perspiration is usually out of all proportion 
 to the previous chilliness and dry heat. It seems to have a close connection with 
 the sleep of the patient : it seldom comes on while he continues to be awake ; but 
 after sleeping he wakes, and find that he is sweating. The perspiration is generally 
 most copious on the upper part of the body, the chest and head. Sometimes it is 
 moderate ; sometimes the patient is drenched and drowned in it. There is a good 
 deal of uncertainty about this symptom, and of obscurity as to its cause. Generally 
 speaking, it belongs to the more advanced stages of phthisis ; but occasionally it 
 accompanies its early period. It will cease without any apparent cause ; and 
 return again with the same capriciousness, A poor friend of mine, who died 
 with phthisis, and was particularly harassed by the nocturnal perspirations, took it 
 into his head that joos/t/re had something to do with them ; and slept for several nights 
 in succession sitting in an easy chair: and during those nights he certainly did not 
 sweat, though he had been doing so profusely before. Louis found that one patient 
 in ten escaped this symptom. 
 
 This is a symptom which is often very distressing to the patient, making him even 
 dread to go to sleep ; it tends also to the rapid exhaustion of his strength ; and 
 betokens, it is believed, when copious or persistent, a short duration of the disease. 
 
 Frequency of pulse is a symptom so generally present in tubercular phthisis, that 
 too much importance has been ascribed to it as a diagnostic sign. I mean, it has 
 been too much the opinion that the lungs are safe, when the pulse does not rise above 
 its natural standard. Sometimes it remains steady nearly up to the period of disso- 
 lution. Such cases are, I beheve, generally slow in their progress. 
 
 Very recently I lost a friend whose lungs were full of cavities and crude tubercK's. 
 He had been a valetudinarian for years ; but the pulmonary disorder had been mani- 
 fested by decided symptoms during a few months only. At no period did his pulse 
 exceed sixty-eight beats in the minute. Commonly, however, the pulse is habitually 
 above ninety ; and often it is much more. When there is nothing to account for this 
 increased frequency of pulse, it is a suspicious symptom. 
 
 Diarrhcpais a common, and an ugly symptom in phthisis. When it occurs early, 
 as it sometimes does ; when a patient, having habitually costive bowels, becomes 
 habitually relaxed ; and you suspect only, from other causes, that he may have inci- 
 pient phthisis ; this change often sets its seal upon the nature of his disorder. Usually, 
 however, diarrhosa does not become urgent until the disease is far advanced, and has 
 aheady declared itself by other and unequivocal symptoms. When it so occurs, it 
 is apt to harass the patient exceedingly ; and rapidly to waste his strength and flesh. 
 He appears to melt away under the influence of the purging ; which is therefore said 
 to be colliquative. It used to be held that the diarrhcea and the perspiration bore iw. 
 inverse ratio to each other: that when one of them abated, the other always increased. 
 But the more exact observations of Louis and others have proved that this is not so : 
 that neither in phthisis, nor in other diseases, have these symptoms any such regular 
 reciprocal relation. One reason, perhaps, fw this error, may be found in the cii 
 cumstance, that acids, which have the effect often of checking the perspiration, tend
 
 640 PHTHISIS. 
 
 also, as is well known, to produce diarrhoea. Louis found that this symptom began 
 early in the disease, and continued through its whole course, in one out of every 
 eight patients ; and in one case only in every twenty-two was it wholly wanting. It 
 depends most commonly, if not always, upofi scrofulous ulceration in the small intes- 
 tines and in the colon. In Louis' experience, there w-ere, invariably, large ulcers, 
 whenever the diarrhoea had been chronic and abiding, and the stools had been 
 numerous. In the small intestines the ulceration evidently commences in the 
 mucous follicles ; the glandulse solitarias, or the glandulse agminatase ; and sometimes, 
 though not often, the ulcer perforates the bowel. It is probable that in the large in- 
 tesune ulceration begins in the same waj', by the deposit of tubercular matter (which 
 is subsequently removed) in the sohtary glands : but when once begun the ulceratino- 
 process extends itself indefinitely to the surrounding mucous membrane. 
 
 I should have stated before that, with this disease of the intestinal canal,. there is 
 often found enlargement of the corresponding glands of the mesentery, which are 
 frequently filled also with tubercular matter. 
 
 Several of the symptoms that I have been mentioning — the state of the digestive 
 organs, which interferes with the due assimilation of the food ; the drain implied in 
 the profuse sweats, and in the habitual diarrhea ; — conduce to cause another con- 
 stant accompaniment of phthisis ; and that is emaciation. — You know that the wasting 
 in this complaint, when it is not cut short by some accidental complication before it has 
 reached what may be called its natural termination, is extreme. It often is one of 
 the earliest, as it is one of the most alarming, of the symptoms which the patient 
 presents ; and it frequently becomes excessive before any perspiration or purging 
 have taken place to account for it. If, without any apparent cause, a person grows 
 thin and his pulse is quick, and his breath at all siiort — these are intimations which 
 seldom prove unfaithful, that tubercular disease is at work in the lungs, and in the 
 abdomen. 
 
 (Edema of the ankles, and even some pufHp.:ss of the hands and face, are circum- 
 stances which seldom fail to appear in pulmonary consumption : but they are among 
 the latest of the symptoms. (Edema does not tell us what the disease is in such 
 cases. We have been satisfied as to that some time before. But (unless there is 
 some marked disease of the heart) it tells us that the disease is about to terminate. 
 It is worth attention as a prognostic symptom merely. 
 
 And the same may be said of aphtha). This is one of the last of the symptoms . 
 but it does not always occur at all. I have lately described this morbid condition 
 of the mucous membrane of the mouth and tongue, and have nothing more to say 
 of it at present. It has the same relation to phthisis as to other chronic disorders : 
 it marks, for the most part, the approach of their fatal termination. 
 
 It is always interesting to couple changes of structure with their appropriate signs. 
 I will therefore take this opportunity of telling you what Louis has observed of this 
 relation, in respect to the larynx and windpipe. 
 
 Ulceration of the epiglottis w'as often latent ; gave no appreciable signal of its 
 existence. The symptoms that belong to it are, a raw, or pricking, or burning sen- 
 sation at the upper part of the thyreoid cartilage, with occasional dysphagia, and the 
 rejection of liquids through the nose, while the tonsils and pharynx present no visible 
 alteration. 
 
 Ulceration of the interior of the larynx is marked, when slight, by trivial pain in 
 that part, and some variation from the natural voice ; when deep, by severer pain, 
 and abiding aphonia. 
 
 Ulceration of the trachea is seldom revealed by any symptom. And this is worth 
 remembering : for patients are continually persuaded by medical men who know no 
 better, that their symptoms are all tracheal. 
 
 There are still a {e\\ other circumstances which, when they occur, accumulate 
 conviction as to the nature of the disorder. The catamenia are suspended in women : 
 and the hair falls ofl^. There are certain physical peculiarities too, which are strongly 
 indicative of a tendency to consumption ; or perhaps I should say of the scrofulous 
 diathesis. Largeness of the pupil, with a sluggish iris — in other w-ords, a nof. very 
 sensible retina — constitutes one of these. A clubbed state of the ends of th« fu'.gers
 
 PHTHISIS. 641 
 
 with convex and adunque nails, forms another. Yet this last is not peculiar to tuber- 
 cular consumption. I have heard of one case in which it was strongly marked : the 
 patient died after a long illness — chronic puriform discharge from the pleura after 
 >aracentesis thoracis : but there were no tubercles. 
 
 LECTURE LVII. 
 
 Phthisis, conlinued. Diagnosis. Forms and varieties of Phthisis. Ordinary 
 duration. Age at which it is most frequently fatal. Influence of sex ; and 
 of occupation. Question of Contagion. Treatment. 
 
 In a former lecture, the twelfth of this course, I entered somewhat fully into the 
 pathology of scrofulous and tubercular diseases in general. I pointed out the fact, 
 that though such diseases afftct vast numbers of persons, and are most extensively 
 fatal, yet that they affect almost exclusively certain classes of persons. That while 
 some are so prone to tubercular disease, as to fall into it upon the operation of the 
 slightest external causes, or even spontaneously — nay, in spite of every care to the 
 contrary — others, again, who are constantly exposed to influences likely to call 
 scrofulous disease into action, either do not suffer therefrom; or if they do become 
 scrofulous, it is only when the external circumstances most favourable to the pro- 
 duction of such disease have been intense in degree and protracted in their appli- 
 cation. 
 
 At the same time I showed you how commonly the disposition to scrofula de- 
 scends in families : and I told you what observation has collected in respect to the 
 causes which may excite scrofulous disease in persons hereditarily disposed to it. I 
 shall not, therefore, go over that ground again. What I then said of scrofulous dis- 
 ease in general is true of tubercular consumption in particular. I will merely 
 remind you that these exciting causes are essentially causes of debility. Whatever 
 tends to depress the vital powers, and permanently to weaken the body, tends also, 
 in a predisposed frame, to engender or to call forth this fearful and most destructive 
 malady. 
 
 With respect to the detection of tubercular disease in the lungs, it is sometimes 
 very easy, sometimes extremely difficult. It is easy when the tubercles are numerous, 
 large, or far advanced : difficult, sometimes, when they are crude, scanty in number, 
 and thinly scattered, and individually small. In the latter case they may not cause 
 any appreciable deviation from the natural resonance of the chest on percussion, or 
 from the natural smooth equable rustle of the breathing. It would be tedious to 
 travel over again all the auscultatory and other symptoms, with the view of pointing 
 out their bearing upon the diagnosis. I touched upon that point incidentally, when 
 discussing the individual symptoms, in the last lecture. Many of the symptoms tell 
 their story so plainly that any attempt to expound or interpret them would be quite 
 superfluous. One or two cardinal points, however, which have rather been hinted 
 at before than expressed, I may just advert to. 
 
 The fact that tubercles occupy the upper part of the lung by preference, is of 
 great moment in relation to the diagnosis. When the symptoms are equivocal ; 
 when, as far as they are concerned, the case may either be one of chronic bronchitis, 
 or of tubercular consumption ; a careful examination of the superior regions of the 
 chest will often decide the anxious question. The sound resulting from the first 
 gentle tap upon or beneath the clavicle, often rings in the physician's ear the knoll 
 of his unfortunate patient. Even unusual distinctness of the sound of e.rpiration, if 
 heard at the summit of the lung, and <2 fortiori if at the summit of one lung only, 
 warrants the terrible suspicion that tubercles are breeding in that luntr. It may, 
 indeed, be laid down as a rule, which is diversified with but few exceptions, that if 
 you find dulness on percussion ; or coarse or insufficient breathing; or undue resa 
 41 3d2
 
 642 PHTHISIS. 
 
 nance of the voice ; or a click or morbid noise of some sort when the patient respires, 
 or speaks, or coughs ; if you find this day after day and always, between the clavicle 
 and the mamma in front, or between the clavicle and upper edge of the scapula, 
 over the top of the shoulder, and nowhere else ; and more especially if these devia- 
 tions from the healthy sounds be limited to one side, or greater on one side than on 
 '.he other, or different in quality on the two sides ; you may set the case down as a 
 case of tubercular phthisis. On the other hand, if in the same parts you still distin- 
 guish all the natural sounds of the respiration, and can still obtain a clear sound on 
 percussion, you are not to condemn the case, nor to despair of recovery, whatever 
 its other circumstances may be. The worst symptom certainly, when auscultatory 
 signs are wanting, is haemoptysis. 
 
 Incipient consumption is most liable to be confounded with chronic bronchitis. 
 Yet the leading features of the two are well contrasted. The morbid sounds belong- 
 ing to chronic bronchitis are chiefly audible in the lower lobes of the lungs : those 
 of phthisis in the upper. Some degree of expectoration attends the cough of bron- 
 chitis from the first : the cough of phthisis is often, for a long while, dry. Simple 
 bronchitis is not accompanied by haemoptysis. The pain that occurs in bronchitis 
 is felt beneath the sternum : in phthisis pain most commonly afiects the sides, and 
 the space between the shoulders. It is enough, I trust, to have drawn your atten- 
 tion to these points, without dwelling upon them longer. 
 
 Dr. Latham, in the little work which I have several times referred to, has laid 
 down certain distinctions most deserving of your notice, in respect to the various 
 forms of phthisis. This portion of his book is quite original. The facts, indeed, 
 nave long been known ; but they have never before, that t am aware of, been made 
 so instructive, by being clearl}'^ disposed, and exhibited in their proper bearings. 
 
 He first divides phthisis generally into two forms, which he calls mixed phthisis 
 and unmixed phthisis. And he illustrates what he means by those terms very 
 simply and skilfully. He takes the case of an absorbent gland in the neck, affected 
 with scrofulous disease. The changes which are liable to take place in it are 
 wrought before our eyes. We have the privilege of watching them. Now, such a 
 gland will sometimes enlarge, in consequence of the deposition of tubercular matter 
 in its substance : it will grow large and hard without there being any pain, or heat, 
 or redness, observable ; and it may remain in that state for weeks, or months, or 
 years. 
 
 But, in the majority of instances, the absorbent gland, after remaining for a certain 
 time in this condition, will undergo, and cause, other changes. Pain, heat, and red- 
 ness, will ensue; the hard gland will soften; the integuments will grow thin, and 
 at length give way ; the softened tubercular matter, mingled with pus, will escape ; 
 and then the pain and heat and redness — the inflammation, in short — will disappear ; 
 and the abscess will heal, leaving behind it nothing more than a slight scar. This 
 process may happen to one such gland, or to more than one, simultaneously ; or to 
 several in succession. 
 
 In this case there has been no more inflammation than was just enough to accom- 
 plish its purpose of removing from the body the tubercular matter. The inflamma- 
 tion has not transgressed what Dr. Latham has called its specific limit. 
 
 But again it may go beyond that limit ; it may be both more severe and more 
 extensive "than is necessary for the removal of the tubercular matter in the diseased 
 gland. It may pervade the whole neck, giving rise to diflused redness, and swell- 
 nig, and pain ; and the whole of the subcutaneous areolar tissue between the angle 
 of the jaw and the clavicle may be loaded with effused serum and pus. 
 
 All this you may see almost any day in the wards or waiting-rooms of a hospital. 
 And Dr. Latham has happily chosen this affection of the cervical glands to elucidate 
 what happens when the tubercular matter is deposited in the lungs, where one can- 
 not see the changes it is suffering or producing. 
 
 Tubercles in the lungs may remain for an indefinite period of time, in their crude 
 state ; never softening at all, or softening only at a very late period. Or they may 
 give rise to just so much of inflammation, and no more, in the pulmonary tissue sur- 
 rounding them, as is sufficient to bring about their own softening and subsequent
 
 PHTHISIS. 643 
 
 expulsion. Or, lastly, the tubercles may excite much more mflammation of the lung 
 around them than is requisite for their elimination : inflammation of every degree, 
 and of any extent. 
 
 Now, to the first two cases, when they occur, he gives the name of unmixed 
 phthisis : the third he calls, on the other hand, mixed phthisis. We learn from aus- 
 cultation whether the case be one of mixed or unmixed consumption ; i. e., we hear, 
 in the unmixed forms, the sounds or modifications of sound which result from the 
 presence of tubercles or of vomicEe ; and we hear these morbid sounds only : in every 
 part of the lung where they are not audible, we hear the vehicular murmur of 
 health. But in the mixed form we also hear these sounds. True, and we hear other 
 morbid sounds beside. The tubercular disease is mixed with common inflamma- 
 tion ; and we hear the sounds that denote common inflammation of the mucous 
 membrane, or of the substance of the lung — sibilus, or large or small crepitation — 
 we hear these sounds mixing themselves with the sounds which belong to the tuber- 
 cular affection. 
 
 This distinction is of considerable importance, for it concerns the treatment of the 
 malady. The tubercular disease, when established, is beyond our power. The inflam- 
 mation which is incidental to it, we may hope to alleviate or to remove. It is in the 
 stage of vomicae that the disease commonly assumes the mixed character; and some- 
 times the bronchial or vesicular effusion upon which the added sounds depend, may 
 be got rid of by the seasonable application of a few leeches, or of cupping-glasses, 
 or of a blister, or by a moderate bleeding from the arm, and the disease be brought 
 back again, for a time at least, within its specific limits, and the patient be relieved 
 from much distress and imminent danger. It is upon this principle that Dr. Latham 
 explains the fact that most consumptive patients improve considerably, soon after 
 their admission into the wards of a hospital. The poor are necessarily much ex- 
 posed to those causes which tend to complicate the tubercular disease. The tuber- 
 cular disease may as )^et be slight and limited ; but the superadded mischief, the 
 bronchial and vesicular effusion, may be immense ; and this being submitted, often 
 for the first time, to treatment, upon their admission to a hospital, is for a while 
 removed. 
 
 Now, if we had not the advantage of the method of auscultation, we could not 
 ascertain these differences, nor detect them when they existed. You will perceive, 
 I am sure, their practical importance. 
 
 Of course, the more ready the surrounding lung is to take on inflammation — in 
 other words, the stronger the disposition in the complaint to assume the mixed cha- 
 racter — the more rapidly fatal is it likely to be. 
 
 But of the unmixed form of phthisis Dr. Latham has made two interesting varie- 
 ties ; and the truth of the distinctions he has drawn will be more manifest to you, the 
 more you see of this terrible disease. In one of these varieties the lungs are appa- 
 rently tenanted by a multitude of tubercles, which remain crude and unaltered for a 
 considerable length of time. In the other, successive crops of tubercles appear to 
 form; or at any rate the tubercles ripen and are expelled in successive crops; and 
 there may be long intervals between each crop and the next. 
 
 Dr. Latham thus describes the former of these two varieties : — "An individual 
 loses the complexion of health, and becomes thin ; he coughs a little ; but perhaps 
 he has no notable fever, and no constant acceleration of pulse." Upon auscultation 
 of his chest, it is found that there is dullness beneath one or both clavicles, or about 
 one or both scapulae, and an indistinct respiratory murmur in those parts; but the 
 vesicular breathing is free and perfect in every other part of the lung. Here we 
 have tubercles, crude, and in the upper lobe alone ; and this state of things may 
 endure for years, without variation ; the patient remaining always a great valetudi- 
 narian. " To such a patient (says Dr. Latham) it is a continual puzzle why he does 
 not get well. He consults an infinite number of medical men ; and it is remarkable 
 that he gets no comfort or satisfaction from those who understand his disease the 
 best, and the greatest comfort and satisfaction from those who understand nothing 
 about it. Those who know what it is, out of kindness do not tell him the truth ; 
 and they cannot asseverate a falsehood stoutly enough to carry any weight with it ;
 
 644 • PHTHISIS. 
 
 whereas they who know nothing about it affirm boldly and unhesitatingly that it is 
 all stomach ; really beheving that the whole and sole disorder is in the stomach, and 
 that it is wiihin the reach of an easy cure." 
 
 But at length — perhaps after a very long period — vomicas are formed ; and then 
 the patient sinks rapidly, and his lungs after death are found riddled by cavities and 
 stuffed with tubercles ; but every part of them not occupied by tubercles or vomicae 
 is crepitant and healthy. In these cases, disease lingers long in the crude stage ; 
 new tubercles are added, probably, year after year ; but none of them soften. They 
 do not excite inflammation in the lung around them. You recognise the presence 
 of the tubercular matter by the ear ; but there are no vomicas. At last vomicae are 
 tbrmed, many at the same time, or in rapid succession, and the patient presently 
 succumbs. 
 
 The other variety of unmixed phthisis may be just as protracted as this ; but its 
 character and progress differ materially. In the former case the patient's condition 
 was one of invariable ill health ; in the one I am about to mention he has fits of ill 
 health, and fits of comparative good health. He spits for a time considerable quanti- 
 ties of puriform matter, and then ceases from expectorating altogether. He has hectic 
 fever, and then throws it off', and then suffers it again : wastes, and recovers his 
 flesh, and again loses it. . You will find such cases common enough ; and in these 
 cases the morbid sounds will be correspondent to the symptoms. During the fits 
 of illness you will hear gurgling respiration or gurghng cough at the apex of one or 
 noth lungs : and during the fits of good health you will hear cavernous respiration, 
 or pectoriloquy, in the same parts ; but ever}'where else you will hear a clear sound 
 of vesicular breathing. Here the tubercular matter excites just enough inflamma- 
 tion around it to achieve its own expulsion, and no more. The lung is destroyed 
 bit by bit. Fresh portions of tubercular matter are deposited ; these ripen and soften, 
 and are expectorated, and a vomica is the result : and then there is a period of quiet. 
 And there being still a large portion of each lung to breathe with, the patient regains 
 more health and strength in the intervals of his attacks, than the former patient pos- 
 sessed habitually. 
 
 But in this form of unmixed pulmonary consumption, a period at length arrives 
 when the patient does not revert to the former state of apparent health. The 
 quantity of lung that has now been destroyed forbids it. You may hear the sounds 
 proper to tubercular disease over a large space, between the clavicle and the 
 mamma, or anywhere about the scapula, on one or both sides ; yet still that part of 
 the lung which is free from tubercles and vomicae is pervious and healthy : but the 
 hectic continues, the emaciation increases, and the strength declines ; and the fatal 
 consummation arrives. 
 
 Of these two varieties of genuine and unmixed consumption, the first is the most 
 hopeless. The tubercles are numerous ; they probably go on increasing in number 
 though they do not soften ; there is not, and there cannot be, any even temporary 
 return to health, either real or apparent. 
 
 Whereas where the tubercles come singly, or in successive crops, and rapidly 
 soften, and are expectorated ; and where some long time interposes between the 
 crops ; the health and strength return, and there is just a chance that no more 
 tubercles may form. It is in this variety of unmixed phthisis that a natural cure, 
 by the contraction and cicatrization of a vomica, may by possibility take place. 
 VVe cannot expect, and we must not permit ourselves to encourage hope, that the 
 disease ivill cease in that manner : but if it ceases in any form of the malady, it is 
 in this. 
 
 [In regard to the curability of pulmonary consumption, Dr. Wood, in his Treatise on the 
 Practice of Medicine, vol. ii., p. 109, remarks, as follows : — 
 
 " I am not one of those who believe that phthisis is in all cases necessarily fatal. On the 
 contrary, I believe that, in one stage or another, it is occasionally cured, or at least ends in 
 perlect recovery. It is no very unfrequent event to see threatening symptoms of phthisis 
 ffive way under suitable treatment. It cannot be proved, with absolute certainty, that these 
 symptoms were tuberculous ; because the evidence of dissection is wanting, and the phy- 
 eical signs are not sufficiently positive, in mild cases of early phthisis, to authorize a certain 
 conclusion. But they are undistingtiishable from symptoms, which, in oth' i cases, are the
 
 PHTHISIS. 645 
 
 forerunners of confirmed phthisis; and we have abundant evidence from dissection, that 
 tubercles are capable of undergoing favourable modifications. The probability is, that the 
 tuberculous matter is absorbed, and sometimes, as shown by dissection, replaced by calcare- 
 ous matter : and, if the diathesis be so far subdued as to prevent the deposition of other tu- 
 bercles, before these have completely run their course, the disease may be said to be cured 
 The circumstance that such remains of tubercles are not unfrequently found in the lungs of 
 old persons, who have died of other diseases, would seem to show, that these cures are 
 sometimes permanent. 
 
 " But this is not all. It occasionally happens, that consumptive symp^toms disappear en- 
 tirely even in the second stage of the disease, after the formation of a cavity. This event, it 
 is true, is comparatively rare ; but some such cases have probably fallen within the notice of 
 almost every practitioner of extensive experience. Even should the disease ultimately return, 
 still, the case may be said to have been cured ; as the occurrence of a second attack of pneu- 
 monia is certainly no proof that the first was not cured. But there have been cases in which 
 no return of the symptoms has taken place during the residue of life, even though consider- 
 ably protracted. Two instances of this kind have occurred in medical men of this city. 
 One of the patients was affected, when a young man, with all the symptoms of phthisis, 
 including frequent attacks of hjemoptysis, severe cough, hectic fever, &c., from which ho 
 completely recovered, and continued exempt up to the time of his death, which occurred 
 many years afterwards of typhoid fever. (See N.Am. Med. and Surg. Journ., viii. 277.) The 
 other was my preceptor and friend, the late Dr. Joseph Parrish, who in early life laboured 
 for a time under the symptoms of phthisis, and after his death, at an advanced age, was 
 found to have several cicatrices of the upper part of one lung, which were obviously the 
 remains of tuberculous cavities. (See jlm. Jour, of Med. Sci., xxvi. 25G.) The probabilities 
 upon tlie whole are, that each tubercle has a tendency towards health, and, if alone, would 
 in time end in perfect recovery; so that the great fatality in phthisis consists in the continued 
 predisposition which causes the constant or frequently repeated deposition of other tuber- 
 cles, before those first deposited have had time to run a favourable course. We may, there- 
 fore, always entertain some hope, if applied to in the early stage, in cases of no great se- 
 verity, of seeing a cure efiected ; and, even in the second stage, when the diathesis is not 
 very strong, or the local disease extensive, there is no reason for absolute despair. Even in 
 cases which appear to offer no chance of ultimate recovery, we may hope to be able very 
 much to prolong the duration of the complaint, and sometimes even to add years to a valua- 
 ble life. There is an individual now pursuing an active business in Philadelphia, though 
 with a cavity in his lung, who eight years since was under my care with severe cough, co- 
 pious purulent expectoration, night-sweats, hectic paroxysms, and great emaciation and debi- 
 lity. When the second stage is clearly established, with severe constitutional symptoms, and 
 the physical signs of extensive disease in the lungs, there is scarcely any ground for hope. 
 If to the ordinary s)a-nptoms, in such instances, are suj^eradded continued vomiting and 
 diarrh(Ea, the case may be considered as quite desperate ; and speedy death may be ex- 
 pected." — C] 
 
 This grouping of the different characters under which puhnonavy consumption 
 may appear, has been performed by Dr. Latham with perfect fidehty. There is 
 nothing overstrained or fanciful about his sketch; it is after nature ; and it is by tlie 
 hand of a master. And there is something very refreshing in original views of this 
 kind. Vastly more instructive too they are, than those presented by a dull compi- 
 lation. I therefore again recommend you to study his little volume. I am sure 
 that / have derived much useful and usable knowledge from it ; and so also 
 may you. 
 
 There is another form still of tubercular consumption which Dr. Latham has not 
 omitted to notice ; but his observations on this form are not so new. It is a strikino-, 
 but not very common form ; and it is sure to arrest the attention of the practitioner 
 when it does occur. I have met with three or four examples of it. The phenomena 
 are of this kind. The patient has difficulty of breathing, cough, htemoplysis per- 
 haps, night-sweats, and much hectic fever : the symptoms, in short, which constitute 
 the acute phthisis of some authors. But if you listen to the chest, you do not heat 
 the sounds that are peculiar to phthisis : you do not find dullness confined to the 
 upper lobes, or pectoriloquy, or gurgling respiration : but you rather find the super- 
 added sounds which accompany mixed phthisis ; small crepitation all over thu 
 lungs, succeeded by an absence or deficiency of the proper breathing everywhere 
 Meanwhile there will be none of the expectoration which is characteristic of phthisis 
 In short, you would not suppose that the disease was phthisis at all. Yet it must 
 be called such, for after death you find the lungs thickly bestrewed everywhere witb
 
 646 PHTHISIS. 
 
 what I spoke of before as the granulations of Bayle ; nascent tubercles, myriads of 
 them, gray and minute : what many persons call miliary tubercles. The tubercular 
 matter, from some cause which we know nothing of, is thickly and uniformly sown 
 over the whole of the air-passages, or throughout the entire extent of the lungs, and 
 its sudden presence there in such abundance excit-es inflammation, which masks and 
 conceals the specific disease ; and the true nature of the case is not suspected unti. 
 after the patient's death. All the instances that I have seen — three or four only in 
 number — were supposed by me to be cases of extensive inflammation of the lungs; 
 and so indeed they were, but they were something more. The tubercles, doubtless, 
 were the cause of the inflammation ; and not the inflammation the cause of the 
 tubercles. 
 
 From what I have been stating you will perceive how difficult it is to say what is 
 the ordinary duration of phthisis ; concerning which a question was put to me at 
 the close of the last lecture. The disease may be present for some time v,-ithout 
 declaring itself b)^ any marked or unequivocal symptoms ; and therefore without 
 attracting attention. But taking the cases as thej' occur, and estimating the duration 
 of the malady from the time when it first manifests itself in a decided form, we find 
 there is quite enough of variation to warrant the distinction that has been made by 
 authors between chronic and acute phthisis ; or, to use the more popular and more 
 expressive phraseology, between slow and galloping consumption. The following 
 tabular statement jf the results observed by Bayle and Louis, will give you a some- 
 Vv'hat more precise notion of the general progress and duration of the disease. The 
 whole number of cases noted was 314. Of these 24 died within three months ; 69 
 between three and six months ; 69 also between six and nine months ; 32 between 
 nine and twelve months ; 43 between twelve and eighteen months ; 30 within from 
 eighteen months to two years ; 12 between two and three years ; 11 between three 
 and four years ; 5 between four and five years ; 1 between five and six years ; 3 
 between six and seven years ; 1 between seven and eight years ; 3 between eight 
 and ten years; and 11 between ten and forty years. 
 
 You will remark that, as far as this account goes, more than one-half of the whole 
 number died within nine months from the time when the disease first became mani- 
 fest. This agrees with the experience of the late Dr. Gregory, of Edinburgh. He 
 used to state that the ordinary duration of phthisis was about six months ; that some- 
 times it lasted onl}' two or thvee months ; and that he had seen one case which 
 proved fatal on the seventeenth day after the sj'mptoms were first observed. On the 
 other hand, he had known one man who was at least 72 years old when he died, in 
 whom symptoms of phthisis first appeared at the age of 18, and who was never 
 free from them during all the intervening period ; being often hectic, and frequently- 
 spitting blood. The average or mean duration of consumption has been computed 
 to be about two years. This is a different thing, you will please to observe, from its 
 ordinary duration. 
 
 There are many other points in the statistical history of phthisis well worthy of 
 attention and inquiry ; but I have not time to go into them in any other than a sum- 
 mary manner. This part of the subject is very well worked up in Sir James Clark's 
 lucid and sensible book upon Consumption : but you will have perceived, from the 
 references I have so frequently had occasion to make to M. Louis, that his work is. 
 the great storehouse or treasury of tabular information, in respect to the facts of tuber 
 cular phthisis. 
 
 It is an interesting question to determine at what period of human life consump- 
 tion numbers the most victims. There are two short tables, one drawn up by Louis, 
 containing observations relative to 123 cases, and the other by Bayle, respecting 100 
 — which throw some light on the question. The two tables agree, in the main, 
 very closely. Thus, from the age of 15 to that of 20, Louis met with 11 deaths 
 from phthisis, Bayle with 10; from 20 to 30, Louis met with 39, and Bayle 23; 
 from 30 to 40, Louis 83, Bayle 23 ; from 40 to 50, Louis 23, Bayle 21 ; from 50 
 to 60, Louis 12, Bayle 15 ; from 60 to 70, Louis 5, Bayle 8. You see from this 
 account how erroneous the common notion is, that consumption does not occur at an 
 advanced period of life : that a person who has reached his thirtieth or fortieth year
 
 PHTHISIS. 647 
 
 IS thenceforth safe from that disease. From these two tables, and others collected 
 by Sir James Clark, it appears that, taking decennial periods, the greatest number 
 of deaths from phthisis happens between the ages of 20 and 30: the next greatest 
 number from 30 to 40 : the next from 40 to 50 : and that, after these, it is a 
 doubtful matter whether more perish of consumption between 50 and 60, or between 
 15 and 20, which last is only one-half a decennial period. These calculations refer, 
 as you will remark, to human life after the age of puberty. Before that age, tuber- 
 cular disease is fearfully common, especially in infancy and childhood. Among 920 
 children (532 girls and 388 boys) who died from the age of 2 to that of 15 years, 
 no less than 538 (nearly three-fifths of the whole) were affected, Dr. Papavoine tells 
 us, with tubercles. 
 
 As far as numerical observation has hitherto been extended, it would appear that 
 more women than men die of consumption. Statistical researches are of still greater 
 interest, perhaps, when they elucidate the influence of different trades and occupa- 
 tions in calling phthisis into existence. Sir James Clark has brought together much 
 curious information on this point. There are certain occupations which appear to 
 provoke pulmonary consumption by the direct application of local irritants to the 
 lungs themselves : and there are others which tend indirectly to bring on phthisis, 
 by lowering the tone of the general health : by producing debility and cachexia. 
 But these two causes often go together: and it is difficult to estimate with accuracy 
 their separate effect. The workmen whose employments have a directly irritating 
 operation upon the respiratory organs, are stone-masons, miners, coal-heavers, flax- 
 dressers, brass and steel polishers, metal-grinders, needle-pointers ; and many others 
 who of necessity inhale during their labour an atmosphere loaded with irritating 
 particles of matter. But, then, most of these men work also in towns, and remain 
 for many hours day after day in a constrained position, in crowded or in close apart- 
 ments. Moreover, some of these occupations, being sedentary, and requiring no 
 great muscular povv'er, are unfortunately selected, for that reason, by persons who 
 are naturally of feeble or delicate constitution. On the other hand, butchers, fisher- 
 men, and their families, and farm-servants, are said to be comparatively free from 
 phthisis. Beddoes ascribed this exemption to the use of animal food by these classes; 
 but much of their better health is due, no doubt, to their habits of active exercise in 
 the open air ; and to the circumstance that such employments demand a certain 
 amount of bodily strength and energy, and therefore are not likely to be adopted by 
 weak and scrofulous individuals. It is obvious that the whole inquiry is beset Avith 
 sources of fallacy. We know, however, on the evidence of undoubted facts, that 
 certain occupations do tend to induce pectoral complaints, and to shorten life. Dr. 
 Knight, of Sheffield, informs us that fork-grinders, Avho are what are called dry 
 grinders, die there of the grinder'' s asthma, or grinder'' s rot, before they are thirty- 
 two years old. Razor-grinders, who grind wet and dry, live a little longer : the 
 moisture diminishes, of course, the number of floating particles of metal. Table- 
 knife grinders work on wet stones, and survive till they are between forty and fifty. 
 I must refer you to Sir James Clark's book for similar facts in respect to the inhala- 
 tion of silex, of the dust of mines, and so forth. Without pretending to assign to 
 each alleged injurious influence its precise contribution of mischievous effect, we 
 must be content, at present, with the practical inference, that such employments 
 should, if possible, be avoided by all those who show any tendency to scrofulous 
 disease. 
 
 Is phthisis contagions? No : I verily believe it is not. A diathesis is not com- 
 municable from person to person. Neither can the disease be easily (if at all) gene- 
 rated in a sound constitution. Nor is it ever imparted, in my opinion, even by one 
 scrofulous individual to another. Yet in Italy a consumptive patient could not be 
 more dreaded and shunned if he had the plague. And in this country the suspicion 
 Will now and then arise that the disease may be infectious. A girl dying of phthisi'! 
 is nursed by her sister, who afterwards droops and dies of the same complaint, 
 Here the presence of peculiar diathesis is strongly presumable. But the parties may 
 be different in blood. A wife watches the death-bed of her consumptive husband, 
 and presently sinks herself under consumption ; and there may be no traceable or
 
 648 PHTHISIS. 
 
 ncKnowledged example of scrofula in her pedigree. Yet even here the latent dia- 
 thesis may fairly be presumed to have existed. Very few families are perfectly 
 pure from the strumous intermixture. The predisposition may be slight; it may be 
 dormant for a generation ; or, like other inherited peculiarities, it may light caprici- 
 ously on some individuals only of the kindred. In both the supposed cases there 
 have been other influences at work, more authentic than the alleged contagious pro- 
 perty, in calling forth the fatal malady. Watching, the want of rest, confinement in 
 the unwholesome air of a sick chamber, and, above all, protracted mental anxiety, 
 than which no single cause perhaps has more power to foster and forward the inbred 
 tendency to phthisis. The disorder, I am satisfied, does not spread by contagion. 
 Nevertheless, if consulted on the subject, I should, for obvious reasons, dissuade the 
 occupation of the same bed, or even of the same sleeping apartment, by two persons, 
 one of whom was known to labour under pulmonary consumption. 
 
 The treatment to be adopted, and the plan of regimen to be observed, in respect 
 to tubercular phthisis, resolve themselves into the methods of prevention when the 
 disease is likely to occur ; of arresting its progress when that disease is incipient 
 or limited in extent; and of alleviating the most distressing symptoms, when no 
 hope remains of stopping its course, or averting its fatal close. 
 
 With regard to the prevention of the disease, in those, who, by inheritance, or by 
 circumstances, are predisposed to it, a great deal might be said ; but the subject 
 belongs rather to the head of medical police, or hygiene, than to the practice of 
 physic. We deem that a person has that predisposition, which is ahnost a neces- 
 sary condition of the development of tubercular disease, when we observe those 
 marks of the scrofulous diathesis which I pointed out in an earlier part of the course : 
 or when we know that the parents possess that peculiarity of constitution ; or when 
 brothers have displayed it. It would be well indeed for society if the multiplication 
 and diffusion of the strumous diathesis could be checked by a prudent avoidance of 
 ill-assorted marriages. But we cannot say — no legislature could say — to a scrofu- 
 lous man or woman, you shall not marry, and propagate scrofula. It is reasonable, 
 however, to conclude, and the conclusion is amply borne out by the observation of 
 facts, that where both parents are strumous, the child will, in all probabiUty, be 
 doubly so ; or that, at any rate, its chance of escaping the scrofulous disposition will 
 be small. It is very desirable, therefore, that correct notions on these subjects should 
 be generally prevalent : and that persons who are conscious that scrofula in any of 
 its shapes exists in their family, and, a fortiori, they who know that it exists in their 
 own corporeal frame, should avoid allying themselves with such as are in the same 
 predicament : and this prudence might be enforced if they could be made to foresee 
 the suffering and misery its neglect is calculated to inflict upon their ofl^spring. In- 
 termarriages of persons of the same family, when that family is subject to tubercular 
 disease, are earnestly to be deprecated. But on these points our advice is seldom 
 asked. 
 
 We are liable, however, to be consulted respecting the mode of ivarding q^ scro- 
 fulous disease in those who have derived an hereditary tendency to it from their 
 ancestors. Now the first, and most efl"ectual prophylactic in such cases, is residence 
 in a warm climate : and next to that is the avoidance of all causes likely to foster 
 the morbid tendency. I need not repeat what I formerly told you on this subject. 
 Pure air; nourishing, but unstimulating food; moderate exercise; early hours; 
 cleanliness; warm clothing; and abstinence from excessive study, from severe bodily 
 toil, and from vicious and exhausting indulgences of all kinds: these are the topics 
 upon which we much insist, when our advice is sought for respecting the means of 
 preventing consumption in children or others, who are in danger of contracting it. 
 
 But when the disease is present — when tubercles actually exist, and are ascer- 
 tained to exist in the lungs — may the progress of the disorder be ever suspended by 
 a change of climate ? Indeed I believe it may : but only in certain cases, and in 
 zertam stages of the disease. When phthisis occurs in either of its slow and un- 
 mixed forms, the question of a change of sky will be worth entertaining. In that 
 form in which tubercles remain long in the crude state, I believe life may be pre- 
 served or lengthened by leaving this country, and residing under a higher and more
 
 PHTHISIS. 649 
 
 equable temperature, provided that no softening of the tubercular matter has yet 
 taken place. And in the other form — when a vomica or vomicae have occurred, and 
 the strength is apparently restored, and the remainder of the lungs gives out the 
 sounds of health — in that case also I would recommend a voyage to a milder climate 
 to those persons who could afibrd to migrate, and to whom it was a matter of im- 
 portance that they should prolong their earthly existence. I believe there is no place 
 to which such persons could go with more hope of benefit than to Madeira. There 
 are, however, places on our own coast that offer no ineffectual substitute for warmer 
 lands beyond the sea, to those who cannot so conveniently expatriate themselves. 
 Hastings, for instance ; the Isle of Wight ; and more especially Torquay on the 
 coast of Devonshire ; and Penzance, or its neighbourhood, in Cornwall. In those 
 sheltered spots the patient may sometimes pass the colder weather of our winter and 
 spring months in comparative security. If, however, the lungs are already in a state 
 of rapid disorganization, no benefit, but on the contrary much inconvenience and 
 useless expense will result from change of place, unless that place in which the 
 patient is residing be notoriously unhealthy. When I am asked about removal, 
 either to another country, or to some distant part of our own, and the state of the 
 patient is such as I have just alluded to, I always advise that he should not forego 
 the comforts of his home — and leave his family and friends — to seek advantao-e 
 which he will not find, among strangers, and amid the discomforts of a lodging per- 
 haps, or an incommodious dwelling. I think it cruel and wrong to send people 
 away merely to die : and that many are so sent to this place and that, in the almost 
 certain prospect of their never returning, no one, I think, can doubt. 
 
 You will find a great discrepancy of opinion among authors, and among practi 
 tioners with whom you may converse, in respect to the regimen, which consump- 
 tive persons should follow. One man gives all his phthisical patients beefsteaks and 
 porter ; another restricts all his to vegetables and asses' milk : and each will boast, 
 and bring forward most triumphant examples, of the success of his system. Now it 
 is quite obvious that for a sick person who receives benefit from the one of these 
 plans of diet, the contrary plan could scarcely be otherwise than injurious ; and 
 reason at once suggests that there must be some distinction between the cases that 
 get better under the one system, and those that improve under the other. Doubtless, 
 we must have regard to the constitution and habits of the patient ; and sometimes 
 trial alone will show which plan is the most beneficial; but I beheve the best clue 
 to lead us out of the difficulty will be found in Dr. Latham's division of phthisis into 
 mixed and unmixed. The object is, to sustain the patient's strength without excitino- 
 inflammation in his lungs. If, with the specific disease, there be conjoined an in- 
 flammatory condition of the pulmonary substance around the tubercles, or of the 
 bronchial membrane ; in such cases an antiphlogistic diet is the proper one. On 
 the other hand, when the disease manifests no tendency to trangress its specific limits, 
 then the diet should be generous and full: and it may be so without being over- 
 stimulant. Debihty, however induced, adds to the disposition to the deposit of tuber- 
 cular matter ; and therefore the debility arising from insufficient nutrition is to be 
 avoided as carefully as is compatible with the other indication, which is, to obviate 
 inflammation of the lung. With these hints, you will be able, I trust, to strike the 
 balance between the risk of augmenting the local mischief directly, on the one Jiand, 
 and that of depressing the general strength, and so increasing the local mischief indi- 
 rectly, on the other. Milk is a sort of animal diet, and it is both nutritious and un- 
 stimulating; therefore milk may, in many cases, form the staple of the food, if the 
 patient hkes it, and it agrees with him : but there is much variety in this respect in 
 difierent persons. I repeat, that you will too often find prejudices entertained, on 
 the one side or the other, in regard to the diet proper for consumptive persons : but 
 the commonest error of the two is, I believe, that of reducing the patient's strength 
 by a needless restriction of his nutriment, lest inflammation should ensue. 
 
 Louis, should you refer to him, would be likely to lead you into the opposite mis- 
 take ; for he affirms, that neither bronchitis, nor pneumonia, nor pleurisy, have any 
 effect in exciting tubercular phthisis. But this opinion is quite opposed to the general 
 sense of. most men of experience. Many a case of consumption can be traced back 
 
 3e
 
 650 PHTHISIS. 
 
 to a severe catarrh, and no further. Many, which rar. a short course, were dat»,'d, 
 \\-ilhin my own knowledge, from the last visitation of influenza. If M. Louis had 
 meant that thoracic inflammation will not produce tubercles in the lungs of a person 
 who has not the scrofulous diathesis, and that tubercles may and do arise without 
 any previous inflammation, I should quite agree with him. But he dryws his con- 
 clusions from cases of phthisis. I have no doubt whatever that the dormant predis- 
 position is often awakened into actual disease, and that latent tubercles are often : 
 accelerated in their progress, by inflammation of the pulmonary tissues. Whether 
 this happens directlj^ from the local inflammation, or indirectly from its effects in 
 lowering the vital powers, is a question which no one can solve, and of which the 
 solution is not of much consequence. What we are sure of is, that every one who 
 bears a real or suspected taint of scrofula in his frame, should scrupulously guard 
 against every known and avoidable cause of catarrh, pneumonia, or pleurisy. I hold 
 M. Louis's doctrine on this head to be unsound and unsafe : and I mention it only to 
 admonish you against it. 
 
 In offering you a few final observations on the remedies of phthisis, I shall take 
 leave to abstain from Aveighing the pretensions of a number of specifics, that have 
 from time to time been highly recommended ; but which never have come into 
 general use, as they would have done, no doubt, if they had been entitled to such a 
 denomination. 
 
 In the first place we must satisfy ourselves as to the kind of case we have to deal 
 with; whether it be mixed or unmixed. We must watch our patient: and keep 
 him on low diet, and take blood either in small quantities from the arm, or by leeches 
 or cupping from the chest, whenever inflammatory symptoms arise; whether they 
 are discovered by observation of the general or of the physical signs. The bleedings 
 must of course be small — and palliative only of the symptoms. 
 
 Emetics, frequently repeated, have been recommended in the early stage of 
 phthisis : partly on account of their reputed efficacy ; partly on theoretical grounds ; 
 it being supposed that the tubercular matter may be thus removed from the mucous 
 surfaces as fast as it is deposited. Of the value of this emetic plan, I am unable tc 
 speak from any experience of my own. 
 
 Counter-irritation is often of undoubted service : mustard-poultices to the chest 
 when it is painful; or a blister or succession of blisters, or pustulation by tartar- 
 emetic ointment, to encounter local symptoms. The effect of counter-irritation upon 
 the progress of the tubercular disorder is apparent sometimes by accident. Dr. 
 Abercrombie has related an example in which cerebral disease operated in this way ; 
 the previous symptoms of phthisis disappearing. In some cases mania seems to 
 have a similar consequence, obscuring the manifestations, and probably retarding the 
 course, of consumption. It has been often remarked — you will find this stated by Sir 
 B. Brodie — that after amputation of a scrofulous leg, phthisical symptoms, very little 
 noticed before, have rapidly increased. And there is another fact, in relation to 
 phthisis, analogous to these, which it is fit you should know and attend to, viz. 
 that the progress of consumption is often suspended by pregnancy : — and when a 
 mother is suckling her child, if the suckling be not too long continued, so as to ex- 
 haust the mother. I suppose there is no doubt that women disposed to phthisis have 
 been kept alive by successive pregnancies and sucklings. It is a very rare thing 
 for a pregnant woman to die of phthisis. I have known only one instance of iL 
 One of my patients in the hospital, a French woman, died of that disease ; and we 
 found suppurating tubercles in her lungs : and a fostus of about five months in her 
 womb. 
 
 Riding on horseback has been strongly advised in the earlier periods of the dis- 
 ease. Its main advantage seems to arise from its allowing the enjoyment of fresh 
 air, and of exercise, without putting the patient out of breath ; and these advantages 
 are great. It is affirmed that many phthisical patients remain free from cough, and 
 those affected with hfemoptysis cease to spit blood, so long as they continue to take 
 exercise on horseback. Gestation in a carriage, or in a boat, has the same good 
 efl^jcts, but in a less degree. We are not able, however, to look upon equitation as
 
 PHTHISIS 65] 
 
 so certain a cure in consumption as Sydenham did, who says that riding on horse 
 back is as much a specific in phthisis, as the Peruvian bark is for an ague. 
 
 Iodine and its compounds, and especially the iodide of potassium, ha\'e been 
 much praised of late years for their reputed efficacy in phthisis. Given in small 
 doses, I believe that they often have a beneficial influence upon the general health. 
 I wish I could tell you that I had ever known them operate a cure of the manifested 
 disease. 
 
 Often — too often — all that we can attempt to do is to relieve the most urgent or 
 distressing symptoms, and to make easier the patient's decline. One symptom 
 which is both distressing and weakening is the nocturnal perspiration. The com- 
 mon remedy for this is the dilute sulphuric acid ; and a very good remedy it is, but 
 it is not equally adapted to all cases. If the bowels are costive — or if the bowels 
 have not, as they often have, a tendency to be relaxed — then the sulphuric acid may 
 be freely given ; and it will often have very good results. It may be exhibited three 
 or four times a day, in doses of from twelve to twenty minims. But when this fails, 
 or when the bowels are irritable and will not bear it, we must have recourse to other 
 means. One of these is sponging the surface of the body at bed-time, or before the 
 patient settles himself for the night, with tepid vinegar and water; using twice as 
 much Avater as vinegar. And if the bowels are at the same time purged, I fiind the 
 compound kino powder of the Pharmacopoeia an admirable medicine. It certainly 
 has much power over the perspiration ; and it has these further advantages, that 
 (containing opium) it tends to control the diarrhcea, and to calm the cough. 
 
 Steel is another substance which exercises a marked influence sometimes over th' 
 hectic fever. It was its efficacy in this way that gave celebrity to the famous ant: 
 hectic mixture of Dr. Griffith, the Mistura Ferri Composita of the Pharmacopogis. 
 Certain it is, that when steel is borne in the advanced stage of consumption, it often 
 docs a world of temporary good ; — but in many cases it is not borne vvell. It in 
 creases the cough, occasions headache, and distresses instead of reheving the patient. 
 Nor is it always easy to say beforehand, whether it is likely to suit the case or not. 
 I apprehend it will at length be found most applicable to the unmixed forms — the 
 uninflammatory forms, that is — of phthisis. I have frequently, however, succeeded 
 in checking the wasting sweats by the tindura ferri miirialis, given in doses of 
 twenty minims thrice a day, after other expedients had failed me. 
 
 When the cough is very troublesome, and especially when it breaks the patient's 
 rest at night, we must endeavour to quiet it ; and there is no drug, I fear, that wc 
 can depend upon for that purpose, but opium. The old paregoric has been, and is, 
 a favourite form for giving opium to appease cough ; and old-fashioned apothecaries 
 will tell you that the alteration which was made by leaving the aniseed out of this 
 compound tincture of camphor, in the last Pharmacoposia but one, impaired its effi- 
 cacy. Whether it was so or not, I cannot tell ; but Dr. Prout is of opinion that 
 aniseed has considerable power in allaying the irritation on which the cough depends. 
 He infuses three drachms, or half an ounce, of the bruised seeds in half a pint of 
 distilled water at a temperature not exceeding 120°, and lets it stand till it is cold. 
 On his strong recommendation I have tried this, as a vehicle for paregoric, when the 
 same dose in other vehicles had failed ; and I must say that it has frequently been 
 followed by a marked abatement of the frequency and violence of the cough. The 
 aniseed is restored in the paregoric of the last Pharmacopeia, that of 1836. Hy- 
 drocyanic acid has sometimes a very soothing effect upon this harassing symptom. 
 However, at last, opium will be found our sheet-anchor, not merely for the cough, 
 but for the diarrhoea which is so seldom absent in the later periods of phthisis. The 
 diarrhoea depends, as I have told you, upon an ulcerated state of the bowels. In 
 those cases in which it could scarcely be kept in check at all, t have always found 
 very extensive ulceration in the large intestines ; but the diseased condition is often 
 seated higher up, in the ileum or jejunum. Catechu is of great service in these 
 cases, combined with laudanum and with the officinal chalk mixture ; — or a few 
 grains of the confectio opii may be given in peppermint water, after every loose 
 evacuation ; or, in obstinate cases, a pill composed of a quarter of a grain of the 
 sulphate of copper, and the same quantity of opium, will often answer well, thougli
 
 652 MELANOSIS 
 
 it sometimes gripes. I mention these several expedients, for you will often require 
 them all. The injection of a small quantity of starch, as much as the rectum will 
 receive and retain, with ten or twenty drops of laudanum, generally affords the 
 patient most sensible comfort, and suspends the further action of the bowels for a 
 considerable time. 
 
 These, I think, are the principal means by which we may endeavour to smooth 
 the pillow of the patient dying of consumption. Sometimes very httle pain or dis- 
 tress is felt at all, from first to last ; the intellect remains free, and the patients are 
 proverbially sanguine about the issue of their disorder. In other cases, do what we 
 will, the patient suffers greatly. One harassing incidental combination of symptoms 
 is nausea and vomiting. I should have stated before, that when, in phthisis, these 
 symptoms last long, and are accompanied by pain and tenderness of the epigastrium, 
 they denote, almost always, a thinned and softened condition of the mucous mem- 
 brane of the stomach. They may be alleviated by a few leeches — by a blister — by 
 the effervescing draught ; or the prussic acid may be used ; that is a medicine which 
 certainly tranquillizes an irritable stomach, and it now and then seems to allay an 
 urgent cough. Sometimes, again, the bones of the miserable patient are laid bare, 
 in consequence of pressure upon parts in which the circulation is already very feeble. 
 We cover these with soap-plaster ; take off the pressure by arranging cushions ; or, 
 what is much the best of all, we put the patient upon the water-bed, invented by Dr 
 Arnott. 
 
 LECTURE LVIII. 
 
 Melanosis of the Lung ; true, and spurious. Accidental intrusion of solid sub' 
 stances into the air-passages. 
 
 I YESTERDAY adverted to certain callings which are unhealthy for various reasons, 
 and among the rest for this : that the work-people engaged in them breathe habitu- 
 ally an atmosphere loaded with particles of matter which clog or irritate the pulmo- 
 nary tissues. There is one morbid condition, so produced, which hitherto, or till 
 lately, has scarcely been mentioned by writers on disease, but which deserves a mo- 
 ment's attention ; for although it is very uncommon in many parts of this country, 
 it is by no means rare in some others. The texture of the lungs is spoiled by mat- 
 ters carried in with the air, in the acts of breathing. This morbid state has been 
 called spurious melanosis. The lungs are found after death to be throughout of a 
 black colour, more or less uniform. Sometimes the pulmonary substance is dry and 
 friable, as well as black ; sometimes moist, (Edematous, infiltrated with an inky fluid ; 
 not unfrequently broken down into irregular cavities of various sizes ; and thesi! 
 cavities are often full of the same black liquor. 
 
 You are not to confound these appearances, when you happen to meet with them 
 -—(and as you will probably scatter yourselves, some here and some there, over vari- 
 ous parts of the kingdom, some of you are very fikely to meet with them) you must 
 avoid, I say, mistaking these black appearances and products, for true melanosis. 
 The disease so denominated is a singular one. It was first fully described and named 
 by. Laennec in 1806. It consists in a morbid product, presenting a black or deep 
 brown colour of various degrees of intensity, moist generally, unorganized, and dif- 
 fering in the form it assumes, and in its consistence, according lo circumstances. I 
 shall take this opportunity, for I am not likely to have a better, to tell you the little 
 that has been ascertained in regard to this kind of disease ; and having done so, I 
 shall revert to a short account of spurious melanosis. 
 
 These black deposits take place most frequently of all in the areolar tissue, and in 
 the adipous tissue : and they occur in greater abundance, and in larger masses, ac 
 cording as these reticular tissues are more plentiful, and more lax. They are met 
 ^kh also m the compound organs of the body ; especially in the hver. Less fre
 
 MELANOSIS. 653 
 
 quently in the lungs. Sometimes in the eye. Occasionally m the brain. The serous 
 membranes are obnoxious to the same kind of disease ; the mucous very little so. 
 The black or dark-coloured matter may also exist, in a liquid condition, in the natural 
 cavities of the body. And lastly, the melanotic material is sometimes mixed up with 
 scirrhous and brain-like malignant tumours. 
 
 With respect to the shapes in which it appears — it is sometimes dotted, the sur- 
 faces affected by it looking as if they had been thickly sprinkled over with coal-dust 
 or soot. But more commonly melanosis assumes the form of solid tumours, of vari- 
 able magnitude. These tumours are largest, where reticular tissue is most loose and 
 abundant. They may be no bigger than a pin's head, or they may be as large as a 
 man's head. Masses of this kind have been found in the horse, weighing as much 
 as six-and-thirty pounds. In the human subject they may attain the size of an 
 orange. These large tumours (like large pulmonary tubercles) are usually formed 
 by the union and agglomeration of several smaller ones, and hence they have gener- 
 ally a lobulated surface : while the shape of the separate smaller tumours is naostly 
 spherical. Sometimes the areolar tissue lying around the melanotic masses is con- 
 densed into a kind of cyst : more generally the black matter is in naked contact with 
 the tissue, whatever that may be, in which it is lodged. 
 
 From the serous surfaces, especially from the pleura and peritoneum, knobs of a 
 dark colour are seen in some instances to project; in others, the round tumours, as 
 big as peas, or cherries, hang from these surfaces by a sort of peduncle. The omen- 
 tum is a common habitat of melanotic tumours. 
 
 Occasionally, I say, the black matter is found spread in a continuous layer upon 
 the serous membranes ; or is collected in a liquid state in their cavities. But this, 
 compared with the occurrence of solid tumours, is rare. 
 
 When this remarkable disease is met with in one tissue or organ of the body, it 
 is met with in others. It is never confined to one part, but pervades several : re- 
 sembling in this respect both the scrofulous matter which constitutes tubercle, and 
 the matter of cancer. Miiller indeed considers melanosis to be a species or variety 
 of carcinoma. 
 
 Scattered notices of these singular and striking changes in the animal frame occur 
 in the works of Morgagni and of Haller ; but since the period when Laennec first 
 drew the special attention of the profession to the subject, the black matter has been 
 carefully analyzed by several expert chemists. Without going into any tiresome 
 detail, which you could scarcely remember, as to its exact composition, it is interest- 
 ing to know that it is very like that of the blood : and no doubt the material is some- 
 how deposited from the blood. Very little, however, has been ascertained about its 
 primary origin and cause. Some have supposed that the melanotic matter is ana- 
 logous to the natural pigments which are found in the animal economy ; all of which 
 are known to be rich in carbon. It is a curious fact that the disease has been more 
 often observed in white or gray horses than in others. (I should tell you that the 
 complaini is not at all uncommon in various quadrupeds : examples of it have been 
 noted in ihe horse, ox, dog, cat, rabbit, rat, and mouse.) It has been conjectured that, 
 in white animals, the colouring matter of the surface, and of the hair, has been di- 
 verted, by some morbid process, from its proper locahty. But the very same disor- 
 der occurs also, though not so often, in dark, or bay, horses and cows : and certain 
 pathologists imagine that in these cases there has been an undue accumulation, in the 
 blood, of the carbon which is destined to colour different parts. In the one case, you 
 see, they hold that the pigment is misplaced ; in the other that it is excessive. What 
 value these speculations as to the nature and origin of the disease may posse^ss, time 
 alone can determine. 
 
 When the tumours are divided, and moist, or when they are rendered moist by 
 admixture with water, they freely impart the colouring matter ; staining white paper, 
 and blackening one's fingers, just as Indian ink might do. The disease most fre- 
 quently happens, when it happens at all, in the decUne of hfe. 
 
 The changes to which the melanotic tumours are liable, are very much like the 
 changes which tubercular matter is apt to undergo. In certain situations where the 
 secr^tjd black material is subject to pressure, and is poured out in a soft consistence 
 
 3e2
 
 654 SPURIOUS MELANOSIS. 
 
 ihe watery parts are sometimes absorbed, and the rhass becomes hard and firm. 
 On the other hand, the pressure occasioned by the tumour sometimes provokes 
 inflammation in the tissues surrounding it ; and then it is hable to be broken down, 
 pxactl\- in the same way as that in which tubercles soften prior to their expulsion 
 from the lungs. 
 
 The injurious effects of these collections of black matter arise from the pressure 
 they occasion ; and they may evidently thus cause pain, irritation, ulceration ; and 
 according to their situation, number, and extent, they may materially interfere with 
 important functions. And in this manner they do, in fact, at length destroy life. 
 
 There are no symptoms that I know of, distinctive of this disease, except the ap- 
 pearance of the black masses upon the surface of the body. Nor can I pretend to 
 point out to you any cure for it, when it is ascertained to exist. 
 
 Yet it is right that you should be aware of what pathologists have learned re- 
 specting this curious morbid state ; although that be little, and not very satisfactory. 
 And I have introduced this brief consideration of melanosis here, somewhat irregu- 
 larly, perhaps, to enable you to distinguish from it that pulmonary disease to which I 
 referred in the outset of the lecture, and to which I shall now return. This, I say, 
 has been called spurious melanosis : and it has doubtless been mistaken for the spe- 
 cific disease of which I have just given you a sketch ; for real melanosis. 
 
 It is, however, a very difTerent affection. 
 
 Laennec had conjectured that certain kinds of black discoloration of the lungs 
 .vere of extraneous origin ; were owing to the introduction of black matters from 
 without in che process of respiration ; and Mr. Pearson, in this country, had thrown 
 out the same idea. But this was first ascertained to be actually the case in Edin- 
 burgh. Dr. J. C. Gregory had a patient who died in the infirmary of that city, and 
 whose lungs exhibited the following appearances : — They both presented one uni- 
 form black carbonaceous colour, which pervaded every part of their substance. The 
 right lung was broken down, in its upper and middle lobes, into irregular cavities ; 
 and the walls of these canities were black ; and they contained a considerable quan 
 tity of a black liquid like ink. Portions of the pulmonary substance were dense, 
 hepatized, and friable. The rest of this lung was (Edematous; and when the serum 
 which then rendered it thus cedematous was pressed out, it also, the serum I mean, 
 was quite black. The left lung was infiltered, in the same manner, with black serum. 
 No tubercles could be detected. The bronchial glands were not enlarged, but they 
 were stained of the same sable hue as the substance of the lungs. No other organ 
 of the body presented any trace of this black discoloration. 
 
 Dr. Chrisiison, who is known to be a very exact and able chemist, undertook an 
 analysis of the black matter contained in the serum expressed from these lungs. I 
 shall not follow out the details of his researches (you may read them at length in the 
 l(K)th number of the Edinburgh Medical and Surgical Journal), but content myself 
 with stating their result. And I may state it in Dr. Christison's own words. "In 
 the product of this experiment (he says) it is scarcely possible not to recognize the 
 ordinary products of the distillation of coal. A gas of the same quality was procured, 
 and likewise a naphthous fluid holding in solution a crystalline principle, analogous 
 to, if not identified with, naphthaline." 
 
 Now the man, whose lungs presented the appearances I have described, had, for the 
 last ten or twelve j^ears of his fife, been employed in the coal-mines at Dalkeith. He 
 had been exposed, therefore, to the habitual inhalation of coal-dust into his lungs in 
 breathing : and taking this circumstance in conjunction with the result of the analysis 
 of the black matter contained in the lungs, and nowhere else throughout the body, 
 we cannot doubt that the carbonaceous substance so abundant in these organs was 
 introduced from without. In truth we have now a large amount of evidence in 
 proof that it must have been so. In the twenty-first volume of the Medico-Chirur- 
 gical Transactions, Dr. William Thomson has recorded the results of extensive 
 inquiry into the subject. Thus he gives ten examples of black sputa going along 
 with pulmonary symptoms during life, and of black infiltration of the lungs disco- 
 vered after death ; and of the ten persons who were the subjects of these observations, 
 nme had been engaged in working coal-mines, and the tenth was a moulder at the
 
 SPURIOUS MELANOSIS. 655 
 
 Carron iron-works. He gives also six cases of black infiltration of the lungs, all 
 occurring in persons exposed to the inhalation of carbonaceous matters (one of them 
 was an engineer, and the others were all colliers) ; but in these six cases there had 
 been no black expectoration noticed during life. 
 
 That such carbonaceous particles, floating in the atmosphere, may be, and must 
 be, and actuall}^ are, drawn into the lungs during inspiration, no one who has been 
 long in this smoky town can doubt. Many persons remark that they expectorate 
 during winter, and while in London, a little mass or two of dark gray, dirty mucus, 
 every morning; but when in the country, in the summer, the mucus so spat up is 
 transparent and clean. So I have noticed, and pointed out to some of you, that the 
 crachoirs of the patients in the hospital often bear witness that there has been during 
 the previous twelve hours, one of our dense and dirty fogs, which come with an 
 easterly wind and bring wnth them a vast quantity of blacks, and soot, and smoke. 
 Immediately after the prevalence of one of these filthy blankets of vapour, we find 
 the contents of each of the httle vessels given to the patients whose expectoration is 
 kept for inspection, to be deeply tinged with black. And I had, in the year 1832, a 
 patient whose sputa were remarkably loaded with dark matter. He came into the 
 hospital complaining of cough, and shortness of breath, and a sensation at the lower 
 part of the right side of the chest, as if it were pierced by needles ; and he was spit- 
 ting a considerable quantity of thick mucus, which was almost black. Tliis colour 
 never entirely left the expectoration while he remained in the hospital ; but it very 
 greatly diminished in proportion as his ailments were relieved. Now this man was 
 a stoker at one of the gas-works. And he attributed his illness, which had come on 
 gradually, to the great alternations of heat and cold to which his occupation exposed 
 him : and the blackness of the sputa he ascribed to the continual inhalation of coal- 
 dust. And no doubt he was right. 
 
 It may seem strange, if the inhalation of atmospheric air loaded with minute par- 
 ticles of coal or other carbonaceous matter be sufficient to produce this remarkable 
 condition of the lungs, and the characteristic black spit, that the change, and its 
 nature and cause, should not have been earlier made out ; considering the vast 
 number of men who are employed in our mines and collieries. It appears, however, 
 that a great repugnance has existed, and probably still exists, among the labourers 
 in the coal-mines, to allowing their dead to be opened and examined. And it ap- 
 pears also that the peculiar state of the lungs which I have been speaking of is pro- 
 duced in a comparatively small number of those who are so employed. The precise 
 cause, why some are thus affected, and some are not, is yet to be discovered. Dr. 
 Thomson has circulated among medical men residing in the coal-districts, a fist of 
 queries (which he gives in his paper), respecting various points of interest in relation 
 to this pulmonary condition : and we may expect to obtain, by degrees, more exact 
 information about it. I recommend it as an interesting subject of inquiry to such 
 among you as may have opportunities of prosecuting it. It has been conjectured 
 that the specific change takes place, in a marked degree, only in lungs that were 
 previously unsound. It is a question whether the cavities met with in the pulmonary 
 substance, in the fatal cases, were the result of spurious melanosis ; or of the explo- 
 sion of tubercular matter which had co-existed with the melanotic state. It is a 
 curious circumstance that the black spit, as it is called in those districts, sometimes 
 does not make its appearance until some time after the labour in the coal-mines was 
 given up. Certainly this is a complaint that offers several interesting points of re- 
 search, and requires further investigation. 
 
 You will remark that the spurious melanosis is distinguished from the true, by ita 
 occurrence in those persons only who are somehow exposed for a certain length of 
 time to breathe an atmosphere which is largely encumbered with carbonaceous par- 
 ticles ; whereas true melanosis may occur in any locality. The spurious discolora- 
 tion never affects any other oro-ans than the lungs and bronchial glands ; the true 
 black deposit of melanosis is never confined to a single organ or tissue. Moreover, the 
 one disorder is absolutely beyond remedy ; the other, as soon as its presence is ren- 
 dered probable, by the black expectoration, and the pulmonary distress, may be 
 tnitigited, checked, perhaps gradually cured, by removing the patient from the ope
 
 656 INTRUSION OF SOLIDS 
 
 ration of the exciting cause, and pursuing such other measures as the symptoms may 
 seem to require. The distinction is not a matter therefore of mere curiosity : it bears 
 upon the treatment to be followed, which is our proper business. It is connected 
 also with medical police or hygiene, which w^e should all of us cultivate as exten- 
 sively as we may : as a science intimately related to our strictly professional pursuits, 
 and to the welfare of the community. 
 
 Other forms of disease, unquestionably cancerous, occasionally infest the lungs. 
 Their chief symptoms, when the malady does not reach the surface of the body 
 result from the pressure which the carcinomatous masses exercise on the parts in their 
 neighbourhood. I shall postpone a more particular consideration of these efTects of 
 intra-thoracic pressure, until I come to aneurismal tumours, which have a similar 
 mechanical influence. 
 
 There is yet another affection of the breath-machine, to which I must briefly direct 
 your attention : a casualty that is apt to befal the air-tubes. I said nothing of this, 
 indeed, last year; but having since witnessed an example of the accident to which I 
 allude — the entrance, namely, of some solid substance into the windpipe — 1 have 
 thus been reminded of my former omission, and taught at the same time the neces- 
 sity that every medical man should have well considered such cases. I was taken 
 to Kentish Town, in the autumn (1837), by a professional friend, to see a child, into 
 whose trachea a small nail, what is commonly called a tack, was thought to have 
 passed. When I saw the boy, he seemed to have nothing the matter with him : but 
 he had been subject, ever since the accident, to paroxysms of most violent choking 
 cough; alarming the parents and his attendants for his hfe, There was good reason 
 for concluding that the nail, which was missing, and which he said he had swal- 
 lowed, had really got into the windpipe, and was still there, or in the lungs ; and the 
 question w^as much discussed, what ought to be done in such a case? The result 
 was, that nothing was done : but that, after the lapse of several weeks, the nail was at 
 length coughed up. 
 
 Now there are some interesting points arising out of this sort of mischance. The 
 instance I have just referred to will probably be published ; and therefore I dwell 
 upon it the less. Dr. Stokes has devoted a short chapter to the consideration of 
 foreign bodies in the air-passages : and examples of that accident are more common 
 than you might suppose. 
 
 It is, at first sight, a surprising circumstance, that a solid body of any considerable 
 magnitude (a molar tooth for instance), should be able to pass at all through the nar- 
 row chink of the glottis. But, supposing the chink to be plugged by the sudden 
 entrance of a passing substance, just at the commencement of a forcible endeavour 
 to inspire, when, of course, the opening is at the widest, that substance must neces- 
 sarily sustain, as the chest expands, a strong degree of pressure from the external 
 atmosphere : strong enough, often, to force it through. If you cork a bottle that con- 
 tains air only, and sink it sufficiently deep in the sea, the pressure of the water will 
 push the cork into the bottle. The condition of the lungs, in the case supposed, and 
 the condition of the bottle, are analogous. A vacuum beyond the plug is attempted 
 by the act of inspiring, and obviated by the displacement of the plug, inwards. 
 There are no such powerful forces called into action to drive the intruding substance 
 out again. 
 
 The matters which have been actually thus caught in the rima glottidis, and 
 forced through, are, as you might almost expect, oddly various in kind. Morsels of 
 food : the stones of fruit ; of these there are many instances : teeth ; three such are 
 referred to by Dr. Stokes : portions of bone : pebbles : a piece of money : a nut : a 
 nut-shell : a button : a musket ball : a large shot : a fragment of nutmeg : iron 
 nails : kidney beans : ears of grass or corn ; of these, four examples at least have 
 been noticed : one is mentioned by Dr. Stokes, two are recorded in the Gazette 
 Medicate, and I show you a monument of the fourth, in this interesting preparation, 
 for the history of which I am indebted to Mr. Mayo, The young son of an English 
 nobleman was riding in a carriage, in or near Paris, and had an ear of rye in his
 
 INTO THE AIR-PASSAGES. GST 
 
 mouth. The carriage made a sudden jolt, and the ear of rye disappeared. Little 
 was thought about this at the time : but soon afterwards symptoms of pulmonary 
 irritation set in, attended with hectic fever, and with the most foetid expectoration. 
 The boy gradually sunk. The ear of rye lay, as you may perceive, in an abscess 
 which was common to the right lung and to the hver, through the diaphragm. 
 
 If any of you have tried the boyish trick of slipping boiieath your wristband an 
 ear of bearded corn, you will have no difhculty in understanding how and why, 
 with every movement of the parts in contact with it, the ear will travel onwards ; 
 and how improbable it is that such a substance should ever be expelled from the 
 lungs by coughing. Yet, in one of the cases, recorded in the Gazette Mklicale, by 
 a physician whose sister was the subject of the accident, an ear of barley was so 
 rejected, seven years after its entrance. During that long period she had suffered 
 repeated attacks of copious hfemoptysis. Her recovery was perfect. 
 
 The very enumeration which I have just made may convince you that the acci- 
 dent is not a very unfrequent one ; and it is more than probable that fatal cases hap- 
 pen, the nature of which escapes detection. 
 
 The results of the accident are various also. 
 
 In the first place, it sometimes causes speedy death by apnoea. 
 
 2dly. It may be followed by inflammation of the lung, and perhaps abscess ; and 
 so destroy life. 
 
 3dly. Death may ensue, after symptoms resembling those of chronic phthisis. 
 
 4thly. The " foreign body," as we oddly enough call it, may be expelled through 
 the glottis, after a variable period of time. Sometimes, yet not always, its expulsion 
 is the condition and the harbinger of the patient's recovery ; but he is never safe 
 while it remains. 
 
 Death may take place in a few seconds when the substance sticks in the glottis. 
 Death has occurred within three days, when the substance had passed the glottis : 
 and in eleven days when it had reached the lung. The intruding piece of matter 
 has escaped, through the natural passages, after remaining imprisoned for seventeen 
 years. In that case, the patient died, hectical and emaciated, a year and a half 
 afterwards. 
 
 It may be worth our while to consider these particulars somewhat more closely ; 
 and to inquire what, in different cases, becomes of the foreign body which thus, to 
 use a common phrase, " goes the wrong way ;" and what the symptoms are to 
 which it gives rise. 
 
 First, then, I say, it may get wedged in the slit of the glottis, and produce imme- 
 diate suffocation. I mentioned, before, the frequency of this kind of death by mis- 
 adventure. If you are summoned to any one whom you find comatose, or apparently 
 just dead, and you learn that he had been suddenly attacked with choking during a 
 rneal, lose no time in examining his pharynx and gullet. You may chance to save 
 a life so. The accident often happens to persons who ar.e drunk. No doubt it hap- 
 pens oftener than we are aware of. The attack is very likely to be mistaken for an 
 apoplectic seizure. 
 
 In these cases of sudden choking, the morsel of food is not always caught in the 
 rima glottidis. If it be large enough to stick fast in the pharynx, it may provoke, 
 through a reflex action, an abiding spasm of the httle laryngeal muscles, and so pro- 
 duce death by apnoea. The remedy for such an emergency, as Dr. Marshall Hall 
 truly observes, must be immediate : and this is what he tells us should be done. 
 
 " Pressure being made on the abdomen, to prevent the descent of the diaphragm, 
 a forcible blow should be made by the flat hand on the thorax. The effect of this is 
 to induce an effort similar to that of expiration; the larynx being closed, OBsophageal 
 vomiting lakes place, and the morsel is dislodged." 
 
 " If this plan fail, not an instant being lost, the pressure should be kept up on the 
 abdomen, the finger should be introduced into the throat, and the same smart and 
 forcible blow made on the thorax as before. By the irritation of the fauces the 
 cardia is opened, and by the blow on the thorax (firm pressure being made on the 
 abdomen) an effort similar to that of expiration, with a closed larynx, is made, and a 
 direct vomiting ensues, and the morsel of food is carried away." 
 42 
 
 ak
 
 658 INTRUSION OF SOLIDS 
 
 2dly. The substance, if small, may, after it has passed the chink, remain in the 
 [ar3-nx : entangled in its ventricles, or between the chordae vocales. In that case 
 it usually occasions very severe laryngeal symptoms — spasmodic gasping coucrh, 
 choking sensations, croupy respiration, and pain in the 'arynx — symptoms which 
 harass the patients without intermission, until death ensues, or until the substance is 
 driv-en upwards into the pharynx, or passes downwards into the windpipe. There 
 7s, however, one instance on record, in which a piece of gold was lodged for years 
 in the ventricles of the larynx, without these distressing consequences. 
 
 3dly. Having passed the upper part of the larynx, it may stop, and become fixed 
 beneath the cricoid cartilage, or in the trachea. In these situations, unless it quite 
 blocks up the passage, its presence may be productive of but little distress. A 
 wheezing or croupy sound during one or both of the movements of respiration, and 
 some degree of pain and tenderness of the part where the substance was lodged, 
 have constituted all the evidence of its position in the air-passages, in more than one 
 instance. A very singular and whimsical case of this kind, related by Professor 
 Macnamara, is referred to by Dr. Stokes. A boy had made a whistle, by perforating 
 a plum-stone, and extracting the kernel. This, during a strong inspiration, passed 
 from between his lips, through the glottis, and became fixed transversely in the 
 larynx. So little inconvenience did it create, that the boy, finding that he still 
 whistled as he breathed, went about for some hours, pleased to display this new ac- 
 complishment. For three days he continued to occupy himself in his childish 
 amusements, suffering now and then a seizure of suffocating cough. He was then 
 taken to the Meath Hospital. He had no pain in deglutition ; but he said when the 
 cough was severe, it caused pain in his throat. He had also uneasiness in the epi- 
 gastrium, a bloated countenance, and a frequent pulse. The chest sounded well on 
 percussion, and the vesicular murmur was natural. The fits of coughing were fol- 
 lowed by white frothy expectoration. Laryngolomj^ was performed; but during the 
 struggle and the convulsive cough which took place when the opening was made, 
 the stone (so the patient declared) was coughed up, and swallowed. The symp- 
 toms, were relieved; and the whistling ceased. But it was found that, as the wound 
 healed, the distress and the whistling sound returned ; which showed that the stone 
 lay above the opening; and that the disappearance of the symptoms had been owing, 
 not to its dislodgment, but to the admission of air below the point where it was fixed. 
 Soon after this, however, it changed its place, passed down into the right bronchus, 
 and then up again towards the larynx. By a second operation it was extracted ; 
 and the lad recovered without any bad symptom. 
 
 4thly. The substance may get beyond the trachea, into one of the bronchi, and stay 
 there. And it is a very curious fact, and one which has evident importance in respect 
 to diagnosis, that it is almost always the n^/t/ bronchus which the substance enters. 
 Dr. Stokes has explained why it is so. The septum that divides the extremity of 
 the trachea into two branches, is not placed in the middle of the channel, but de- 
 cidedly towards the left ; so that any solid body falling down through the windpipe, 
 is naturally directt-d into the right bronchus. Perhaps this tendency is aided by the 
 more vertical direction, and by the somewhat greater capacity of that tube, com- 
 pared with its fellow. Now you will readily apprehend what sort of symptoms would 
 be likely to result from the impaction of a solid body in either of the primary bronchi. 
 It would be very apt to excite inflammation of the corresponding lung, which inflam- 
 mation would reveal itself by its proper signs; but it would produce pecuhar aus- 
 cultatory phenomena, prior to and independent of such inflammation. It would 
 prevent, partially or ahogether, the entrance of air into the lung of that side. Hence, 
 when we have other reasons for thinking that a solid body has passed the glottis, 
 if we find the vesicular murmur suspended or enfeebled in one lung, while percus- 
 sion gives out its usual clear sound, we may conclude that the intruder is lodged in 
 the bronchus belonging to that lung. 
 
 Dr. Stokes believes, and his opinion is fortified by his own experience on the sub- 
 ject, that smooth bodies (beans or shots, for example), are more calculated than such 
 as are rugged and uneven to cause urgent distress when impacted in one of the 
 nronchi ; inasmuch as they more completely plug and obstruct the tube, thereby
 
 INTO THE AIR-PASSAGES. 659 
 
 Jepriving the patient at once of the use of half his lungs. An irregular substance, 
 which can neither seal the passage up, nor be closely grasped by its spasmodic con- 
 traction, will probably occasion less dyspnoea, and at the same time will be less likely 
 to be dislodged by the effort of expiration. Under these circumstances we look for 
 more chronic symptoms. 
 
 Sthlj^ and lastly. The intruding substance may not be fixed anywhere, but may 
 shift its place from time to time ; and this, in fact, is what most frequently happens ; 
 and when it does happen, it gives rise to a very striking and distinctive series of 
 symptoms. Paroxysms of suffocating cough and extreme distress, when the sub- 
 stance is driven up into or near the larynx; with intervals of comparative quiet, and 
 sometimes indeed of apparent health, when it subsides into the trachea or bronchi. 
 But during these intervals, the signs that sometimes mark its situation in those tubes 
 may perhaps be discoverable. 
 
 There are, then, a set of general symptoms, which lead us to behave, or to suspect, 
 that some solid body has entered the air-passages : and there are other sets of par- 
 ticular symptoms, which inform us, with more or less certainty, whereabouts it is 
 fixed, or that it is not fixed at all. A person, previously in good health, is seized 
 with violent cough and choking dyspnoea, suddenly, during a meal, or while he had 
 in his mouth some loose substance, which he fancies he has swallowed. This is a 
 sufficient clue to the probable nature of the case : and we next inquire for a sense of 
 soreness in the windpipe, and wheezing respiration; for signs of bronchitis or of 
 pneumonia, especially in the right lung ; for signs of obstruction of the bronchus on 
 one side, and especially on the right side, or of alternations of suffocating cough, 
 with intervals of outward calm. In the last case, we may expect to find the bronchus 
 unstopped during the periods of laryngeal irritation ; and vice versa. 
 
 When we know that a sohd body has been entrapped in the air-tubes, our business 
 is plain ; there is no room, in my opinion, for hesitation ; we must let the substance 
 out through an artificial wicket. There is danger, so long as it remains in these 
 vital passages, of speedy suffocation ; of fatal damage to the larynx, or to the lungs ; 
 of cerebral mischief during the violent paroxysms of coughing. Convulsions and 
 apoplexy have, under such circumstances, actually occurred. Against these perils 
 there is no security, except in the early performance of tracheotomy. If the in- 
 cluded substance be loose and smooth it will presently be shot forth at the new 
 orifice; if it be fixed, or angular, it may generally be extricated by a skilful and 
 delicate hand. 
 
 Even while this sheet has been passing under the press, (May, 1843,) another 
 instance has occurred of the same accident, and excited a degree of anxious interest 
 in the public mind, scarcely less than is accorded to a royal illness. It befel a gen 
 tleman whose name was previously famous. Mr. Brunei, in amusing the children 
 of a friend with some tricks of legerdemain, put a half-sovereign into his mouth ; 
 and the coin shpped, as from its size and shape it might easily do, through the chink 
 of the glottis. It seems to have occasioned no very urgent distress. The patient 
 was made aware, by some internal sensation, that it lay towards the tight side. After 
 more than three weeks had passed, the trachea was opened ; but the piece of money 
 did not come forth. Probably its weight prevented its being driven up and down in 
 the windpipe ; and its form, when it lay edgeways, did not oppose much impedi- 
 ment to the breath. The same weight, however, brought it back to the larynx when- 
 ever Mr. Brunei placed himself with his head downwards. In some of these 
 experiments, coming crossways I suppose, it produced most violent cough, and feel- 
 ings of impending suffocation : but in a final and happier trial, at the end of six 
 weeks, it dropped out again, through the natural passage — ^just as a coin may some- 
 times, by good luck, be shaken out of a box through a sht in its lid
 
 660 DISEASES OF THE HEART. 
 
 LECTURE LIX. 
 
 Diseases of the Heart : usually partial. Changes in its Muscular Texture. Me 
 chanism of those changes. Natural Dimensions of the Heart. Natural 
 Sounds. Modifications of these by Disease. Review of the Physical and 
 General Signs that accompany Cardiac Disease. 
 
 You will perhaps accuse me, gentlemen, of a disposition to magnify the import- 
 ance of every new class of diseases at which we arrive, in our survey of the morbid 
 conditions of the various parts of the body in succession. There are few complaints, 
 in truth, which are not important ; either from the discomfort to which they give 
 rise, or from their tendency to abbreviate the span of human existence. Yet of tha 
 s'.rictly vital organs the derangements are necessarily the most perilous ; and there- 
 fore, to us, the most interesting. Two props of the tripod of life we have passed in 
 review, and seen how they may be weakened, an-d how they may fail altogether. 
 The office of the heart is not less essential to life and health, than that of the brain, 
 or of the lungs. The well-being of every portion of the frame depends upon its 
 being duly supplied with arterial blood, and duly relieved of that which has become 
 venous : and this supply and relief require that the central organ of the circulation 
 should be sound in its structure, and perfect in its working. But it is frequently 
 otherwise. I can remember, indeed, the time w'hen disease of the heart was thought 
 to be a very rare thing ; but it is now well known to be one of the commonest of 
 disorders, and it connects itself with a variety of other affections, with which it was 
 formerly supposed to have no relation. 
 
 Like other organs that are complex of structure and formed of different tissues, the 
 heart is subject to partial disease. Its lining membrane alone may, in the first in- 
 stance, become the seat of inflammation, with its various effects ; or its investing 
 membrane only may undergo morbid alterations ; or the muscular substance that 
 constitutes the organ itself may be gradually changed in its qualities, in its bulk, or 
 in its proportions. 
 
 But the morbid conditions of the investing and lining membranes do not always, 
 or immediately, compromise the fife of the patient. They are fatal at length, in 
 ninety-nine cases out of a hundred, through the alterations to which they lead in the 
 muscle wherewith they are connected. It may be practically useful therefore to 
 consider, first, these ultimate morbid states which are incompatible with the con- 
 tinuance of life ; and then to trace them back to the next fink in the chain of their 
 causes, which will be found, in a very great number of instances, to consist in some 
 antecedent morbid state of the exterior or of the interior membrane. 
 
 The heart, you know, is a living forcing-pump ; a hollow muscular engine, with 
 its chambers and their outlets, its contractile walls and their strength and thickness, 
 so admirably adjusted, that the healthy balance of the circulation is continually main- 
 tained, under many varying outward influences and inward emotions which tend to 
 destroy it. In treating of disease of the heart we have to consider, therefore, the 
 modes in which its mechanism may be spoiled or deranged : and the effects of such 
 derangements. 
 
 Not only the component tissues, but different portions also of the organ, may be 
 separately diseased. It seldom happens, indeed, that the whole heart is affected ; 
 although that is probably the vulgar belief. The left side is much more obnoxious 
 to morbid changes than the right : and when both sides are implicated, the altera- 
 tion is almost always more decided and conspicuous in the left than in the right 
 chambers. 
 
 In the rapid sketch which I attempted of general pathology, in the outset of the 
 course, I pointed out the various kinds of alteration to which the tissues and organs 
 of the body, and therefore the heart among the rest, are subject. One or more of 
 the chambers of the heart, you will remember, may become larger or smaller than 
 IS natural ; or have their walls increased or diminished in thickness, and consequently
 
 DISEASES OF THE HEART. 661 
 
 >«3 power ; or one or more of its outlets and orifices of communication may be widened 
 Pf contracted : and the purposes and function of the organ will be more or less im- 
 paired by these changes. 
 
 In order, then, to have a clear conception of cardiac disease, it is necessary to 
 analyze it, and to investigate the derangements of the several parts of the heart. 
 And I begin with hypeiirophy ; augmentation of bulk in its muscular substance. 
 And I must first of all define one or two phrases which are current among patholo- 
 gists in respect to this condition. 
 
 The muscular tissue of one, or more, of the chambers of the heart may become 
 thicker and stronger than natural, while the capacity of that chamber, or of those 
 chambers, remains unaltered. The hypertrophy in that case is said to be simple. 
 
 But, while the muscular parietes are thickened, the corresponding chamber may 
 become unnaturally large. This constitutes the active aneurism of the heart of 
 Corvisart, the eccentric hypertrophy of more modern writers. 
 
 On the other hand, it has been supposed that the capacity of a cavity of the heart 
 may diminish in size as its walls increase in thickness : that the hypertrophy may 
 take place at the expense (as it were) of the chamber. This has been called con- 
 centric hypertrophy. 
 
 Now of these three reputed forms of hypertrophy, considered in their relation to 
 disease, two only, the simple and the eccentric, have any real existence. The third, 
 or concentric form, never occurs, I believe, except as a congenital malformation. 
 And of the two genuine species of hypertrophy, the eccentric, which is plainly a 
 compound affection, consisting of hypertrophy with dilatation, is much the most 
 common. The reason of this is to be found in the physical cause of the morbid 
 condition, in most instances. The physical cause, in nineteen cases out of twenty, 
 is some obstacle, mechanical or virtual, to the perfect accomplishment of the func- 
 tion of the chamber ; some obstruction opposed to the free and thorough exit of the 
 blood from it ; or something which hinders the easy play of the organ : hence, in 
 the first place, a gradual yielding, or tendency to yield, in the sides of the affected 
 chamber, from the continual and unwonted pressure of the accumulated blood against 
 them, and in the second place, a striving action of the muscle to overcome the 
 hindrance, or to counterbalance the obstacle ; and consequently, according to the 
 law formerly announced, an augmentation in the bulk of the muscle whereof the 
 function is thus increased. If the hypertrophy, which is the result of a truly con- 
 servative process, keeps pace exactly with the amount of the obstacle and exactly 
 balances it, no dilatation happens, or next to none. But this is comparatively seldom 
 the case. According to the principles of mechanics, a httle distension of the sphe- 
 roidal cavity must require an increase of force to propel from it a given quantity 
 of blood, in the same time, through a given discharging orifice. So that incipient 
 dilatation becomes (in addition to the supposed obstacle) an efficient cause of hyper- 
 trophy : and the two, the dilatation and the hypertrophy, commonly make progress 
 together. Ij 
 
 Cruveilhier appears to have been the first to reject concentric hypertrophy from 
 the catalogue of cardiac diseases. The smallness of its cavity, with a proportional 
 increased thickness of its walls, was regarded by him as a transient condition of the 
 ventricle, depending upon the mode of death. He found these phenomena very 
 strongly marked in the hearts of all those whose bodies he had examined after de- 
 capitation by the guillotine ; " Les parois ventriculaires se touchaient dans tous 
 leurs points." It is therefore his opinion that the hearts which had been thought 
 by others, to present examples of concentric hypertrophy, were in reality " hearts 
 more or less hypertrophied, which death had surprised in all their energy of con 
 iractility." 
 
 This question has since been considered by Dr. Budd, in a communication to tht 
 Medical and Chirurgical Society, which you may read in the twenty-first volume of 
 its Transactions. He has lately favoured me with a statement of his matured viewa 
 upon the subject. 
 
 The semblance of concentric hypertrophy is most common in the left ventricle ; 
 and depends upon the ventricle being nearly empty at the time of death, and upon 
 
 3f
 
 662 DISEASES OF THE HEART. 
 
 the corpse being examined while the heart is contracted by the rigor mortis. The 
 fallacious appearance is accordingly noticed in cases where, from the manner of 
 death, the left ventricle, or the entire heart, contains but little blood, and where, from 
 the muscular powernol having been previously exhausted, the rigor mortis is of long 
 duration. 
 
 " In all these concentrically hypertrophied hearts (writes Dr. Budd) the ventricle 
 may be readily dilated by means of the fingers, and always dilates of itself when the 
 rigor mortis goes off." 
 
 " In the published cases of concentric hypertrophy, in which there was no disease 
 of the valves (I have given eight such cases in my paper, and could now add a long 
 list to them) there were no signs, or only very slight signs, of disease of the heart, 
 during the lifetime of the patient. This circumstance is sufficient proof that the 
 cavities of the heart in these cases could not have been during life permanently in 
 the contracted state in which they were found after death. A left ventricle that 
 could scarcely contain an almond (a common form of expression in the description 
 of these cases) would surely have caused a great impediment to the circulation." 
 
 Moreover, concentric hypertrophy could answer no mechanical purpose ; nor 
 could its formation be accounted for on mechanical principles. But " concentric 
 hypertrophy of a ventricle, in a high degree, with obstruction at its discharging 
 orifice, and an extraordinary channel for the passage of the blood, occasionally 
 exists as a congenital malformation ; and, in most cases, the right is the ventricle so 
 affected." 
 
 To resume. Recollect that there may be two distinct kinds of physical cause of 
 excessive action of the heart, and therefore of hypertrophy. In the one kind, there 
 is some mechanical obstruction to the exit of the blood from one or more of the cavi- 
 ties ; a constricted state of the orifices is the most common condition. In the other 
 kind, without any such mechanical bar or dam to the fluid, there is something to 
 hinder the free and sufficient play of the organ ; an adhering pericardium, it may 
 be, or mal-position of the heart. If the heart be pushed, for instance, out of its pro- 
 per place and posture by effusion into the pleura, or by distortion of the chest, it will 
 not work with the same ease as when all is perfect and symmetrical; and the unu- 
 sual labour imposed upon it fully to execute its office, will lead to hypertrophy. 
 The causes of hypertrophy may therefore be situated within the heart itself, or with- 
 out and beyond it ; but in all those cases in which the effect of the hindrance or 
 obstacle is to detain the blood in one or more chambers, the hypertrophy will be 
 likely to be accompanied by dilatation: and, generally speaking, the h)''pertrophy 
 and dilatation result from disease in some part which lies beyond the affected cham- 
 ber, in the order of the circulation. Thus, either a narrowing or a dilatation of the 
 aorta at its commencement, will tend to cause hypertrophy and dilatation of the left 
 ventricle. 
 
 That contraction of the aorta, or of the aortic orifice, may have this consequence, 
 you will have no difficulty in perceiving. The blood cannot so readily pass through 
 the narrowed channel; hence it will tend to accumulate in undue quantity in the 
 ventricle, therefore to stretch and dilate it; and the increased muscular efforts neces- 
 sary to drive the delayed blood onwards, tend also to thicken the muscle itself. But 
 it may not be so obvious that dilatation of the mouth of the aorta — a wider channel 
 of egress — would also virtually prove an obstacle to the emptying of the ventricle. Yet 
 it certainly would, in two ways. In the first place, dilatation of the entrance of the 
 aorta implies a diminution in the elasticity of that vessel; and the blood, after it has 
 left the heart, is urged onwards by the heaUhy elasticity. But, again, dilatation of 
 the mouth of the aorta commonly implies an imperfect closure of that vessel by the 
 sigmoid valves ; so that, during the diastole, a part of the blood is apt to regurgitate 
 from the aorta, and to keep the ventricle morbidly full. You see, therefore, that a 
 deviation from the healthy state of the aorta, and of the valvular apparatus which 
 lies ac its mouth, may obstruct the course of the blood, and lead to hypertrophy and 
 dilatation, whether the deviation be in the one way or in the other ; whether, I mean, 
 uie naturai size of the vessel be increased or diminished. Again, disease of the 
 mitral valve, obstructing the flow of the blood at that point, will lead to an accumu-
 
 HYPERTROPHY. 663 
 
 lation in the left auricle, in the pulmonary veins, and in the lungs them- 
 selves. The auricular action is always less regular and energetic than the ven- 
 tricular, so that we less frequently meet with hypertrophy of the auricles ; but very 
 often with dilatation. And if we go to the other side of the heart, we find hyper- 
 trophy with dilatation, and more especially dilatation of the right ventricle, when, 
 from some reason or other, the blood passes with difficulty towards or through the 
 lungs: either from disease of the pulmonary artery, or from disease in the substance 
 of the lungs — emphysema, for instance : and if the difficulty be great, the accumu- 
 lation and distension will atfect successively the right auricle, and the vensB cavas ; 
 and then we have, in most cases, general dropsy. So that, I repeat, disease in the 
 heart tends to propagate itself in a direction contrary to that of the circulation. Fur- 
 thermore, if the muscular tissue of the heart be pale, flabby, soft, and weak — as it 
 frequently is in feeble, ill-nourished, cachectic persons-^it will the more readily yield 
 to the centrifugal pressure of the blood it embraces. In this way we may have dila- 
 tation without any hypertrophy. I am anxious that you should in the outset com- 
 prehend the mechanism by which the natural dimensions and relative proportions 
 of different parts of the heart may be altered in disease. 
 
 One reason why disease of the heart used formerly to be overlooked, was that 
 these natural dimensions and relative proportions were not ascertained or much 
 attended to. It is not easy to form any very precise estimate of the size of a healthy 
 heart. It is commonly held that if the heart be about the same size with the closed 
 fist of the subject, its general dimensions maybe considered as being natural. Bouil- 
 laud, who has taken much pains with this matter, weighing and measuring a great 
 number of different hearts, states that the mean weight of that organ, with the ori- 
 gins of its large vessels, and empty of blood, in adults from twenty-five to sixty years 
 old, is from eight to nine ounces ; that in subjects from sixteen to twenty-five years 
 old, it may be one or two ounces less ; and that, in very large and robust persons, it 
 may rise to ten or eleven ounces. Also, what we should expect, that the weight is 
 less in women than in men. 
 
 So much for the general bulk of the heart. And we must have some standard 
 whereby to estimate its relative proportions. Every one knows that the walls of the 
 left ventricle are thicker than those of the right. Bouillaud found that the mean 
 thickness of the walls of the left ventricle at its base was seven lines, while that of 
 the right ventricle was two and a half fines. And taking the thickness generally 
 he says that the thickness of the parietes of the right ventricle has not a greater ratio 
 to that of the parietes of the left, than two to five, or even than one to three. 
 
 So again of the auricles ; he lays it down that the mean thickness of the walls of 
 the left auricle is, to the mean thickness of those of the right, as three to two. 
 
 He holds, also, that the mean capacity of the right ventricle exceeds, by a little, 
 that of the left ; and that the right auricle is larger than the left. You must always 
 make allowance, in actual cases, for the possible distension of these cavities with 
 blood, beyond the size to which they would have contracted if they had contained no 
 blood. 
 
 I may add, that the same author declares the rule I just now mentioned, which had 
 been proposed before his researches were instituted — the rule, viz., which makes the 
 bulk of the heaUhy heart equal to the fist of the subject — to be tolerably correct. 
 By keeping in mind these general facts, you will be better able to appreciate the 
 appearances presented by the heart when it is taken from the body to be examined ; 
 but you will recollect that they relate to averages only. 
 
 Now, having pointed out the modes in which the natural proportions of the heart 
 and of its several parts may be morbidly altered; and given you a rough standard 
 which may enable you to estimate these proportions in the state of health, and the 
 deviations from them in the state of disease ; I will go on to consider the symptom,* 
 by which the altered conditions are accustomed to declare themselves. And it ij 
 with respect to the heart, as with respect to the lungs ; there are general symptoms 
 or signs, and there are physical symptoms or signs : and the information derived from 
 these sources respectively is of variable utility. Neither of them can be safely ne- 
 o-lected ; and it is often found that the indications derived from one of these sets of
 
 664 DISEASES OF THE HEART. 
 
 symptoms are confirmed or corrected by those collected from the other. I believe it 
 will be best to pursue the same course in both cases, and to speak, in the first place, 
 of the signs that are brought within our notice by the sense of hearing. 
 
 But, in order that we may comprehend the morbid sounds of the heart, we must 
 first make ourselves acquainted with those that belong to its healthy condition. 
 
 The heart ma)'' be heard by the ear laid flat against the prascordial region, or 
 through a stethoscope, to beat over a certain space. That space, in ordinary cir- 
 cumstances, corresponds to the inferior half of the sternum, and to the cartilages 
 of the ribs, from the fourth to the seventh, on the left side. The apex of the organ 
 may often be seen to pulsate between the cartilages of the fifth and sixth left ribs ; 
 about two inches below the nipple, and or..^ inch from it towards the sternum. 
 
 This is the space over which, in the sound state of the heart and lungs, the pulsa- 
 tions of the former are plainly audible. But there are several diseased conditions 
 both of the heart itself, and of the parts around it, which interfere with this rule. 
 
 In the first place, if the heart be larger than natural, it will be heard to beat over 
 a proportionally larger space. In this way it may come to be heard all over the 
 chest in front ; and behind on the left side of the spine ; and even, in extreme cases, 
 on the right side of the spine. 
 
 Again, the extent of space over which the heart may be heard to beat will be in- 
 creased in proportion to the thinness of its walls ; and diminished, csetcris paribus, 
 according to the thickness of its walls. So that when the heart is nearly its proper 
 size, if its walls be thin, it will be heard beyond its natural limits ; and if its walls 
 be morbidly thick, i. e., if it be affected with considerable hypertrophy, it will not 
 be heard beyond, nor even to the extent of its natural limits. I will endeavour, pre- 
 sently, to explain the reason of these differences. 
 
 Again, and this it is of great importance to remember, the heart may be heard far 
 beyond its natural limits, even when it is perfectly healthy, in consequence of the 
 lung between the ear and the heart having become solid, and therefore a better con- 
 ductor of sound : and the solidification may have resulted from hepatization, or from 
 the presence of a number of crude tubercles. The sound of the heart's action will 
 also be conveyed to a distance by the liquid effusion in pleurisy. If we are not 
 aware of these circumstances, we are continually liable to fall into mistakes. 
 
 The heart is likewise heard more distinctly, and over a space which is compara- 
 tively larger, in children than in adult persons ; and I need scarcely say that it may 
 be heard over a wider extent of the chest whenever its action is augmented by exer- 
 cise, by emotion of mind, or by febrile excitement. 
 
 The impidse of the heart is another point which you must attend to. In healthy 
 persons who are thin, you may generally feel the stroke which the heart gives to 
 the ribs, by placing your hand on the prcecordial region. In persons who are fat, 
 you often cannot feel the heart at all in this manner. For obvious reasons, it is felt 
 more distinctly, over a larger space, and higher up, while the person is stooping for- 
 wards, or makes a forced expiration ; less distinctly, over a smaller space, and lower 
 down, when he makes a deep inspiration, or is lying on his back. In proportion as 
 the heart is enlarged by disease, it can be felt more extensively : and when there is 
 hypertrophy, the force with which it strikes the parietes of the chest is sometimes 
 extraordinary, and very instructive. You will see the ear and head of the listener 
 distinctly lifted at every pulsation ; sometimes the whole of the patient's body, nay 
 his very bed, is shaken by the strong shock of the heart during its systole. There 
 is no sign of hypertrophy so sure as that afforded by the heart's impulse. You feel, 
 not a smart, quick, and sudden knock, but a steady, heaving, irrepressible swell, 
 which is perfectly characteristic. You may always infer increased thickness of the 
 walls of the organ, when you meet with this regular heaving motion ; and the extent 
 to which the whole heart is enlarged in such cases may be conjectured by the extent 
 of space over which the heaving impulse is perceptible. 
 
 The sounds which we hear are two. One of them coincides, in point of time, 
 with the impulse; and barely precedes the beat of the radial artery. It happens, 
 therefore, when ih^ ventricles contract; during the systole. It is called, accord 
 ugly, the systolic sound, or the Jirst sound of the heart. The other of the two
 
 NATURAL SOUNDS. 665 
 
 sounds coincides with the diastole, and is spoken of as the second or the diastolic 
 sound. It takes place at the instant when the heart reverts to that place aftd condi- 
 tion in which it had been prior to the systolic movement. These two sounds occur 
 m quick and regular succession, and then follows an interval of silence, after which 
 the two sounds are repeated ; and so on. 
 
 The two sounds are not, however, exactly alike. They differ somewhat, both in 
 quality and in duration. The first is a dull, prolonged noise ; the second a shorter 
 and smarter sound, having more of a clacking or flapping character. Attempts have 
 been made to assign the respective duration of each sound, and of the period of re- 
 pose, I confess that I have never succeeded in measuring them satisfactorily in my 
 mind. Probably Dr. C. J. B. Williams' estimate is as near the mark as any. He 
 divides the whole period, from the beginning of one pulsation to the beginning of the 
 next, into five equal parts : and allots two of these to the first sound, one to the 
 second, and the remaining two to the interval of silence. This order of succession 
 /s called the rhythm of the heart : and it may be perverted. 
 
 Respecting the physical causes of these natural sounds, there have been much 
 /ecent discussion and research. Our time, however, will permit me to do little more 
 than tell you what I believe to be the facts of the matter. And I take, first, the 
 disastolic sound, as being the simpler of the two. It used to be ascribed to the 
 coKtraction of the auricles : but that was quite a mistake. The contraction of the 
 auricles, such as it is, happens immediately before each systole of the ventricles ; 
 whereas the sound in question occurs immediately after it, and is succeeded by the 
 period of silence. This we know from the visible movements of the organ when 
 sxposed in a hving animal. In truth, the auricular contractions are very feeble, 
 and not attended with any appreciable noise. I have no doubt that the second sound 
 is produced mainly, if not altogether, by the sudden shutting of the floodgates placed 
 at the mouths of the two great outlets of the heart. The recoiling blood forces back 
 Jie semilunar valves of the aorta and of the pulmonary artery, as one unfurls an 
 ambrella: and with an audible check as they tighten. There is no other tenable 
 mode of accounting for the sound. Experimenters have contrived, by hooks and 
 vvires, to prevent these valves from unfolding; and then the flapping sound has been 
 converted into a hiss. Disease of the same valves demonstrates the same things; 
 as we shall presently see. Nevertheless, it is both possible and probable that the 
 relapse of the whole organ to its former place may contribute an ingredient towards 
 uiis second sound. 
 
 The first, or systolic sound, is more complex. Partly it is owing, as I believe, to 
 a similar cause with that which occasions the diastohc sound, viz., the abrupt closure 
 of the orifices of communication between the auricles and ventricles, by the reflux 
 of the blood against the ventricular surfaces of the tricuspid and mitral valves ; 
 panly, sometimes, to the blow of the heart's apex against the ribs ; chiefly, however, 
 it consists of the sound that results from the muscular contraction of the ventricles. 
 The systolic sound commences with the tightening of the walls of the ventricles, 
 including the valves ; and it is prolonged by the muscular noise. You are aware, 
 I dare say, that the vigorous contraction of a large muscle is accompanied by audi- 
 ble sound. If, during the stillness of night, when lying in bed, with your cheek 
 and eai upon the pillow, you set your teeth firmly, you will hear a continuous dull 
 rumbhng, like the noise of carriage-wheels in the street, and evidently caused by 
 tlie action of the masseter and the temporal muscles. Dr. Williams slates that, 
 with the help of a flexible stethoscope, one may hear the voluntary jerking con- 
 traction of his own abdominal muscles ; the sound being as loud as that of the heart's 
 systole, and very Hke it in character. That the systolic sound is essentially due to 
 muscular contraction is proved by the fact, that when a heart is taken from the 
 living thorax and placed upon a table, its contractions (which persist for awhile) arc 
 still attended with a noise similar to the natural first sound, though weaker. Here 
 there is neither collision of the blood, nor valvular reaction, nor impulse against the 
 ribs, to render the experiment ambiguous. 
 
 If you acknowledge and comprehend this source of sound, you will understand 
 without difficulty why the heart, cscteris paribus, is heard more clearly and exteti- 
 
 3f2
 
 666 DISEASES OF THE HEART. 
 
 sively when its walls are thin, less widely and loudly when they are ihick. "The 
 transition (says Dr. Williams) of a thick muscle from slack to tight can never be so 
 complete and sudden as that of a thin one. Where there are many fibres they 
 choke and muffle each other's vibrations ; hence the sound is dull and prolonged, 
 rather than loud and clear. If we observe the different sounds produced on tight- 
 ening thin silk and thick baize or cloth, we find that the thinness of the silk gives a 
 unity and briefness to the impulse which it receives, and the sound is short and loud ; 
 whilst in the baize the impulse is divided and prolonged in the complexity of the 
 fibres, and the sound is dull and less brief: so, under similar circumstances, a thin 
 ventricle w'ill give a louder, sharper sound than a thick one." 
 
 The natural sounds which I have been describing are liable to be changed, or 
 modified, by disease. Some of the modifications, indeed, I have adverted to as I 
 went along. But others, of a more striking and extraordinary character, are yet to 
 be explained. Either sound, or both, may be accompanied by a noise, which, in its 
 commonest type, very closely reseml)les that produced by the blowing of a pair of 
 bellows. Four persons out of five, I should think, if they were asked what this 
 sound resembled, when they heard it accompanying each sj'-stolic movement of the 
 heart, would say that it was exactly like the repeated blowing of bellows in an 
 adjoining room. It is called, accordingly, by the French, the "bruit de soufflet ;" 
 and, in homely English, a bellows sound. This is the generic sound. It may be 
 divided into species ; but it is scarcely worth while so to divide it. We are only 
 likely to confuse our notions by over-refinement. So I will only add, that, when 
 this bellows sound is very harsh or rough, persons will tell you that it is more like 
 the noise of a rasp, or a file, or a saw : but all the while it is some kind of bellows 
 sound. These sounds are often denominated murmurs also. 
 
 Now what is the cause of this singular deviation from the natural noises made by 
 the successive contractions and relaxations of this hollow muscle, the heart ? The 
 whole matter may, I believe, be briefly thus expressed. The blowing sound may be 
 occasioned by any change which alters the due proportion between the chambers of 
 the heart, and their orifices of communication with each other, and with the blood- 
 vessels that respectively enter or leave them ; it may also be occasioned by a preter- 
 natural velocity in the passage of the blood through a healthy and well adjusted 
 heart. Dr. Elliotson, I think it is, who has offered this apposite iUustration of the 
 phenomenon. If the arches of a bridge have a certain relation to the quantity of 
 water in the river, and to the force of the current, the water passes through them 
 quietly, and without any noise. Diminish the size of the arches, and the water 
 begins to go through them with an audible rushing or roaring sound. The very 
 same thing wifl happen if the arches remain unchanged in size, but the quantity of 
 water in the river, and therefore its velocity and force, be augmented by heavy rains. 
 So it is in the heart. If one of its orifices — say the aortic orifice — be narrowed, by 
 disease of the valves, or in any other way, the blood wiU not, as before, glide through 
 it smoothly and without noise, but will yield that sound which we call a bellows 
 sound. So also, if the orifice retain its natural dimensions, but the capacity of the 
 cavity from which the blood is driven be augmented. Nay. the same blowing sound 
 may be produced though the cavities and orifices are all healthy, and duly propor- 
 tioned to each other, if the velocity of the circulating blood be increased beyond a 
 certain measure. If you bear this explanation in mind, it will be found applicable, I 
 think, to almost every case in which there is a blowing sound accompanying the 
 systole of the organ. If, at the same time, the valves over which the blood must pass 
 be rigid, or rough, or even loose and vibrating, those circumstances may modify the 
 blowing sound and render it louder, or lioarser than it would otherwise be, and justify 
 the appellations of bruit de scie, and bruit de rape, with which you will find the 
 French books, and many of our English also, fuU. 
 
 But this explanation applies to a systolic blowing sound only. What are we to 
 say when there is a similar sound attending the diastolic movement of the heart ? 
 Why a diastolic bellows sound will mostly, if not always, be found to accompany 
 and denote some organic disease affecting the valves of the heart. Thus, if the 
 mitral valve be converted, as it often is, from a loose flapping valve into a bony and
 
 NATURAL SOUNDS. 637 
 
 rigid unvarying chink, the blood which passes through it from the auriclt, to the 
 ventricle, during the diastole, may (though it seldom does) cause a rushing or blow- 
 ing sound. On the other hand, the reflux of blood through the unshut mitral orifice, 
 during the ventricular contraction, may also be attended with an audible noise ; and 
 thus we have another and not unfrequent source of a systolic murmur. Again, if 
 the aortic valves are imperfect, as they often are, and do not effectually close that 
 vessel, blood will regurgitate through them during the diastole, and produce a bellows 
 sound. That this is the true explanation of the diastolic murmurs, 1 am convinced, 
 both by the observation of disease, and by the results of experiments on animals. 
 In some of Dr. Hope's experiments, which he was good enough to allow me to wit- 
 ness, the short clack of the diastole was at first distinctly audible ; then hooks were 
 introduced, so as to prevent the perfect closure of the sigmoid valves during the 
 diastole, and then the short smart clack was converted into a prolonged bellows 
 murmur; and upon letting them go again, the short smart clack recurred. The 
 presence of a diastohc bellows sound has repeatedly enabled me to foretell some dis- 
 ease of the sigmoid valves, interfering with their proper function — that of forbidding 
 the re-entry of the blood into the ventricle from the aorta ; and what I have thus pre- 
 dicted during life, has been verified by observation after death. 
 
 Such are the principal sounds, natural and morbid, which are audible to the 
 naked ear, applied to the precordial region, or which may be heard through the 
 stethoscope. But we derive assistance, in respect to cardiac disease, from percus- 
 sion also. It enables us to measure, in some cases, the bulk of the heart ; in others, 
 to ascertain that the pericardium is distended by fluid. In the perfectly healthy 
 state of the viscera of the thorax, the heart is somewhat overlapped by the thin edge 
 of the lungs ; and the sound elicited by percussion over a part of the prsecordial 
 region is intermediate between the hollow sound rendered by lung, and the flat sound 
 yielded by the solid heart. In the centre of the prsecordial region, where the heart 
 is not covered by lung, the sound is decidedly dull. When, however, the heart is 
 enlarged by disease, a larger part of its surface is exposed, and a larger portion of 
 the prsecordial region yields a dull sound on percussion. And when the pericardium 
 is full of liquid, which distends and expands it, you will sometimes find that not less 
 than a third part of the anterior and lateral portion of the left side is quite dull : and 
 it is interesting often to measure, by percussion, the diminution or extension of the 
 limits of the dulness, as the amount of fluid decreases or aucfments. 
 
 What I stated before, concerning the effect of diflierent positions of the body upon 
 the space over which the healthy beating of the heart may be heard, felt, and some- 
 times seen, applies, ?>tz//a/«s mutandis, io the natural dullness which it causes when 
 the prsecordial region is percussed. This dullness comprehends a space of between 
 one and two square inches, reckoning from the spot where the impulse is felt, toward 
 the left edge of the sternum. The dullness should diminish or disappear, in the 
 supine position, and when a full breath is drawn ; and increase in degree and extent 
 upon a forced expiration, and when the posture is prone. 
 
 There is another physical sign which is much dwelt upon by Laennec, and which 
 is sometimes very striking. In certain conditions of disease, the hand placed over 
 the situation of the heart perceives a peculiar thrill or vibration accompanying its 
 movements. The sensation conveyed to the hand is really very much like whai 
 Laennec compares it to, viz., that tremor which you feel, when coaxing the back of 
 a cat while it is purring with pleasure. Accordingly he calls this sensation, " fre- 
 missement cataire," the purring thrill. You feel this vibration often when there it, 
 present also a loud and strong bellows sound ; and Dr. Davis is of opinion, that the 
 bruit de soufflet, and the fremissement cataire, constitute, in fact, but one phenomenon, 
 which is rendered evident to the touch by the vibrations communicated to the hand; 
 and to the ear by the vibrations communicated to it through the solid walls of the 
 chest. I know, however, that the fremissement cataire does accompany other sounds, 
 as well as the bellows sounds : sounds of which I have not yet had any occasion to 
 speak, but which I shall make you acquainted with when we come to the subject of 
 pericarditis. And I pass from this general account of the sounds belonging to th'^j
 
 668 PALPITATION. 
 
 action of the heart, in health and in disease, to consider tlie other symptoms by which 
 ue judge that such disease is present. 
 
 Among the general symptoms, then, of cardiac disease, some are direct — as pain ; 
 palpitation or excessive action of the heart perceptible by the patient ; irregular or 
 inlernn'ttent action, which the patient may or may not be conscious of: and some 
 are indirect, declaring themselves through the medium of other parts and organs — 
 such are dyspnoea; cough; dropsical accumulations; hemorrhages; various affec- 
 tions of the nervous system, especially an increased and morbid sensibility, what 
 IS usually called nervousness : and some others, which I will cursorily notice as we 
 proceed. 
 
 I shall take this opportunity of considering, once for all, some of these symptoms ; 
 whether they reall}^ proceed from organic disease of the heart or not : for the deter- 
 mination of the question, whether they do or do not indicate such disease, is often of 
 great moment, and is not always easy. 
 
 We are not, in general, sensible of the beating of our hearts : but when the pulsa- 
 tions become inordinately forcible, they make themselves felt, and the sensation is, 
 m many cases, a most troublesome and distressing one. Palpitation implies increased 
 force, or increased frequency — or an increase both in force and in frequency — of the 
 contractions of the heart. Every one has experienced palpitation in his own person 
 who has run himself out of breath. The pulsations are sometimes tumultuous also, 
 and irregular, as well as unduly frequent and forcible; but this is by no means al- 
 ways or necessarily the case. There may be great palpitation with perfect regularity 
 of the heart's action. The increased beating not only can be fek internally by the 
 patient, but it may often be heard both by himself and by others. However, we do 
 meet with persons whose hearts throb with excessive violence, without their being at 
 all aware of it. Such cases are always, I believe, cases of disease ; whereas the 
 palpitations that annoy and harass the patient are very often connected with functional 
 disorder only. 
 
 In egular action of the heart consists in some derangement or discord of its rhythmi- 
 cal movements, and is discovered by the condition of the arterial pulse — by unna- 
 tural fluctuations in the strength, or in the number, of its beatings, or in both. Some- 
 times a few rapid and feeble pulsations occur at uncertain intervals, and are followed 
 by others that are fuller and slower. Sometimes one or more beats are left out, and 
 the next beat, as if to make up for this pause, is unusually strong. The pulse is 
 then said to intermit. The intermissions may be unperceived by the patient him- 
 self; but in general they are attended wi.th a singularly disagreeable fluttering, or 
 trembhng sensation in the breast. The pulse may intermit though the heart does 
 not : the ventricle may now and then contract so faintly as not to propel a wave of 
 blood so far along the artery. Intermission implies irregularity ; but the action may 
 be irregular and disorderly without intermitting. 
 
 Now, any of these deviations from the natural rhythm and action of the heart alarm 
 people ver}" much, and impress them with a belief that they have some fixed disease 
 of that organ ; and you will cojitinually be appealed to for your opinion on this point. 
 I suppose there are few medical students who have not, at some time or other, ad- 
 mitted into their minds the apprehension that they had disease of the heart ; an 
 apprehension engendered by its occasional palpitation or irregularity. For though 
 there may be palpitation wuhout irregularity, yet it is practically convenient to con- 
 sider the two together. 
 
 These deviations certainly belong both to organic disease and to mere functional 
 disorder of the heart; but I repeat, that in a great number, nay, in a great majority, 
 of the cases in which they so distress and alarm the patient as to lead him or her to 
 complain of them, tliey are unconnected with any change of structure ; and this it 
 is of much importance that you should be aware of. 
 
 Palpitation of the heart, and intermission or irregularity of the pulse, are often 
 dependent upon some disordered condition of the stomach, and will cease at once 
 when that disorder is rectified. Tt is curious that this may happen although the gas- 
 tric afTection does not manifest itself by any other symptom : and it is curious, too, 
 liow slight a cause may suffice to produce the irregular action. A friend of mine,
 
 VENOUS MURMURS. 669 
 
 a barrister, used to be very anxious about himself, because a fluttering sensation fre- 
 quently occurred at his heart ; an intermission of one or two beats, and then a vio- 
 lent throb when the organ again resumed its play. This is a sensation very familiar 
 to myself, and probably most persons have occasionally experienced it. However, 
 It happened so often to the gentleman I speak of, that it made him very unhappy. 
 He persuaded himself that he had disease of the heart, and that he should some day 
 suddenly drop down dead. But there was no other symptom of cardiac disease 
 direct or indirect, general or physical. He was accordingly told that the intermis- 
 sion depended upon some fault in his digestive organs ; and he was advised to leave 
 off different articles of food and drink in succession, in order to discover whether 
 any one thing in particular offended the stomach, and gave rise to the symptom. He 
 began by abstaining from tea, which he had been in the habit of drinking in consi- 
 derable quantity ; and thereupon the fluttering of the heart ceased. After a while 
 he took to tea again, and then the fluttering returned. He repeated the experiment 
 many times, and always with the same result, till at length his mind was satisfied ; 
 and by renouncing tea altogether he got rid of his palpitation and of his apprehen- 
 sions. I mention this instance, because it came within my own cognizance ; but 
 it is only a sample of many such, and tea is frequently found to be the disturbing 
 substance. 
 
 I must caution you, however, against the mistake, which is often made, of infer- 
 ring that the heart is free from orgaiixfi change because its irregular movements are 
 accompanied by dyspeptic symptoms. Structural disease of that organ is very apt 
 to derange the digestive functions. You will commonly find that patients who 
 labour under such disease are exceeoingly liable to flatulence of the stomach ; and 
 free eructation of the gas which plagued them mitigates wonderfully the cardiac dis- 
 tress. It does so, no doubt, by relieving the diaphragm from that upward pressure 
 which embarrassed the motions of the heart. 
 
 We judge that palpitations and irregularities are merely symptomatic conse- 
 quences of gastric disorder, when they occur occasionally only ; when the rhj'^thm 
 of the heart is perfect during the intervals ; and when we fail to discover any other 
 pl^sical or general signs that its texture has undergone alteration. 
 
 Besides these overstrong or irregular movements, Avhich are symptomatic of dis- 
 order of the stomach, and are remedied by correcting that disorder, there are pal- 
 pitations of a purely nervous kind. *I mean, that they depend upon a peculiar and 
 highly sensitive condition of the nervous system ; which condition is itself dependent, 
 in general, upon a particular state of the vascular system. Persons of a "movable" 
 constitution, whether male or female, are subject to these palpitations : but especially 
 young women ; and, of these, such as are pale, exsanguine, hysterical, in whom the 
 menstrual functions are deficient, or excessive, or somehow unnatural. Ansemia, if 
 not a constant, is certainly a frequent and most remarkable feature of this nervous 
 state. The blood is aqueous ; poor in fibrin, and in red particles. The age, and 
 frequently the sex, of the patient form leading points in the diagnosis. Nervous 
 palpitations are apt to come on when the patient is quite at rest : palpitations that 
 result from organic disease are, on the contrary, always mitigated by repose. The 
 occurrence of palpitations in the night, however, is but an equivocal circumstance, 
 for nervous persons who dream, awake often with palpitation ; and the recumbent 
 posture generally excites or aggravates the palpitations that are organic. Neither, 
 m forming our diagnosis, can we trust entirely to the presence or absence of physi- 
 cal signs. The heaving impulse of hypertrophy is indeed wanting; but, as I told 
 you formerly, the short abrupt knock of chlorotic palpitation is often attended with 
 a bellows sound. The weak and flabby muscle dilates (I fancy), and the natural 
 proportion between the chamber and its outlet is for a time destroyed. The sound 
 may partly depend upon the thinness of the blood in such patients ; and this reminds 
 me of another diagnostic clue which you should be acquainted with. In nervous, 
 susceptible persons, especially if they exhibit the pallor of anaemia, very curious 
 noises are often audible, by means of the stethoscope, in the neck. Continuous rush- 
 ing or roaring sounds, very like those which are to be heard in shells, and whicn 
 poets feign, and the vulgar beheve, to be the noise of the distant sea
 
 670 DISEASES OF THE HEART. 
 
 Shake one, and it awakens ; then apply 
 Its polished lips to your attentive ear, 
 And it remembers its august abodes, 
 And murmurs as the ocean murmured there. 
 
 Sometimes the sound is more like the hum of a gnat, or the sighing of the wjnd 
 through a crevice. Dr. Hope very truly states that it may be imitated by a pro- 
 longed whispering pronunciation of the syllable ivho. Bouillaud, from its resem- 
 blance to the whizzing of a well-known toy, calls it the " bruit de diable." He sup- 
 posed this singular sound to reside in the arteries of the neck ; but it is quite distinct 
 from the true arterial bellows murmur; and it has been clearly shown (tirst by Dr. 
 Ogier Ward, of Birmingham,) that it is produced by the descent of the attenuated 
 blood through the great cervical veins. The sound, though continuous, has often a 
 marked and regular increase, or swell, which keeps time with the heart's systole, 
 and is believed to depend upon the pulsating pressure of the contiguous artery. It 
 is best heard on the right side of the neck, just above the clavicle, and just behind 
 the posterior edge of the sterno-mastoid muscle. You must take care not to pro 
 duce these sounds, as you easily may, by pressure with the stethoscope. So, also, 
 you may suspend them at your pleasure, by pressing, above the stethoscope, upon 
 the track of the veins, so as to stop the current of blood through them, without 
 arresting the pulsation of the arteries. This proves that the murmurs are venous. 
 I have no leisure to go more into particulars concerning these sounds ; but when you 
 meet with them, concurring with cardiac palpitations, in a young, nervous, anasmic 
 subject, the palpitations, ninety-nine times in a hundred, will turn out to be simply 
 functional — independent of any organic disease. No doubt there may be co-existing 
 change of structure ; but that is a rare exception, and, when it does occur, the signs 
 proper to structural disease will be present, and will betray it. 
 
 Now, these palpitations, and these musical or rushing sounds in the jugular veins, 
 are to be cured by remedying the state of the blood. And the remedies are prepa- 
 rations of steel, aloetic purgatives, animal food, the cold shower-bath, and exercise 
 short of producing great fatigue, in pure air. 
 
 I have further to remark, with respect to intermissions of the heart's action, aftd 
 therefore of the pulse at the wrist, that they are frequently connected, both in health 
 and in disease, with feebleness, and also with unusual slowness, of pulsation. So 
 that a slow pulse, which is likewise feeble, is often converted into an intermitting 
 pulse by depletion ; by blood-letting, for example, or by an active purgative ; and 
 the intermittence may be removed again by a stimulant. I mention this now, be- 
 cause there is another and very different state of disease, in which the pulse is apt 
 to intermit. 1 mean when there is plethora capitis, and cerebral mischief is present 
 or impending. But then the pulse will be full and strong, and labouring. In these 
 cases, a stimulant treatment would of course be injurious ; while blood-letting, which 
 would cause the other form of intermission, is the remedy of this. 
 
 Some assistance in determining between organic disease and mere functional dis- 
 order of the heart, may perhaps be derived from observing the position of the patient. 
 It is stated that when there is mere nervous palpitation, the patient lies as well, and 
 perhaps better, on the left side than otherwise ; whereas, when the heart is actually 
 diseased, the decubitus on the right side is more comfortable than that on the left. 
 If there be any tenderness of the heart, or of its enveloping membrane, the posture 
 on the right side is supposed to be the easiest, because the heart is further removed 
 from the ribs, and impinges upon them during the systole with less force. How- 
 ever, no great stress can be laid upon this symptom. 
 
 Of the remaining general symptoms of heart-disease there is not much to be said. 
 Dy!>pncea and cough are indirect symptoms declared through the lungs, between 
 which and the heart there is a close and obvious reciprocal influence. But dyspnoea 
 und cough are direct symptoms of pulmonary disease ; and even of pulmonary disease 
 they scarcely help the precise diagnosis. That disease of the heart may materially 
 alter the quantity of blood that is sent to, or transmitted from the lungs, is too plain 
 V> require any formal proof; and where the quantity of blood in the lungs is affected, 
 
 I
 
 DISEASES OF THE HEART. 671 
 
 the quantity of air necessary to ventilate that blood must vary : in other words, dysp- 
 noea must ensue. Hcemoptysis is also an equivocal symptom. 
 
 One very common effect of cardiac disease is an impeded and sluggish trans 
 mission of venous blood from the abdominal viscera. Hence congestions of various 
 parts, and especially of the liver, which enlarges and grows tender; and the biliary 
 secretion and functions are deranged. These symptoms are a fruitful source of 
 mistake, leading the unwary practitioner into the belief that the whole of his patient's 
 malady is hepatic ; whom he comforts accordingly with the assurance that " it is all 
 liver." 
 
 The circulation through the brain is also apt to be much disturbed in heart dis- 
 eases ; and to this circumstance we must attribute the headaches and giddiness that 
 often accompany them ; the dread and causeless apprehension which such patients 
 frequently exhibit ; the cowardice and irritability which disease of the heart engen- 
 ders in men who previously were intrepid, and of strong and firm nerves ; also that 
 propensity to dreaming, and especially to distressful and frightening dreams, so com- 
 monly observable in them ; and the sudden starting from sleep in horror and alarm. 
 The relations that exist between apoplexy and organic disease of the heart, were 
 full}'- discussed in a former lecture. 
 
 One of the most common indirect symptoms of cardiac disease is dropsy; yet, 
 sometimes, the disease of the heart may continue long, and even prove fatal, without 
 giving rise to any dropsy. It will produce that symptom, or not, according as it 
 leads to venous congestion or not. Hence, dropsy is more particularly connected 
 with dilatation and attenuation of the right cavities of the heart. But these are 
 points to which I must revert. 
 
 Having thus run over, gentlemen, the morbid changes to which the heart, as a 
 muscular organ, is liable ; the alterations of thickness in its walls, and of capacity 
 in its chambers, and the derangements of the natural relations between the several 
 cliambers and their orifices ; having considered, also, in a brief and cursory man- 
 ner, the sounds which the heart gives out in its different movements during health, 
 and the modifications to which these sounds are subject in disease ; and having, 
 moreover, passed in revietv the general symptoms which frequently display them- 
 selves in connection with cardiac disease, we shall be the better prepared, I hope, 
 to investigate, when we next meet, some of the specific diseases of that important 
 organ. 
 
 LECTURE LX. 
 
 Diseases affecting the muscular texture of the heart ; and their treatment. Changes 
 to which the valves of the heart are subject. Effects, and diagnosis of thos« 
 changes. .Angina pectoris. 
 
 I KNOW not how I can so well put you in possession of what I know, or think cou 
 cerning particular structural diseases of the heart, as by taking them in succession, 
 and offering a sort of running commentary upon them. The mechanism of those 
 structural changes, and the altered sounds, and the other physical signs, arising out 
 of them, I endeavoured to explain in the last lecture. Bear in mind that in this 
 place I can do no more than draw broad outhnes. 
 
 Simple hypertrophy of the left ventricle. This sometimes occurs when we can 
 discover no mechanical obstacle to the passage of the blood out of the ventricle, 
 which might account for it : none, I mean, by the closest scrutiny made even after 
 death. Is it then possible that this change may be brought about by physical causes 
 which are not perniarient, and have no place within the body : such as undue action 
 of the organ for a length of time, in consequence of habitual bodily exertion ? A 
 runner, for example, vve may conceive to keep his heart beating with a degree of 
 force and frequency beyond what is natural, for the greater part of the day; and thai
 
 672 DISEASES OF THE HEART. 
 
 for many days, or weeks together. Again, can simple hypertrophy grow out of that 
 excessive action of the heart which may be kept up, day after day, fbr a long period 
 by protracted mental emotion? It is difficult to answer these questions. But I pre- 
 sume that causes of this kind — that any cause, in short, which im.plied long-continued 
 uicrease in the function of the organ, — would suffice to generate hypertrophy. What 
 's certain, however, is that such causes seldom do act with sufficient intensity and 
 constancy to produce these effects: and simple hypertrophy of the left ventricle, 
 with no ph3'sical obstruction to the flow of blood through the heart, and no impedi- 
 ment to the free play of the organ, is rare. 
 
 We ascertain its existence when it does exist, first, b)"- the account which the 
 patient gives of himself. He has a sensation of beating of his heart, which he 
 ought not to have ; he feels it, and hears it beating as he lies awake in bed ; or even 
 at other times when he is at rest. The pulsations are regular. Hypertrophy has 
 no tendency in itself to cause the pulse to intermit or to become irregular. There is 
 no marked dyspnoea : the circulation of the blood through the lungs is not much af- 
 fected by this akeration of the left ventricle ; they are in fact protected by the mitral 
 valve : there is seldom any dropsy : but the arterial circulation being forced, there is 
 a tendency to active congestion in the capillary vessels. As there is no mechanical 
 obstacle to bridle the excessive power of the muscle, the pulse is full and strong; the 
 face is florid ; the patient is liable to headache, to bleeding from the nose, to active 
 hemorrhage, and to local inflammation. If you listen to the heart in such a case, you 
 find that the systolic sound is less loud and clear than natural. It is not heard beyond 
 the prtecordial region, nor even perhaps over its whole extent : but there is no bel- 
 lows sound. And if you place your hand upon the left breast, you feel that steady, 
 swelling, incontrollable impulsion, which I spoke of in the last lecture as the surest 
 sign that I am acquainted with, of hypertrophy. Sometimes the prsecordial region 
 is manifestly bulging and prominent. 
 
 If I were to preach for an hour concerning the treatment of such cases, I could say 
 no more than this : that they require perfect quiet of mind and body ; undeviating 
 abstinence ; in short, the strict observance of the antiphlogistic regimen as formerly 
 described ; and some of the antiphlogistic remedies : particularly moderate topical 
 bleedings, often repeated ; v\'ith a close attention to the functions of the digestive 
 organs. These are the cases in which, if any, we may expect to cure hypertrophy. 
 
 If simple hypertrophy of the left ventricle be rare, hypertrophy of the same 
 chamber from a mechanical obstacle, or from some hindrance to the easy working 
 of the hydraulic machine, is exceedingly common. What difl^erence, then, let ua 
 inquire, is made in the symptoms, in the treatment, and in the prospect of recovery, 
 by the presence of a physical impediment, out of which the hypertrophy has grown ? 
 
 The mechanical impediment will frequently signify its existence, by causing some 
 unnatural sound : a systolic bellows sound most commonly, which is audible over 
 the sternum, along the course of the aorta. And the mechanical impediment will 
 tend to cause faltering of the pulse; but generally the hypertrophy corrects that 
 tendency. So, on the other hand, the mechanical obstacle corrects the tendency of 
 the hypertrophy to cause active capillary congestion : and when the obstacle is con- 
 siderable, it will prevent the pulse from being so full and strong as in the former 
 case. If to the physical signs of hypertrophy of the left ventricle there be added a 
 bellows sound, and a disproportionate smallness and feebleness of the pulse at the 
 wrist, we may safely conclude that there is some impediment to the escape of the 
 blood from the left ventricle into the aorta ; and that this impediment has given 
 occasion to the hypertrophy. 
 
 Now, in this case, the hypertrophy is really an endeavour towards health. The 
 mcreased power of the ventricle compensates for the bar which is opposed to the 
 current of the blood. The blood would not be able to goon without the hypertrophy. 
 There would ensue a tendency to stagnation in the circulation, a faltering pulse, im- 
 perfect arterialization of the blood, blue cheeks and lips, dyspncea, dropsy ; but the 
 augmentation of bulk and force in the impelling muscle obviates this ; obviates it at 
 least for a while : puts off" the evil day to a distance. Since this is the case, and 
 since rt'e have no means of removing the mechanical impediment, we should be mad
 
 DISEASES OF THE HEART. 673 
 
 to desire the cure of the hypertrophy, which is to a certain degree a remedy for the 
 impediment; nor indeed could we cure it if we would. But we have to endeavour 
 to keep it within due bounds. If the beating be troublesome to the patient, we may 
 alleviate that symptom, and check what there may be unnecessarily active in the 
 contractions of the morbid chamber, by abstracting blood from the pra:!Cordia by 
 leeches ; and by sohciting the action of the kidneys, by means of cooling diuretics, 
 among which small doses of digitalis may find an appropriate place. The labouring 
 action of the heart is sometimes calmed by the application of a belladonna plaster. 
 In this variety, also, of the disease, it is of primary importance that no undue efforts 
 of the body be made, and that the patient be protected, as much as possible, against 
 all causes of mental emotion ; that scrupulous temperance be enforced ; and that all 
 the functions of the body be carefully watched and regulated. 
 
 These are not cases in which we can look for recovery: but they are cases which 
 bad management and imprudent habits may hurry on to a fatal termination; and 
 which judicious treatment and a well-regulated course of living may render tolerable, 
 and carry forwards for a considerable period. 
 
 Under the same condition of mechanical impediment, we oftener have eccentric 
 hypertrophy of the left ventricle ; hypertrophy, i. e., with dilatation. Of course the 
 bulk of the whole organ is augmented by both of those conditions ; and sometimes it 
 becomes enormous, as big as that of a bullock. The symptoms will differ somewhat, 
 according as the hypertrophy, or the dilatation preponderates, and tiierefore it will 
 be as well to state here what are the symptoms of simply dilated ventricles. They 
 are a diminished imptdse of the heart's action; and therewith a clearer sound than 
 IS natural. The first sound approximates to that of the heart's diastole ; to the 
 clacking second sound, and it is heard extensively. There is more or less tendency 
 to fluttering palpitations and irregularities of the pulse, which is usually weak and 
 small ; to faintness and debility, and to coldness of the extremities: and when the 
 right ventricle is dilated, there are some other symptoms which I shall notice 
 presently. 
 
 Now, I say, there will be a mixture or modification of the symptoms, when the 
 left ventricle is both dilated and hypertrophic. The dilatation will aid the mechanical 
 impediment in giving a tendency to irregularity and intermission of the pulse ; and 
 the hypertrophy will tend to rectify that disposition. And we must trim our man- 
 agement of such cases accordingly. If the pulse flutters, we cautiously administer 
 tonics, or stimulants : if it is steady, and the signs that belong to simple hypertro- 
 phy predominate, and are excessive and troublesome, we must starve the patient, 
 take blood from his side, purge him, and give him diuretics; but at all times keep 
 him as tranquil as we can. 
 
 Simple hypertrophy of the right ventricle is not a common disease. When it 
 occurs, it results from some actual or virtual impediment to the passage of the blood 
 from the ventricle into the lungs. The most extreme instance of it that I ever saw, 
 was in the heart of a medical friend's son, who died at the age of seventeen ; having 
 been for many years affected with the morbus cseruleus as it has been called, i. e., 
 an habitual blue state of the cheeks, lips, and tongue, finger-nails, and the skin 
 generally ; attended with shortness of breath, and augmented by every kind of ex- 
 ertion. It is seldom that persons thus affected live so long as this poor boy did. 
 The heart, as is usual under such circumstances, was malformed. The septum 
 between the ventricles was imperfect at its upper part ; and the aorta belonged as 
 much to the one ventricle as to the other. The pulmonary artery would not admit 
 a goose-quill ; the walls of the right ventricle were as thick as those of the left. 
 
 Authors tell us that hypertrophy of the right ventricle of the heart is a cause of 
 pulmonary apoplexy. I explained to you in a former lecture why I cannot believe 
 in this doctrine. In the first place I say that the increased thickness and strength 
 of the walls of that chamber supply a measure of the difficulty, and not of they'ree- 
 dom and force, with which the blood is conveyed to the lungs. In the second place 
 pulmonary apoplexy does not result from rupture of vessels by the vis a tergo, nor 
 in general from rupture of vessels at all ; and therefore is a quite different lesion 
 from cerebral appoplexy. It is simply an accident of pulmonary hemorrhage. Ana 
 43 3o
 
 C74 DISEASES OF THE HEART. 
 
 lastly, I never met with pulmonary apoplexy coincident with mere hypertrophy of 
 the right ventricle. The right ventricle lies on this side the lungs, in the order 
 of the circulation ; and accordingly, following the rule I mentioned in the last lec- 
 ture, its morbid states are for the most part effects, and not causes of pulmonary 
 disease. 
 
 The commonest affection of the right ventricle is dilatation without any increase 
 of thickness, but with attenuation even, of its muscular parieles. This is in general 
 the consequence oi long standing pulmonary disease ; which has prevented the easy 
 passage of the blood out of the right ventricle. It is often, or ultimately attended 
 with dilatation of the right auricle, and of the jugular veins, which stand out in 
 relief from the sides of the neck, and exhibit an undulating sort of pulsation, pro- 
 duced by the regurgitation of a part of the blood, whenever the ventricle contracts. 
 I have taken from the neck of a person dead of such disease, veins into which I 
 could pass my forelinger. With all this there is a fluttering action of the heart, an 
 irregular pulse, great distress and shortness of breathing, a dusky skin, and blueness 
 of the countenance, which is bloated and anxious: and a tendency to delirium and 
 drowsiness ; while, sooner or later, the whole areolar tissue of the body becomes 
 charged with accumulated serum. Some degree of this may now and then be 
 noticed towards the fatal close of phthisis. Much oftener it accompanies the latter 
 periods of extensive pulmonary emphysema. The same condition of the right cham- 
 bers, producing the same afflictive consequences, is the very frequent sequel of 
 organic changes that originated in the left side of the heart. 
 
 Disease, such as I am now describing, in its advanced stages especially, is diiScult 
 to treat. If you stimulate, you run the risk of increasing the patient's distress ; if 
 you deplete, you incur the hazard of producing fatal syncope, of bringing the heart 
 to a pause from which it is never able to recover. Here, again, you must try lo keep 
 the kidneys active ; you must enjoin that, as far as may be possible, all causes of 
 agitation or hurry, everj'thing which has previously been found prejudicial to the 
 patient, may be sedulously warded off. I have found more benefit in these cases 
 from steel cautiously employed, than from any other drug. Without forcing the 
 heart's action, it appears to have the effect of increasing the tone of its muscle ; 
 which it thus enables, ybr a lime, to compete more successfully with the load it has 
 to carry, and the impediment which it cannot overcome. We can do no more in 
 such cases than palliate. 
 
 Sometimes the parietes of one or of the other ventricle becomes so thin — either in 
 consequence of dilatation with tenuity, or through ulceration of the muscular tissue- 
 as to bulge out into a pouch, or even to crack ; in which case the patient almost 
 always dies suddenly, the motion of the organ being stopped and strangled by the 
 effusion of blood into the pericardium ; so that to die of a broken heart, is not a mere 
 metaphor. A clergj'man from the country, whom I previously knew, called at my 
 house in the autunm, and waited some time in my absence ; but went away at last 
 without seeing me : and after consulting Dr. James Johnson, set out for his home, 
 ten miles on the other side of Colchester. He had been unwell for some time ; had 
 suffered occasional attacks of dyspnoea; and was unusually nervous and irritable. 
 He must have been conscious of some severe distress, for he was extremely anxious 
 to get home, and bribed the post-boys to drive fast. As soon as he reached his own 
 house, he took some supper, and went to bed, apparently comfortable. Half an hour 
 afterwards one of his servants went to him, and found, him asleep. At the expiration 
 of another half-hour, he was again visited, and was then a corpse. Among other 
 changes, the pericardium was full of blood, which had escaped from the heart through 
 a rent in the left ventricle, large enough to admit one's finger. That part of the 
 ventricle which surrounded the laceration, was unnaturally thin, to the extent of a 
 crown-piece. There are several specimens of rupture of the left ventricle in the 
 Museum at St. Bartholomew's Hospital. George II. died of rupture of the heart. 
 It is curious enough that a Duchess of Brunswick, of the same family with George 
 II., died of the same disease. In her case an ulcer penetrated the parietes of the 
 'ight ventricle, which in other respects was healtny. In most instances, the rupture 
 has taken place in the left ventricle. The same chamber is also liable to aneurisma .
 
 DISEASES OF THE HEART. 
 
 that is, to partial distension of its walls into lateral cells or pouches. This form of 
 disease has not been met with in the right ventricle. 
 
 Hypertrophy — or dilatation — or dilatation and hypertrophy — may affect, in their 
 various degrees and combinations, one chamber only of the heart ; or several at the 
 same time ; or all of them together. It would be vain to attempt to represent, in 
 verbal description, these complicated changes. Enough, I trust, has been said, to 
 enable you to unravel them when they come before you ; and to ascertain, with 
 sut'ficient exactness, the general indications which they severally furnish, and the 
 plan of treatment which they require. 
 
 You will often find the muscular substance of the heart pale, soft, and flabby; 
 easily broken down, or penetrated by pressure. This may occur with general de- 
 bihty and looseness of tissue ; it sometimes accompanies a plentiful deposit of fat 
 about the organ : and it is supposed to be sometimes also a consequence of inflam- 
 mation affecting the muscle. Walls thus soft are likely to yield under pressure ; 
 but I know of no particular symptom by which we can detect such a state of 
 softening. 
 
 The morbid conditions of which I have been speaking, involving the muscular 
 substance of the heart, spring very frequently indeed from pre-existing morbid con- 
 ditions of the membrane lining the heart, or of the membrane investing the heart. 
 It is necessary therefore, in the next place, to inquire into the nature and history of 
 these morbid changes : and I will first request your attention to the diseases of the 
 Jning membrane. The investing membrane is familiar to you as the pericardium. 
 Of late years, since the diseased states of the internal membrane have been more 
 studied and understood than they formerly were, it has been called the endocardium: 
 a convenient enough name, which may occasionally spare us circumlocution. Now, 
 certain parts of the endocardium are much more obnoxious to disease than others : 
 those parts which enter into the fabric of the valves and orifices of the organ. The 
 membrane is here in close contact with a dense fibrous tissue; and participates in 
 the changes to which that tissue is subject. And it is an important fact, that the 
 valves and orifices of the left side of the heart are much more frequently affected 
 with disease than those of the right side. I have adverted to this fact before. What 
 is the prevaiHng cause of it I cannot tell ; but it seems to be a portion of a more 
 general fact ; namely, that the arteries are more liable to chronic morbid changes 
 than the veins. Some explain the difference by alleging that the left side of the 
 heart has the heavier task to accomplish. But nature seldom executes her purposes 
 so clumsily, as not to adjust the strength of her machinery to the labour it is destined 
 to perform. Others remark that fibrous tissue is more abundant, and therefore the 
 changes proper to that tissue are more numerous and extensive on the left side. And 
 this may be the true explanation. Others, again, have conjectured that the arterial 
 blood is more irritating than the venous. But there is no evidence of this : and it is 
 better to content ourselves with noticing the fact, without attempting to account for 
 it by mere gratuitous hypothesis. 
 
 You are not, however, to suppose that the right side is exempt from valvular dis- 
 ease. When there is much change on the left, we often find a less degree of the 
 Fame kind of change upon the right. The valves of the pulmonary artery are, per- 
 haps, the least frequently of all the valves found otherwise than healthy. 
 
 Many of the alterations that take place in the internal lining of the heart result, 
 apparently, from inflammation, which causes a deposit of lymph upon or beneath 
 the serous membrane. The valves are apt to lose their thinness, and transparency, 
 and pliancy. They become thick, stiff, puckered, curled up, or glued to each other, 
 or to the opposite walls of the channel. On the other hand, quite independently 
 of inflammation, they may become morbidly thin, riddled with holes, and even 
 rent asunder. What are called vegetations or excrescences may also project from 
 them, very much resembling warts. Or they may be converted wholly or partly 
 into bone. 
 
 Alterations of some kind or another are very frequent in the semilunar valves of 
 the aorta. When they are of such a nature as to diminish the orifice during the 
 systole, they commonly occasion a systolic bellows sound. When the diseased
 
 676 DISEASES OF THE HEART. 
 
 valves offer no obstruction to the exit of blood from the ventricle, but do not close 
 again immediately afterwxirds, so as effectually to prevent the reflux of that fluid 
 from the aorta, they commonly give rise to a diastolic bellows sound. When both 
 these defects of function occur, there is often a double bellows sound ; a sawing 
 alternate noise ; one murmur during the systole, another, distinguishable in tone and 
 quality, as well as in time, during the diastole. These sounds are conveyed along 
 the tube in which they are formed, and are therefore most audible in the track of 
 the aorta, as it leaves the heart. If the sound be diastolic, it will take the place of 
 the smart clack of the second sound of the heart, or perhaps succeed it. Sometimes 
 the new sound is very loud and curious. I had a patient in the hospital last year, 
 in whom this diastolic sound was, in character and intensity, like the cooing of a 
 pigeon. The patient could plainly hear it ; nay, it could be heard by a person 
 standing near him, but not touching his body, even with a stethoscope. In that in- 
 stance we found one of the aortic valves irregularly thickened, with its free edge 
 loose and flapping, and unable to fulfil its function of closing the aperture. During 
 the diastole it was retroverted, and vibrated in the regurgitating stream of blood ; 
 and thus, no doubt, the musical note, heard alternately with the first sound, was 
 produced. In March, 1837, I heard in a man (Henry Milton) who was under Dr. 
 Latham's care in St. Bartholomew's Hospital, and who had had acute rheumatism, 
 a very shrill diastolic sound, like the repeated whining of an imprisoned puppy-dog 
 wishing to be released. This remarkable sound was audible by means of the stetho- 
 scope, even in the radial artery. The patient died at last in St. George's Hospital, 
 and his case is mentioned in Dr. Hope's book on the heart. One of the aortic valves 
 was torn downwards to some distance from its edge, and formed a flap, which was 
 perforated by a round hole. 
 
 I need not again point out to you the manner in which such disease of these semi- 
 lunar valves tends to produce hypertrophy and dilatation of the left ventricle. 
 
 The niitrul valve is often thickened ; and it is particularly subject, more so even 
 than the aortic valves, to ossification. And the effects of the ossification are to pre- 
 vent its closing the auricular orifice durmg the systole ; and to prevent its lying- flat 
 against the walls of the ventricle, and allowing a free passage of the blood out of the 
 left auricle, during the diastole. The orifice is often converted into an unvarying 
 oval slit, with puckered edges, and resembling a button-hole ; or the valve projects, 
 like a thimble of bone, into the left ventricle. And it is remarkable how small the 
 chink, which is thus permanent, may be, and yet life go on. The heart having been 
 taken out of the body, and the auricle filled with water, I have seen the water pass 
 into the ventricle, by its gravity, stillathn ; drop by drop. 
 
 Let me just remind you, that the direct and necessary consequence of constriction 
 of the mitral orifice, is an accumulation of blood behind it ; i. e., in the left auricle, 
 in the pulmonary veins, in the lungs. Hence so much mechanical congestion, that 
 the blood bursts at length through the bronchial membrane ; hemorrhage, slow or 
 copious, ensues from the air-passages ; and pidmonary apoplexy is formed. 
 
 In extreme cases, where the mischief is chiefly confined to that valve, the blood 
 necessarily reaches the ventricle in a penurious manner ; that chamber contracts un- 
 steadily and irregularly ; and its cavity sometimes diminishes. This I think I have 
 seen. But far more commonly there is disease of the aortic valves also; and the 
 condition of the left ventricle is that of hypertrophy with dilatation. 
 
 When there is a permanent chink in place of the limber valve, there may be a 
 double bruit. The first heard during the systole, and produced by the regurgitation 
 of blood from the ventricle into the auricle, through the rigid slit. This is common. 
 The second accompanying the diastole, and resulting from the mechanical impedi- 
 uient to the free passage of the blood from the auricle into the ventricle. This is 
 uncommon. The constriction must be great for the diastolic murmur to occur a* 
 all : and when it does occur, it is faint ; from the comparative feebleness (I presume) 
 of the auricular contractions. 
 
 The fonn and the consistence of the altered valves being the same, no difference 
 whatever in the sounds, or in the general symptoms, will arise from the particulai 
 nature of the changes. It will, 1 mean, make no difference whether the obstacle to 
 
 I
 
 DISEASES OF THE HEART. 677 
 
 rhe flowing blood, or the imperfect closure of the orifice, depends upon mere thicken- 
 ing of the valve by cartilaginous deposition, or upon ossification, or upon wart-like 
 vegetations. These last may be found upon any of the valves, but, like other 
 morbid states, they are less frequent on the right than on the left side of the heart • 
 «nd they are most common of all on the aortic valves. Ossification — the deposition 
 of the phosphate of lime — is almost confined, I believe, to the left side. I never saw 
 the tricuspid valve, or the semilunar valves of the pulmonary artery, converted into 
 bone. 
 
 The warts, or w^art-like excrescences, which are so often found upon the valves 
 of the heart, are very curious things. Sometimes they are separate, like rows of 
 beads. Sometimes several appear to spring from a common base, which spreads 
 out so as to exhibit a cauliflower appearance. And occasionally they hang in long 
 strings from the valve into the adjoining chamber of the heart. In a patient of Dr. 
 Hawkins', I saw a cylindrical excrescence of this kind which measured an inch in 
 length. The valves presented sht-like perforations ; and from the edge of one of 
 these slits in the mitral valve, this long vegetation dangled into the ventricle. The 
 whole of the valves of the aorta were covered, on their ventricular surface, with 
 similar but shorter excrescences. 
 
 They vary much, these vegetations, in consistence. Sometimes they are soft, 
 easily crushed, and capable of being readily detached from the smooth surface of the 
 valve. Others are more firm, and yet separable from the valve without injury to it. 
 Others, again, are so adherent, so rooted into the valves, that they can be removed 
 only by tearing or cutting them off. They are found sometimes on the free edge 
 of the valves ; sometimes on their surface, or even on the inner membrane of one 
 of the chambers, especially of the left auricle. 
 
 Much difference of opinion has prevailed respecting the nature and origin of these 
 singular appearances. It was a common notion among the French, at one time, that 
 they were really, what they so much resemble, venereal warts. What seems to be 
 certain is, that they are somehow connected with inflammation of the internal lining 
 of the heart ; and of that which covers the valves in particular. But, then, are they 
 lymph poured out from the inflamed membrane ? or are they fibrin deposited from 
 the blood upon an inflamed membrane 1 It is probable that the last is, sometimes 
 at least, the true explanation of their origin. You know, that when the membrane 
 lining a vein becomes inflamed, the blood in contact Avith it has a strong tendency to 
 coagulate upon it, and to adhere to it. The fleshy excrescences found on the valves 
 are often attached to the edges of slits in the valve : the broken surface having pro- 
 bably been the especial seat of inflammation. When then the formation of vegeta- 
 tions is recent, they are very soft and frangible. But the most interesting fact that I 
 am acquainted with, in evidence of the mode in which these little projections arise, 
 is one that accidentally came to light in one of Dr. Hope's experiments upon an ass, 
 at which I was present. The aortic valves had been held back by a wire passed 
 into the vessel, with the view of ascertaining the physical cause of the second sound. 
 The animal was previously rendered insensible by a narcotic poison ; and the circu- 
 lation was kept up — languidly, however, towards the last — by artificial respiration. 
 Upon the final cessation of the heart's motions, the organ was removed from the 
 body and exammed : and the valve that had been mechanically irritated by the 
 wire, was found studded with these little wart-like appearances, which were so soft 
 as to admit of being readily brushed off from the subjacent membrane. Here the 
 deposit took place after the death of the animal, and while some of the functions of 
 organic hfe alone were kept up by the artificial breathing. 
 
 There are still some curious circumstances to be mentioned, connected, in some 
 instances, with the formation of these warty vegetations. I shall not, however, enter 
 upon them in the present lecture : but when I speak, at our next meeting, of rheu 
 matic inflammation of the heart and its membranes. 
 
 Any or all of the lesions that I have been describing may and must lead, at lengtli, 
 according to their places and magnitude, to some of those changes in the actual and 
 relative dimensions of the heart that were considered in the last lecture. They 
 obstruct the stream of blood when moving in its natural course, and when its passage 
 
 3g3
 
 678 DISEASES OF THE HEART. 
 
 ought to be free ; or they allow of its refluent course, when it ought to be effectually 
 opposed : and the necessary results, in either case, are dilatation of one or more 
 of the chambers of the heart, with thickening, or with attenuation, as the case may 
 be, of its walls. I have already spoken of the symptoms, physical and general, to 
 which these secondary changes give rise ; and of the treatment which they admit 
 and require. 
 
 There being valvular disease, and that valvular disease giving rise to a bellows 
 sound, can we distinguish the particular valve affected ? Generally, we can. Our 
 skill in diagnosis outruns here, as indeed it too often does, our skill to cure. A few 
 simple rules and considerations enable us, in most cases, to satisfy our natural curi- 
 osity to penetrate the exact conditions even of changes that are incapable of repair. 
 These rules relate chiefly to the time when the murmur is heard ; to the direction in 
 which it is most audible ; and to the state of the arterial pulse. 
 
 When a bellows sound accompanies the systole, it must be caused by a current 
 passing out of a ventricle. But serious disease of the valves, sufficient to occasion 
 a murmur, on the right side of the heart, is very rare. In nineteen cases out of 
 twenty, valvular murmurs belong to the left side; so that practically the distinction 
 lies, almost always, between two orifices, the mitral and the aortic, the inlet and the 
 outlet of the left ventricle. The natural inlet has become an outlet also: or the 
 natural outlet is obstructed. Now if the sound be heard at the base of the heart, 
 and along the track of the thoracic aorta, up towards the right clavicle, and even in 
 the carotids ; and if it be less audible towards the apex, and if the pulse be steady 
 and regular, the mischief is seated in the semilunar valves of the aorta : there is 
 some obstacle which produces a ripple in the onward stream of the blood. 
 
 On the other hand, if the pulse be irregular, and if the sound be heard better 
 towards the apex of the organ, on the left, it is owing to regurgitation through a dis- 
 eased mitral valve. Such regurgitation is often attended with a purring thrill. 
 
 When, what scarcely ever happens, the sound does result from injury of the 
 semilunar valves of the pulmonary artery, it is heard plainest in the track of that 
 vessel, up towards the left clavicle. So also a murmur produced by change in the 
 tricuspid valve would be loudest towards the apex, on the right. The arterial pulse, 
 for obvious reasons, is but little influenced by disease affecting the orifices of the 
 right heart. 
 
 Again, if the morbid sound be diastolic, it accompanies the entrance of blood into 
 a ventricle ; and for similar reasons as before, the fault is most probably in the left 
 ventricle. It may be owing to the direct, but impeded, passage of the blood from 
 the left auricle through a narrowed mitral orifice : yet this very seldom occasions 
 any audible noise. Or the diastolic murmur may proceed from regurgitation through 
 the defective aortic valves : the natural outlet having become an inlet also : and this 
 is exceedingly common. We attend, as before, to the situation and the track in 
 which the sound is the loudest. We listen also for the smart clack of the natural 
 second sound ; and if it is not to be heard, or is verj' indistinct, we have, in that cir- 
 cumstance, corroborative evidence of an imperfect aortic flood-gate. Moreover, we 
 are again assisted by the pulse. The pulse of aortic regurgitation is very striking 
 and peculiar : sudden, like the blow of a hammer, without any prolonged swell of 
 the artery. It always reminds me of the well known chemical toy, formed by 
 including a small quantity of liquid in a glass tube, exhausted of air, and hermeti- 
 cally sealed. On reversing the tube, the liquid falls from one end of it to the other 
 with a hard short knock, as if it were a mass of lead. The sensation given to the 
 finger by the pulse, when there is much regurgitation through the aortic valves, is 
 very similar to this. It is as if successive balls of blood were suddenly shot along 
 under the finger. Dr. Hope calls this pulse a jerking pulse ; the pulse of unfilled 
 arteries. And this abrupt pulse makes itself visible in the arteries : the wave of 
 blood lifts, and moves, and sometimes contorts the vessel. When this kind of pulse 
 occurs with a diastolic bellows sound heard in the track of the aorta, and the short 
 clack of the second sound is absent or diminished, you may be quite sure that the 
 aortic orifice is patulous during the diastole. The reflux of the blood, when the 
 patency is great, is strong enough sometimes to produce a palpable shock or iog.
 
 DISEASES OF THE HEART. . 679 
 
 called the diastolic impulse. And this refilling of the ventricle from the artery may 
 even provoke it to a supernumerary contraction. 
 
 In a patient by whom I was lately consulted, the hard, sudden, hammering pulse 
 led me to conclude that the blood regurgitated from his aorta ; and accordingly, 
 upon applymg my ear to his chest, I discovered a loud murmur, coincident with the 
 diastole, and most distinct in the direction of the right clavicle. The shock of this 
 man's artery was plainly to be felt, through his clothes, by one's hand laid lightly 
 upon the bend of his arm. His wife told me that, for five years past, this jarring 
 blow had made it uncomfortable for her to take his arm when they were walking 
 together. The same kind of jerking impulse was strikingly perceptible in the 
 femoral arteries, and in the carotids. 
 
 Of regurgitant sounds belonging lo the right side of the heart I can tell you 
 nothing. I never heard one, that I know of, from the pulmonic valves. Through 
 the tricuspid orifice the blood is believed to be often refluent ; causing, as I stated 
 before, turgescence and pulsation of the jugular veins. The structure of the valve 
 permits this ebbing movement of the blood under circumstances which might other- 
 wise be perilous. The tricuspid has accordingly been called the safety valve of the 
 heart. But the reflux seldom, if ever, announces itself by a bellows sound. 
 
 We cannot always thus rigidly connect morbid changes with definite signs. Dis- 
 orders arise, of which the symptoms are more cognizable and constant than the seat. 
 We assign a name to the peculiar assemblage of symptoms, and make it thenceforth 
 a distinct object of our study ; tracing the symptoms, as well as we can, up to their 
 organic causes and conditions. Now, the complaint called angina pectoris is one of 
 this kind. It is, moreover, a very curious and interesting disorder ; and I shall de • 
 vote the remainder of the present hour to its consideration. 
 
 This disease was first accurately described, in this country at least, by the cele- 
 brated Dr. Heberden, the author of the Commentaries. It had been adverted to by 
 many writers before, but obscurely ; and Dr. Heberden's observations were quite 
 original. The description that he has given of the complaint, in the second volume 
 of the Transactions of the College of Physicians, is very accurate and striking. He 
 calls it a disorder of the breast ; and observes that "the seat of it, and the sense of 
 strangling and anxiety with which it is attended, may make it not improperly be 
 called angina pectoris." 
 
 " Those who are afflicted with it are seized whilst they are walking, and more 
 particularly when they walk soon after eating, with a painful and most disagreeable 
 sensation in the breast, which seems as if it would take their fife away, if it were to 
 increase or to continue. The moment they stand still, all this uneasiness vanishes. 
 In all other respects the patients are, at the beginning of this disorder, perfectly well ; 
 and in particular have no shortness of breath, from which it is totally different." 
 Such is the brief description of the malady given by Dr. Heberden. You will 
 observe that the distress occurs in paroxysms, and the patient at first has intervals of 
 apparent health ; and even when the disease is more advanced, he has periods of 
 comparative ease between fits of suffering. The paroxysms are especially liable to 
 come on Avhen the patient is walking, and, above all, when he is ascending — going 
 up a hill. He is then seized, all at once, with a painful sensation, which seems to 
 be, in many cases, indescribable, but which is always referred to the heart, or its 
 neighbourhood. Sometimes the sensation is spoken of as being a spasm, as giving 
 the patient a notion of constriction ; but it also carries with it the impression that any 
 continuance of the exertion, the stirring another step, would be fatal. Yet the patient 
 is not out of breath. It is not dyspnosa that oppresses him ; for he can, and gene- 
 rally does, breathe freely and easily. He lays hold of any neighbouring object for 
 support. His face is pale and haggard ; and you would suppose, from his appear- 
 ance, that he was actually at the point of death. But in the early stages of the dis- 
 ease, the pang soon subsides, the distress is over, and the patient is entirely himseK 
 again. However, after the lapse of some time, generally of some months, the anguish 
 does not so instantaneously cease upon standing still, nor does it always require somt* 
 bodily exertion to bring it on. It will occur when the patient is quiet, even xn be.'
 
 080 DISEASES OF THE HEART. 
 
 He feels as if the action of the heart was arrested ; and he is obliged to rise up 
 every night perhaps, for many weeks together. In exquisite cases it will be brought 
 on by causes of any kind that slightly accelerate the circulation : coughing, straining 
 at stool, mental emotion. 
 
 The pain, which is at first referred to the region of the heart, frequently extends, 
 accompanied by a sort of numbness, from that part to the left shoulder, and down 
 the left arm ; slopping short, in a curious manner, and from some inexplicable cause, 
 either just about the insertion of the deltoid muscle, or at the elbow, or at the wrist. 
 Sometimes, however, it runs down to the very extremities of the fingers ; particularly 
 of the last two fingers, following mainly the course of the ulnar nerve. And occa- 
 sionally similar pains affect the right side and arm. There is (I say) no dyspnoea in 
 the genuine form of the disease; although you will find it stated by some modern 
 writers of good repute, that the paroxysm is accompanied with difficulty of breath- 
 ing. In the instances that I have seen, and they have been few, the patient was 
 able slowly and fully to inspire and expire, even when the fit was on him. The 
 truth I believe to be, that other affections, more akin to asthma, have been confound- 
 ed with angina pectoris ; and this confusion has led to the belief that it is not altoge- 
 ther so dangerous a complaint as used to be thought ; but in its genuine shape it is 
 undoubtedly a very fatal disorder. Dr. Forbes, by a diligent search among authors, 
 has collected some statistical facts respecting it which are worth remembering. Thus, 
 out of eighty-eight cases, eight only, or one in eleven, occurred in females. The 
 ages, in eighty-four of these eighty-eight cases, are recorded ; and of the eighty- 
 four, seventy-two were above fifty years ; and twelve, or one-seventh of the whole, 
 under fifty years. It is a disease, therefore, for the most part, of advanced life ; and 
 this alone would afford a strong presumption of its dependence upon some organic 
 change. Again, the event of the disease was recorded in respect to sixty-four of the 
 patients. Of these, forty -nine died, almost all of them suddenly ; while fifteen reco- 
 vered, or were relieved. And among the forty-nine fatal cases, there were only two 
 of women. 
 
 That the seat of the disorder is the heart, and that it consists in some structural 
 change, can scarcely be doubted. Yet some pathologists are disposed to consider it 
 a merely neuralgic afft.'ction, " commencing for the most part in the pneumogastric 
 nerve, and spreading in different directions, as other nerves become involved." But 
 this doctrine is scarcely consistent, in my judgment, with the facts — first, that the 
 paroxysm is excited by such causes as are " especially calculated to disturb the natu- 
 ral action of the heart, bodily exertion, and mental emotion ;" and, secondly, that the 
 disease is so very frequently and so suddenly /«/«/. This is not at all the character 
 <f^ mere neuralgic diseases in general. And when we add to these facts the further 
 fact, viz., that, in a vast majority of instances, organic disease of the heart, or of the 
 great blood-vessels, has been discovered after death, I think we shall be obliged to 
 admit that the symptoms are often (for I will not say always) dependent upon cardiac 
 disease. One theory explains the " breast-pang," by supposing that the blood, when- 
 ever its movement is accelerated by exercise or otherwise, arrives in the heart faster 
 than it can be transmitted onwards, and, accumulating in its cavities, painfully dis- 1 
 tends them. It is not improbable that the paroxysm may be sometimes so produced. ' 
 The great Dr. Jenner took a most ingenious view of the matter, which was made 
 public and further enforced by Dr. Parry. He had found, in examining the bodies 
 of some who had died of well-marked angina pectoris, that the coronary arteries of 
 the heart were ossified ; converted into bony canals, and constricted in their calibre. 
 He thence concluded that the paroxysms result from the circumstance, that when 
 some increase of the muscular contraction of the heart happens to be called for, the 
 increased supply of blood, rendered necessary by the additional exertion, is not capa- 
 ble of being furnished by the diseased nutrient arteries of the organ ; that the heart 
 comes to a stand, because its muscular tissue is not duly injected with arterial blood ; 
 and the phenomena of the paroxysm agree remarkably well with that theory. He 
 calls the disease, accordingly, " .syncope anginosa." And this simple and beautiful 
 theory was for some time admitted as the true one. However, later investigations 
 have abun'lantly shown that angina pectoris may occur in a decided form, without 

 
 DISEASES OF THE HEART. 681 
 
 there being any ossification or other disease of the arteries ; and, on the other hand, 
 that the coronary arteries may be ossified, and yet no angina pectoris be the result. 
 
 I may here again avail myself of the researches of Dr. Forbes, and give you a 
 numerical account of the organic changes in the heart that have been found asso- 
 ciated with this disease. The total number of instances collected by him, in which 
 the body was examined after death, was forty-five. Of this number, there was dis 
 ease found in the hver only, in two instances : organic disease of the heart, or great 
 vessels, in forty-three. Dr. Forbes, indeed, makes the last number thirty-nine, 
 instead of forty-three, excluding four cases in which nothing morbid was found in 
 or about the heart, except an excessive coating of fat. This Dr. Fothergill consid- 
 erea the essence of the disease ; and certainly a heart cannot hi said to be in a 
 healthy condition which is thus loaded with adipous matter. The fat is generally 
 deposited at the expense of the muscular substance, which is apt in such cases to be 
 thin, pale, and soft ; atrophied, in short. Taking, however, the table as it is given 
 by Dr. Forbes, the thirty-nine cases in which there was no disease except in the 
 heart and great vessels, were thus distributed : — In ten of the cases there was organic 
 disease in the heart alone : in three, organic disease of the aorta alone. In one 
 instance only was the disease confined to the coronary arteries ; but there was ossifi- 
 cation, or cartilaginous thickening of the coronary arteries, combined with other 
 disease, in sixteen instances. Again, there was ossification, or other disease of the 
 valves of the heart, in sixteen cases also. There was disease of the aorta (ossifica- 
 tion, or dilatation, or both), in twenty-four cases ; and in twelve cases there was pre- 
 ternatural softness of the heart. 
 
 My friend, Dr. Latham, lately gave me this sketch of a case of angina pectoris, 
 which had fallen under his own observation. It is remarkable for the shortness of 
 its course. A gentleman, about fifty years old, was recovering from the influenza, 
 of which nothing remained but a slight cough, that troubled him at night. It was 
 to relieve this that Dr. Latham was consulted. The gentleman looked perfectly 
 well. After Dr. Latham had prescribed for this little ailment, the patient begged to 
 see him the next day, to talk over with him (he said) a very strange affection he had. 
 Accordingly, he then described a paroxysm of angina pectoris in terms that could not 
 be mistaken ; dwelHng especially upon the prsecordial pain, the sensation down the 
 left arm, the sense of approaching dissolution, and then the perfect recovery. This 
 gentleman had, during the previous summer, performed a walking tour through 
 Switzerland, and returned home in excellent health. The first notice of his angina 
 was not more than a month ago, when he was walking up Hampstead Hill. It was 
 then that he had his first paroxysm. In the short period which had elapsed, the 
 attacks had rapidly increased in severity and frequency ; occurring now every two 
 jr three days, or every day, or several times a day, with or without an exciting 
 cause. Dr. Latham made a careful examination of the chest, and found the respi- 
 ration perfect, the heart free from all unnatural murmurs, and its beats rhythmical. 
 The only t-hing that particularly attracted his notice was the exceeding feebleness of 
 its impulse. In the afternoon of the next day. Dr. Latham visited him again, when 
 he described a paroxysm he had suffered in the course of the morning, of much 
 greater severity than any that he had hitherto experienced. Dr. Latham saw enough 
 to convince him that his patient's existence was very precarious : and as he had pre- 
 viously been a stranger to him, he inquired about his friends, and took down the 
 address of a brother, intending to call and apprise him of what'he feared. On reach- 
 ing his own home, two hours afterwards, a messenger met him, announcing that his 
 patient had fallen into another paroxysm, soon after he left the house, and was dead 
 The body was carefully examined by a thorough anatomist, Mr. Stanley. There 
 was no disease of the aorta, or of the heart generally ; but the coronary arterici 
 resembled tubes of coral, being completely ossified as far as they could be traced. 
 
 The patient may even expire in the first or second paroxysm. This happened, 
 I believe, in the case of the late lamented Master of Rugby school. 
 
 You will perceive, from what has been said, that the prognosis of this singular 
 and formidable affection is extremely unfavourable. The cases are very rare in 
 which no disease of the heart has been detected ; and the organic changes thai
 
 682 PERICARDITIS. 
 
 have been found are remediless, and, for the most part, progressive ; and, in point 
 of fact, the greater number of those who have laboured under the disease have died 
 suddenl3^ 
 
 It follows, also, as another corollary from the facts now brought before you, that 
 there are very few cases in which we can dare to contemplate a cure. Our mea- 
 sures must be preventive when the paroxysms are absent; and our object will be to 
 shorten the fit when it is present and protracted. 
 
 Now, the preventive measures are simple and obvious. The patient must be cau- 
 tioned to avoid the exciting causes of the paroxysm ; walking up hill, or against the 
 wind, which has also been known to produce it. Whatever is likely to hurry the 
 circulation, and therefore, among the rest, all mental emotion and anxiety, should be 
 guarded against as much as possible. John Hunter died of angina pectoris : and 
 the fatal seizure was brought on by a fit of anger. Care should be taken also to 
 obtain and preserve a healthy state of the digestive organs. It is observable of this, 
 as 1 mentioned before it is observable of other cardiac diseases, that they are often 
 attended and aggravated by flatulence of the stomach and bowels. Persons labour- 
 ing under a paroxysm of angina often experience great and sudden relief upon get- 
 ting rid of a quantity of gas, by which the stomach had been distended. The flatu- 
 lence acts, no doubt, by pressing the diaphragm upwards, and so diminishing the 
 dimensions of the thorax, and impeding the play of the heart. It is upon the same 
 principle that we must explain the fact, that the paroxysms are particularly apt to 
 come on if the patient walks soon after a meal: also that they occur in the night, 
 when he is in a horizontal position, and are relieved by his getting out of bed ; that 
 is, by his assuming the vertical posture, and taking off the pressure of the abdominal 
 viscera from the diaphragm. 
 
 In the paroxysm itself, bleeding has been fairly tried ; but, as I think might have 
 been foreseen, it has seldom been attended with any benefit, and sometimes it appears 
 to have done harm. The affection has a nearer relation to sy'icope, and often to 
 syncope by asthenia, than to any thing else. That is the way in which the patients 
 die; and consequently, cordials, stimulants, and antispasmodics, are found to be of 
 service. Dr. Elliotson thinks prussic acid is the best thing you can administer 
 Dr. Davies has more faith in belladonna plasters than in most other things. Dr. 
 Copland advises stimulant liniments externally; and warm carminative or aperient 
 medicines, as the circumstances may require, internally. The general condition of 
 the sufferer will suggest, I believe, the proper treatment. Not that it will suggest 
 any particular drug, but it will teach you the main principle on which you are to 
 proceed. If auscultation reveal any of those morbid states of the heart which were 
 noticed in the beginning of the lecture, the means which I pointed out as suitable 
 for remedying them may be put in force. 
 
 LECTURE LXI. 
 
 Pencardifis ; its frequent connection with Acute Articular Rheumatism. Rhcit- 
 malic Carditis. Anatomical characters of acute Inflammation of the Pericar- 
 dium ; of the Eiidocardium. General symf '07ns Auscultatory signs. Rela- 
 tions of Carditis with Rheumatic Fever. 
 
 I YESTERDAY Considered, cursorily indeed, but as fully as the limits of these lectures 
 will permit, the effects of hypertrophy, and of dilatation with and without hypertro- 
 phy, of the several chambers of the heart : and of the means we possess of obviating 
 t»r alleviating those effects. I passed in review also the chronic changes to which 
 the endorcardir/m, especially in those parts where it covers the valves, and the ten- 
 dinous rings that give support to the valves, is liable ; and most of the circumstances 
 which give origin to such changes : and I spoke of that singular and perilous aflTcction
 
 PERICARDITIS. 683 
 
 to which the name of angina pectoris has been applied. I proceed this aflernoon to 
 the diseased conditions of the pericardium. This membrane is often the seat of 
 acute inflammation ; and the consequence of such inflammation is sometimes, though 
 rarely, the speedy extinction of life. But in nineteen cases out of twenty, the dis- 
 order proves fatal at a remote period ; destroying the subject of it more slowly, ind<^ed, 
 but almost as surely. Pericarditis is therefore, and has always been regarded as, a 
 very interesting disease ; a«d the more so, that it is in many instances a very insidious 
 disease also. 
 
 Acute pericarditis is Hable to arise, like all other internal inflammations, after ex- 
 posure to cold ; or when no exciting cause is to be discovered. But for one such 
 case of what may be called spontaneous acute inflammation of that membrane, you 
 will meet with a dozen, or more, in which it occurs in connection with a disease that 
 we have not yet had before us — acute rheumatism; a febrile disorder, characterized 
 by inflammation of a specific character, affecting the structures that lie around the 
 joints, or enter into their composition — the Jibrous tissues. I shall therefore consider 
 acute pericarditis with reference to its occurrence in rheumatic fever ; for in so doing, 
 I shall embrace all the practical points which belong to it under any form. But I 
 must tell you that when /pericarditis happens, in the course of an attack of rheuma- 
 tism, so also, to the best of my belief, in almost every instance, does enc/ocarditis. 
 For this reason I shall include, in the account I am desirous to give you of rheumatic 
 carditis, both these inflammations : inflammation of the investing membrane, and in- 
 flammation of the lining membrane of the heart. I mentioned in the last lecture, that, 
 in respect to the latter, to endocarditis, there were some peculiarities noticeable which 
 I should reserve for the present occasion. 
 
 The pericardium is one of the serous membranes ; so also may the endocardium 
 be considered. But the pericardium is also a shut sac; and the primary effects of 
 inflammation upon it are the same, mutatis mutandis, as upon the shut sac so near 
 it, the pleura. The second series of effects is, however, much more formidable. 
 Adhesion of the pleura does not necessarily abbreviate the natural term of the 
 patient's life ; adhesion of the pericardium almost always does : and effusion into the 
 cavity that contains the lung is far less serious than effusion into the bag that sur- 
 rounds the heart. In the one set of organs the mischief may be great, but it is final; 
 in the other, it leads, with unfailing certainty, sooner or later, to worse changes, which 
 at length prove incompatible with the further continuance of life. 
 
 You will understand, then, without the necessity of my going again into much 
 detail, that the pericardium, under acute inflammation, may undergo the same 
 changes, which, on a former occasion, we saw that the pleura might undergo. 
 Coagulable lymph may be poured forth from the entire membrane, and abolish the 
 cavity by glueing the whole of the pericardium to the heart : or serous fluid may be 
 effused, distending the bag of the pericardium, and keeping its smooth surfaces more 
 or less asunder : or both serum and lymph may be effused together ; or fibrin, in some 
 shape or another, may be deposited, for aught I know, from the homogeneous fluid 
 which is thrown out by the inflamed membrane in the first instance ; and the result of 
 this mixed effusion may here, also, as in the case of the pleura, be the partial adhe- 
 sion of the membrane to the heart. 
 
 But in the majority of instances the inflammation spreads over the whole mem- 
 brane, as it is apt to do in serous membranes generally ; and one of these two things 
 happens : either there is a large quantity of liquid effusion, which is not reabsorbed ; 
 and then generally the patient dies in a few days : or there is not much linuid eflfu- 
 sion, or the liquid part is absorbed, and the pericardium becomes permanently agglu- 
 tinated to the heart, and apparent recovery takes place. 
 
 In the cases that have proved fatal at an early period, when the inflamed mem- 
 brane has been unadherent, it has been found to contain serous fluid ; sometimes clear, 
 oftener turbid, frequently tinged with blood : and it has been seen to be covt.red 
 with a coating of the fibrinous or albuminous part of the blood ; what we caU plastic 
 or coagulable lymph. The deposited lymph assumes a variety of forms in differen: 
 cases ; but in every case that I have seen, the prevaihng character of the unattached 
 surface has been that o[ roughness ; and this is a circumstance of some importance.
 
 684 RHEUMATIC CARDITIS. 
 
 as we shall presently sec. The lymph is not arranged in smooth layers ; but it is 
 rugged, villous, or cellular. According to the fancy of different observers, it has 
 been thought to resemble lacework, or a sponge, or a honeycomb, or some kinds of 
 coral, or the interior of a calf's stomach. Sometimes it brisdes with a multitude of 
 small, short, pointed papillae : less frequently, it is softer and shaggy ; always it is 
 rough and uneven. Dr. Hope, following Laennec, states that the surface looks some- 
 times like that which would be produced by suddenly separating two flat pieces of 
 wood, between wdiich a thin layer of butter has been compressed. To my own eye, 
 the appearance presented by the membrane, in its recent condition, has been more 
 like the rough side of the pieces of tripe which you see in butchers' shops than any 
 thing else. 
 
 When, on the other hand, the patient dies, as he sometimes will do, soon after the 
 whole of the membrane has become adherent, you will find the medium of adhesion 
 to consist of lymph, in which a number of bloody points or streaks are visible : but 
 still the connecting substance is soft, and the agglutinated membranes can readily be 
 torn apart. 
 
 Such is the state of things on the outside of the heart in such cases. But what 
 do we find within ? Why, here also, in all cases probably, certainly in by far the 
 majority of cases, we discover evident traces of active inflammation ; and we dis- 
 cover them chiefly on the valvular apparatus. There does not appear to be such a 
 tendency in endocarditis to diffuse itself over the whole membrane. Occasion-ilIy 
 that naturally transparent portion of it which covers the muscular fibres is rendered 
 whitish and opaque ; and occasionally some of the deposits that are common on the 
 valves, encroach also somewhat beyond them, and even stud, here and there, the in- 
 terior of one or more of the chambers of the heart, and especially of the left auricle. 
 But the valves or the fibrous rings from which they spring, are the parts first and 
 chiefly implicated, especially the aortic valves, and the mitral valve : not uncom- 
 monly the tricuspid valve also ; and sometimes even the semilunar valves of the pul- 
 monary artery. Inflammation thus affecting both the external and internal mem- 
 branes of the heart, in acute rheumatism, I would call rheumatic carditis. 
 
 The inflame^-^alves undergo two kinds of change, distinct from each other. They 
 become thickerV&Jtf^natural ; they lose their transparency and pliancy, and are 
 puckered. These changes depend upon the deposit of lymph beneath the mem- 
 brane ; between the membrane and the fibrous substance it covers. Sometimes they 
 are folded down, and glued, as it were, to the opposite surface. This must be by 
 coagulable lymph deposited on the outer side of the membrane. But more frequently 
 than all, they present more or fewer of those wart-hke excrescences, or fleshy granu- 
 lations, which I spoke of in the last lecture, and which are of course above the mem- 
 brane. Sometimes these vegetations are scattered irregularly over the convex surface 
 of the valve, or in its immediate neighbourhood ; but much oftener they have a more 
 definite and curious distribution ; an arrangement which I have never seen noticed 
 by any author, but which it has been my lot so many times to observe, that it has 
 led me to remark an anatomical peculiarity with which it is connected ; and this 
 piece of minuter anatomy I have looked for in vain in books, and have in vain sought 
 information about it from all my anatomical acquaintances. They none of them 
 have seemed to be aware of it, though they acknowledged that the fact was so when 
 1 pointed it out to them. Recently, indeed, I have been told that the peculiarity of 
 structure to which I allude is somewhere adverted to by Morgagni. 
 
 It becomes necessary, therefore, that I should describe this discovery of mine (if it 
 deserves so grand a name) to you, as I have, for several years past, been in the habit 
 of showing it to the pupils of the hospital in the dead-house. It derives its chief 
 interest from the light it throws upon the morbid appearances to be spoken of pre- 
 sently. You will find, then, if you examine closely the semilunar valves of the 
 aorta, or of the pulmonary artery, that in each valve there may be distinguished two 
 parts ; one thicker, the other thinner. The thicker part lies next the base of the 
 valve, the thinner next its edge. And the valve does not become thin by degrees, 
 but the difference is marked by a manifest line of separation between the thicker and 
 thinner portions ; and this is not a straight, nor even one sweeping curved line, but
 
 PERICARDITIS. 685 
 
 it is a double curve. It consists of two semicircular lines, running each from the 
 centre of the edge of the valve, from the sesamoid body there situated, to either extre- 
 mity of the edge, where the edge joins the side of the aorta. So that there are two 
 segments, of a crescentic shape, thinner and less opaque than the remaining part of 
 the valve, and lying near its free margin. This peculiarity of structure is uniformly 
 present. It is less distinctly visible in the valves of the pulmonary artery than in 
 those of the aorta ; and it is much less apparent in some individuals than in others : 
 but it is always to be seen when it is looked for. 
 
 The anatomical account of this arrangement is not far to seek. The cardiac 
 valves consist of a loose duplicaiure of the delicate endocardium, between the folds 
 of which is received a thin prolongation of fibrous tissue, from the tendinous rings 
 surrounding or constituting the several orifices that are furnished with a valvular 
 apparatus. In the semilunar valves tliis fibrous substance does not interpose itself 
 between the entire space of the folded membrane. It reaches the free edge of each 
 valve at three points only ; namely, at the centre, where it forms the corpus aurantii, 
 and at the two extremities. Between these points it stops short, and has a definite 
 limit and outline ; a scolloped edge : and so leaves two crescentic portions of the 
 valve formed merely by the doubled endocardium. The crescentic margins are thin 
 and transparent : the remaining shield-shaped portion of the valve is more or less 
 ihick, firm, and opaque. 
 
 And the physiological reason of this arrangement is also apparent enough ; though 
 I failed to perceive ii until it was pointed out to me by JMr. Thurnam. Each valve, 
 when opened out, is convex towards the ventricle. The three valves do not merely 
 meet by their edges. Their common purpose would be but insecurely provided for 
 if such were the case. They meet and bend up, and come broadly into contact 
 with each other. Each valve during the diastole has its right and left crescentic por- 
 tion applied respectively to the corresponding portion of its right and left fellow valves. 
 The thin segments are pressed mutually together, and lie dos-d-dos, as dancers say; 
 while their edges look in the direction of the vessel. All this you may convince 
 yourselves of by injecting the aorta of an ox with wax, and picking out the wax 
 when it is cold. 
 
 Now the curious fact which first led me to remark this natural structure is, that 
 the minuter vegetations, which form upon the aortic valves, in acute rheumatic car- 
 ditis, most commonly arrange themselves in a row, like a string of beads, along the 
 line of union between the scolloped edge of the thicker scutiform portion of the valve, 
 and the inner convex margin of the two thinner crescentic portions. Sometimes 
 they follow that double festoon very -exactly and completely: sometimes the conti- 
 nuity of the line is broken, and the excrescences straggle from it a httle ; but still 
 the general tendency to adhere to it is evident. No one that I know of has publicly 
 noticed this fact ; yet that it is a fact, a good many persons, who have been for some 
 time about the Middlesex Hospital, are perfectly aware. The truth is, that death 
 seldom happens early in these cases ; and perhaps the valves have not always been 
 carefully examined when opportunity did offer. My friend. Dr. Latham, had been 
 watching, for such a case in vain for some years. Recently, however, two of his 
 hospital patients died in the first attack of rheumatic carditis ; and he tells me that, 
 looking with great interest for the morbid appearances within the heart, he found 
 them such as 1 have been stating. I have chanced to see six or eight such early 
 fatal cases. 
 
 The arrangement just described is the most common one, so far as the aortic valves 
 are concerned : but sometimes even there, and generally upon the mitral and the 
 tricuspid valves, the little wart-like excrescences have a different position ; jaggino- 
 the free edge of the valve with numerous fine serrae, like the teeth of a small saw; 
 or being disposed, just within its border, in one continuous line. 
 
 After what has been said, you will readdy delect the physical cause of this curi 
 ous distribution of the wart-like excrescences. The membrane suffers acute inflam- 
 mation. Soft lymph exudes from, or is deposited upon it : and as fast as it is formed 
 it is pressed aside, by the repeated concourse of the opposed surfaces, from the cre- 
 scentic portions of each valve ; and heaped up along the boundary lines of contain 
 
 3h
 
 686 RHEUMATIC PERICARDITIS. 
 
 just as a thin laj^er of butter on a board would be displaced, and heaped uj) m a 
 little curvilinear ridge, by the pressure of one's thumb. The double festoon, and the 
 httle marginal teeth, are obviously both formed in this way. 
 
 If my verbal description has been insufficient to make all this clear to your appre- 
 hension, the drawings before you speak, I hope, in plainer language. 
 
 These, then, are the appearances commonly seen within and without the heart, 
 when the patient does not long survive the first attack of rheumatic carditis. When 
 death takes place at a later period, you find more than this. You find the conse- 
 quences which flow from these primary lesions, operating as mechanical causes of 
 further change : hypertrophy and dilatation in their various degrees and combina- 
 tions. 
 
 You will please to bear the primary changes in mind : for they satisfactorily 
 account for the physical signs of pericarditis and of endocarditis which are displayed 
 in these cases, and which I shall describe and explain after I have shortly inquired 
 into the general symptoms. 
 
 The symptoms, then, of pericarditis, as set down by authors, and such as I have 
 myself frequently noticed, are the following. There is often, very early in the 
 disease, a singularity of manner, and peculiar expression of countenance, difficult to 
 describe, yet strikingly manifest to the observer ; a strangeness of deportment mixed 
 somehow with an aspect of distress. To this are frequently added, palpitation ; a 
 sense of oppression at the epigastrium; a catch in the breathing; a dry cough; 
 inability or unwillingness on the part of the patient to lie on his left side ; pain in 
 the situation of the heart, increased by a full inspiration, by pressure upon or be- 
 tween the corresponding ribs, and more particularly increased by pressure upwards 
 against the diaphragm by means of the fingers thrust beneath the cartilages of the 
 false ribs ; stifthess and pain in and about the left shoulder, and extending thence 
 down the left arm, and stopping short perhaps at the elbow or wrist. This last cir 
 cumstance, howev^er, the pain shooting down the arm, is more common in chronic 
 affections of the heart. And I have yet another symptom to mention, and a very 
 important one ; and that is delirium, sometimes quiet, but often wild and furious de- 
 lirium, not dependent upon any disease of the encephalon. 
 
 Of course there are also the febrile symptoms which accompany the acute rheu- 
 iiiatism ; or if the pericarditis occur independently of acute rheumatism, there will 
 be fever symptomatic of the local inflammation. 
 
 Now each of these symptoms I have repeatedly observed ; but they seldom all con- 
 cur in the same case. If they did there would not be much difficulty in the diag- 
 nosis : nor would the cardiac disease be so often overlooked as it is. The diagnosis 
 of pericarditis has been confessedly uncertain and obscure. Not unfrequently, 
 nearly all the symptoms I have been enumerating are wanting ; or so indistinctly 
 marked as to attract no attention. It is therefore an important matter to ascertain 
 what help we may derive, in these equivocal cases, from auscultation. 
 
 In truth, the help we sometimes get is peculiarly valuable and satisfactory. There 
 are certain morbid sounds to be heard when the heart is beginning to labour under 
 rheumatic carditis. 
 
 The morbid sounds which may reach the ear appHed in such cases to the surface 
 of the chest are two : very distinct the one from the other, and very distinguishable: 
 depending upon different causes, and denoting diversities of operation and of site in 
 the morbid processes going on within. But they are not both heard in all cases. 
 
 One of these sounds I have been accustomed to call a. to and fro sound. It 
 conveys to the ear the notion of the rubbing of two rough surfaces, backwards 
 and forwards upon each other. It seems near to the ear ; and therefore near to 
 the surface of the patient's body. Like all the other morbid sounds heard within 
 the chest, it is capable of much variety in tone and degree. Sometimes it very closely 
 resembles the noise made by a saw in cutting through a board. Sometimes it is 
 moie like that occasioned by the action of a file, or of a rasp, or of a nutmeg-grater. 
 But its essential character is that of alternate rubbing; it is a to and fro sound. This 
 very pecuhar sound I had noticed and described, and explained, before I was aware 
 ihat it had attracted the attention of any other persons. Others, however, had re-
 
 PERICARDITIS. 687 
 
 marked it, and had correctly interpreted its meaning. I claim no credit therefore 
 for the discovery of what I think a very important symptom : but I claim for the 
 sj'mptom itself that additional weight which accrues to it, from its having been 
 originally perceived by different observers, independently of each other. The 
 physician who, in this country, without my being aware of it, had noted and pub- 
 lished some cases in which this phenomenon occurred, is Dr. William Stokes, of 
 Dublin. There is a good deal said about it by Bouillaud also ; and he too appears 
 to have discovered the sound, without any previous knowledge of its having been 
 noticed by others, I have heard the to and fro sound now in upwards of a score 
 ofca^es. In a few of these it never ceased except with life. The patients died 
 during the primary attack, and the to and fro sound remained as long as the heart 
 continued to beat. In all the other cases, the to and fro sound was audible for a 
 few days only, and then ceased entirely and for ever : the patients recovering more 
 or less completely. 
 
 The other of the two morbid sounds, is the ordinary bellows sound, with which 
 you are already familiar. In the cases in question it is a single sound ; a deep-seated 
 rush, or whiz, accompanying the systole of the heart. It usually continues long ; 
 often for life. 
 
 These two sounds, the superficial to and fro sound and the deep-seated bellows 
 sound, may sometimes be heard, by a careful listener, to exist together. Sometimes 
 the bellows sound begins to be distinguished when the rubbing sound ceases; ap- 
 pears to supervene upon it, or to take its place; perhaps it then first becomes audible, 
 simply because it was previously drowned in the louder superficial sound. Some- 
 times there is no to and fro sound, but only the deep blowing noise; or (what in 
 many cases is extremely probable, nay, what I may venture to say is certain) the 
 to and fro sound has C07ne and g07ie unnoticed — un listened to. 
 
 Now of these sounds, which I repeat are perfectly distinct, and capable of being 
 easily discriminated the one from the other, the first mentioned, viz., the to and fro 
 sound, is always indicative of inflammation of the external membrane ; the other, 
 the bellows sound, is always, as I believe, in these cases, indicative of inflammation 
 of the internal membrane of the heart. You will bear in remembrance, that I am 
 speaking of these sounds as they somewhat suddenly occur for the first time, and 
 especially as they occur in rheumatic carditis at its first accession. 
 
 Those of you who have seen the thorax opened in an animal whose heart still 
 continued to palpitate, may have observed, as I have done, that the pericardium lies 
 closely in contact with the heart, but that a considerable extent of shpping motion 
 between them goes on at every successive act of systole and diastole. They glide 
 over each other evenly and without noise ; but this is only while the surfaces are 
 smooth and healthy. When they are already made rough by inflammation and the 
 deposition of lymph, which lymph always, as I have shown you, is rough in such 
 cases, then the irritation will be no longer noiseless : it will give rise, in the alternate 
 movements of the organ, to the harsh and superficial to and fro sound. But why 
 does that sound, when once it has occurred, at length cease ; and why, having once 
 ceased, does it never by any accident, when the inflammation has been universal, 
 recur? Clearly because the pericardium has become adherent to the heart : after 
 which there can be no motion of the one membrane over the other, and therefore 
 no sound indicative of such motion. 
 
 That this is the true explanation of the occurrence, and of the permanent cessation, 
 of the to and fro sound, I am now (March, 1837) convinced. It was a matter of 
 inference with me for some time. A few of the patients died during the primary 
 attack. By much the majority recovered. I do not mean got perfectly well as they 
 had been before ; but they regained a great share of their usual health, perhaps 
 thought themselves ivell, and left the hospital where they had been under treatment. 
 Now of those who died, the pericardia were non-adherent. The opposite surfaces 
 of the membranes were rough, and like tripe : and the to and fro sound never ceased 
 in these persons. Such cases are always soon fatal. But, in the others, did adhe- 
 sion take place ? I make no doubt of it. Within the last twelve months I have had 
 demonstrative proof of it in two instances. One of these occurred in a hospital natient.
 
 688 PERICARDITIS. 
 
 whose case has been published in the Medical Gazette* He was a painter, nine 
 teen years old ; and he became my patient last May, with acute rheumatism and 
 carditis. From the 20th of May to the 13th of June, a to and fro sound was dis- 
 tinctly audible, as well as a bellows sound which had preceded it. After that date, 
 the bellows sound continued, but the rubbing sound was no longer to be heard. The 
 patient improved ; and was about to be discharged from the hospital : when, on the 
 29th of June, sixteen days after the sound of friction had finally ceased, he suddenly 
 dropped down dead in the garden of the hospital. 
 
 Here 1 had concluded that the pericardium was adherent ; though I had not ex- 
 pected to have so soon the opportunity of verifying my opinion. And accordingly, 
 except over a small portion of the posterior part of the right ventricle, the union was 
 complete at all points. The agglutination was evidently the work of recent disease. 
 The medium of adhesion was of considerable thickness : and consisted of coagulable 
 lymph and coagulated half-organized blood. The pericardium was stripped ofT, as 
 1 have seen a poulterer skin a rabbit, and with about the same ease. This was a 
 very interesting case to me, for it was the first in which I had had the privilege of 
 examining the heart after having witnessed the pecuhar succession of phenomena 
 that I have been describing. 
 
 But since that time, I have met with another such a case in private practice. The 
 particulars of it are sufficiently important to warrant my relating them.t 
 
 In the month of October, 1836, 1 was taken by Dr. Sweatman to see a patient 
 of his ; whom I found sitting up in bed, pale, with sharp features, breathing 
 shortly and laboriously. His legs were anasarcous, and his belly was tense and 
 fluctuating. 
 
 I learned that he had been for years given up to intemperance in drinking, and to 
 indolent and low habits. He told me that the wind troubled him, shooting up through 
 the whole of the left side of his chest. On further inquiry I found that he meant 
 that he had much pain there. There was loud wheezing over the upper lobes of 
 both lungs : both sides of the thorax were dull on percussion at their lower part ; 
 and on the right side no breathing whatever was audible below. These latter symp- 
 toms were indicative of dropsical effusion into the pleura also. The jugular veins 
 were swollen and tortuous on both sides of the neck. On applying my ear to the 
 precordial region I at once heard a very loud and distinct to and fro sound. This 
 was equally manifest when he held his breath. Dr. Sweatman, who was not so 
 much accustomed as I have been to listen to the sounds of the heart in disease, re- 
 cognized instantly the peculiar character of this sound. I ventured to express my 
 certain conviction, that the patient was labouring under recent and acute pericarditis. 
 I added, that he had also hydrothorax ; and that, whatever chronic changes might 
 have taken place in his heart previously to his present illness, dilatation of the nght 
 cavities constituted at least one of them. 
 
 He had been attacked by his present urgent symptoms three days before I saw 
 him, viz., on the 8th of October. On that day, in all probability, the inflammation 
 of the pericardium commenced. 
 
 This was his history. In the spring of the year, having, from indolence, kept the 
 house for months before, he crossed from the Isle of Man to Liverpool, and was sick, 
 and suffered a good deal during the passage. After landing he had a mile or more 
 to walk. His companions outstripped him, but were called back to him, and found 
 him very pale, breathing with difficulty, and unable for a time to proceed. He 
 attributed all his subsequent complaints to that exertion: and he had been ailing, 
 though not confined to his room, till the Sth of October. I did not venture, in his 
 condition, to open a vein: but leeches were applied to the praecordia, and he took 
 diuretics. 
 
 I did not see him again till the 15th of October, four days after my first visit. The 
 rubbing sound was still there, though less loud, less harsh, and less extensive. The 
 leeches had given him much relief. His pulse was very small. A blister was now 
 applied. On the 20th I saw him for the third and last time ahve. The rubbing 
 
 • Vol. xviii. p. 701. + Medical Gazette, vol. xzi. p. 544.
 
 PERICARDITIS. 689 
 
 sound was quite gone. This Dr. Sweatman also satisfied himself of. There was a 
 dull systolic bellows sound in its place. The pulse was scarcely perceptible ; but 
 he continued apparently improving, making avast quantity of urine, while the drop- 
 sical swellings fast diminished, till the 31st; when, after talking a short time oddly, 
 and in a peculiarly loud voice, he sat up to take some medicine, and, having done 
 so, reclined his head against the nurse, and expired. Mr. Shaw assisted in the sub- 
 sequent examination of the body. I omit giving an account of the conditioa of the 
 lungs and pleura, which was what we had anticipated, and confine myself to the 
 state of the heart. That organ was large. The pericardium was adherent univer- 
 sally by means of lymph, mottled with blood ; and it was easily separated, so that 
 the adhesion must have been recent, as was proved, indeed, by the symptoms. The 
 right cavities of the heart were very large, and the aorta was diseased. 
 
 The existence of the to and fro sound in these cases, no one can doubt who has 
 once listened for it when present ; and the facts respecting it, which have been estab- 
 lished beyond the reach of controversy, are these : — 1st. That when it occurs cle 
 novo, it always surely denotes acute inflammation of the pericardium. I say de 
 novo, because (as I stated in the last lecture) a bellows sound may accompany each 
 movement of the heart, in consequence of internal disease of some standing; and 
 this double, sawing, bellows sound, might possibly be confounded with the alternating 
 noises produced by the attrition of the opposite surfaces of the inflamed pericardium. 
 2dly. The to and fro, or rubbing sound, is never of long duration, but soon termi- 
 nates in one of two ways. Either the patient dies in a short time, the sound conti- 
 nuing to the last; and then the pericardium is found coated with rough lymph, but 
 throughout the far greater part of its extent, or altogether, i<jjadherent : or the sound 
 ceases, never to return, while the condition of the patient improves; or he even 
 seems, to himself and to others, to recover his perfect health. In these cases, the 
 sound ceases from a physical impossibility of its continuance, viz., from adhesion of 
 the pericardium over the whole, or the greater part, of the surface of the heart. And 
 in this category of apparent but unreal recoveries, I cannot doubt that many of Bouil- 
 laud's cases of '■'■ pericarditis terminating in health" ought to be included. 
 
 It follows as a necessary consequence from these facts, that acute pericarditis, so 
 far advanced as to occasion the pathognomic rubbing sound, does not admit of a per- 
 fect cure ; and that its best event is the adhesion of the membrane, and the oblitera- 
 tion of its cavity. 
 
 And even then, I say, the change is not final. Mere adhesion of the pericardium 
 does so embarrass the movements of the heart as to produce at length, sometimes 
 rapidly, sometimes slowly, hypertrophy, or other alterations which have already been 
 considered. It is held, too, and I believe justly, though I am not so sure of this as 
 of some of the other points I have been dwelling upon, that the inflammation which 
 begins in the membrane, sometimes dips into the muscular substance of the heart,. 
 weakens its elasticity and cohesion, and so leads ultimately to dilatation of its 
 cavities. 
 
 I need not occupy much of your time in speaking of the other morbid sound that 
 is audible in these cases, the bellows sound : which sometimes may be heard before 
 the to and fro sound commences ; which I have heard through the to and fro sound ; 
 and which often remains after the superficial rubbing sound has ceased. This de- 
 pends, no doubt, upon those alterations in the valves of the heart which take place 
 from inflammation, at the same time with the alterations of the pericardium. And 
 when it is met with in such cases, it may be set down as very strong evidence of the 
 existence of endocarditis. 
 
 I am anxious that you should take an interest in the disease which I have been 
 speaking of at so much length this evening, and that you should keep it in mind in 
 your future practice ; for I am sure that it is a fertile, but often unsuspected, source 
 of chronic disease of the muscular substance of the heart, and of its consequences : 
 asthma, dropsy, sudden death. The number of patients that come into the hospitals 
 of London affected with acute rheumatism, is annually very large ; and I am sure 
 that I do not exaggerate when I say that nearly one-half of them have the heart or 
 •is membranes imphcated. The cardiac affection may easily be overlooked, both by 
 44 3h2
 
 690 RHEUMATIC CARDITIS. 
 
 the patient and the phj'sician. The recovery may appear to be perfect. But after 
 some time, palpitation begins to be occasionally felt ; and, by degrees, other symp- 
 toms, marking disease of the heart, declare themselves : but their origin is unsus- 
 pected dr forgotten. You will be surprised, if you search back into the past history 
 of all the patients who apply to you having disease of the heart, especially among 
 the lower classes of society, — you will be surprised to find how many of them will 
 tell you that at some time or other of their lives they have been laid up with rheu- 
 matic fever. 
 
 It is no part of my purpose to treat at present of that specific disease of the joints 
 to which we give the name of acute rheumatism : but I may as well complete what 
 I have to say of carditis as it occurs in connection with that disease; and then 1 shall 
 not need to repeat myself when I come to rheumatism itself. 
 
 In the first place, then, I would say a word more respecting the nervous dis- 
 turbance which is apt to supervene in such cases, and to mask the real disease, and 
 to mislead the unwary practitioner. Patients labouring under rheumatic carditis 
 very frequently become affected with delirium, or violent mania, or stupor and coma, 
 or convulsions, or all of these in succession : and you might suppose that they were 
 labouring under inflammation of the brain, or of its membranes. Such cases are in 
 fact spoken of as cases of metastasis to the brain. It may sometimes be so, nay, I 
 know that it sometimes is so ; but not often. Again and again, when death has 
 occurred, and the delirium had been extreme, no traces of disease have been dis- 
 coverable within the skull, while marks of violent and intense inflammation were 
 visible in the pericardium. I presume that the acute cardiac affection interferes 
 somehow with that regulated supply of blood to the head, which is necessary for the 
 due performance of the cerebral functions. But whatever the explanation, recollect 
 the fact ; and whenever, in acute rheumatism, you find your patient flighty and 
 wandering, or more distinctly delirious, examine carefully the condition of his heart. 
 As this is really a point of great importance, and as you will not find much in- 
 formation respecting it in books, I shall take leave to quote, here, some part of a 
 clinical lecture delivered by myself at the Middlesex Hospital, in the year 1835, and 
 printed in the IGth volume of the Medical Gazette. My subsequent experience has 
 been quite in conformity with what I then stated. 
 
 "The functions of the brain not unfrequently become disordered in rheumatic' 
 fever: and disordered in such a manner and degree as would lead, and has led, 
 many to believe in the presence of active inflammation of that organ, or of its 
 enveloping tissues. Yet this affection of the brain is not, I beheve, inflammation, 
 tut some secondary affection of the circulation therein ; resulting from disturbance 
 dt the central organ of the circulation, capable of producing a corresponding derange- 
 ment in the cerebral functions. I can best explain what I mean by reciting a few 
 examples. 
 
 " The first case of this kind that I ever saw or heard of, occurred in St. Bartholo- 
 mew's Hospital, many years ago. I took notes of it at the time, and will read you 
 the substance of them. Charlotte Rankin, aged 17, was admitted there on the 12th 
 August, 1824, under the care of Dr. Roberts, with acute rheumatism of the joints. 
 Her illness had come on suddenly a week before, after unusual exposure to cold and 
 wet. The pain and swelling had shifted much from joint to joint. She had been 
 bled, on account of pain in her left side, two days before admission. On the 14th, 
 she complained of much difficulty of breathing, and of pain when even slight 
 pressure was made upon the chest. These symptoms were entirely removed by a 
 blistex. On the 16th, she was observed to be odd in her manner — peevish, querul- 
 ous, restless, without sleep, and desirous of getting out of bed. Her pulse was then 
 100. On the 20th the pulse had risen to 120; it was quite regular. She said she 
 felt no pain, except the soreness occasioned by the blister. She slept very little. On 
 the 21st, the pulse was 128. Some jactitation of the left arm was now observed, 
 which, she said, had never happened before. No sleep. On the 22d, about nine in 
 the evening, she became furiously maniacal, and it was necessary to confine her by 
 a strau-wais'coat. She continued in that state for upwards of four hours, and then 
 died
 
 HEAD SYMPTOMS. 691 
 
 "Twelve hours afterwards the body was examined. The brain was found quite 
 healthy : its vessels seemed, indeed, somewhat fuller of blood than is usual, but there 
 was no effusion, nor any other vestige of inflammation. 
 
 " The pericardium was glued to the heart in several places, by recent adhesions ; 
 and it was universally coated, where not adherent, by a layer of rouo-h, reticulated 
 lymph, remarkably harsh to the touch. 
 
 " Now here the most prominent symptoms were such as we are accustomed to 
 refer, with tolerable confidence, to inflammation of the membranes of the brain ; 
 whereas, in fact the inflammation was strictly confined to the heart. If no examina- 
 tion of the body had been made, the case might have been quoted, with much show 
 of reason, as a well-marked example of metastasis to the brain. It was so considered 
 before the brain was inspected. 
 
 " There had, indeed, been symptoms which indicated, and that not obscurely, the 
 cardiac disease. At that time, however, I did not know how frequently carditis is 
 combined with acute rheumatism. Auscultation had not yet come much into fashion 
 in this country ; at any rate, I knew little or nothing of its use ; and I had supposed 
 (and it had been supposed by others who witnessed the case) that the chest symp- 
 toms resulted from rheumatism of the intercostal muscles. 
 
 "Another instance, in which the course of the symptoms was somewhat different, 
 yet equally calculated to mislead, you have lately seen in this hospital. 
 
 " William Wilkins, a post-boy, 28 years old, was admitted on the 25th of last 
 November. 
 
 " He complained of pain in most of the large joints, shifting from one joint to 
 another. There was no visible redness or swelling, but he had much fever. The 
 pain was greatest at night. He had profuse perspirations, during which the pain 
 was not mitigated. 
 
 " He had been ill eight weeks ; and at first his joints (according to the statements 
 of his friends) were both swelled and red. He appeared to be recovering at one 
 time, but relapsed. For three or four days previously to his admission he had 
 coughed a little, and spoken of pain at the pit of the stomach. He lay more com 
 fortably on the right than on the left side, but this was habitually the case. He had 
 never had acute rheumatism before. 
 
 " He rambled a good deal during the night of the 26th, and on the 27th, he began 
 to refuse to take his medicine, appeared confused and stupid, and answered questions 
 tardily and imperfectly. He was bathed in perspiration, which had the strong acid 
 smell so common in cases of acute rheumatism. 
 
 " During the next ten days he remained in a singular state of quiet delirium, re 
 jecting medicine and food, saying he had had enough ; getting out of bed, especially 
 in the night, and declaring that he was going home. When questions were put tc 
 him, his lips moved, and his limbs began to stir and fidget, as though he Avere about 
 to answer; yet he said nothing. He understood what was said to him, and put out 
 his tongue when desired so to do ; imperfectly, however, and with slowness and 
 apparent difficulty. His bowels were costive, and he passed his stools, when pur- 
 gatives acted, in the bed. His pulse was small and frequent ; and when his wrist 
 was taken hold of that the artery might be felt, he always resisted, and forcibly con- 
 tracted his arm. 
 
 "Then for three or four days he appeared to improve ; his countenance became 
 more clear and lively ; but he still showed the same restlessness, and maintained 
 the same dogged silence when spoken to, and obstinately refused to swallow medi- 
 cine. He was somewhat cunning, too, for he would take pills into his mouth, and 
 then, when he thought he was not observed, chew and spit them out again. 
 
 " His pulse became at last very frequent, and his strength diminished rapidly. 
 He died on the 18th December, and the body was examined on the following day. 
 
 " The cerebral veins were gorged with dark blood, and there was a considerable 
 quantity of serous fluid beneath the arachnoid and in the lateral ventricles. 
 
 " The pericardium was free from disease ; but upon the mitral valve, near its edg« 
 the/e was a perfect row of small, slender, bead-like warts. 
 
 ' A lew weeks ago I was consulted in a case of a similar nature -^-Jiich occurred
 
 692 RHEUMATIC CARDITIS. 
 
 in the practice of a gentleman who was formerly a pupil here, and who was fully 
 aware both of the frequent occurrence of carditis in acute rheumatism, and of the 
 anomalous symptoms with which it is sometimes attended. The patient was a young 
 man, 24 years of age, 
 
 " On the '?2d of December he was seized with pain and swelling of several of the 
 larger joints, and with fever. The attack was ascribed to exposure to cold the day 
 before ; he had previously enjoyed perfect health. The inflammation shifted rapidly 
 from one joint to another. He was confined to bed for six days : then, feeling better, 
 he got up, changed his room, and presently underwent a relapse. Mr. Elwin tells 
 me that, after that time, he was never comfortable about this patient ; his countenance 
 was pale, and his aspect unpromising; his pulse frequent; and more than once he 
 complained of slight pain in the epigastrium, increased by a full inspiration. This 
 was removed by a mustard-poultice. No morbid sound was detected upon a careful 
 examination of the proecorcfial region by the ear. He remained low-spirited, but 
 slowly mending, till the 3d of January, when in the evening, without any notice or 
 obvious cause, he began to be restless and delirious. 
 
 " On visiting him the next morning, Mr. Elwin found him with an anxious coun- 
 tenance ; a frequent and irregular pulse, which occasionally intermitted ; his mind 
 wandering ; the action of his heart strong, and attended towards the sternum with a 
 loud bellows sound. The next day his breathing was difficult, and 'catching;' the 
 pulse 120, hard and wiry. At that time I had the opportunity of seeing him. He 
 was lying in a sort of stupor, yet not unconscious, for he put out his tongue at my 
 request, and answered pertinently one or two questions, after they had been frequently 
 repeated. He had the air of a person obstinately determined to say as httle as pos- 
 sible. He became more distinctly delirious towards evening; and the next day his 
 pulse and breathing were both so frequent (148, and 78, in the minute respectively), 
 that he was thought to be dying. A distinct bellows sound was audible near the 
 left mamma. This state continued, with slight fluctuations, till the 8th, when his 
 condition appeared somewhat more hopeful. He was calm, had no d3^spno5a, and 
 conversed more readily, — saying sometimes that he felt as if he were 'dead ;' some- 
 times that he was ' burnt up.' He complained, for the first time, of pain in the right 
 temple ; his gums were slightly under the influence of mercury ; his pulse scarcely 
 exceeded 100; the bellows-suund was very manifest. 
 
 "On the 9th he again became, first restless, then violently and wildly delirious, 
 screaming out, refusing to take medicine, or to open his mouth when it was offered ; 
 yet he evidently knew what was said to him. During the night general convulsions 
 came on in occasional spasms, of a tetanic character: in the intervals between them 
 he lay in a state of coma. He survived in this condition till the 12th. 
 
 " I was present at the inspection of the body ten hours after death. Some of his 
 family insisted on being in the room with us ; but we were able to make an accurate 
 examination of the head, and of the heart. 
 
 "The veins of the brain seemed somewhat fuller of blood than is common. The 
 arachnoid was slightly elevated by a clear serous fluid collected in the pia mater. 
 There was but a small quantity of a similar fluid in the lateral ventricles. The lungs 
 appeared quite healthy. 
 
 "There was no fluid in the pericardium. Its surface was everywhere exceed 
 ingly vascular, but it presented no appearance of lymph, e.xcept where it adhered to 
 the posterior side of the heart, over a space about two inches and a half in length, 
 and upwards of an inch in breadth. The lymph which formed the medium of con- 
 nection was firm, but evidently of recent formation; and a very slight degree of 
 force sufficed to separate the adhering membranes. The heart was rather small, 
 and the left ventricle had a singular wrinkled appearance externally. Towards the 
 edge of the mitral va've there was a profuse crop of little Avart-like vegetations, of 
 th*^ size of millet-seeds ; and numerous red lines converged towards them from the 
 base of the valve. The aortic valves all presented curious festoons of similar ex- 
 crescences, larger, however, and more prominent, than those upon the mitral valve. 
 
 " In the beginning of the year 1832, a girl nineteen years old, Frances Kirk by 
 Dame, was a patient of mine in the hospital, with acute rheumatism of the joints,
 
 HEAD SYMPTOMS. 693 
 
 ^■^d carditis, manifested by many of the most usual symptoms — by pain in the situa- 
 tion of the heart, dj'spncEa, great frequency of pulse, and a distinct bellows sound. 
 She lived two months from the commencement of the cardiac disease. Durin^^ that 
 period she was at times wildly delirious — at times stupid, taciturn, and almost idiotic 
 — and at times quiet and rational. The brain in that case was found perfectly healthy, 
 except a slight serous effusion beneath the arachnoid. The pericardium was every- 
 where adherent to the heart. By some mismanagement the opportunity of inspect- 
 ing the inner membrane of the heart was lost. 
 
 "In each of the three last-mentioned cases there was more or less serous fluid 
 found in the meshes of the pia mater, and in the lateral ventricles. You may ask, 
 perhaps, whether this effusion was not good evidence of previous inflammation there ? 
 whether it did not show that the metastasis, which I have spoken of as seldom hap- 
 pening, really did happen in these very cases ? 
 
 "I apprehend not; and for the following reasons: — In one only of these cases 
 was the amount of the serous accumulation at all considerable. There was no other 
 trace of inflammatory action in any of them ; no redness, nor pus, nor lymph ; none 
 of the unequivocal products of inflammation. What quantity of serous effusion be- 
 neath the arachnoid, or in the ventricles of the brain, is requisite to establish its 
 morbid origin — within what hmits such effusion maybe considered natural — whether 
 it may not be ascribed wholly, or in part, to mechanical transudation after death ; 
 these are questions which have not yet been definitely settled among pathologists. 
 For my own part, whenever I see the veins of the pia mater full of blood, I expect 
 to find serum between that membrane and the arachnoid. How much of it may 
 have been poured out before death, and how much afterwards, it would be difficult 
 to estimate. In each of the cases before us there was evidence, not to be mistaken, 
 of cardiac inflammation. Now that acute inflammation, fixing itself upon some 
 portion of the heart, should embarrass its action, and modify the condition of the 
 circulation through the cerebral blood-vessels, is not only conceivable, but highly 
 probable. Any retardation of the venous circulation in the head — any engorgement 
 or congestion of that system of vessels — would be hkely, if we may reason from the 
 analogy of other parts, to produce effusion. I have seen, in the brain of a criminal 
 who had been hanged while in a state of perfect health, as much serum collected in 
 the same parts as we found in the patients whose cases I have been relating. It is 
 possible that, in them, the disorder of the sensorial functions depended upon simple 
 disturbance of the cerebral circulation ; it is possible that the same disorder depended 
 upon the serous effusion ; and it is possible, and (I think) probable, that it depended 
 in part upon both these causes. It is very certain that similar symptoms have 
 occurred in similar cases, when there was no appreciable effusion ; and, apparently, 
 from mere derangement of 'he natural circulation of the blood in its vessels. On 
 the other hand, we know that an equal, or a greater amount of effusion, has often 
 been observed, when no such cerebral symptoms had manifested themselves. I 
 conceive, therefore, that the symptoms referable to the brain, and the quantity of 
 serum found effused there (whether these bear to each other the relation of cause 
 and consequence, or not), are both to be regarded as secondary effects of the cardiac 
 disease ; that they denoted no inflammatory condition of the brain, or of its mem- 
 branes, but were the common result of that inflammation of the heart, concerning 
 the existence of which the inspection of the bodies left us no room to doubt. 
 
 "That this view of the matter is correct, is the more probable because (as I just 
 now stated) the same symptoms have been known to accompany carditis, although 
 no serous effusion was met with in the head. There was none in the case of the 
 girl Rankin ; none in a case related by Dr. Davis ; none in a remarkable case do- 
 tailed by Dr. Latham ; none in a striking example of a similar kind which fell under 
 the observation of that accurate and most accomplished pathologist, Andral. I shf^li 
 take the liberty of citing these two instances. 
 
 " ' One of the children of Christ's Hospital,' says Dr. Latham, ' had, in the opmion 
 of all who saw him, the severest inflammation of the brain. The attack was sudden, 
 with great heat and frequency of pulse. He had delirium and convulsions, and 
 poinl( d to his forehead as the seat of his pam. In three days he died, and. upon
 
 094 RHEUMATIC CARDITIS. 
 
 dissection, not a vestige of disease was found within the cranium ; but the heart was 
 exclusively the seat of the disease, and no other part of the body discovered the 
 slightest morbid appearance. The disease of the heart was not confined to its invest- 
 ing membrane. It was the most intense inflammation pervading the pericardium 
 and the muscular substance.' 
 
 "Andral's case, which is referred to by Dr. Latham, occurs in his Clinique Me- 
 dicale. 
 
 "A woman, twenty-six years old, was brought to La Charite, in a state of delirium, 
 and no account could be obtained of her previous condition. The delirium was re- 
 markable for the obstinate taciturnity which attended it. When questioned, the 
 patient turned a fixed gaze upon the person who spoke to her, but made no reply. 
 Her face was pale ; her pulse smaL' and frequent. During the two following days 
 the head was frequently drawn backwards, the trunk was shaken at intervals by 
 convulsive movements, and she had subsuhus tendinum; but she now spoke, and 
 appeared to comprehend what was said to her, but talked incoherently. The pulse 
 was very frequent, and intermitting. On the fourth day the delirium ceased ; she 
 complained of nothing but great debility. The muscles of the face were almost 
 continually agitated by convulsive twitchings, and the arms from time to time pre- 
 sented a sort of tetanic stiffness. On the fifth day the delirium returned ; the patient 
 then fell into a state of coma, and died the next morning. 
 
 "Neither the brain, nor the spinal marrow, nor their membranes, presented any 
 appreciable morbid appearances. The pericardium was lined by coagulable lymph, 
 and its opposite surfaces were connected, in some places, by recent bands of adhe- 
 sion. It contained also some ounces of a greenish flaky serum. No other trace of 
 disease was discoverable. 
 
 "Now if you are not made aware beforehand of this strange course of the symp- 
 toms arising, sometimes, out of rheumatic carditis, you will be apt to overlook the 
 cardiac affection, and to direct your remedial measures wide of the mark. In a se- 
 cond instance mentioned in Dr. Latham's essay, 'the whole force of the treatment 
 was directed to the head, from a belief that the brain was inflamed. Upon dissection 
 the brain and its coverings were found in a perfectly healthy and natural state ; and 
 the pericardium, towards which during life there was no symptom to direct the 
 slightest suspicion of disease, discovered the unequivocal marks of recent and acute 
 inflammation.' Dr. Davis, also, in reference to a case published by him so early as 
 1808, has the following remark : — 'The restlessness in the case of Miss H. C. was also 
 attended with delirium, a symptom not previously noticed as belonging to pericarditis 
 by any writer whom I have consulted. It was so prominent a feature of the disease 
 under which this young lady laboured, as to divert the attention of her medical at- 
 tendants from its actual seat,' 
 
 "This occurrence, in the course of rheumatic carditis, of cerebral symptoms calcu- 
 lated to perplex and obscure the true nature of the disease, is probably not so rare as 
 has been supposed. In less than three years three instances of it have fallen under 
 my own notice ; and I have been informed by a medical man residing in the neigh- 
 bourhood, that a friend of his, who has a very large general practice among the 
 middle and lower classes, attended within the last year or two not less than twenty 
 cases of acute rheumatism, in which a metastasis, or an extension of the inflamma- 
 tion, appeared to take place to the brain. 
 
 " In all the detailed cases of this kind that I have met with, and in those which I 
 have myself watched, there were certain general points of similarity, which you will 
 do well to bear in mind. In all of them the pulse was extremely rapid ; the deli- 
 rium, though violent and active at intervals, was characterized for the most par^ by a 
 singular, and, as it seemed, perverse taciturnity : even when the patient was evi- 
 dently able to speak, and understood the questions that were put to him, he main- 
 tained a sullen silence. In most of these patients, also, not long before the fatal 
 event, a brief interval of amendment took place, and encouraged some hope of 
 rpcovery. In many of them various convulsive movements were observed ; and in 
 two of the cases the head symptoms, and probably the heart disease also, supervened 
 after a relapse of the rheuniatism of the joints." 
 
 f 
 
 I
 
 HEAD SYMPTOMS. 695 
 
 It is a curious circumstance that rheumatic carditis is sometimes the first step in 
 the whole disease ; the cardiac s3^mptoms will sometimes, I mean, precede those of 
 the joints ; even by two or three days. For example. A lad was brought to the 
 hospital with acute articular rheumatism, and with unequivocal symptoms, which 1 
 need not detail, of carditis. He gave the following distinct history of his illness : — 
 He had been on a visit into the country several days before, and there, after having 
 felt poorly for nearly a week, with a sensation of " sinking within him," he ate 
 largely of oysters, and drank more porter than he was accustomed to. On the same 
 day he was seized with pain in the left side of the chest, and violent beating of the 
 heart. The attack was probably a severe one, for he applied to a medical man, 
 who immediately bled him. In the course of the ensuing night he began, for the 
 first time in his life, to feel some stiffness beneath and about his knees, but he was 
 able to walk about the next day. On the evening of the second day the joints 
 became so painful and swollen, that he could not leave his bed, and then the pain of 
 the side and the palpitation diminished. This boy has several times since returned 
 to the hospital with acute rheumatism, and on each occasion presented manifest in- 
 dications of some permanent affection of the heart, — slight, probably, in amount, but 
 aggravated upon every return of inflammation of the joints. 
 
 I have met with one or two other instances in which the cardiac disease appeared 
 to have preceded the arthritic; but none so well made out as that I have just related 
 Dr. Duncan, in the Edinburgh Medical and Surgical Journal for 1816, gives a 
 case of " inflammation of the heart" which began with symptoms oi pectoral inflam- 
 mation, succeeded the next day by rheumatic affections of the joints. 
 
 One law respecting the connection between the cardiac and the arthritic symp- 
 toms may be stated with confidence, namely, that the younger the patient is who 
 suffers acute rheumatism (and I have seen it so early as the third or fourth year) the 
 more likely will he be to have rheumatic carditis. The chance of the combination 
 appears to diminish, after puberty, as hfe advances. I have known only two persons 
 pass through acute rheumatism with an untouched heart prior to the age of puberty; 
 and in these two I am by no means certain that the articular disease was genuine 
 rheumatism. In each of them, the large joints became painful, and swelled, for a 
 day or two only, towards the close of scarlet fever : — a circumstance not, I believe, 
 unusual. I was dreadfully apprehensive of carditis, but it did not occur. 
 
 I have observed, also, that when a patient has come under my care who has had 
 repeated attacks of acute rheumatism, in him I have generally found reason to believe 
 that some organic affection of the heart was present. Probably the disposition to 
 such repetitions of the disease, so remarkable in some individuals, may be kept up 
 by the cardiac complication. 
 
 AVith respect to the period of the actual attack, and the circumstances under 
 which the extension of the disease to the heart occurs, no fixed law has been ob- 
 served. Sometimes the cardiac affection declares itself as the inflammation of the 
 joints declines. Quite as often, however, they proceed together, and are aggravated 
 or mitigated simultaneously. On this point my own experience nearly agrees with 
 that of Dr. Latham, who says : — " It (the cardiac affection) is incident to all the de- 
 grees and all the stages, and all the forms (?) of acute rheumatism. It is not more to 
 be looked for when the disease is severe than when it is mild; more at its beginning 
 than during its progress and decline ; more when it is shifting and inconstant in its 
 seat, than when it is fixed and abiding." 
 
 There are some other symptoms that I must not omit to mention as occurring in 
 some cases of pericarditis. In one of the fatal instances which fell under my own 
 notice, there was a very strong purring tremor felt by the hand placed upon the 
 region of the heart. This is not a constant, nor even a frequent, symptom ; but it 
 has a certain degree of corroborative value when it does occur. 
 
 When the fluid products of the inflammation predominate, when there is much 
 serum poured out, the symptoms, as well as the danger, will be different from thosw 
 which are remarked when there is not so much serous liquid. If the pericardium 
 be distended, percussion will furnish a dull sound over an unusually large space 
 much beyond the natural hmits of the precordial region: and yDu may often mea-
 
 696 RHEUMATIC CARDITIS. 
 
 sure the amount of the effusion, and its daily increase or decrease, very accurately 
 in this manner. But the general symptoms will vary also. The pulse will be 
 feebler, and more disposed to falter and to become irregular, in proportion as the 
 liquid effusion is large ; and at the same time the patient will frequently be fixed in 
 one position, and unwilling or afraid to change it, lest that small exertion should fur 
 ther excite the action of his heart, and hurry his respiration. He will lie, perhaps, 
 always upon one side ; or he will remain immovable on his back, with his head ele- 
 vated ; or he will sit up continually, with his body leaning forwards; and he will 
 not dare to alter his posture. But when the solid products of the inflammation pre- 
 dominate ; when there is coagulable lymph, and but little serum ; when the peri 
 cardium, instead of being distended, becomes attached to the heart; then the pulse 
 will retain that force and regularity with which the disease commenced, the dull 
 sound yielded to percussion will not transgress the precordial limits, and the patient 
 will not in general experience any absolute necessity of accommodating his body to 
 one constrained position. 
 
 Of a merely adherent pericardium there are no diagnostic signs to which, so far 
 as I know, we can trust, either ausculatory or general. None, I mean, presented by 
 the body at the time. If we are accurately acquainted indeed with the history of 
 the patient's disease, and if we know that, at any time, a to and fro sound existed, 
 which to and fro sound soon ceased, and has never recurred ; then our conclusion 
 that the pericardium is adherent will scarcely be open to any source of fallacy. 
 
 When the opposite surfaces of the membrane have been once united, they never 
 separate again ; the adhesion remains for life. But the lymph interposed between 
 them, if the inflammation be not renewed, becomes less and less thick ; until at length, 
 in some cases, a mere layer of firm, but thin, areolar tissue is left, through which the 
 heart is visible. 
 
 But when inflammation has stiffened the valves of the heart, or studded them with 
 little wart-like masses of fibrin, how far do these morbid states admit of perfect re- 
 covery ? It is not so easy to say. I am not aware of any facts, which would forbid 
 altogether the hope that here, as in iritis, the re-absorption or removal of the lymph 
 may be total, and the restoration of the parts complete. On the contrary, the com- 
 parative infrequency of wart-hke excrescences in the slowly fatal cases of rheumatic 
 carditis leads to the opinion that such deposits may disappear as readily and entirely 
 from the valves of the heart as from the iris. 
 
 Since I lectured upon this subject last year, two examples of rheumatic carditis 
 have occurred among my hospital patients, diff'ering in some remarkable points from 
 any that I had ever seen. A brief description of them will complete my personal 
 experience of this terrible disease. 
 
 The histories of the two cases are curiously similar. The patients were young 
 women ; their ages respectively twenty-one and twenty-two. They were admitted 
 during the same week ; one a day after the other. Both were suflvring under a first 
 attack of rheumatic fever; both had also acute pleurisy, with effiision into the chest; 
 and both died ; one of them three weeks, and the other a month, after her admission. 
 In both cases there were symptoms referable to the heart ; pain, and unnatural sounds; 
 but in neither case was there any friction-sound ; nor were any traces of pericarditis 
 discovered after death. But the inflammation had fallen, partially, upon the aortic 
 valves ; whence it had extended (so I imagine) to the muscular substance. I show 
 yoii the morbid appearances represented in these drawings, made by Mr. Lonsdale 
 fit the time : and, better still, I show you the parts themselves, which are preserved 
 ill our museum. 
 
 The whole of one of the aortic valves was, in each case, a mass of ragged ulcera- 
 tion ; and the adjacent portions of the two other valves Avere, in a slighter degree, 
 implicated in the mischief. What remained of the tattered valve was covered with 
 rough irregular shreds of lymph, or vegetations. In one of the cases, the ulcerating 
 process had penetrated through the valve, and into the muscular substance beyond, 
 and had eaten a hole completely through the septum. A portion of lymph protruded 
 just below the valve of the pulmonary artery through the channel of communication 
 ihu? formed between the left and right sides of the heart. In the other case, ari
 
 ACUTE PERICARDITIS. 697 
 
 abscess as large as a hazel-nut was found in the muscular substance of the septum, 
 immediately opposite the disorganized valve. 
 
 Till I met with these cases, I was not aware that this destructive incrus'tation of 
 the cardiac valves with wart-like excrescences was ever the result of acute inflamma- 
 tion. Chronic changes of that kind are not uncommon. Suppuration in the heart 
 is very rare. In these two instances the cardiac affection was complicated with acute 
 pleurisy. I should have mentioned before, that the pleura very often participates in 
 the inflammation when pericarditis occurs. You will not wonder at this if you 
 consider the close vicinity, and the similarity in texture, of these two serous mem- 
 branes. 
 
 I must defer what I have to say respecting the treatment of acute pericarditis and 
 endocarditis, to the next lecture. 
 
 LECTURE LXII. 
 
 Treatment of Acute Pericarditis, and Endocarditis : blood-letting; mercury; 
 blisters. Chronic and partial Inflammation of the Pericardium. Disease of 
 the Aorta. Thoracic Aneurisms; their various situations, and symptoms; 
 plan of treatment. 
 
 I TRUST that I made distinctly apparent, in the last lecture, the great danger which 
 belongs to every case of acute inflammation of the pericardium. First, there is the 
 danger of speedy death. If the inflammation goes to the extent of effusion, and the 
 collection of serous fluid be large, and the pericardium be distended by it, the action 
 of the heart is so much oppressed by the liquid surrounding it, that it falters and 
 flutters, and at length stops, and goes on no more. Secondly, there is the danger 
 that (the pericardium having become adherent) other structural changes will, soon 
 or slowly, develop themselves ; and first render hfe bsrdensome and full of suffering, 
 and then consign the patient to an earher grave than might else have awaited him. 
 
 Now what can we do to prevent, or to diminish, these evils ? I once thought that 
 d we caught the inflammation at its very commencement, we might calculate upon 
 a perfect cure, by first bleeding the patient freely, and by, secondly, putting him as 
 speedily as possible under the specific influence of mercury. I am sorry to be 
 obliged to say, that the more I see of this formidable malady, the more reason I find 
 for fearing that it is seldom within the possibility of thorough repair. Bring the in- 
 flammation to a stop, you perhaps may ; or nature will do it for you ; and you may 
 greatly assist the natural powers in effecting this. But that alone can be called a 
 cure, which either leaves the structure of the part affected in its original integrity ; 
 or, at any rate, leaves no spring or source of further changes for the worse : and such 
 complete recovery as this I seldom dare to hope for in cases of acute and general 
 pericarditis. 
 
 There can be no use in deceiving ourselves in this matter; but we may very easily 
 deceive ourselves. In a large proportion of cases, Avhether they be treated well, or ill, 
 or not treated at all, the patients will seem to recover. But I say that the recovery 
 is so far unreal, that it involves the germ of future destruction. If any of you have 
 read Bouillaud's heavy, yet instructive work on diseases of the heart, you will know 
 that he boasts of the success of his treatment in acute pericarditis. He declares that 
 by the bold use of the lancet he extinguishes the inflammation ; jugulates (as he 
 calls it) or slaughters the disease at its birth ; and restores the patient to the full con- 
 dition of health, or to the state in which he was before the disease came on. You 
 must hereafter judge of this question for yourselves ; but it is my duty to caution jou 
 ogainst crediting these statements. Not that I Avould insinuate a doubt of M. Bouil 
 -aud's veracity ; but I believe that he has been deceived by false recoveries ; and 1 
 
 3i
 
 696 ACUTE PERICARDITIS. 
 
 would not have you beguiled, by his representations, into the indiscriminate adoption 
 of that "enlightened hardiness" which he endeavours to inculcate. 
 
 But if we look closely at his statements, we do not find, after all, any such won- 
 derful success. Of 18 patients, 6 died ; a very large proportion, 1, viz. in 3. To be 
 sure, with some ingenuity he makes the proportion to be 1 in 7. For three of the 
 fatal cases occurred, he says, before he took to his heroic plan of blood-letting; and 
 excluding these 3, he has 15 cases, and only 3 deaths ; or 1 in 5. But one of these . 
 three proved fatal from the supervention of tetanus ; therefore setting that also aside, 
 there will be 14 cases of the disease and 2 deaths. Now, I have not, hitherto, been 
 able to look through my case-books in reference to this point, but I am quite certain 
 that the mortality m the Middlesex Hospital has been nothing like so great as that — 
 the immediate mortahty, of course, I mean — either among my patients, or among 
 those of my colleagues ; and 1 know that, until within the last twelve months. Dr. 
 Latham had not lost a single case of rheumatic pericarditis in the course of the first 
 attack of that disease for several preceding years. 
 
 But what I most doubt about, is the true recovery of Bouillaud's surviving patients. 
 I say such patients do apparently get well. In some of them, indeed, a bellows 
 sound remains, sufficiently indicative of the damage that the organ has sustained : 
 and I have already told you that any amount of change, however small, which alters 
 the healthy proportion of the cavities and their outlets, or which interferes with the 
 natural play of the heart, is a seed from which further changes will at length be 
 found to rrrow. But patients will get so far well that you can detect nothing wrong 
 about them. Follow them, however, in their subsequent lives ; and you will learn that 
 many of them very soon begin to find that they are incapable of doing or enduring 
 all that they could do or endure before their illness : and if this does not soon happen, 
 it does at last. The disease of the heart (if the patient be not cut off by some other 
 malady) becomes at length obvious ; and when he dies, the source of the ultima.te 
 change^ is commonly to be detected. There is an adherent pericardium ; or there 
 is disease of the valves; of which no other account can be given than that it had 
 contmued to exist since the primary symptoms of carditis ceased ; and that it had 
 caused all the rest — the hypertrophy, to wit, and the dilatation. 
 
 The remarks that I have now been making bear upon the question, to what amount 
 blood-letting should be carried in acute pericarditis. If the general symptoms teach 
 you that it exists, and yet no sound of attrition is heard, you may, in that case, if in 
 any, hope to arrest tlie inflammation, and to achieve a complete cure, by early and 
 copious bleeding. But if the to and fro sound has been audible, I do not think the 
 consequences of the inflammation can be so abolished. I believe that the best event 
 which can then happen is adhesion. We must, however, in many cases, take blood 
 by the lancet from the arm, or by leeches from the precordial region ; yet not in the 
 lavish manner recommended by Bouillaud. I know that his treatment has been fairly 
 tried in this country, and has failed. And I think (but this I only offer as an opinion) 
 that there is a peculiar risk in frequently bleeding to syncope in this aflt-ction. There 
 is, almost always, endocarditis (in rheumatic cases at least) coincident with the peri- 
 carditis ; and there is a readiness or tendency towards a deposition of the fibrin of 
 the blood, in the shape of minute vegetations, upon the inflamed valves : and it is 
 probable that this tendency may be favoured by a retarded movement of the blood 
 over them ; and still more so by its temporary stagnation. In the experiments on 
 the ass, referred to before, the circulation (kept up by artificial breathing) became 
 lano-uid and sluggish, and vegetations were deposited upon those valves which had 
 been irritated by the wire. Hence there is, I think, a danger in bleeding to such an 
 extent in these cases, as to bring the heart's action to a pause in deliqidiim. Bleed, 
 therefore, (if you deem it requisite to bleed at all,) till some efl^ect upon the pulse has 
 been accomplished, and then stop : and renew the venesection, or refrain from it 
 according to circumstances. But you may freely cup the precordial region, or cover 
 it repeatedly with leeches : and to this mode of abstracting blood, from the neighbour- 
 hood of the inflamed part, my own experience would assign the preference. In fact, 
 I seldom open a vein in such cases. 
 
 At the same time, you will endeavour to get the gums tender with mercury. And
 
 ACUTE PERICARDITIS. 699 
 
 It is most unfortunate that, in this disease, the system frequently resists, with great 
 obstinacy, the influence of that mineral. Sometimes, do what you will, you fail to 
 altain your object. A knowledge of this fact may render you less scrupulous than 
 you would otherwise be in the use of the remedy. Not only should calomel be given 
 in frequently-repeated doses, guarded, if need be, by opium : but mercurial inunc- 
 tion should also be had recourse to, in these perilous cases, from the first. When 
 the gums do begin to rise, there will always be, according to my experience, a 
 manifest subsidence of the distress, and mitigation of the symptoms. There will be 
 less pain, less palpitation, less dyspnoea. The mouth should be kept sore for some 
 time together : for supposing the membranes to adhere, it does not follow that the 
 inflammatory process should thereupon cease. 
 
 When you learn, from symptoms and signs already described, that the pericardium 
 is distended by liquid eflTusion, I would advise you to lay a large blister over the 
 precordia. The diminution, or complete disappearance of the liquid, under this 
 treatment, is often rapid and striking. 
 
 Even when all the symptoms have vanished, previous disappointments have taught 
 me not to be sanguine as to the permanency of the recovery. I beheve that months, 
 and years even, may elapse before the secondary effects of the mischief left behind 
 by the inflammation begin to be palpable. But in many instances, they show them- 
 selves very early. Others have noticed all this: especially Dr. Latham, who truly 
 remarks, that "in acute pericarditis there is no medium between complete cure and 
 certain death." He deemed, at the time when the lectures from which I quote were 
 given, that the early and vigorous use of mercury would be equal to the complete 
 cure. I think I may venture to say that he has since seen reason to doubt on that 
 point. I have several times already expressed my own belief, that where the to 
 and fro sound has manifested itself, that is, where the inflammation has gone so far 
 as the efflision of coagulable lymph, if the patient does not die outright, he survives 
 at the expense of an adherent pericardium ; and he survives only for a time. Hacret 
 lateri lelhalis anindo. But I am also of opinion, that by the cautious employment 
 of the lancet and of leeches, and by the early and unshrinking use of mercury, the 
 mischief may be greatly limited, and the consecutive changes staved off to a distant 
 period. The final catastrophe arrives much more slowly where there is mere adhe- 
 sion of the pericardium, than where that condition is complicated with permanent 
 disease of the valves within the heart. I need scarcely say that other, minor expe- 
 dients are to be put in force ; strict abstinence I mean, perfect quiet, and an occa- 
 sional purgative to clear out the alimentary canal. 
 
 When the pericardium has once become adherent, if (as is very likely) the patient 
 again suffers acute rheumatism, he may again have heart symptoms. Not, of course, 
 the to and fro sound ; but pain, palpitation, and dyspnoea. Now it is of some prac- 
 tical importance to be aware that this renewal of morbid action does not require that 
 active treatment which the primary inflammation demanded. The effect of such 
 renewal will be to augment the existing mischief; but the morbid process is much 
 less vigorous, and much more easily subdued. It will generally yield to the repeated 
 application of leeches, or of blisters, over the situation of the heart, and to the mode- 
 rate exhibition of mercury. 
 
 Although acute inflammation in this, as in other serous membranes, shows gene- 
 rally a strong disposition to spread all over the affected surfiice ; yet does the peri- 
 cardium seem readily susceptible of slight and partial inflammation. You will very 
 frequently indeed see, upon laying the bag open, a white spot, as big as the finger- 
 nail, upon the surface of the heart. I have examined these spots very often ; and I 
 believe they almost always consist of a thin flake of lymph lying sometimes beneath, 
 but ofiener upon, the membrane. They may, in fact, be peeled off sometimes, and 
 the subjacent membrane left smooth and sound. On one occasion, I met with a long 
 riband of lymph passing from the centre of one of these white spots, to connect 
 itself with the loose bag of the pericardium. I conclude, therefore, that these spots 
 are really the result of a very limited inflammatory process : but under what condi- 
 tions they arise, or whether during their formation they furnish any synaptoms, I do 
 not know.
 
 700 ACUTE PERICARDITIS. 
 
 Such is the view which I had long taken, and taught, of these white spots upon 
 the surface of the heart ; and I am glad to have it confirmed by the observation of 
 Mr. Paget, who has recently adduced (in the twenty-third volume of the Medico- 
 Chirurgical Transactions) conclusive evidence, both of their frequency, and of 
 their inflammatory origin. 
 
 So much then for the heart itself, and its membranes. There still remain to be 
 considered the morbid conditions of the great vessels that spring from it, and lie in 
 the thorax, and especially of the aorta: those morbid conditions I mean, whicl- 
 declare themselves by symptoms, and which become the object of medical treat 
 ment. 
 
 The aorta is very- frequently indeed found diseased, and its disease, as I have 
 already explained, is a common cause of organic changes in the left ventricle of the 
 heart. You will find that its inner membrane, instead of being smooth, and of a 
 uniform yellowish-white colour, is rendered very uneven by a great number of yel- 
 low opaque projections, of cartilaginous consistence, lying immediatel)'^ beneath the 
 membrane. And in a more advanced stage of the same diseased condition, you may 
 perceive that some of these projecting little masses consist of irregular scales of bone, 
 having sharp edges ; and sometimes these plates of ossific matter are quite bare ; the 
 inner membrane is gone, and the exposed bone is washed hy the current of blood. 
 Now the necessary effect of these changes is to diminish and destroy the natural 
 elasticity of the vessel ; and as there is a perpetually recurring strain upon it, by the 
 blood sent out from the heart, the vessel dilates, becomes larger than it should be. 
 This, if j^ou please, you may call aneurism ; but a simpler name is dilatation. In 
 other ca.ses, the enlargement is not general, but partial. A pouch is formed on one 
 side of the artery, and this pouch may be very small or very large. It appears to 
 result from the giving way, the rupture in short, or the ulceration, of the inner and 
 middle coats of the artery, and then the blood, passing through the broken part, 
 presses against the cellular coat of the vessel, and distends it into a sort of bag. 
 There have been curious discussions as to what should be called true aneurism, and 
 what should be called false aneurism ; discussions upon which I have neither time 
 nor taste for entering. It is enough for all practical purposes to state, that the artery 
 sometimes dilates only, sometimes throws out a pouch. I know that you have re- 
 ceived, or will receive, from my colleague, Mr. Arnott, all the information that is 
 requisite concerning the modes in which aneurism may arise. These are matters 
 of the highest interest in surgery, for surgery can cure an aneurism ; an achieve- 
 ment which is but seldom within the skill of physic. 
 
 I have known two cases in which the diseased artery all at once cracked across — 
 its inner and middle coats, I mean — and death very rapidly ensued. In one of these 
 instances, the crack extended round a considerable part of the circumfen'nce of the 
 aorta. It looked exactly like a clean cut made by a sharp knife. The blood, in this 
 example, dissected its way (if I may so say) between the middle and external coat 
 of the aorta, and got at last into the pericardium, and coagulated round the heart in 
 a uniform layer: so that a bag of coagulated blood was enclosed in the bag of the 
 pericardium. Of course, nothing can be done for such cases as these. 
 
 Most commonly the aneurismal tumour goes on enlarging; and often it becomes 
 lined, and sometimes it is nearly fdled up, by layers of coagulated blood, which form 
 in its interior. At length the tumour bursts, and the patient perishes. 
 
 Aneurisms of the thoracic aorta are met with chiefly in the earlier portions of that 
 vessel, in its ascending part, and in its arch. There seem to be two reasons for this. 
 One is, that the diseased state of the coats of the artery (to which the rupture and 
 subsequent aneurismal pouch, or the dilatation, as the case may be, are owing) is 
 more common, and more advanced generally in that part of the aorta; and another 
 reason is, that the momentum of the blood, as it is forcibly propelled from the left 
 ventricle, is sustained chiefly by the same part. 
 
 Mere disease or dilatation of the commencing aorta, affords, as I formerly endea- 
 voured to explain, a physical impediment to the due emptying of the left ventricle 
 It is a common cause, therefore, of hypertrophy and dilatation of that ventricle ; 
 and ronseauently, the signs of hypertrophy and dilatation of the left ventricle of
 
 THORACIC ANEURISMS. 701 
 
 he heart will at length result from disease and enlargement of the aorta near its 
 mouth. 
 
 When aneurismal pouches form, as they often do, at the very entrance of the 
 aorta, or in the coronary arteries, they often defy detection. I, at least, know of no 
 sign of their existence upon which a physician can rely, or which can lead him 
 even to suspect such a state of matters. But all at once the patient drops down 
 dead : and upon searching for the cause of this sudden extinction of life, you find 
 the pericardium distended with blood, and the source of that blood you find to be 
 the ruptured aneurismal pouch, so near the root of the aorta, as to project within the 
 pericardium. In the preparation which I hold in my hand, an unbroken aneurism 
 actually bulges into the right ventricle of the heart. 
 
 When the aneurismal tumour occupies a portion of the ascending aorta a little 
 more distant from the heart, or is formed at the arch itself, it sometimes attains a 
 large size, and the evidence of its existence is derived from the effects its enlarge- 
 ment produces on the surrounding textures ; and these effects are apt, for a while, 
 to be obscure and equivocal, until an external pulsating swelling makes its appear- 
 ance, or a sudden gush of arterial blood through the mouth discloses the true nature 
 of the malady. 
 
 In these cases we infer the existence of aneurism sometimes from peculiar symp- 
 toms. Aneurism at the arch of the aorta may come to press upon the trachea, and 
 impede the breathing; or by its effect upon the recurrent nerves, it may cause a 
 very accurate mimickry of laryngitis. The operation of tracheotomy, as I told you 
 before, has more than once been performed, to relieve the supposed inflamed condi- 
 tion of the larynx, while the sole disease was aneurism at the arch of the aorta. 
 Such mistakes are always discreditable; and the lesson they furnish should not be 
 lost upon us. Whenever we find that a wheezing dyspnoea has gradually arisen, 
 which no apparent affection of the air-passages satisfactorily accounts for, and the 
 patient has a sense of pulsation within the thorax, we may suspect that an aneurism 
 is at the bottom of these symptoms. 
 
 The effect of aneurismal enlargements of the artery in causing absorption of the 
 neighbouring tissues, upon which the tumour presses, is very curious. You know 
 that even the solid bone is removed, worn away as it were, before an advancing 
 aneurism. Hence it not unfrequently happens that the trachea, or some of the 
 larger bronchi, are at first flattened, and then give way; the aneurism breaks into 
 the air-passages ; and the patient, overwhelmed by a torrent of blood into and from 
 • his lungs, perishes in a few seconds. Or the tumour may contract adhesions with 
 the pulmonary tissue, and destroy it to a certain extent, and so cause mortal haemop- 
 tysis. But such cases are not always fatal at once. 
 
 Again, according to its situation and extent, an aneurism of the thoracic aorta may 
 press upon the oesophagus, and cause the ordinary symptoms of stricture of that 
 tube. Hence cardiac disease, and pulsation within the chest, accompanied at length 
 by the signs of a constricted oesophagus, form strong presumptive indications of the 
 existence of an aneurism ; and in such cases, the oesophagus may at last ulcerate 
 through, and then copious and fatal hemorrhage ensues. Hsematcmesis it may be 
 called, though the blood is vomited not from the stomach, but from the gullet. A 
 patient in the Middlesex Hospital, with symptoms of stricture of the oesophagus, 
 one day brought up from the throat a red mass, which, at the moment, was sup- 
 posed to be a bit of meat that he had been trying to swallow. It really was part of 
 the clot from an aneurism ; and it was speedily followed by a stream of red blood, 
 and by death. 
 
 Again, aneurism of the thoracic aorta does frequently obstruct, by its juxtaposition 
 and pressure, the vena cava superior ; nay, it may even obliterate that vessel, of 
 which I have seen two instances. To one of these cases I alluded before, as a most 
 curious example of dropsy. It illustrated exceedingly well the effect of venous ob- 
 struction in causing serous effusion. The man was a patient of Dr. Hawkins. He 
 presented a most extraordinary spectacle. His face, neck, and arms, were tumid 
 and anasarcous to an enormous degree ; while there was not the least trace of swell- 
 ing or oedema anywhere below the ribs. He looked as if his upper half had been 
 
 3i3
 
 702 THORACIC ANEURISMS. 
 
 stuHed ; and except that it was distressing, nis appearance was extren:ieJj.' comical 
 H»s countenance was livid ; his eyes soemea starting from their sockets ; and even 
 the areolar tissue beneath the conjunctiva was cedematous. The integuments of his 
 neck and chest were quite brawny ; and his arms were so swollen that they projected 
 from his sides. The surface of the thorax in front was embossed by numerous veins, 
 which were turgid with blood ; and here and there patches of ecchymosis were 
 visible. You may form some notion of the degree of mechanical congestion that 
 existed, when I tell you that, upon the scarificator being applied, after a cupping- 
 glass was taken off, upwards of twenty ounces of blood escaped in two minutes. 
 The epigastric veins were visible and tortuous, and a free communication by anas- 
 tomosis existed between these veins ascending from the inguinal region, and the 
 mammary veins. There was a bellows sound, which increased in loudness and 
 harshness, from the root of the aorta to the top of the sternum. The patient soon 
 died ; and a larf^e aneurism of the aorta was laid open by lifting up the sternum, 
 to which the artery had adhered, and into which, indeed, it had eaten a little. Not 
 far above the right auricle, the vena cava was totally impervious; its sides having 
 been gradually pressed together, as the tumour grew. The other case, of the same 
 kind, which occurred in one of my own patients, I shall have occasion to refer to 
 hereafter. 
 
 But aneurism of the thoracic aorta may exercise its pressure in another quarter, 
 and Avear away the bones of the vertebrse, and cause pain in the back, and ultimately 
 palsy of the parts below that portion of the spinal cord ; so that pain in the back, 
 with pulsation, may justly awaken suspicion of aneurism making its way backwards. 
 I remember hearing Dr. Farre describe a case of this kind, to inculcate the necessity 
 of paying attention to the sensations of a patient. A man came to him for advice, 
 having been told by another physician that there was nothing the matter with him — 
 that he was fanciful. But when an adult person makes constant complaint of certain 
 morbid feelings in a part, the probability is that he has something the matter, and 
 we must investigate the case with what helps we can get. In the instance in ques- 
 tion, there were two signs of disease, and two only ; a white tongue, and pain in the 
 back. The whiteness of the tongue soon disappeared under the use of some medi- 
 cine addressed to the digestive organs. The pain in the back remained. Dr. Farre 
 interrogated the patient minutely every time he visited him, till at last the man got 
 vexed and tired, and said, pettishly, "I know that if 5^ou split me down the middle, 
 I am sound on my right side, and diseased on my left." Very soon after, he was 
 found dead in his bed. What he had said was perfectly true : there was an aneu- 
 rism pressing on the left side of the dorsal vertebras. 
 
 Another consequence of an enlarging thoracic aneurism, sometimes observed, is 
 pressure upon the thoracic duct, causing engorgement of the absorbent vessels and 
 glands, and inanition. In short, whatever parts the aneurism may reach, and subject 
 to its pressure, may have their function thereby suspended or disturbed, or their 
 structure spoiled. 
 
 One sign, which I have myself. frequently verified, of aneurism of the arch of the 
 aorta, is a difference in the force of the pulse in the two radial arteries. The pulse 
 in the one wrist will be extremely feeble, or even disappear. This happens when 
 the state and position of the arteria innominata, or of the left subclavian artery, be- 
 come altered in consequence of the enlargement of the aorta ; and sometimes the 
 one or the other of these arteries is completely closed up. But inasmuch as a similar 
 difference of the pulses may arise from other causes, we can only look upon this 
 symptom as one which may help to solve an ambiguous case. To give you an 
 example of a difference in the beating of the arteries in the two wrists from othe' 
 causes, I may mention a case in which the subclavian artery was thrown forwards, 
 and compressed by an exostosis on the first rib. The case is mentioned in Mr. Mayo's 
 Pathology. It occurred in a patient of mine, the husband bf a nurse in my family. 
 I had a girl for some time in the hospital, in one of whose arms no artery could be 
 found to pulsate. Why, we none of us could make out. 
 
 Very lately, d surgeon from the country came to my house, desirous (he said) to 
 consult me about a sense of discomfort in his head ; and particularly about the state
 
 THORACIC ANEURISMS. 703 
 
 of his vision. When erect, he saw things obscurely. At three yards' distance he 
 could see my face, but could not distinguish the "separate features. What he 
 thought very strange was that he could see perfectly well when in the horizontal 
 posture. 
 
 On my proceeding to feel his pulse, he said, in a careless manner, "By-the-by, 
 that is another thing wrong with me ; I have no pulse." Nor could 1 detect any, in 
 either arm. He then told me that, four or five years previously, a medical friend, 
 intending to feel his pulse in the left wrist, could find none. He was confident pulsa- 
 tion had existed a short time before that. After a while, the movement of the radial 
 artery returned, in a very slight degree ; and then finally ceased. Within nine or 
 ten months of this discovery, the right pulse, after growing less and less distinct by 
 degrees, had vanished also. Though somewhat weak, and subject to faintness, this 
 gentleman had not wasted ; nor had the muscles of his arms lost either bulk or vigour. 
 Their veins were full enough of blood. His hands were often cold ; and he felt alto 
 gether worse during cold weather. 
 
 Failing to detect any pulsation in the brachial and subclavian arteries, I next felt 
 for the carotids : but I could perceive no beating in the track of their course. I had 
 placed my finger, for a few seconds onl}^ in front of the left sterno-mastoid muscle — 
 when I saw that his head drooped, his cheeks became white, and he was on the 
 brink of fainting. But he recovered immediately. Then I made similar pressure, 
 for a moment, on the right side of the neck, and the same phenomena were instantly 
 repeated, with the addition of convulsive jerking movements of the head and arms. 
 He rallied again directly upon my removing my finger, and was scarcely aware of 
 what had happened. For a second or two he had been unconscious. His femoral 
 arteries throbbed as usual. 
 
 I next examined his chest. There was no external irregularity or want of sym 
 metry. Percussion gave a clear resonant sound everywhere in front. The heart 
 was heard, beating with frequency, but without any bruit, over the greater part of 
 the thorax. Its impulse in the precordial region, below the nipple, was feeble : but 
 a strong jarring impulse was communicated to the ear when the stethoscope was 
 applied to the upper part of the sternum. 
 
 The patient complained of pains aflfecting his shoulders, clavicles, and the back of 
 his neck ; and of slight difficulty of swallowing. 
 
 From the intelligent physician who had attended this gentleman in the country I 
 learned the instructive fact that, twenty months before, a loud rasping bruit had beer 
 ludible, without impulse, at that part of the sternum where he, as well as 1, now 
 found no bruit at all, and a very considerable impulse. 
 
 I cannot doubt that in this painfully interesting case there is aneurismal disease 
 of the aorta, interfering with and lessening, but not absolutely excluding, the stream 
 of blood through the arteries which spring from its arch. 
 
 In the numerous specimens upon the table, you will find ample evidence and 
 illustration of almost every one of the effects which I have described as apt to result 
 from the pressure of thoracic aneurisms of the aorta. But similar effects would ensue 
 from the same degree of pressure, however caused ; and other morbid tumours, 
 cancerous tumours in particular, are not uncommon within the thorax. Hence these 
 same effects, considered as symptoms, are in themselves, of equivocal import. If 
 they occur in conjunction with signs of disordered circulation, or of a diseased heart, 
 we may reasonably conjecture that they are produced -by an aneurism. But we can 
 seldom be quite sure of this, until the advancing aneurism comes near the surface, 
 and causes an external prominence or tumour which pulsates visibly, or of which 
 the pulsations are perceptible by the touch. And even then it may require some 
 care and tact, to avoid mistaking an enlarged gland, or a malignant growth, lying 
 over a sound artery, and receiving an impulse from it, or communicating to it some 
 unnatural sound, from the diseased vessel itself. 
 
 The pulsating tumour, if the aneurism has formed in the ascending aorta, makes 
 its appearance, usually, on the right side of the sternum. If the aneurism is situated 
 in the forepart of the arch, it produces a bulging at the sternal extremities of the 
 upper ribs on that side. When it springs from the summit of the arch, the tumour
 
 1 
 
 704 THORACIC ANEURISMS. 
 
 rises abovo the sternum, and the sternal ends of the clavicles ; and when the disease 
 occupies the descending portion of the thoracic aorta, it will sometimes destroy the 
 ribs and the bodies of the vertebrce, and push forward the lower part of the left sca- 
 pula : or it may show itself in front, beneath the left clavicle. 
 
 When such a tumour presents itself, and is attended with a steady, heaving pulsa- 
 tion, synchronous with the systole of the heart, the doubt and obscurity which may 
 have previously hung over the nature of the patient's disorder is cleared away. A 
 little attention to all the circumstances of the case, will generally suffice to deter- 
 mine its true character. 
 
 There are, however, some errors prevalent respecting these pulsating tumours, 
 which errors I shall glance at in passing. In the first place, the pulsation of the 
 tumour is frequently, most frequently, attended with a rough bellows sound ; and 
 some persons rely upon this as distinctive of the nature of the pulsating tumour. 
 They hold that this harsh bellows sound is always discernible in an aneurismal 
 tumour ; and that when such a sound cannot be heard, the tumour is not an aneur- 
 ism. But this is a mistake. There have been in the Middlesex Hospital within the 
 last six months (1887), two instances of pulsating tumours in the fore part of the 
 thorax, unattended with any bellows sound; yet they were both ascertained, after 
 death, to be aneurismal tumours. One of the aneurisms is before you. In the case 
 of the country surgeon, a bellows sound was present at a certain period of the dis- 
 ease, and absent at a more advanced period. I may say the same of the purring 
 thrill. It is a common, but by no means a necessary attendant upon thoracic aneur- 
 isms. Again, much stress was laid by Laennec, upon the circumstance of the 
 aneurismal pulsation being single, being unattended by any second sound. But this 
 is not a true rule if taken universally. In the instance which furnished this very 
 preparation, the sounds were double, just like those of the heart. The second 
 sound heard is, no doubt, the second sound of the heart, conveyed from the place of 
 the aortic valves, where it originates, along the course of the vessel, to the aneurism • 
 which often indeed lies in contact with the heart, and could scarcely fail to have the 
 diastolic sound propagated through it. It is a fact not so easily explained, yet it cer- 
 tainly is a fact, that a double sound may be audible in aneurisms very distant from 
 the heart. Dr. Davies states, that he never heard a second sound in abdominal 
 aneurisms ; yet I presume that, under favourable circumstances, the sound of the 
 closing of the floodgates at the root of the aorta, may be heard far along its channel. 
 I can account in no other way for the second sound, heard by myself and by many 
 others, in a popliteal aneurism, I mentioned before, a patient whom I saw in St. 
 Bartholomew's Hospital, and in whom an exceedingly loud diastolic sound, like the 
 sharp whining note of a dog, was audible by the ear placed upon his arm, over the 
 brachial, and even over the radial arteries. 
 
 There are some very judicious remarks made by Dr. Hope upon the sounds that 
 are apt to be heard in these pulsating aneurismal tumours to the right of the ster- 
 num ; showing how they may be distinguished from the natural sounds of the heart 
 itself, conveyed to that spot through some dense conducting medium. He observes 
 (and all that I have seen has been consonant with this observation), that the first of 
 the aneurismal sounds, when there are two, the sound that coincides with the pulse 
 is always louder than the natural systolic sound of the heart, and generally louder 
 than any of the morbid systolic sounds ; and that instead of increasing in intensity, 
 as the stethoscope is moved gradually towards the precordial region (as it ought to 
 do, if it were the conducted sound of the heart itself), it diminishes in loudness, 
 until it is gradually lost in the actual systole of the heart. Whereas the second 
 sound heard over the tumour does augment as we get nearer the heart, for it is, in 
 truth, the diastolic sound of the heart, and therefore is more audible as we approach 
 the point where it is generated. The sounds of aneurisms of the aorta are usually 
 audible in the back also; and if a very loud bellows sound be heard there, where 
 the natural sounds, if heard at all, are always much abated, that circumstance fur- 
 nishes a strong additional ground for suspecting the presence of an aneurism, or ol 
 some great change in the aorta. 
 
 To give you some notion of the course which aneurism of the thoracic aorta
 
 ** THORACIC ANEU^IISMS. 705 
 
 may run, I will describe another instance of that disease which occurred under 
 my own observation. The subject of it suppUed tiie preparation to which I last 
 referred. 
 
 He was a stout, healthy-looking rnan, forty years old, a private coachman. He 
 became my patient in the hospital on the Sth of September, 1836. He complained 
 of pain and tenderness around and above the right mamma. The pain was increased 
 by a full inspiration ; and when lying on the opposite side, he felt as though he was 
 tied in the painful part. 
 
 He had been ill a month only. His illness commenced with severe rigors, 
 and fever, and sudden pain in the side, for which he was bled three times with 
 much relief. He attributed the attack to having lain, upon his right side, in a damp 
 bed. 
 
 There was scarcely any projection at the spot where the pain and tenderness were 
 -experienced. By careful examination several times repeated, I satisfied myself upon 
 *he following points. 
 
 On the right side of the thorax no vesicular breathing could be heard ; and thp 
 whole was dull on percussion. On the left side percussion gave a hollow sound, and 
 (he respiratory murmur was clear and strong. In the tender spot, an inch and half 
 above the mamma on the right side, a strong pulsation could be felt, and two sounds 
 were distinctly audible, the first of them keeping time with the pulse at the wrist. 
 But there was no bellows sound. M. Sanson, the celebrated French surgeon, was 
 then in London, and went round with me one day, and examined this patient; and 
 he expressed his opinion that it was not a case of aneurism, because there was no 
 ivhiz or bellows sound to be heard. Of course his examination was a cursory one, 
 and I mention this circumstance merely to show you what importance is attributed 
 to the presence or absence of a bruit de soiifflet in such cases. M. Sanson suggested 
 that the heart might be displaced, and pushed over to the right side. However, it 
 was clear to me that this could not be the case, because the breathing was deficient, 
 not on the left, but on the right side ; and, above all, because the apex of the heart 
 could be both seen and felt beating in its proper situation, in the precordial region on 
 the left side. Also on the left side, percussion made on the edge of the ribs gave a 
 tympanitic sound, indicating the place of the stomach ; on the right a dull sound, 
 pointing out the situation of the liver ; so that it was not a case of transposition of 
 the viscera, such as had been found, not long before, in one of my patients. In the 
 course of the disease, a shght bellows sound did become perceptible over the right 
 mamma, when the patient sat up ; but even then the natural sounds of the heart, 
 without any morbid quality, could be heard in the natural position of that organ. 
 QCgophony was audible at the back part of the right side of the chest. 
 
 This patient had repeated attacks of pain, dyspnoea, restlessness, and inability 
 to lie down ; and these attacks were always most sensibly mitigated by the appli- 
 cation of leeches to the diseased part. By the Ilth of October he was so com- 
 fortable that he wished to go out ; and he went to his master's in Connauo-hi 
 Place. 
 
 Two days afterwards, he sent to beg that I would go and see him there. He 
 had brought up, on the preceding evening, during a paroxysm of coughing, about 
 a pint of bright red blood ; and he had continued to cough, and to expectorate small 
 quantities of blood. I had him again brought to the hospital on the 14th of Octo- 
 ber, where he remained, apparently much the same as before he went out. But on 
 the 19th he suddenly expired. The whole duration of his illness had been nine or 
 ten weeks. 
 
 We found the heart natural in size and in appearance ; the pericardium healthy, 
 and containing no more than the usual quantity of serum. All the cavities were 
 natural in their dimensions, and in the thickness of their walls ; and all the valves 
 healthy, excepting one white spot on the mitral valve, which could not have inter- 
 fered with its motions. 
 
 The aorta at its origin was also natural in size ; but it began to i^ilate just befoii) 
 it escaped from the pericardium, and the dilatation continued to the o-iving ofifof this 
 left subclavian, where the vessel resumed its proper capacity. The arteries arisiiii; 
 45
 
 706 THORACIC ANEURISMS. 
 
 from the aorta did not partake of the dilatation ; but the sac overlapped and adhered 
 to the external surface of the innominata, for about a quarter of an inch from its 
 origin. This explained a symptom I omitted to mention, viz. : that the right radial 
 artery beat much more feebly than the left. 
 
 The pouch formed by the aneurism adhered in front, for the space of two inches, 
 to the inner surface of the third rib ; and close to the edge of this adhesion there 
 was a small irregular aperture about two lines in diameter, by which the interior of 
 the pouch communicated with the right pleural cavity. Nearly a pint of loosely 
 coagulated blood was found in that cavity, together with a greater quantity of serous 
 fluid than could have belonged to the coagulum. Just above the adhesion to the rib, 
 the pouch adhered to the substance of the lung, over a space about an inch square ; 
 and here the parietes of the artery seemed wholly wanting. This, doubtless, had 
 been the channel of the copious haemoptysis a week before his death : and it is inte- 
 resting to observe that the opening of the aneurism into the lung was not imme- 
 diately fatal. The artery was much diseased, in the usual manner. The right lung 
 was nearly all of it "carnified" by the compression it had undergone. 
 
 If this case had not terminated as it did, no doubt the aneurism would have made 
 its way outwards through the ribs, as happened in the very remarkable specimen 
 before you ; in which you see that the sternum and five of the ribs have disappeared 
 before the pressure of an aneurism in the ascending portion of the aorta. Some- 
 times, the tumours that form in this manner, project and attain the size of the head 
 of a full grown fcEtus before they burst. 
 
 What can we do in these melancholy cases ? Not much. Certain points of prac- 
 tice are so obvious that it is almost superfluous to meniion them. I mean the ob- 
 servance of quiet, and the religious avoidance of every thing likely to excite or 
 quicken the circulation : bodily exertion, therefore ; straining of all kinds; mental 
 emotion ; stimulating food and drink. These are not only likely to aggravate the 
 existing mischief, but prove often the immediate cause of the rupture of the aneu- 
 ••ism, and of sudden death. 
 
 I mentioned, in describing the morbid anatomy of aneurism, that when the diseased 
 vessel began sensibly to dilate, and more especially when it was protruded into a 
 sack or pouch, the blood began to coagulate upon the diseased membrane. And it 
 continues to do so, from time to time, in successive layers, so that upon dividing the 
 aneurismal sac, you will see concentric laminae of firmly coagulated blood. This is 
 clearly a strengthening of the weak place — a reparatory and compensating process 
 analogous to others which we have already had occasion to notice. And our object, 
 here as in other cases, must be, not to interfere with the natural attempts towards 
 repair, but to assist and promote them, if we can. 
 
 This principle has long been distinctly recognized in the treatment of anuerisms 
 that are incapable of relief by surgical means. 
 
 But it is much to be doubted whether the principle, so sound in itself, has been 
 judiciously followed out. You have probably heard, or will hear, a good deal of 
 Valsalva's and Albertini's mode of treating aneurisms. It was simply that of bleed- 
 ing the patient repeatedly, and keeping him upon as low a diet as was barely 
 enough to prevent his perishing of inanition. The object of this plan of treatment 
 was to facilitate the coagulation of the blood by diminishing its force and velocity, in 
 the hope that at length such a solid barrier might be built up and organized, as might, 
 in some sort, furnish a new wall to the artery in the dilapidated part. When this 
 object had had the best chance of being accomplished ; when the patient had been 
 so reduced as to be scarcely able from weakness to raise his hand from the bed, to 
 which he was strictly confined ; then Valsalva increased his quantity of nourishment 
 by degrees, until the necessary strength was restored. 
 
 Now I quite agree with Dr. Copeland in thinking that this practice may be car 
 lied, and has been carried, to a hurtful extent. He says that he has seen cases " in 
 which aneurismal tumours had existed for some time without any increase, so long 
 as the patient avoided any marked vascular excitement, and continued his accus- 
 tomed diet , but when repeated depletions, and vegetable or low diet were adopted, 
 gr-^at augmentation of the tumour, and fatal results, soon followed."
 
 DISEASES OF THE VEINS. 707 
 
 In truth, we shall perceive reason to expect that this would be the case, when we 
 consider, first, that the starving system, and the frequent abstraction of blood, diminish 
 the quantity of fibrin in that fluid, rendering it more watery, and less disposed to 
 coagulate ; and, secondly, that what is called reaction — or a violent palpitating action 
 of the heart — is very apt to follow repeated losses of blood ; and this forcible action 
 of the heart must tend rather to sweep away the existing coaguk, than to cause an 
 additional deposit. 
 
 A more reasonable and hopeful plan of management, therefore, would, in my 
 opinion, be one which should keep the action of the heart gentle and moderate, and 
 the motion of the blood as slow and languid as possible, without impoverishing that 
 vital fluid. We should husband the materials of repair, and promote the deposit of 
 them where they are wanted. A nutritious but unstimulating diet ; perfect repose 
 of mind and body ; and a due regulation of the natural functions ; with the abstrac- 
 tion of so much blood only as may be necessary to alleviate pain, or to subdue exces- 
 sive arterial action, or to unload vessels which are manifestly oppressed by their 
 contents ; — these, I humbly conceive, constitute the most rational means of furthering 
 the endeavours of nature towards a cure. Few cures, indeed, can be hoped for in 
 any way. Yet hfe may be prolonged in these cases, by great care ; and the exten- 
 sion of existence even for a month or two, or a week, or a day, may sometimes be 
 an acquisition of the greatest moment. 
 
 I have little to say concerning particular drugs. Digitalis may, perhaps, be some- 
 times of use ; and the acetate of lead is well spoken of by those who have tried it. 
 I have not had sufficient experience of either of these remedies in the treatment of 
 aneurism, to enable me to state any thing to you, confidently, in respect to their 
 value. 
 
 LECTURE LXIII. 
 
 Diseases of the Veins. Phlebitis; adhesive, and suppurative: consecutive scat- 
 tered Abscesses. Treatment of Inflammation of Veins. Effects of the gradual 
 obstruction of large Venous Trunks. 
 
 Yesterday I concluded what I had to say, as a physician, respecting diseases of 
 the arteries : and this seems as fitting a time as any for taking a final notice of some 
 of the morbid conditions of the veins — especially of their inflammation. Already, 
 more than once, brief reference has been made to this important subject : important, 
 whether we consider the large amount of mortal disease which it comprehends, or 
 its wide and intimate relation with general pathology. I should have done better if 
 I had given you, in the earlier part of the course, a more complete and connected 
 account of phlebitis, and its consequences. It is this malady which gives to many 
 fatal injuries, and to many, nay to most, of the fatal operations of surgery, their 
 mortal character : it is of surpassing importance, therefore, to the surgeon. The 
 same malady lies at the bottom of the deadliest cases of puerperal fever : it is con- 
 sequently of the deepest interest to the accoucher. It occurs also, not seldom, in the 
 practice of the physician, appalling him by its insidious, its rapid, and too frequently 
 its resistless course. Moreover, its pathology, which has been successfully investi- 
 gated only within these few years, furnishes a key to that of other morbid conditions 
 of great moment. 
 
 The first efTect of inflammation of a vein is to impede, or arrest, the passing bJood, 
 which, coagulating upon the inflamed surface, adheres to it. In some instances the 
 inflamed coat of the vessel is merely (as Mr. Hunter said) furred over: in others its 
 channel is completely dammed up. The obliteration of a small vein in this manner 
 can seldom have any serious consequence ; but much suffering, and distress, and 
 even death itself, may result from the sudden and continued obstruction of one of the 
 large venous conduits. For example, the painful disorder, called phlegmasia dolena
 
 708 DISEASES OF THE VEINS. 
 
 is caused by a stoppage of the blood in the femoral vein. A similar arrest of its 
 current in the sinuses of the brain, is a mortal change. 
 
 This adhesive form of phlebitis is a local disease. Whatever ill effects it may 
 produce are purely mechanical ; and depend upon the closure of the canal. If the 
 organ mechanically affected by it be not a vital organ ; — if the system can await the 
 development of a collateral venous circulation ; — all, at length, may end well. Some- 
 times, indeed, as the inflammation gradually subsides, the coagulum is softened and 
 partly reabsorbed, the blood drills for itself a fresh passage through the centre of the 
 plug, and the restoration is restored to its accustomed channels. 
 
 This is, fortunately, the commoner form of phlebitis : but sometimes the inflam- 
 mation advances beyond the adhesive, and into the suppurative stage. Even then 
 the disease may remain a local one. The adhesive process may bound and isolate 
 the suppurative in both directions : and an abscess in the part is then the usual 
 result. 
 
 But if the suppurating surface of the vein be not so shut off", and pus mingle and 
 circulate with the blood, the disorder is no longer merely local. The contaminated 
 blood is conveyed to distant parts, and the whole system tainted. The malady has 
 become general, and of the most formidable character. 
 
 It had long been noticed, as a matter of fact, that collections of pus were not 
 uncommon in various parts of the body, when death had followed mechanical inju- 
 ries, or great surgical operations. Abscesses in the liver, in particular, were known 
 to be associated w:lh mortal fractures of the skull. Very fanciful reasons were 
 assigned for this coincidence. By degrees it was ascertained that these scattered 
 collections of matter — occurring most commonly in the lungs and hver, but not un- 
 frequently in or near the joints also, in the serous cavities, among the muscles, in the 
 brain, in the eye, and elsewhere — were connected with the introduction of some 
 vitiating secretion, and especially of pus, into the current of the venous blood. 
 
 And this step having been gained, fresh speculations arose, concerning the manner 
 in which the internal collections of pus were formed. In the viscera they were 
 usually small, well-defined, surrounded by the healthy tissue of the organ, and 
 several in number. Some maintained, that the pus, in substance, was carried to the 
 parts in which it was found, and there simply deposited. Others were of opinion 
 that the tainted blood created in the system a general tendency to inflammation, 
 which Avas developed in many places simultaneously. Neither of these suppositions 
 was quite true, neither of them quite false. The pus discovered in the serous cavi- 
 ties was accompanied by unequivocal traces of inflammation in those parts. This 
 alone rendered it probable that the smaller purulent collections were not merely 
 dropped there by the blood in its course, (a thing very difficult to conceive,) but 
 were the products of actual inflammation, excited somehow in those veiy spots. And 
 it is now believed that these abscesses of, as well as in, a part, proceed from suppu- 
 rative inflammation, provoked by the presence of particles of pus, brought thither 
 with the circulating blood. 
 
 I told you before, that foreign substances, entering the blood, and failing to pass 
 out of it again through the natural emunctories of the body, are liable to be stopped 
 when they arrive at the first network of capillary vessels that lie in their course. 
 Now the blood, circulating in the veins, reaches (much of it at least) in each of its 
 circuits, two such great networks, the hepatic and pulmonary. Through the pul- 
 monary network all the blood must pass, through the hepatic some of it ; and it is 
 there, in the capillary tissue of these organs, that particles of pus, and other material 
 substances, foreicrn to the blood, and incapable of elimination with the customary 
 excretions, are apt to stick, or to be entangled, and to excite inflammation. Some 
 of them, however, in general, pass on, and arriving at the left side of the heart, are 
 transmitted, with the arterial blood, to various parts of the body, there to exercise a 
 himilar deleterious influence. 
 
 Such was, and is, the theory : and it has been tested and confirmed by direct ex- 
 periment. Inasmuch as the conveyance of the pus cannot be traced by the eye, 
 nor the manner of its being collected into an abscess demonstrated, except bv in- 
 ference, Cruveilhier introduced quicksilver into the veins of animals : a metal whi^h
 
 PHLEBITIS. 709 
 
 IS liquid, and divisible into very minute particles, and which exerts no chemical 
 agency upon the vital fluid. When the mercury was inserted into the veins whicn 
 concur to form the vena portce, the whole, or the greater part of it, was arrested in 
 the liver. In that organ, the animal being killed a certain time after the introduction 
 of the metal, small, roundish, red spots were always discoverable, which passed 
 gradually into little abscesses surrounded by a halo of inflammatory redness ; and in 
 the centre of each red spot, and of each abscess, lay a minute globule of mercury. 
 A few similar points of suppuration were usually to be seen in the lungs also. But 
 when the quicksilver was put into the blood in its direct course towards the vena 
 cava, then it was in the lungs that these points were either exclusively detected, or 
 at any rate most numerous. 
 
 You must, I think, perceive how strictly these experiments bear upon the rational 
 humoralism acknowledged at the present day. If pus, and mercury, may thus be 
 distributed to particular organs, and thus excite circumscribed inflammation, so 
 doubtless may other extraneous impurities — introduced by the poison of what is 
 called good living, by the respiration of foul air, and in various other ways — reach 
 and settle in different parts of the body (the liver, the lungs, the kidneys, the joints), 
 and there produce, if not inflammation and pus, yet such changes at least as spoil the 
 texture of the organ, and pervert its healthy office. That cancer is propagated in 
 this way we have heretofore seen reason to believe. In all probability the deposi- 
 tion and increase of tubercles fall under the same law. There is, however, this 
 remarkable difference between tubercles and phlebitic abscesses, that the former 
 occupy chiefly the upper portions of the lungs, while the latter are generally most 
 numerous in their lower lobes. 
 
 Suppurative phlebitis — wath all its horrible efl"ects — is liable to arise, not only 
 after severe but also after slight injuries ; from the trivial as well as the grand ex- 
 ploits of surgery ; nay, spontaneously, as it were, without any local hurt, under the 
 agency of natural causes, such as exposure to cold. And the part in which the 
 phlebitis occurs has some influence, as you will now understand, in determining the 
 principal seat of these scattered abscesses. When they succeed amputation of a 
 limb, or fracture of the skull, or the interference of surgery with varicose veins, or 
 (as they may) even the simple operation of phlebotomy, they are likely to be most 
 numerous in the lungs. But they are more conspicuous to hasty observation in the 
 liver than in the lungs; and that is why hepatic abscess was supposed to have some 
 special connection with injuries of the head. Morgagni, however, long ago pointed 
 out the fact, that other parts also were affected in those cases. Again, we may ex- 
 pect to find these disseminated abscesses chiefly in the liver, when suppurative 
 phlebitis occurs in any of the tributary veins of the vena porta): when it supervenes, 
 therefore, upon operations on the bladder or on the intestines — operations for the 
 removal of stone, for the release of hernia, for healing fistula in ano, for the cure of 
 piles. 
 
 It is, however, very common for the poison to pervade the whole body, and for 
 abscesses to form in various other situations, as well as in the lungs and liver. I 
 once saw a young woman die, in the Middlesex Hospital, from phlebitis, with large 
 abscesses in many parts, and especially in the joints, after the simple excision, with 
 scissors, of some small spongy irritable gxowths about the orifice of her urethra. 
 
 Two or three instances of suppurative phlebitis, unconnected with any known 
 hurt, and originating apparently in exposure to cold, have fallen under my own ob- 
 servation: but I prefer giving you the following short case, with the details of which 
 I have been favoured by Dr. Maiden, of Worcester. 
 
 Miss , a teacher in a Ladies' School, was attacked, after exposure to wet 
 
 and cold, with acute pain, heat, and redness, in the front of the left forearm. Mr. 
 Cole, an eminent surgeon, of Bewdley, by whom she was at first attended, discovered 
 inflammation following the course of the cutaneous veins. Upon its subsidence the 
 veins were left like hard cords. Soon afier the right arm was affected in a similar 
 way: and next, both the lower extremities, which became anasarcous. All this was 
 attended with paroxysms, simulating those of tertian ague ; exhausting sweats, diar- 
 rhoea, and a frequent feeble pulse. At the end of a month, deeo-ocdted fluctuation 
 
 3k
 
 710 DISEASES OF THE VEINS. 
 
 was detected in the rignt thigh, three inches below Poupart's hgament. The abscess 
 gradually approached the surface, and was opened, and more than three pints of 
 very fetid pus were discharged. The wound never closed, and she sank, exhausted, 
 a month after it was made. 
 
 There was no pain, premonitory or attendant, connected with this formation of 
 matter. 
 
 The abscess was traced, after death, upwards, behind the muscles of the pelvis, as 
 far as the sacro-ihac symphysis, where the bones were extensively carious. 
 
 Many of the superficial veins, both of the upper and lower extremities, were 
 found to be completely obliterated by adhesive inflammation, or sealed up by coa- 
 gula of blood. 
 
 This spreading and morbiferous inflammation of veins is sometimes so remarkably 
 prevalent, as to partake of the character of an epidemic disorder: and this, its occa- 
 sional prevalence, appears to beowing to some peculiar condition of the atmosphere 
 — or rather to some ^-^'•edisposition of the human body, engendered by the operation 
 of influences which are probably atmospheric. During such periods prudent men 
 refrain, if they can, from the performance of surgical operations. 
 
 The view which I have now set before you of suppurative phlebitis, and of its 
 distant effects, involves some apparent difiiculties, and some curious questions. A 
 short consideration of these may serve to throw a clearer light upon the main subject. 
 First, then, how is it — if indeed the disseminated abscesses result from the intro- 
 duction of pus into the blood — hoAV is it that we do not meet with them oftener? Pus 
 is absorbed, in numberless instances, without the occurrence of any such formidable 
 consequences. We see great abscesses disappear spontaneously, and yet no other 
 smaller scattered abscesses ensue. Does not this fact invalidate the theory of the 
 cause and formation of such distant points of suppuration ? No. It seems, that for 
 their production, pus assuch, pus in substance, pus in the mass, must be received 
 into the veins, and circulate with the blood. The pus which is taken up by ordinary 
 absorption, is altered, probably, by that process, before it reaches the blood : at any 
 rate it has not the same mischievous and fatal effect. 
 
 You may here inquire in what manner pus gets into the circulation, in conse- 
 quence of an amputation ? Is it not absorbed from the suppurating stump ? I con- 
 ceive not. Supposing the amputating knife to cross and sink into an existing abscess, 
 and to divide a vein — then, indeed, pus might be sucked into the vein, and the usual 
 consequences follow. But the veins that lead to, or rather from, a stump, become 
 blocked up, and impervious, from adhesive inflammation, or from mere coagulation 
 and adhesion of the blood in them, before the stump has had time to suppurate. 
 How then does the pus ever find admission ? No doubt it is a product, in this case 
 also, of phlebitis. The interior of a vein inflames, and goes on to suppuration ; and 
 the pus which it pours forth mingles, as pus, with the circulating stream. 
 
 Indeed these scattered abscesses appear to originate always in phlebitis. Such is 
 the opinion of my colleague, Mr. Arnott, who has contributed a valuable paper on 
 this subject to the MeJico-Chinirgical Transactions. Such is also the opinion of 
 M. Cruveilhier. It has been objected that, in some fatal cases of this kind, no 
 phlebitis could be detected: that the principal veins have been diligently traced, yet 
 no vestige of suppuration, nor even of adhesive inflammation, has been visible. To 
 make this objection valid, all the veins throughout the 'body should be scrutinized ; 
 and that has seldom, I fancy, been done. I have known several instances, in which 
 most of the larger trunks were searched in vain, till at length a short tract of one of 
 them, an inch or two perhaps, was found, bearing marks of having been inflamed. 
 You must not conclude therefore against the antecedent existence of phlebitis, until 
 vou have examined everj^ vein in the soft parts of the body : no, nor even then. 
 You must go deeper than the more obvious veins. There is good reason for believ- 
 ing ihat the hones and their veins are often the seat of the primary mischief, the 
 fountain from which the pus, which thus renders the blood a poison, first proceeds : 
 the veins, for example, of the diploe of the skull, when scattered abscesses ensue 
 upon injuries of the head ; the veins of the bones of the extremities after unsuccess- 
 ful operations. Tliere is yet another explanatory supposition applicable to some
 
 PHLEBITIS. 711 
 
 cases. All local traces of the primary inflammation may vanish before death, while 
 the vital powers are being undermined, and about to sink under its secondar}^ effects, 
 
 Cruveilhier repeatedly performed the following' experiment, and always with simi- 
 lar results. He introduced crude mercury within the hollow shaft of the thigh bone 
 of a living dog. When the quantity was considerable, death occurred in a few days, 
 and the metal was found strewed thickly through the lungs, each globule occupying 
 a capillary branch of the pulmonary artery, and surrounded by a small sphere of 
 inflammatory redness. When the quantity was minute, the animals lived longer, 
 and little abscesses, enclosing each a particle of mercury, were then discovered in 
 the same organs. The mercury he supposes to have found a direct entrance into the 
 blood, in these cases, from the cancellous portion of the bone: and through the same 
 channel it seems to be that pus often enters the circulation. You may remember 
 my relating some fearful examples of scattered abscesses, supervening upon chronic 
 disease of the bones of the ear. Cruveilhier states that having been present at the 
 examination of the body of one who had sunk after amputation of the leg, and whose 
 lungs were full of little abscesses, he sought, without success, for some inflamed vein : 
 but upon dividiqo- the tibia and fibula, he found the spongy extremities of these bones 
 in filtered with pus. Here, beyond question, had been the source of the visceral 
 mischief. 
 
 The local phenomena, when a superficial vein of some magnitude is inflamed, are 
 pain and tenderness in the course of the vessel, which, in the adhesive variety of the 
 complaint, is soon converted into a tangible, hard, and sensitive cord. Whether the 
 vein be near the surface or deeply seated, there is usually more or less oedema of the 
 areolar tissue of the part. Phlebitis of this kind has been sometimes confounded, I 
 believe, with inflammation of the lymphatic absorbent vessels. You distinguish the 
 latter by the slenderness of the painful cord ; by its position, which is still more 
 superficial than that of a subcutaneous vein ; by the number of little knots which 
 diversify its course ; and by the streaks and patches of bright inflammator}'" redness 
 which appear along the same track. Dr. Graves remarks {Clinical Medicine, p. 
 451), that inflammation of the lymphatics " is seldom continuous, but is developed 
 at certain insulated points." 
 
 In the suppurative form of phlebitis the general symptoms take the lead. The 
 formation of pus in separate and often distant parts is rapid, and frequently unan- 
 nounced by any local pain. When, however, the joints, or parts near the joints, are 
 the seat of suppuration, much soreness is complained of, and the malady is liable to 
 be mistaken for rheumatism ; and when the serous cavities are implicated, the pain 
 is sometimes severe. Suppurative phlebitis is commonly attended in its progress 
 v/ith repeated shiverings, and with profuse sweats, and occasionally with copious and 
 very unnatural discharges from the bowels. These last have been noticed in ani- 
 mals soon after the introduction of pus, or of putrid matters, into their veins. Nature 
 seems to attempt to eliminate the poison in this way: and where the quantity of pus 
 so introduced has been small, the attempt is now and then successful. But in gene- 
 ral there is a continual supply of the noxious substance, and the system is irrecover 
 ablj' infected. Typhoid symptoms occur in most cases, but not in all. Very con- 
 stantly there is great agitation, and a marked disturbance of the nervous system. 
 
 I have called this purulent infection of the blood a formidable disorder : in truth 
 it is almost always a fatal disorder. Yet that it is not inevitably mortal I know by a 
 case which has recently occurred in Mr. Arnott's practice at the Hospital, and which 
 he permits me to mention. He had occasion to amputate the forearm of a mar. 
 whose hand had been crushed by machinery. Two or three days after the operation, 
 the patient's pulse quickened, and he had a severe rigor. These two circumstances 
 led Mr. Arnott to ipprehend the supervention of phlebitis; and accordingly one of 
 the large, superficial, visible veins of the forearm became swollen, hard, and tender. 
 Leeches v/ere applied along its course ; and the parts were kept covered wjth the 
 water dressing. In no long time an abscess formed in the other arm ; next, a larp,e 
 one in the back, from which twenty ounces of pus were evacuated; then one beneath 
 the glutei muscles of the buttock, on both sides — each of these two contained about 
 sixteen ounces. In short, datmg between the beginning of October and the middle
 
 712 DISEASES OF THE VEINS. 
 
 of December, no less than seven collections of matter presented themselves in vanoiw 
 places. The last of them was in a very unusual part, beneath the man's tongue, in 
 the ordinary situation of ranula, for which, indeed, it was at first mistaken. In every 
 instance the pus was let out as soon as possible, and the main feature in the general 
 treatment was the administration of opiates, and of wine, with a Hberal allowance 
 of good beef-tea in the earlier stages, and of meat afterwards. This m'an recovered ; 
 and was seen in the month of May following, in perfect health. The case is ex- 
 tremely interesting. It shows, I say, that suppurative phlebitis, even when it dissemi- 
 nates consecutive inflammation and suppuration throughout the body, is not absolutely 
 and hopelessly fatal. Whether abscesses, from this cause, distributed in the lungs 
 or liver, are capable of repair, I cannot tell you. Under the treatment employed, the 
 inflammation of the vein m the arm gradually subsided. All outward evidence at 
 least of its existence, all induration even, disappeared ; and presumptively all inward 
 evidence too. So that had this patient sunk, late in the course of his disorder, under 
 the multiplied secondary abscesses, his venous system might probably have been 
 searched in vain for any remaining traces of phlebitis : and yet we know that at one 
 time he had phlebitis, more severe and extensive than belongs to the natural and 
 kindly healing of every stump. 
 
 The treatment found most suitable in phlebitis has just been briefly indicated ; 
 local depletion when the inflamed vein is accessible ; regulation of the bowels ; strong 
 animal broths and wine to support the strength. Our object is in the first place to 
 subdue and resolve the inflammation ; or at any rate to prevent its passing beyond 
 the adhesive stage. To this end, the vein, being obvious and superficial, we apply 
 leeches, cold lotions, or fomentations. 
 
 [In cases of phlebitis from venesection, the late Dr. Physick recommended the application 
 of a blister over the orifice in the arm, as soon as the inflammation commences, the oritice 
 itself being first defended by a plaster of simple cerate spread on linen. He found this to 
 be invariably beneficial in causing the arrest of the inflammation. Dr. Dorsey also found a 
 blister thus applied to produce always a good eflect ; and in a case related by Dr. f^vaus, 
 (Transac. College of Physicians of Philadelphia, vol. ii., p. 106,) the good eflect of blisters in a 
 case of spontaneous phlebitis, was strikingly evinced. — C ] 
 
 During the progress of the malady, especially when suppurative phlebitis is pre- 
 valent, it would be unsafe to cut into a large vein, lest by that shght violence we 
 establish a fresh local phlebitis. Indeed, after the suppurative form has once been 
 set up, general blood-letling does no good ; but, on the contrary, impairs the power 
 of the system at large to struggle against the disease. 
 
 The obliteration of a large vein, whether by adhesive phlebitis or in anj' other 
 way, is perilous in proportion to its magnitude, and to the rapidity with which its 
 complete occlusion has been effected. The gradual stoppage of even the largest — 
 the primary venous trunks, the vense cavce — admits of some degree of compensa- 
 tion. In one instance of this kind, which I briefly described yesterday, and which 
 I myself witnessed, the superior cava was flattened, and its channel completely 
 effaced, by the pressure of an aneurismal tumour : in another, which I mentioned 
 formerly, on Mr. Kiernan's authority, an immense varix of the superficial veins of 
 the abdomen supplied to the returning blood the passage denied to it, in its natural 
 course, by the partial obliteration of the inferior cava. To impress upon your recol- 
 lection the ordinary phenomena that result from these grave derangements in the 
 hydraulic machinery of the body, I will state here, from my hospital case-book, the 
 outlines of two additional examples of a similar character. 
 
 James Buck, aged thirty-three, was admitted on the (3th of March, 1838. The 
 ajjpearance of this man was very remarkable. His countenance was swollen and 
 livid ; his eyeballs projected ; his fips, the end of his nose, and the rims of his ears, 
 were of a deep purple colour. It was manifest that the blood did not freely descend 
 from the head. Further evidence of this became apparent when the trunk of his 
 body was uncovered. The throat was very full and tumid, like that of a goitrous 
 ;)erson, yet the swelling was not owing to enlargement of the thyreoid gland, nor to 
 <£dema ; but fek firm and fleshy. The jugulars were distended ; and the whole sur-
 
 PHLEBITIS. 713 
 
 face of the thorax in front, with that of the shoulders, and of part of the abdomen, 
 was thickly overspread with a network of prominent veins. The external mammary 
 veins were seen to communicate freely with veins proceeding from the neck on each 
 side, with the veins of both the upper extremities, and with the epigastric veins from 
 beneath. Here and there were patches of minute purple varicose branches, crowded 
 closely together. 
 
 He told us that whenever he stooped down, to tie his shoe-strings, for instance, he 
 became giddy, his head swelled, and his face and ears grew black : that he was very 
 nervous, easily flurried, and dreamed much, thinking he was flying in the air, falling 
 down precipices, and the like. He had not noticed any swelling of the face or throat 
 until three weeks previously ; and he had never, he said, had a day's illness before. 
 He knew of no cause for the complaint ; had been making no extraordinary bodily 
 effort ; had never suffered rheumatic fever. He professed, also, temperate habits, 
 but he had been a soldier, and afterwards a pugilist, and his wife informed me that 
 he had led an irregular life. • 
 
 The evidence 1 say was strong, of some obstruction to the return of the blood 
 through the superior cava. Now such obstruction is most commonly produced by 
 intrathoracic tumours — sometimes by carcinomatous ; much oftener by aneurismal 
 tumours. There were no circumstances to make it likely that the malignant growths 
 existed ; but there were circumstances which corroborated my first suspicion, that 
 the symptoms were dependent upon aneurism of the aorta, or of one of its primary 
 branches. 
 
 There Avas indeed no external prominence, no pulsative or other swelling, no 
 aneurismal whiz, to guide us to this diagnosis. Upon careful and repeated auscul- 
 tation of the chest, the murmur of respiration was found to be in some parts feeble 
 and unequal. This might consist with the presence of any kind of tumour. The 
 heart's action was heard, and fek, strong and heaving, in the proper place, beneath 
 the left nipple. To the right of the sternum also, and near the middle of its upper 
 portion, one's ear was distinctly jarred at each systole of the heart, though with less 
 force than in the precordial region. But in the space intermediate between these 
 two spots, no such jarring sensation was perceptible, although the heart could be 
 heard, beating with a slight bellows sound. Moreover, the right radial artery was 
 considerably weaker and smaller than the left. This showed that the innominata 
 was interested in the disease. The symptoms, taken together, left no doubt on my 
 mind than there was an aneurismal pouch beneath the sternum, where the jar was 
 experienced. I have gone somewhat into particulars to show you how confidently 
 sometimes, by close observation, you may pronounce upon the condition of parts 
 which you can neither see nor touch. 
 
 All that could reasonably be hoped for from medicine, was postponement of the 
 evil day. To. relieve the oppressed blood-vessels by taking away part of their con- 
 tents, by freely purging the patient, and by setting his kidneys to work — this Avas 
 what was to be attempted ; and this was done. He was repeatedly cupped, and 
 always with most sensible relief to his feelings, the blood flowing copiously. Pur- 
 gatives and diuretics also acted well ; and so much was the man benefitted by these 
 measures, that twice he left the ward, and became an out-patient. 
 
 About the middle of June a new symptom arose — severe pain extending from the 
 right collar-bone across the shoulder. He died on the 10th of July. Three or four 
 days before his death, he had rigors and extreme dyspnoea, complained of pain over 
 the whole thorax, and declared that his " heart seemed on fire." These symptoms 
 were caused by the supervention of pericarditis, which proved speedily fatal, A thin 
 layer of recent, reticulated lymph was found covering a considerable extent of the 
 surface of the heart. 
 
 The body was examined by Mr. Shaw, after injection of the veuis, and of the tho- 
 racic duct. 
 
 There was a large aneurism of the arteria innominata ; of which I omit all parti 
 cular description, my present object being to draw your attention to the state of the 
 veins. The two great trunks that, coming from either side, unite to form the vena 
 cava superior, were completely closed up, as well as the corresponding portion of :he 
 
 3k2
 
 714 
 
 DISEASES OF THE VEINS. 
 
 cava itself, which was lost and confounded in the walls of tne aneurisnrial sac. The 
 subclavian veins were pervious up to the point where they joined the internal jugu- 
 lars, but no further. The preparation of these parts, which is before you, and the 
 rough diagrams v/hich I here exhibit, will aid your comprehension of the mode 
 \vhereby the blood descending from the head, found its way at length, through many 
 circuitous channels, to the heart The larger deep-seated compensating veins were 
 not greatly magnified, but the number of the smaller branches was much augmented. 
 The vcnaazygos, for example, was very little above its usual size ; yet it was appa- 
 rently provided with a greater number of considerable branches than are commonly 
 observed under natural circumsiances. 
 
 A, Obstructed veins. 
 
 B, Seat of the ri?ht auricle. 
 
 C, Tlioracic, pectoral and mammary reins convey- 
 
 ing the blood in a contrary course to its usual 
 direction, and anastomosing witli the inter- 
 costal and epigastric veins. 
 
 As the veins into which the trunks of the absorbent vessels discharge their con- 
 tents were obliterated, it became interesting to examine the state of these vessels, and 
 of the lymphatic glands. But the condensation and confusion of all the parts 
 around the tumour rendered it difficult to trace the thoracic ducts. The glands 
 were remarkably large, of a purple colour, and gorged with bloody serum. The 
 fulness of the neck, noticed during hfe, was occasioned by this turgescence of the 
 glundulx concatenatie. Large glands were seen studding the walls of the aneurism, 
 and adhering to the great vessels connected with it : /. <?., in situations where, under 
 ordinary circumstances, such glands, from their minuteness, can scarcely be detected 
 at all. 
 
 With this case, contrast the following : — 
 
 Harriet Baldwin, thirty-three years old, was admitted December 29, 1840, anasar- 
 cous as high as the hips, and with an enlarged abdomen. The swelling had begun, 
 she said, a fortnight before. 
 
 She complained of cough, and of expectoration, which was sometimes tinged with 
 blood. She could not lie down in bed for dyspncEa, Her urine was scanty and 
 dark-coloured. 
 
 She told us she had dropsy, quite as bad, five years ago, of which she was cured 
 m St. Bartholomew's Hospital. 
 
 All this we learned in the admission-room. The next day, when she was in bed, 
 we learned a good deal more. 
 
 The large abdomen did not owe much, if anv ot its bulk to ascites. It contained
 
 OBLITERATION OF VEINS. 
 
 715 
 
 a palpable tumour, filling the right hypochondrium, and extending thence far beyond 
 tJje umbilicus to the left, and into the right groin. This tumour, from its situation, 
 and from the coutinuous dullness elicitea by percussion from the right mamma down- 
 w-ards over its whole extent, was evidently formed by the liver, much enlarged, and 
 out of its place. 
 
 But besides the tumour, the abdomen presented on its surface a very singular ap- 
 pearance. Two zig-zag lines of large, varicose veins ran up its middle, n^ar the 
 right edge of the linea alba. These, which were evidently the epigastric veins, 
 inosculated above with the mammary. Large, but straighter veins, wandered over 
 the front of the thorax on both sides. 
 
 The swollen legs of this woman were quite purple from innumerable clusters of 
 small varicose veins. 
 
 Other symptoms also there were, but I pass them by as irrelevant to my present 
 subject. It was plain that the current of the blood 
 along the vena cava inferior was suffering impedi- 
 ment. That vessel was presumably compressed, 
 perhaps rendered totally impervious, by the superja- 
 cent tumour. The existence of the tumour ; the 
 great cedema of the legs, compared with the shght 
 amount of liquid in the cavity of the belly ; tlie va- 
 ricose state of the cutaneous veins of the legs ; and, 
 above all, the remarkable condition of the superficial 
 veins of the abdomen : — these were the evidences. 
 The blood from, the lower extremities passed mainly 
 by the way of the intercostal and subclavian veins, 
 to the heart. Death took place on the 19th of Janu- 
 ary, 1841. A part of the liver appeared perfectly 
 healthy ; another part contained a prodigious quan- 
 tity of hydatids. When removed from the cyst 
 which had contained them, they filled a large wash- 
 hand basin. The sides of the inferior cava were 
 pressed together by the tumour, and its channel was thus completely closed up for 
 the space of three inches. 
 
 In each of these two cases, the closure of the great venous trunk was gradually 
 effected, as the compressing tumour augmented ; and time was afforded for the deve- 
 lopment of collateral supplementary channels. In both cases, the superficial veins 
 of the thorax and abdomen contributed largely to supply the growing needs of the 
 system ; but the stream of returning blood ran oppositely in the two cases : from 
 above downwards in the first, from below upwards in the second. The direction in 
 which the blood in the veins is moving can, of course, be always readily ascertained ; 
 and this might furnish a test, were other tokens wanting, whereby to determine whe- 
 ther the obstruction lay in the superior or in the inferior cava. And there is another 
 circumstance worthy of remark, and of which the same use might be made. In the 
 first case, the dilated veins of the thorax were tortuous, those of the abdomen direct. 
 In the second, this was reversed ; the epigastric veins were singularly sinuous, the 
 mammary veins were straight. In other words, those veins were, in each instance, 
 contorted and winding, in which the actual course of the blood was retrograde. The 
 vessels were bent and twisted as the current forced its backward way against the 
 opposing but inefl^ectual barrier of the valves. 
 
 It is impossible, I think, to find more clear evidence than these interesting cases 
 exhibit, of the power inherent in the animal body of rectifying, to a certain extent, 
 its own accidental derangements. You cannot, under such circumstances, overlook 
 the existence, or mistake the tendency a vis medicalrix naturse.
 
 716 ASTHMA. 
 
 LECTURE LXI^. 
 
 Ssfhmu : its nature; comjMcations ; exciting cauixM ; and treatment. Diseases 
 of the (Esophagus : InJIa m /nation ; Stricture.; Spasm; Dilatation. 
 
 I MUST not leave the subject of thoracic disease without saying a word or two 
 respecting asthma; a complaint which might have been properly arranged among 
 the nervous spasmodic diseases, in a former part of the course. But 1 purposely 
 deferred speaking of it, because, though in many instances purely spasmodic, and 
 independent of any discoverable faulty structure, it is still more often connected with 
 organic diseases of the heart, or of the lungs; which diseases had not then been 
 described. 
 
 I scarcely need caution you against the vulgar error of calling all kinds of diffi- 
 cult breathing by the name of asthma. You will be constantly meeting with per- 
 sons who, labouring under some permanent embarrassment of the respiration, tell 
 you they are asthmatic. They conceive that asthma is simply an inconvenient, and 
 not at all a dangerous affection : and they please themselves with the notion — con- 
 sumptive patients and their friends do this continually — that they are merely asthmatic. 
 Asthma is dyspnoea, but dyspncEa is not necessarily asthma. 
 
 Asthma may be defined as being — great difnculty of breathing : occurring in 
 paroxysms; accompanied by a loud wheezing sound of respiration ; going off, after 
 some hours, with more or less mucous expectoration ; and unattended with fever. 
 And these paroxysms of dyspnoea are believed to depend upon a spasmodic constric 
 tion of the bronchial lubes. 
 
 To go rather more into detail : the phenomena which constitute and characterize 
 a fit of asthma, are somewhat as follows : — The patient, if he have previously suf- 
 fered under the disease, has usually some well-understood warnings that an attack 
 is hanging over him. Loss of appetite ; frequently much flatulence and eructation : 
 languor, irritability, drowsiness, oppression, chilliness ; and he goes to bed ill and 
 uncomfortable. The dyspnoea comes on generally after midnight, about two or three 
 o'clock in the morning; often during sleep; and the patient wakes with a sense of 
 tightness and constriction about the chest, and an inability, as it seems to him, freely 
 to expand it. He is obliged at once to rise up ; and he sits, leaning forwards, with 
 his knees drawn up, his elbows on his knees, and his head supported by his hands, 
 labouring for his breath, and making such a loud wheezing noise as to be audible at 
 a considerable distance. He experiences a strong desire or necessity for fresh air: 
 opens the door of his room and goes out upon the stair-case, or flies to an open win- 
 dow, even in very cold weaiher : and remains there, with his head out, sometimes 
 for hours. That he can do so wiih impunity is a strong presumptive proof that it 
 is the nervous system which is principally affected in these cases. His extremities 
 at the same time are usually cold, and his countenance is distressed and haggard : 
 while the trunk of his body may be wet with perspiration. Sometimes the face is a 
 .ittle flushed and turgid : but more commonly, it is somewhat pale, and shrunk. The 
 pulse is often small, feeble, and even irregular; and in many instances there is 
 much palpitation of the heart. At other times the pulse remains undisturbed. If 
 uriue be passed, as it frequently is, at the beginning of a fit of asthma, it is copious 
 and watery, pale, and without smell, like the urine of hysterical women. The 
 bowels are also sometimes relaxed, with "something (as Dr. Forbes observes) of the 
 impatient hurry and imperfection of spasmodic action." There may be some 
 propensity to coughing, but the patient can hardly achieve a cough ; and is so occu- 
 pied with his breathing, that he can speak in an interrupted manner only, with 
 difficulty and uneasiness. He has not, however, in general, any misgivings about 
 the event of the attack, but looks forward with hope to the expected termination of 
 the paroxysm. 
 
 " These symptoms often continue for many hours together ; and particularly from 
 fliidnight till morning is far advanced. Then, commonly, a remission takes place
 
 ASTHMA. 717 
 
 by degrees. The breathing becomes less laborious, and more full ; so that the per- 
 son can speak or cough with more ease. And if, as is usually the case, the cough 
 brings up some mucus, the remission becomes immediately more considerable, and 
 he falls into a much-wished-for sleep." 
 
 Paroxysms of this kind will often continue to recur for many nights in succession : 
 remitting at length in their severity ; and ceasing, for a period, altogether. 
 
 Daring the intervals between these paroxysms, in the day-time, the patient may 
 be perfectly well ; but he seldom is so ; though so great is the difference between 
 his condition during the remissions, and in the paroxysms, that he declares, and per- 
 haps fancies, that he is quite well. You will mostly find, however, that he is short- 
 winded ; that he does not utter many words of a sentence before he pauses to take 
 breath ; that slight bodily exertion hurries his respiration ; and that he is not easy in 
 a horizontal posture, with his head low. 
 
 Ahhough the dyspncsa is thus intermittent, or remittent, you are not to suppose 
 that the paroxysms recur with the regularity of those of ague. The interval is of 
 uncertain duration ; and the circumstances of the paroxysm differ in different in- 
 stances. I may remark also, that when the paroxysm ceases with little or no expec- 
 toration, the case is said to be one of dry asthrna ; when expectoration is copious, it 
 is humid, or humoral asthma. 
 
 Now this, I say, is looked upon as being essentially a spasmodic affection. Upon 
 what grounds ? 
 
 Why, in the first place, the patients have a sensation of constriction in the chest. 
 An old gentleman whom I saw lately, and who is subject to fits of asthma, made 
 use of the term cramp when he described what he felt about the thorax ; and his 
 attacks were always accompanied or succeeded by actual cramp of the muscles of 
 the calves of his legs. This is no uncommon circumstance, this co-existence of 
 decided spasm in other parts ; and it throws some light upon the nature of the dis- 
 order. Again, the rapidity with which the dyspnoea comes on, and the suddenness 
 with which it often abates, resemble the caprice of spasm. The supervention of 
 extreme, sometimes enormous flatulence, and the secretion of hysterical urine, mark 
 also the nervous character of the symptoms. So likewise do the juvantia and the 
 Ixdentia, as I shall presently explain further; the affection being suddenly produced 
 by certain causes of irritation, and even by mental feelings — suddenly relieved, some- 
 times, by medicines which are reckoned antispasmodic. If we add to these consi- 
 derations the fact that patients dead of asthma have often, on being examined, pre- 
 sented no vestige whatever of disease, either in the lungs or in the heart, we obtain 
 very strong presumptive evidence, that the phenomena attending a fit of asthma are 
 often the result of pure spasm. 
 
 But if this be so, what are the muscles thus fixed in spasmodic contraction ? 
 
 You are doubtless aware that the air-tubes are encircled with a series of little 
 fibres, or bundles of fibres. I have more than once shown you these, exaggerated 
 by hypertrophy, in the larger bronchi. They have been traced, by Reissessen, in 
 tubes of a very small diameter. Laennec states that he had distinguished them in 
 bronchial ramifications less than one line across. Now, supposing these circular 
 fibres to be muscular, it becomes at once, and (i priori, likely that they, no less than 
 other muscles, should be liable to spasm. And the phenomena of asthma prove, to 
 my mind, that they are so. Analogy would say that the fibres, thus disposed, are 
 slender muscles, similar to those which surround the intestines and the urinary 
 bladder : and the microscope, scrutinizing their minute texture and appearance, 
 asserts that they are actually muscles, of the unstriped kind ; like other involuntary 
 muscles subserving the organic life. This fact — which I know has been doubted — 
 I state upon the authority of Professor Todd and Mr. Bowman ; both known to you 
 all as faithful and expert observers. But a test, less fallible than the microscope, 
 has practically settled the question. Dr. Williams has recently demonstrated, by a 
 set of ingenious and satisfactory experiments, that the lungs and air-tubes are actually 
 contractile to a very considerable degree, under electrical, chemical, and mechanical 
 stimuli. The contractions take place steadily and deliberately ; and are followed, 
 as soon as the stimulus is withdrawn, by an equally gradual relaxation. This is
 
 718 ASTHMA. 
 
 very like tonic spasm. The contractions were rendered apparent by means of a 
 bent ojlass tube, containing coloured liquid, and adapted to the windpipe of an animal 
 just deprived of life. The column of liquid in the glass tube would of course be 
 readily movable by any contraction of the lungs and air-tubes, causing pressure of 
 the included air against it. In one of the experiments, "on passing a galvanic 
 current from the margin of the lungs to the insertion of the tube in the trachea, the 
 fluid rose quickly, but gradually, nearly two inches ; sunk speedily on breaking the 
 contact ; again rose upon completing it ; but fell slowly when the current was con- 
 tinued for some seconds ;" i. e., when the irritability of the tissues was temporarily 
 exhausted. Temporaril)^ I say, for on waiting two or three minutes between each 
 application of the galvanism, the liquid was raised again and again for upwards of 
 an hour; till, in fact, the organic life was extinct. Is not all this exceedingly like 
 the behaviour of parts acknowledged to be muscular, under similar influences ? 
 
 The phenomena were not occasioned by any general shrinking of all the pulmo- 
 nary tissues. For when the lungs were cut across by sharp scissors, at right angles 
 to the air-tubes, and the open sections of these tubes were galvanized, they were 
 seen to contract to one-half of their former diameter; and even to become smaller 
 than that. The contraction was the most distinct in the m.iddle-sized tubes, being 
 about the bigness of a straw : but it was sensible enough in the trachea, which was 
 sometimes so far reduced in dimensions, that the ends of its cartilaginous rings came 
 together. 
 
 A foreign experimenter, M. Valentin, carries us a step nearer to the full solution 
 of this interesting question. He found that the rings of the trachea could be made 
 visibly and distinctly to contract, by irritating the par vagum. 
 
 Upon the whole, we may safely conclude that asthma is one of the spasmodic 
 disorders of the excito-motory system of nerves. I believe, moreover, that, as in 
 most other disorders of the same class, the spasm may be of centric, or of eccentric 
 origin. In the eccentric form, the par vagum is doubtless the afferent nerve ; and 
 the impression it conveys to the medulla oblongata is reflected, through associated 
 motor nerves, upon the bronchial muscles. The centric variety results from a similar 
 impression originating in the nervous centres : which respond, mysteriously, to cer- 
 tain feelings of the mind. 
 
 I have never had a favourable opportunity, since I became aware of the value of 
 auscultation, of listening to the sounds of the breathing during a paroxysm of pure 
 spasmodic asthma. But they who have enjoyed such opportunities declare that no 
 respiratory murmur, or very little indeed, can be heard. And an attentive inspec- 
 tion of the outside of the chest shows, that amidst all the tugging and heaving for 
 breath, the expansion of the thorax is very hmited. The patient cannot open his 
 lungs as it were : and what air does get in, has a difficult and narrow passage, as 
 the wheezing noise demonstrates. Laennec affirms, that if the patient, after holding 
 his breath nearly as long as he can, attempts a quiet and gentle inspiration, the 
 spasm may often be overcome as if by surprise ; and, for a kw seconds, the entrance 
 of the air into the cell may be heard in a clear and even puerile sound. If this be 
 true, it is a strong additional proof that the obstruction to the admission of air was 
 really owing to a tonic contraction of the little muscular fibres of the bronchi and 
 their ramifications. 
 
 The hereditary nature of asthma is perfectly consistent with the same theor}% 
 It is one of the maladies which are distinctly transmitted — the disposition to them, 
 I mean — from parents to children. And like other spasmodic disorders, it facili- 
 tates its own return. When it has once occurred, it seldom fails to happen again 
 and agam. 
 
 But though I believe, for the reasons I have now mentioned, that asthma, in the 
 restricted sense of that term, is purely a spasmodic affection, yet I know also that it 
 is very frequently indeed combined with organic alterations within the thorax. These 
 changes of structure are to be regarded as so many strongly predisposing causes. 
 They induce a readiness to take on spasmodic action : and some of them are perhaps 
 aggravated, or even produced, by the fits of asthma, upon which they afterwards
 
 ASTHMA. 719 
 
 react injuriously. Judging from my own experience, I should say that genuine 
 uncomplicated spasmodic asthma was rare. 
 
 The organic diseases with which spasmodic asthma is often found connected, are 
 principally emphysema of the lungs, and structural changes in the heart and great 
 blood-vessels. It is extremely probable that the first step towards the production of 
 the spasm, consists in some altered condition of the circulation through the lungs. 
 The chilliness of the surface, and the sensation of want of air, make it likely that 
 the blood accumulates in the lungs at those times: that there is congestion of the 
 membrane, as well as spasm of the circular fibres. And it would seem that, in the 
 humoral asthma, the congestion is relieved by a copious secretion of mucus ; and 
 that, with the congestion, the spasm also subsides and disappears. You will observe 
 that very generally the paroxysms come on during the first sleep : at which time, as 
 Dr. Alison has suggested, "the blood is perhaps in fullest quantity, its movements 
 slow, and its congestion in internal parts easiest, because it is least solicited to the 
 organs of sense or locomotion." But there seems to be another reason for this re- 
 markable circumstance. Respiration is mainly an automatic act ; yet it also obeys 
 the will. During sleep this moderating influence of the will is suspended. Those 
 changes of posture, and those voluntary alterations in the rate of breathing, which 
 are wanted to balance and correct the commencing derangement of the pulmonary 
 circulation, and which are prompted at once during the waking state, do not occur: 
 until at length the derangement reaches that pitch at which it provokes spasmodic 
 contraction, and rouses the sufferer. 
 
 This same congestion, leading to spasm, sometimes passes into a slight form of 
 inflammation ; and we have symptoms of bronchitis. And these symptoms may 
 remain manifest even during the intervals of the paroxysms. It appears probable 
 also that the vesicular emphysema of the lungs, which so often accompanies asthma, 
 is increased by the paroxysms, even if it be not, in all instances, originally induced 
 by them. In either case, there will be some abiding dyspnoea between the fits. 
 
 Many of these asthmatic patients have just healthy lung enough to breathe with, 
 in tolerable ease and comfort, under ordinary circumstances ; and dyspnoea is brought 
 on whenever even a slight additional demand upon the respiration .anyhow arises. 
 Hence, as I stated before, flatulent distension of the intestines, undue repletion of the 
 stomach by an excessive meal, the recumbent posture, all of which cause pressure 
 against the vmder surface of the diaphragm, may suffice to bring on the fit. Hence, 
 also, probably, in part, its frequent occurrence in the night-time. 
 
 In like manner, any extraordinary task imposed upon a heart which is barely 
 equal to its functions while the body is in repose, may induce a paroxysm of asth- 
 matic dyspnoea. 
 
 Asthma is a disorder which is incident to both sexes, but it is much more common 
 in men than in women. It is incident to all ages also ; but it belongs more to adoles- 
 cence, and to the middle portion of life, than to its extremes. It is not, I think, a 
 common disease prior to the age of puberty : yet instances of it do occur at an earlier 
 period than that. I have lately seen a boy of eight or nine, who has had several 
 well-marked attacks of pure asthma. Nor does it often begin to show itself in old 
 age. Sometimes, after plaguing the subject of it for several years, it leaves him alto- 
 gether. The chronic dyspnoea, with occasional irregular exacerbations, which is so 
 frequent a disorder among old people, and which always depends upon organic dis- 
 ease, is not to be confounded with true asthma. It is said that asthmatic persons are 
 exempt from phthisis : and I understand that one physician in this town, who an- 
 nounces that consumption is curable, maintains the doctrine of the incompatibility 
 of phthisis and asthma ; and endeavours to bring about the latter, that he may protect 
 his clients from the former. It may be that persons affected with genuine asthma 
 seldom become the victims of pulmonary consumption : but I am sure the rule is not 
 universal. One of my earliest friends had from time to time, while we were school- 
 fellows, and long afterwards, the most exquisite fits of spasmodic asthma. At length, 
 when he was between thirty and forty years old, they wholly ceased : whereupon 
 he greatly congratulated himself. But they only yielded before a worse aisease. 
 He began, in a few months, to spit blood : and in a few months more he died of well
 
 720 > ASTHMA. 
 
 marked phthisis. Our lamented principal, the late Mr. Rose, afforded another sad 
 example of the same sequence. And 1 have known two or three families in which 
 one individual was subject to asthma, while others were scrofulous and phthisical. 
 
 The exciting causes of the asthmatic paroxysm are manifold ; and some of them 
 curious. They seem to be reducible to two classes. 1. Particular states of the 
 atmosphere, which irritate or offend the mucous surface of the air-passages ; or 
 rather, some of the fibrils of the par vagum. 2. Certain subtle influences which 
 afTect in a peculiar manner the nervous system. All the known exciting causes of 
 catarrh are therefore likely to bring on attacks of asthma in the predisposed. But 
 there is a singular caprice in asthmatic patients in this respect. Some persons, sub- 
 ject to the disorder, are unable to breathe in the thick smoky air of London ; require 
 a high and clear situation; and respire easiest in "the difficult air of the keen 
 mountain-top." Others can nowhere breathe so comfortably as in low moist places: 
 in some of the streets by the water-side in the city, for instance. The friend to 
 whom I lately alluded lived at Newmarket ; a most exposed and bleak spot. But 
 if he left it, and attempted to sleep in a strange place, he never was certain that he 
 should not be assailed in the night by his well-known enemy. So that there were 
 towns in which, after experiencing the effects of their atmosphere, he dared not 
 sleep ; and there were others in which he knew he might go to bed in security. It 
 would have been difficult, I believe, to point out any essential difference between 
 some of those localities. His lungs, however, formed an infallible eudiometer. 
 Another college acquaintance of mine, much tormented by asthma, is equally sensible 
 to these inscrutable influences. Two inns in Cambridge are named respectively the 
 Red Lion, and the Eagle. He can sleep in one of them, and not in the other. Nay, 
 he is thus variously affected within much narrower limits. He assures me that, 
 when in Paris, he never escapes a fit of asthma if he attempts to sleep in the back 
 part of Meurice's Hotel, and never suffers if he sleeps in a front room. Dovei 
 Street suits him ; Clarges Street does not. He cannot rest in Manchester Square. 
 This he attributes to its being built upon piles. Whether it really has such a 
 foundation I do not know. And agencies still more slight and subtle are enough to 
 set the springs of these seizures in motion. The mere absence of light, for instance. 
 Laennec speaks of a man who invariably was roused from his sleep by a paroxysm 
 of asthma, if his lamp was extinguished ; or if his chamber-door was shut. The 
 consciousness that the customary preventive remedy was not at hand, has, appa- 
 rently, brought on a fit. 
 
 There are many persons who never fail to become asthmatic if they inhale cer- 
 tain effluvia. Particles of ipecacuan floating in the atmosphere, or (what is perhaps 
 the same thing) its mere odour, are insupportable to many. They are thrown into 
 a paroxysm of dyspnoea if they enter an apartment where that drug is under prepa- 
 ration. I think I mentioned before a certain laboratory-man at St. Bartholomew's 
 Hospital who possessed this peculiar and inopportune susceptibility : he was obliged 
 to fly the place whenever ipecacuan was about. Most persons, probably, who have 
 had much experience in druggists' shops, are acquainted with similar examples : so 
 that the influence of ipecacuan in exciting fits of difficult breathing, resembling 
 asthma, is undoubted, and cotnmon to many constitutions. We might as well speak 
 of ipecacuan asthma, as of hay asthma, which is a precisely analogous affection. 
 Dr. Marshall Hall calls attention to the familiar but interesting fact, that the same 
 drug, ipecacuan, acting upon the gastric branches of the par vagum, excites the 
 reflex spasmodic act of vomiting. 
 
 I have said, that the relief afforded by antispasmodic remedies affords presumptive 
 evidence of the spasmodic nature of these attacks. If asthma supervene upon mani- 
 fest bronchitis, or if there^be any signs of congestion about the head, it may be pru- 
 dent to abstract blood : but this measure will not in general be requisite, and when 
 not requisite it should be avoided : for whatever tends to debilitate the patient, or to 
 »ower his vital powers, tends, at the same time, to augment his susceptibility to the 
 f xciting causes of the disease. The dyspnoea may frequently be moderated or alto- 
 gether assuaged by some form of narcotic. Now opium is the narcotic to which 
 we most trust for the mitigation of spasm in general : and opium is of vast service
 
 ASTHMA. . 721 
 
 m paroxysms of asthma. But there is also another of the vegetable narcotic sub- 
 stances which has obtained an especial repute for its effect in quieting the difficult 
 breathing in these cases ; and that is stramonium. This herb, the datura stramo- 
 nium, and another species of the same genus, the datura ferox, had long been em- 
 ployed in India as a remedy for asthma. And when it was introduced into this 
 country, about the beginning of the present century, it was cried up as a specific : 
 and every body who called himself asthmatic began to smoke stramonium : for that 
 is the way in which it has been chiefly employed. The leaves and stalks are cut 
 and pui into a pipe, and smoked like tobacco. The smoke descends, of course, into 
 the lungs: and when the saliva is swallowed, the remedy is introduced into the 
 system in that way also. 
 
 Stramonium thus used, sometimes fails altogether : sometimes calms the paroxysm 
 like a charm. The late Dr. Babington told me of a patient of his who had been 
 grievously harassed for a series of years, by asthma, but who declared to him, after 
 he had made a fair trial of stramonium, that he no longer "cared a fig" for his 
 asthma ; which he could always stop in a moment. So a Mr. Sills, in a collection 
 of communications relative to the datura stramonium, published in London in 1811, 
 states, that he had been a great sufTerer from asthma: that the fits usually continued, 
 A'ilh short interruptions, from thirty-six hours to three days and nights successively; 
 'uring which time, he had often, in the seeming agonies of death, given himself 
 jver, and even wished for that termination of his miseries. But having at length 
 discovered the virtues of stramonium, he uses this strong language: — "In truth, the 
 asthma is destroyed. I never experienced any ill effects whatever from the use of 
 the remedy ; and I Avould rather be without life than without stramonium." 
 
 This, then, is an expedient which it will always be well to suggest, for relieving 
 the urgent distress of the paroxysm of asthma. But most patients subject to that 
 complaint try it of their own accord. We have still to learn why it is so efficacious 
 in some cases, and so entirely useless, or even hurtful, in others. This probably 
 depends something on the presence or absence of organic disease in the lungs 
 or heart : but more accurate observations are wanted on this point. 
 
 Some of the animals upon whose lungs Dr. Williams performed his experiments 
 had been killed by poison. In two instances stramonium was the poison employed; 
 and it is interesting to know that scarcely any contraction of the air-tubes could be 
 produced by the galvanic apparatus. The trachea, at the same time, was lax. It is 
 requisite to notice the condition of the wind-pipe in these experiments ; for the same 
 want of contractility would be apparent, supposing the parts to be already in a state 
 of tonic spasm, from the operation of the poison. This seems to have been the case 
 when conium was used : the tluid in the glass tube indicated scarcely any com- 
 pression of the air contained in the lungs ; but then the wind-pipe was so far con- 
 tracted, that the extremities of its rings met. There w^s but little contractility, and 
 a lax trachea, after death by belladotma; and after death by the meconate of mor- 
 phia. The contractility was slight when hfe had been destroyed by strychnia; but 
 the condition of the trachea is not reported. 
 
 Experiments of this kind appear to be well worthy of careful repetition. 
 
 I have found a mixture of opium and sulphuric aether of great service in tranquil- 
 izing the breathing in asthma. And in one case, which was under my care for some 
 time, I made comparative observations respecting opium and stramonium. Bo*h 
 gave much relief; but stramonium the most, and the most certainly, if it were 
 applied in time. This patient was in the habit of being roused from sleep by the 
 supervention of the paroxysm: and if he had the means of lighting his pipe in- 
 stantly, he could slave the (it off'. But when once it had attained its full intensity, 
 he was nnalde to smoke. Under such circumstances, he would swallow the mor- 
 phia and aether; and the effect of this depended also in a great measure upon the 
 period at which it was taken. It would stop a commencing paroxysm; but had 
 liule influence over one that was fully formed. 
 
 It has been suggested, as one clue towards determining the particular kind of casi: 
 to which ;he stramonium is applicable, that it succeeds if it produces expectoration ; 
 and not otherwise. But I doubt about this. The relief is sometimes too sudden to 
 4G 3l
 
 722 DISEASES OF THE CESOPHAGUS. 
 
 admit of its being so explained. Dr. Forbes quotes the following passage of a letter 
 from an old and intelligent asthmatic to himself. " Smoking tobacco or stramonium 
 is sure to give relief, if it produces expectoration ; and it will generally do so if, the 
 moment I awake {i.e., in the incipient paroxysm), I begin to smoke, and continue to 
 do so for three or four hours. Smoking, I am able to say, after fifteen years' prac- 
 tice, and suffering as much as mortal can suffer and not die, is the best remedy for 
 asthma, if it can be relieved by exyectoratioti. I have been in the hands of all the 
 doctors of the place for fifteen years ; and still I say, smoke.'''' 
 
 The lobelia inflata has been of late much lauded for its beneficial operation upon 
 dyspncea of all kinds, and upon asthma in particular. I believe its virtues have been 
 overrated. It sometimes, like stramonium, has an almost magical effect ; but fre- 
 quently it fails to do the smallest good ; and I know that sober practitioners who have 
 employed it more than I have, have thought that it may occasion dangerous symptoms. 
 Of my own knowledge, I have nothing worth communicating to you of this drug. 
 
 Strong coffee is a common domestic remedy for asthma. The friend and school- 
 fellow already mentioned used to take it in considerable quantities, and, as he assured 
 me, with very great benefit. It is a safe, and simple, and grateful remedy, and has 
 numerous testimonies from medical practitioners in its favour. But it is much less 
 sure than the stronger narcotics. 
 
 Ipecacuanha, which is so frequently the canse, has also been recommended for the 
 cure of asthma ; and a host of drugs besides, with which I have no intention to 
 weary you. Among the rest, the application of galvanism was once in great vogue. 
 In the only patient who ever tried it under my own eye, — and he insisted upon 
 being galvanized when his fits were quite absent, — the galvanism broup-ht one on 
 immediately. 
 
 If we can shorten or mitigate the paroxj'sms, we do our patient a most essential 
 service, and spare him a great deal of suffering. And during the intervals between 
 the fits, we must endeavour to prevent their recurrence. 
 
 For this purpose, I can only just hint at the principle upon which we should go. 
 In the simple form of the complaint, when it is apparently uncomplicated with 
 any organic disease, we must caution the patient against whatever has a tendency to 
 disturb the general health. He must be temperate in all things ; he must pay atten- 
 tion to the regulation of his digestive organs; he must discover what kind of situa- 
 tion suits him best ; and avoid those which experience has shown to disagree with 
 him. And if any one remedial measure be likely to fortify him against his malady, 
 I believe that measure will oftenest be found in the shower-bath, employed in the 
 way which I formerly recommended. 
 
 If the asthma occurs in connection with any obvious pulmonary or cardiac disease, 
 we must, in addition to the means I have now been adverting to, apply ourselves to 
 the mitigation of such superadded disease. And in respect to this I have nothing 
 more to offer. 
 
 I go next to the morbid conditions of the oesophagus, so far as they concern the 
 physician ; and these morbid conditions are not many. The cesophagus lies partly 
 in the chest, and partly in the belly, and therefore may very properly close the sub- 
 ject of thoracic diseases, and introduce those of the abdomen. 
 
 The oesophagus is less liable to disease than any other part perhaps of the ali- 
 mentary canal. It differs in structure somewhat (as you know) from all other parts. 
 Its mucous membrane is provided with a thick epithelium, which extends a httle 
 beyond the cardiac orifice of the stomach. Beneath lies a dense web of areolar 
 tissue, and two layers of muscular fibres ; the one layer being disposed circularly 
 around the tube — the other longitudinally, in the direction of its axis. In some cases 
 there are pouches found in the sides of the cesophagus, formed apparently by a kind 
 of hernia of the mucous membrane, between the separated fibres of the muscular 
 coat. These are not common, however, and scarcely worth mentioning, except that 
 their existence has been supposed to have a possible connection with a curious phe- 
 nomenon, peculiar to some persons; the power, viz., of ruminating ; the power of 
 cringing into the mouth again, by a voluntary effort, food which has been for some
 
 DISEASES OF THE CESOPHAGUS. 723 
 
 time swallowed, as cows, and the rest of the ruminantia do. There are but few 
 individuals of the human species who possess this faculty ; there are but few who 
 have appendices to their oesophagus. Whether the phenomena in question belongs 
 to these last few has never been determined ; but as the possible connection of the 
 two circumstances has been suggested, it is well for you to be aware of it, that you 
 may refute or verify the notion, in case you ever have the fortune to examine the dead 
 body of a person who had the power of ruminating. 
 
 The covering of cuticle protects the oesophagus from the injurious influence of 
 matters passing over it, which might otherwise be hurtful. The morbid state for 
 which we are most often consulted is stricture, actual or spasmodic. I believe that 
 the oesophagus is very little subject to inflammation, except from mechanical violence 
 or chemical injury. I have seen a few cases, however, in which I inferred a spon- 
 taneous inflammatory condition of the tube, from the symptoms complained of; 
 which were a sense of heat and pricking exactly in the course of the oesophagus, 
 and felt between the shoulders, and precisely in the part (the patients said) where a 
 potato, swallowed too hot, gives pain while it is descending into the stomach. With 
 these symptoms there was some degree of dysphagia, not explained by anything 
 visible in the throat or pharynx : and some degree of fever. In all the instances of 
 this kind that I have met with, the symptoms have yielded in a ffew days to absti- 
 nence, purgatives, and the application of leeches along the track of the oesophagus. 
 
 This part of the alimentary canal often suffers severe injury from the deglutition 
 of certain poisons, especially the corrosive poisons ; the strong mineral acids, 'or ex- 
 ample, or the caustic alkalies. We have, in the museum of the college, some very 
 interesting specimens of the effects of these destructive substances. Sometimes, 
 when the quantity of the poison has been small, and its transit rapid, the cuticular 
 hning alone of the gullet is destroyed. It is shrivelled up, broken into fragments, 
 abraded. At other limes, the subjacent textures are affected, and ulceration takes 
 place, which at length heals, and leaves a permanent, and generally a progressive 
 constriction of the oesophagus ; and sometimes the whole of the internal membranes 
 slough away, and are discharged in one continuous tube, from the mouth ; and yet 
 the patient survives for some time. My colleague. Dr. Wilson, had a case of that 
 kind. The patient, a young woman, swallowed about a tablespoonful of oil of vitriol. 
 A week afterwards, she brought up, during a paroxysm of choking cough, a com- 
 plete cast of the gullet, with ragged ends ; or, rather, the gullet itself. Some of the 
 muscular fibres of the oesophagus were plainly visible on the outside of this tubular 
 slough, in its recent state. She lived eleven months afterwards, swallowing all that 
 time with difficulty and pain, and subsisting on slops and soft food. Yet at one pe- 
 riod she certainly gained flesh. After her death, the channel, as it remained after 
 the injury, was taken out and examined. They are both before you — the original 
 slough, and the ultimate gullet. The latter was formed by a surface which consisted 
 of an irregular cicatrix. The tube was contracted considerably in the lower two- 
 thirds of its course. 
 
 When patients have sufl^ered inflammation and ulceration of the oesophagus from 
 these causes, and do not perish at the time, they are very liable indeed to hfy^e their 
 existence abridged by the occurrence of stricture of the gullet, which goes on slowly 
 increasing until no food can pass it, and then, of course, the patient dies of starvation. 
 I show you here an cesophagus taken from a man whose case I had opportunities of 
 observing from the beginning. He was under the care of Dr. Macmichael, in th& 
 Middlesex Hospital. He was brought there in November, 1830, having swallowed, 
 half an hour before, a solution of the impure carbonate of potass, which had been 
 made for the purpose of cleaning paint, and which he had mistaken for beer. Not 
 more than a tablespoonful passed the fauces, and probably none of the poison reached 
 the stomach. He suffered severely, and was in considerable peril for several days, 
 in consequence of inflammation of the fauces and epiglottis ; but this gradually sub 
 sided, and he went out apparently well. From what I knew of the result of such 
 cases, I ventured, however, to predict that this man would, sooner or later, come back 
 with stricture of the oesophagus. He had always pointed out a spot about half-wav
 
 724 DISEASES OF THE CESOPHAGUS. 
 
 down the sternum, where he said the oil of tartar had caused him extreme pain at 
 the very first, and below which he had not felt it. 
 
 Accordinglj^ I was not surprised to see the poor fellow at the hospital in February, 
 1834, attending as an out-patient. He came there, he told me, because in eating 
 some soup he had accidentally swallowed, without chewing it, a piece of carrot, 
 which lodged in its way down, and which it became necessary to push onwards into 
 the stomach by means of a probang. Morsels of food had stuck in the same spot 
 before ; and it was the very spot where he felt the efTects of the caustic at the time 
 of the accident. He looked tolerably stout and healthy ; but said that, since swal- 
 lowing the potass, he had never been the man he was before. 
 
 He continued to make his appearance, from time to time, at the hospital, with 
 similar symptoms, till the 5th of last December (1836), when he was brought there 
 insensible, and evidently dying. We could obtain no satisfactory account of his 
 recent symptoms. He had the mark of a blister, however, on his left side ; and 
 upon closely examining him, it was plain that that side was full of fluid. It was 
 perfectly motionless in respiration; it was palpably larger than the right side; it 
 yielded everywhere a dull sound on percussion ; and no vesicular breathing w^hat- 
 ever could be heard there by the ear. The respiration on the right side was puerile ; 
 and the beating of his heart, with a systolic bellows sound, was audible on the right 
 of the sternum. 
 
 Although I was certain that the left pleura was full of liquid of some kind, I did 
 not have the thorax punctured ; because, in the first place, he was manifestly in 
 articulo mortis, and I thought that his death, which was certain, might be attributed 
 to the operation ; and secondly, because he was not dying of suffocation. His 
 breathing was not laborious or much distressed ; but he was dying of coma, and his 
 extremities were already cold, and his pulse was fluttering. I conjectured that an 
 ulcer of the oesophagus had made its way into the pleura, and caused inflammation 
 there. But my conjecture was wrong. 
 
 I will mention the main particulars of the examination of the dead body, because 
 the case was, in several respects, an interesting one. 
 
 There was a considerable quantity of serous fluid in the meshes of the pia mater, 
 bent-ath the arachnoid ; and there was some liquid of the same kind in the lateral 
 ventricles. No other diseased condition could be detected in the brain. The effu- 
 sion was sufficient, supposing it to have come on suddenly, to explain the coma. 
 
 I had the ribs sawn away on the right side, leaving their cartilages attached to the 
 sternum ; and then we saw plainly that the heart and mediastinum were thrust over, 
 about four inches by measurement, beyond the mesial line on the right side. The 
 body was on its back. It was easy to perceive how a pleura thus full of fluid must 
 oppress the lung of the other side, especially when assisted by the force of gravity. 
 The left cavity was distended by a grayish-coloured and most ofTensive fluid, of the 
 consistence of gruel; the pleura pulmonalis was covered by a layer of coagulable 
 lymph; and the lung was flattened against the vertebral column. AVe could not 
 discover any communication between the cavity of the pleura and the oesophagus or 
 air-tubes. 
 
 About the middle part of the oesophagus there was a distinct stricture, occupying 
 about half an inch of the tube. Through this portion it was impossible to push 
 one's little finger, which elsewhere found a loose and ready passage. 
 
 In this case, the man did not die of the stricture ; but he w'ould have done so, had ' 
 not another disease carried him off. I do not know why the constriction, after it has 
 once taken place, should go on continually increasing ; yet it seems to be so. In 
 his Surgical Observations, Sir Charles Bell mentions three cases like that just de- 
 scribed. In one of them, where soap-lees had been the substance swallowed, death 
 took place by starvation from stricture of the gullet, twenty years afterwards ; and 
 Sir C. Bell had no doubt that the stricture originated in the chemical injury inflicted 
 by tne soap-lees.. 
 
 When the symptoms of stricture come on in these cases, physic can do almost 
 nothing Surgeons pass bougies into the gullet, and attempt to dilate the strictured
 
 DISEASES OF THE CESOPHAGUS. 725 
 
 portion, or to prevent any further narrowing. But this expedient is usually of tem- 
 poraiy benefit only, and the patient dies at last of inanition. His miserable existence 
 may perhaps be protracted a httle by injecting nutritive enemata into the rectum. 
 Sometimes the oesophagus ulcerates through, and a communication is formed between 
 it and the neighbouring parts. 
 
 But the (Esophagus, like the urethra, and like the bronchial tubes, — like every 
 canal, indeed, in the living body, that is surrounded by circular muscular fibres, — is 
 liable to temporary constriction and closure, by the spasmodic action of its own mus- 
 cles ; and this affection is, of course, a far less formidable one than the last. 
 
 Patients who are subject to spasmodic stricture of the (Esophagus experience occa- 
 sionally, in some point or other of that tube, a sensation as if there were a knot ; or 
 sometimes a feeling as if some solid substance was ascending from the stomach 
 towards the pharynx. If they happen to be then engaged in eating, the morsels of 
 food, after mastication, readily pass the pharynx ; but, at a certain distance down the 
 gullet, they stop, and occasion pain which is felt between the shoulders, or distinctly 
 in the passage itself. Great anxiety and distress accompany this stoppage, and the 
 food is often rejected by a reversed action of the (Esophagus. 
 
 The symptoms, in fact, are identical with those which result from permanent stric- 
 ture of the gullet, except that they are not permanent. When the stricture is or- 
 ganic and abiding, the symptoms occur during or after every meal. When it is 
 simply spasmodic, they come and go, capriciously, we often cannot conjecture why 
 or wherefore ; after the fashion of other spasmodic ailments. 
 
 Spasmodic stricture may be independent of any disease of structure in any part 
 of jhe body ; but it is of some importance to be aware that it may also be symp- 
 tomatic of very serious organic changes. Mr. Mayo relates the case of a young 
 man " who had difficulty of swallowing ; he could get diDwn liquid food only ; and 
 that not without an effort. A bougie being introduced, some resistance was found at 
 the' upper opening of the (Esophagus, but it yielded : the resistance was spasmodic, 
 and depended upon neighbouring irritation caused by ulceration in the interior of 
 the larynx. The use of the bougie for a few days, with appropriate remedies to the 
 larynx, removed the dysphagia." 
 
 The purely spasmodic cases occur principally in persons of a movable constitu- 
 tion : in young women whose uterine functions are deranged, and who are liable to 
 hysteria. The remedies for hysteria will prove remedies for the spasm of the oeso- 
 phagus also. And whatever is calculated to excite ordinary hysterical symptoms, 
 • whatever tends to render the system weak and irritable, will lend to aggravate the 
 oesophageal stricture. I alluded to such cases in a former lecture. I give you ano- 
 ther, related by Sir Benjamui Brodie. A lady consulted him, unable to swallow the 
 smallest morsel of solid food ; and swallowing liquids not without great difficulty. 
 The symptoms had been coming on upwards of three years. A full-sized (Esopha- 
 gus bougie being introduced, entered the stomach without meeting the slightest 
 impediment. This lady's iace was pale and bleached : her feet were ojdemalous. 
 She had long laboured under internal piles, from which repeated discharges of blood 
 had taken place. Under the use of remedies which reheved the piles and the bleed- 
 ing, the difficulty of swallowing went away. 
 
 It is a singular, and it might, if more frequent, be a puzzling circumstance, that 
 very nearly the same symptoms which occur when the esophagus is permanently or 
 temporarily constricted, happen also sometimes under a totally opposite condition of 
 that tube ; I mean its dilatation into a large, inelastic, inert bag. One remarkable 
 example of this I witnessed in a woman whom I attended in conjunction with Mi. 
 Mayo, some years ago, in the Middlesex Hospital. The case has been fully de 
 scribed by Mr. Mayo, in the third volume of the Medical Gazette ; and more briefly 
 in his Oullbics of Pathology. She was thirty-three years old. She was Drought 
 to the Hospital in a state of extreme feebleness and emaciation. They who brought 
 her said that for the preceding month she appeared to keep down nothing. What 
 she took as food seemed to her to stop in the gullet; and, after a few minutes, it 
 leturned. A large ccsophagus bougie passed readily into the stomach. She could 
 swallow liquids more easily than solid food. When she look a small quantity, it did 
 
 3l3
 
 726 DISEASES OF THE CESOPHAGUS. 
 
 not feel to her as if it reached the stomach ; and in three or four minutes it was inva- 
 riably rejected. The vomiting was not preceded by nausea, although in its progress 
 it had the appearance of ordinary retching. She craved for food and drink, and 
 seemed literally starving. The complaint had begun ten years before, during her 
 pregnancy, and had gradually got worse. The belly was so shrunk that the umbi- 
 licus was not more than an inch distant from the spine. There was no enlargement 
 nor hardness about the stomach ; no particular tenderness on pressure of the epi 
 gastrium ; nor any uneasiness there. She died, utterly extenuated, sixteen days after 
 her admission. 
 
 The stomach was found small, and contracted at its middle to the breadth of an 
 inch and a half. The upper part of the duodenum was but half the ordinary size 
 of the ileum. The oesophagus I show you, turned inside out. 
 
 It is enlarged to an extraordinary degree of dilatation, as you perceive. It was 
 healthy, and of its natural size, at and near each extremity. Intermediately the lining 
 tunic was thickened and opaque, with numerous depressions in it. The musculai 
 fibres, which appeared to have multiplied with the expansion of the canal, were of 
 their natural colour and thickness. 
 
 Here is another preparation : a dilated oesophagus with cancerous degeneration of 
 the cardiac orifice of the stomach. I do not know its history ; but the mechanism 
 of such dilatation is intelligible enough. The food, unable to pass out of the gullet 
 into the stomach — or passing slowly and uncertainly — the tube behind it is habitually 
 distended, and loses at length its proper contractility. I saw last summer, in con- 
 sultation with Mr. Mayo, an old gentleman, of seventy, who, for two years, had 
 experienced difficuhy in«getting food into his stomach. He would eat a few mouth- 
 fuls very well ; and then, of a sudden, the next mouthful, after passing the pharynx, 
 would stop just short of the stomach ; and a sensation of swelling would arise in the 
 lovi^er and middle part of the cesophagus ; and presently up the mouthful would come 
 again. Sometimes, by waiting quietly a little while, the morsel would go on ; some- 
 times he could wash it forwards by a gulp or two of drink : but if once the food got 
 fairly into the stomach he had no further trouble with it. This gentleman had no 
 discoverable disease of the heart or lungs. He gradually grew worse. At last he 
 began to vomit grumous matters, resembling coffee-grounds, and soon died. He was 
 at some httle distance from London at the time, and the body was not (I believe) 
 examined. I have no doubt that he had malignant disease of the cardia ; and I 
 think it probable that his oesophagus was dilated. I had a female patient about two 
 years ago in the hospital with very similar symptoms ; and her stomach was found, 
 to be full of cancerous disorganization. The state of her gullet is not recorded. 
 We are apt, in such cases, to satisfy ourselves with ascertaining the gastric disease, 
 without carefully examining that part of the alimentary canal which lies above. 
 
 For maladies like these medicine has no cure. Opiates may give comfort, and 
 promote the euthanasia : and that is all. 
 
 [During the period of infancy, the mucous membrane of the cesophagus is not unfrequently 
 the seat of inflammation, of a diphtheritic, follicular, or erythematic character. The disease, 
 however, is not very often detected during the life-time of the patient, in consequence of the 
 symptoms by which it is accompanied being those which are common to many of the affec- 
 tions of the earlier months of existence. In fact, almost the only symptom in many cases 
 of oesophagitis in the infant is frequent vomiting ; — 'immediately after the deglutition of 
 drinks, or of aliments of any kind, these are discharged by vomiting, without having under- 
 gone any change. The infant usually refuses the breast and fluids generally, evidently from 
 the pain excited by the act of deglutition; occasionally, however, he will swallow, without 
 much difficulty, half solid aliment when given in small quantities at a time. If the stomach 
 be affected with inflammation at the same time with the cesophagus, the undigested food and 
 drinks discharged by vomiting will be, occasionally, mixed with the morbid secretions of 
 that organ. The disease is seldom attended by any degree of febrile excitement — The 
 infant is, usually, fretful and restless, and becomes rapidly emaciated. Whenever an infant 
 iejects the breast, or any species of fluid aliment, vomits frequently, and discharges what- 
 ever he swallows in the same state nearly as when it was taken, it is the duty of the prac- 
 titioner to institute a minute examination, in order that he may detect the inflammation of the 
 oesophagus if it exists. It is probable that pressure along the whole track of the cesophagui 
 wrill pxcit» the cries of the child, when we can have no hesitation as to the diagnosis. IC
 
 DISEASES OF THE ABDOMEN. 727 
 
 this does not happen, we may nevertheless be tolerably certain as to the existence of the 
 inflammation, if the infant be labouring at the time, or has very recently been labouring, 
 under one or other of the forms of stomatitis. If the inriammation is confined entirely to 
 tlie mucous membrane of the gullet, and is not aggravated by improper food or drinks, it 
 will often subside, after a few days, spontaneously ; but when it is connected, as is very 
 generally the case, with inflammation of the stomach or intestines, it is an atfection diiBcult 
 to control, and usually fatal. In perhaps the majority of cases, oesophagitis in the infant is 
 preceded by erythematic, diphtheritic, or follicular stomatitis. 
 
 The frequency with which inflammation attacks the mucous membrane of the CESophagus 
 in the infant, is evidently due to the predisposition which exists, at this period, to disease of 
 all the mucous surfaces from their constant state of hyperssmia ; it is liable to be excited by 
 too much or improper food, or that which is too hot or stimulating. In infants confined to 
 the breast, it may be occasioned by the bad quality of the mother's milk, or by some tempo- 
 rary morbid change occurring in the latter — and which may be produced by a variety of 
 causes. CEsophagitis has been known to result from the reprehensible nursery practice of 
 admmistering to infants infusions of spices, or even gin and water, for the purpose of expel- 
 ling wind, or to relieve the colicky pains with which they are so frequently affected. — In 
 common with all the affections of the mucous membrane in early life, inflammation of the 
 ossojihagus occurs most frequently, and is the most difficult to manage in infants exposed to 
 the baneful influence of personal and domestic filth, and a confined and impure air. Accord- 
 ing to Billard, tlie aflection of the gullet is almost invariably preceded by stomatitis — parti 
 cularly, we may add, of a diphtheritic or follicular character. 
 
 The pathological changes detected after death in cases of (Esophagitis, are stated by Bil- 
 lard to be vivid redness, with destruction of the epithelium, of some portion of the mucous 
 membrane of the cesophagus, especially of its upper portion; in some cases, a curdlike ex- 
 udation, more or less extensively difl'used, is present ; in others follicular ulcerations ; a sepa- 
 ration of portions of the epithelium, often in large shreds, is occasionally met with ; nume- 
 rous red or dark-coloured striae occurring where the epithelium is not destroyed ; large, 
 irregular eschars of a black colour, with intervals of deej), bright-red excoriations, are occa- 
 sionally met with, and, in some cases, gelatinous softening of nearly the entire thickness of 
 the oesophagus. 
 
 When 'an infant is affected with oesophagitis, there should not be given to it any stimulat- 
 ing or hot drinks — it will be proper, however, to supply it, at short intervals, with a small 
 quantity of some perfectly bland mucilaginous fluid, as gum water, or an infusion of the pith 
 of sassafras, or of the inner bark of the slippery elm, given cold ; the throat should be co- 
 vered externally with a soft, emollient poultice, especially when the inflammation of the 
 oesophagus has succeeded to stomatitis ; a few grains of calomel may also be administered, 
 and followed by injections of milk with the addition of sugar. If it be found necessary, the 
 strength of the infant may be supported by injections of milk and broth, or milk with rice 
 flour, tapioca or arrow root. We have derived advantage in cases presenting the symptoms 
 of oesophagitis, from a few leeches applied along the sides of the neck, and internally a tea- 
 * spoonful, every three hours, of a solution of four grains of the acetate of lead in one ounce 
 of water, with the addition of a few drops of strong vinegar. — C] 
 
 LECTURE LXV. 
 
 Diseases of the Abdomen: sometimes difficult to identify. Method of investigating 
 these diseases ; by the eye, the hand, the ear. Inflammation of the Peritoneum: 
 its symptoms; and causes. Puerperal Peritonitis. Peritonitis from Perfo- 
 ration. 
 
 I AM about to consider the diseases of the abdomen. The organs contained in 
 this cavity of the body are not vital organs in the same sense in which the brain, the 
 the heart, and the lungs, are vital. That is to say, the functions of the abdominal 
 viscera will bear to be suspended for some considerable time, without the extinguish- 
 nient of life. But these parts are subject to numerous diseases, some of which ait 
 apt to be quickly fatal, and others carry with them a vast amount, and very severe 
 kinds, of suffering. 
 
 The parietes of the fore part of the belly being soft and flexible, you might natu 
 rally suppose that the physical morbid conditions of the organs they cover would 
 submit themselves to an easy diagnosis ; that the sense of touch, exercised through
 
 728 DISEASES OF THE ABDOMEN. 
 
 these yielding walls, would detect alterations of bulk, of form, or of place, in the 
 subjacent viscera, with much facility and exactness. But the truth is, that since the 
 discovery of the method of auscultation, the diseases of the abdomen are much more 
 iiard to discriminate than the diseases of the thorax. The reason of this is to be 
 found in the number and complexity of the parts contained in the abdomen ; the 
 loose manner in which some of them are packed ; and the consequent readiness w'lih 
 which they pass out of their proper and natural situations. It is necessary that I 
 should say a few words, but I shall not detain you long, respecting the mode of ex- 
 mniniag the abdomen, with the purpose of investigating its diseases. 
 
 In the description of symptoms, we are often obliged to speak of particular por- 
 tions of the abdomen: and it will be of future convenience to us if we make ourselves 
 acquainted, at starting, with such a superficial map, marking out the topography of 
 the belly, as I exhibited to you sometime since, in reference to the chest. Draw a 
 horizontal line round the body, touching the extremity of the ensiform cartilage; and 
 this will form the superior boundary of the abdomen, thus roughly defined for prac- 
 tical purposes. Draw another such line round the body, horizontally, touching the 
 lower edge of the last false ribs : and a third touching the crest of each ilium. We 
 then have three horizontal zones formed. These must be further divided by vertical 
 lines : one on each side from the anterior spinous process of the ilium perpendicu- 
 larly upwards. Each zone will thus be subdivided into three regions. The middle 
 region of the upper zone is the epigastric region ; on either side are the hypovhon- 
 dria. The middle region of the middle zone is the umbilical region ; the iliac 
 regions or the Jlanks lie to the right and left of it. The hypogastric region is the 
 middle region of the lowermost zone ; and the inguinal regions are contiguous to it. 
 This is all the division which is necessary. 
 
 Now independently of the general signs of diseases that have their seat in the 
 abdomen, we are greatly assisted in many cases by the physical signs. I shall take 
 a very brief survey of the modes by which these physical signs are collected. They 
 are derived from the exercise of the three senses of sight, of touch, and of hearing. 
 
 The sense of sight suppUes, occasionally, very valuable information ; and in all 
 serious and equivocal cases we must not dispense with its use. We are not, indeed, 
 to make an ocular inspection of the naJced abdomen unnecessarily: and I hold it 
 superfluous to admonish you that when we do avail ourselves of that mode of in- 
 vestigation, especially in the case of females, we are bound to do so with the most 
 careful attention not to ofiend the patient's delicacy. We may sometimes ascertain 
 all that is required concerning the movements, size, and shape of the abdomen, 
 without removing the under garments. 
 
 This rule applies, indeed, to all parts of the body that are ordinarily covered by 
 the dress. 
 
 I was lately consulted by a lady, who told me she had, on the rear of her person, 
 a painful boil. She thought any physician ought to be competent to prescribe for a 
 boil, without wanting to see it. But she seemed very ill, and her sister told me that 
 the boil had lasted a fortnight, and was a very large one ; so that I was obliged to 
 press for an inspection. And I found — a boil sure enough, but of that gigantic and 
 formidable species which we call carbuncle. 
 
 M. Rostan relates a case still more in point. Going round the Avards of his hos- 
 pital, he came to an old woman, who was complaining of severe pain in the abdo- 
 men, towards the left iliac region. Her face was flushed, her skin hot, her pulse 
 strong and frequent, her tongue dry ; and she was very thirsty. The abdominal 
 pain was exasperated by pressure, and by the movements of the patient. Upon 
 these data Rostan founded his diagnosis. He concluded that the case was one of 
 acute abdominal inflammation ; and he prescribed accordingly; and with befitting 
 energy. One of the pupils, however, lingered behind him : and having removed 
 ihe woman's chemise, in order to examine the seat of the pain, he discovered that all 
 ihe symptoms proceeded in reality from a very harmless, though troublesome, disor 
 ;ii'i. herpes zoster ; what is vulgarly called the shingles. 
 
 Vestis adempta est 
 Qua posita, nudo patuit cum corpore crimen.
 
 PERITONITIS. 729 
 
 In the second place, we gather very important intelh'gence by the sense of touch. 
 We learn the existence and the size o^ tumours ; we approximate to a knowledge of 
 their nature, whether it be solid or fluid ; we determine whether they are movable 
 or fixed, painful or indolent, hard or soft, smooth or uneven, pulsating or not. We 
 ascertain whether the surface be hot or cold. In order to make palpation most 
 effectual, the patient should be placed in the most favourable posture for its perform- 
 ance; i. e., he should lie on his back, with his head a little raised, and his knees up. 
 In this position, the abdominal muscles are relaxed and unstrung : and the patient is 
 to be cautioned not to do anything which may make them tense. Sometimes, in 
 spite of this caution, and in spite, probably, of the patient's endeavours to obey it, 
 the recti muscles remain so tightly contracted as to prevent any satisfactory examina- 
 tion of the parts beneath them. The very occurrence of this instinctive striving 
 against the pressure of our hand may be taken as a ground of suspicion that those 
 parts are not in a healthy state. We must take care, when the muscles are thus 
 obstinately rigid, not to mistake the swelling central portions of the recti, or their 
 well-defined edges, for tumours, or for indications of an enlarged stomach or liver. 
 By a peculiar management of the palpation, we often satisfy ourselves at once of 
 the presence of liquid in the cavity of the peritoneum, or in a cyst: we obtain that 
 sensation which we cdX\ fluctuation. 
 
 The exploration by the sense of touch is very much aided — often confirmed, some- 
 times corrected — by that which addresses itself to the sense of hearing. Sometimes 
 we listen to the natural sounds through a stethoscope ; and we may thus decide the 
 important question, whether a pulsating tumour be or be not an aneurism ; or the 
 question, sometimes scarcely less important, whether a different kind of tumour en- 
 closes another hving being or not. But, for the most part, our information respect- 
 ing the maladies of the abdomen, collected by the sense of hearing, is obtained by 
 listening to sounds which we ourselves produce; in one word, hy percussion : and 
 mediate percussion, percussion performed through the finger as a ready plexi meter, 
 is particidarty applicable to the disorders of the abdomen. By this expedient we 
 can tell whereabouts the intestines lie ; whether the parts beneath the place per- 
 cussed be hollow and filled with air, or solid ; or, though naturally hollow, distended 
 with liquid. By making the patient change his posture, we are enabled often, 
 through the aid of percussion, to trace fluid effusions hither and thither, when they 
 have changed their relative situation, by reason of the force of gravity ; and then we 
 know that they occupy the cavity of the peritoneum. All these points I pass over 
 cursoril}% because I must advert to them again when speaking of particular diseases. 
 And I shall proceed, on that account, without further delay, to the consideration of 
 those special diseases. 
 
 Consulting your convenience, and mj'- own, rather than any scientific order, I 
 shall take, in succession, the several parts and organs contained in the cavity of the 
 belly, and inquire separately into their diseases ; inflammatory, organic, and func- 
 tional. And I begin with the peritoneum; the great serous sac which lines and 
 constitutes the cavity of the abdomen, and in which most of its viscera are wholly or 
 partially folded. 
 
 Like the serous membranes in general, the peritoneum is very ready to take on 
 inflammation, upon the operation of certain exciting causes. Acute inflammation, 
 beginning in one spot, is almost sure to transfer itself to any other spot that happens 
 to lie in contact with the first ; and is very apt to extend itself rapidly to the whole 
 membrane. The inflammation tends to the effiision of serum, and of coagulable 
 lymph ; it is of the adhesive kind : and its efiects are those of distending the peri- 
 toneal cavity with fluid — or of gluing its opposite surfaces together so as to obliterate 
 that cavity — or of forming partial attachments. In all these respects, the analogy 
 between inflammation of the peritoneum and inflammation of the stious membranes 
 of the thorax — the pleura, and the pericardium — is perfect: and therefore these aru 
 points which I shall not dwell upon, except where specific differences arise, from 
 original diversities of structure or function in the parts affected. 1 may observe at 
 once, that the morbid conditions which are apt to remain after peritonitis, are some- 
 times, hke those which follow pericarditis, inceptive of further disease; sometimes
 
 730 DISEASES OF THE ABDOMEN. 
 
 like those of the pleurte, final, and limited to their hmnediate influence upon the 
 health and comfort of the individual : or even protective against some worse evil. 
 
 Acute inflammation of the peritoneum is characterized by pain in the abdomen, 
 increased on pressure, and attended with fever. But as these symptoms are common 
 to almost all the inflammatory conditions of the parts contained in the abdomen, we 
 must look for more distinctive circumstances. CuUen defines the disease in this 
 manner: "Pyrexia: dolor abdominis, corpore erecto auctus, absque propriis aliarum 
 phlegmasiarum abdominalium signis." He concludes that it is the peritoneum 
 simply that is inflamed, when the specific symptoms that indicate inflammation of 
 particular organs are wanting. It is not inflammation of the liver, for there is no 
 pain of the right hypochondrium in particular, increased by lying on either side, no 
 pain of shoulder, no jaundice, no vomiting, perhaps : neither is it inflammation of the 
 bowels or stomach, for there is no disturbed function of the alimentary canal to 
 denote such inflammation. 
 
 The pain, Cullen says, is increased if the patient sits up. He might have added, 
 that it is increased also by drawing a long breath, by coughing, sneezing, or strain- 
 ing, and by pressure made with the hand upon the belly. All these circumstances 
 resolve themselves into the same obvious principle ; viz., that of pressure aggravating 
 the pain of an inflamed membrane. The erect posture throws the weight of the 
 viscera upon the peritoneum, and tends to stretch parts of it. The pain occasioned 
 by pressure is often excessive ; the patient cannot even bear the weight of the bed- 
 clothes. Though the pain is, at first, sometimes confined to particular spots, yet it 
 generally soon extends over the whole abdomen ; and this is a circumstance of some 
 importance as respects the diagnosis. But before the inflammation has become uni- 
 versal, while it is yet restricted to particular spots, the pain is often much increased 
 by pressure made on other parts of the abdomen. In truth, in a shut sac of that 
 kind you cannot compress any one part without exercising pressure indirectly upon 
 every other part. The patient cannot sit up, nor, usually, lie on his side ; but 
 remains always upon his back : in which position you will perceive that the pres- 
 sure made by the viscera upon the peritoneum is a minimum ; is the least possible. 
 He draws up his legs too. And he lies still ; for movements cause pressure, and 
 therefore pain. The descent of the diaphragm in inspiration presses also upon the 
 membrane ; and the patient not only complains of the pain thus produced, but in 
 order to avoid it gets into a way of breathing by means of his ribs only. So that 
 upon inspection of the abdomen, it is perceived that, instead of rising and sinking 
 alternately in respiration, it remains motionless. The phenomena of thoracic respi- 
 ration is a symptom of peritonitis. The breathing is necessarily shallow in these 
 cases, and less air being admitted at each movement of respiration, the number of 
 those movements therefore is increased : the breathing is quick as well as shallow : 
 there are perhaps forty, or even sixty respirations executed in a minute, instead of 
 -eighteen or twenty. When we find a person lying only on his back, with his knees 
 up, breathing in this manner, and complaining of tenderness of the belly on pressure, 
 and feverish withal, we may be tolerably sure (unless that person be an hysterical 
 girl) that the peritoneum is inflamed, whatever else may be the matter. 
 
 The pain in peritonitis is generally sharp, cutting, or pricking in its character 
 And independently of any pressure made from without, or caused by any change 
 of posture, this pain is apt to be much aggravated at intervals. This, when the 
 inflammation is general, is sometimes owing to the passage of flatus along the bowel, 
 partially distending it, and stretching the inflamed membrane ; so that here also, it 
 is r^^aWy pj-essure which augments the pain. 
 
 When you explore the abdomen by pressure, take care not to make the examina- 
 tion unnecessarily a source of pain. Press first gently, with the open flat hand ; 
 and keep your eyes on the patient's face at the same time. You will perceive by 
 the expression of his features, Avhether you are hurting him ; even before he takes to 
 verbal complaining. 
 
 Acute peritonitis generally sets in with well-marked symptoms : sharp rigors, and 
 nigh fever, with a hard and strong pulse, which very soon becomes frequent, and 
 often oecomes feeble, and is sometimes small from the very first. After the disease
 
 PERITONITIS. 731 
 
 has continued for a certain time, it is attended with tension and swelling of the be^Iy. 
 The tension and swelhng are tympanitic in the earlier stages. You learn this with 
 certainty by mediate percussion. As the disease advances, the enlargement is some- 
 times occasioned, in part at least, by the effusion of serum : of the presence of which 
 infallible indications may be obtained by the joint employment of the finger and the 
 ear ; by palpation and auscultation ; and by noticing the difference, as to the results 
 of percussion, caused by alterations of posture. 
 
 When the disease is advancing towards a fatal termination, the abdomen often be- 
 comes greatly distended ; the pulse is exceedingly frequent and feeble ; the counte- 
 nance (which in all the stages of the disorder is expressive of anxiety) becomes 
 pincheu and ghastly ; cold sweats ensue ; and the patient dies at length by asthenia : 
 death beginning at the heart. The mind is often clear to the very last. 
 
 Such is the ordinary course of peritonitis. But other symptoms, which I have not 
 mentioned, do sometimes accompany it ; arising out of the peculiar circumstances of 
 different cases. Thus sickness and vomiting occur very frequently ; and these 
 symptoms are supposed to denote that the peritoneal covering of the stomach is 
 especially implicated : but I question whether this is always a correct inference. 
 When strangury happens, which is not uncommon, that part of the membrane 
 which is reflected over a portion of the bladder is probably involved in the mischief. 
 Inflammation of that part of the peritoneum which lies in the immediate vicinity of 
 the kidneys, may cause. Dr. Abercrombie thinks, suppression of urine. 
 
 Peritonitis is apt to arise under the influence of cold, like other internal inflamma- 
 tions : especially when cold combined with moisture is applied, under certain condi- 
 tions, to the surface of the body. It is occasionally produced by mechanical inju- 
 ries inflicted upon the abdomen. It often prevails epidemically, and produces 
 great moriality, among parturient women : and there is ground for believino- that 
 this form of the disorder is propagable, and often propagated, by contagion. Be- 
 sides this, a very terrible kind of peritonitis is a frequent result of the extravasation 
 of the contents of the alimentary canal, or of urine, or of bile, into the cavity of the 
 membrane ; through apertures that are sometimes made by external violence, but 
 more often are the consequences of the progress of previously-existing disease. 
 
 I shall make a few observations in respect to one or two of these points, and but 
 a few. 
 
 That awful disorder, puerperal fever, is more frequently accompanied with hiflam- 
 mation of the peritoneum, than with any other inflammation. This variety of peri- 
 tonitis necessarily engages the attention of the accoucheur; and it doubtless is more 
 fully considered in the lectures of the Professor of Midwifery than I propose to 
 consider it. Indeed, if you would understand puerperal fever as a whole : its shiftincr 
 aspects, its single source, and its appropriate management ; you must study Dr. Fer- 
 guson's masterly and conclusive essay on that subject. 
 
 Of forty-four fatal cases of well-marked puerperal fever which fell under the 
 observation of Dr. Robert Lee, and in which the bodies were carefully examined, 
 the peritoneum and uterine appendages were found inflamed in thirty-two : i. e., in 
 eight cases out of every eleven. The inflammation commences, no doubt, in the 
 uterine portion of the membrane, and spreads thence over the larger part of its sur- 
 face. Now this peritoneal inflammation, occurring in women after childbirth, may 
 be accidental and sporadic ; or it may prevail in a district epidemically. And a most 
 dreadful and deadly affection it may then become. In either case, the peritonitis 
 may commence a few days, or even a few hours after parturition. The pain gene- 
 rally begins low in the abdomen, in the situation of the uterus ; which may be felt 
 through the abdominal parietes, and is tender on pressure : but soon a universal 
 swelling takes place, and the womb can no longer be distinguished. Cases of this 
 kind arise sometimes, apparently from cold ; and exhibit no peculiar feature. It is 
 just what we might expect when a female, in a state of weakness and irritability, 
 happens to be exposed to the exciting causes of inflammation. In such a state, a 
 less degree of the exciting cause would be sufficient to produce the inflammation . 
 and probably a less degree of inflammation may prove fatal. 
 
 But when peritonitis is frequent among women after childbirth in a particular
 
 732 DISEASES OF THE ABDOMEN. 
 
 neighbourhood, or in a lying-in hospital, it is marked by greater depression of the 
 vital powers, and runs a more irregular course. The nervous system suffers, the 
 sensorium is apt to become affected, and the complaint assumes rather the character 
 of continued fever than of simple inflammation of the peritoneum. And no wonder ; 
 since this variety of peritonitis forms part of a disease which, like continued fever, 
 is a general disease, and results from contamination of the blood. This, Dr. Fergu- 
 son has clearly established. The contamination may originate in the body of the 
 patient herself: the noxious material being supplied by putrid coagula, or portions 
 of placenta, remaining in the uterus. Or some of the products of inflammation may 
 enter the blood-vessels, and constitute the poison. And this it may be difficult or 
 impossible to prevent. But, on the other hand, the contamination may arise in the 
 way of contagion : this horrible malady may be communicated from one lying-in 
 \Vornan to another by the intervention of a third person ; and doubtless it is so 
 carried and propagated, in many instances, by midwives and accoucheurs. Now 
 this source of the disorder may be obviated ; and therefore it is of the utmost im- 
 portance that it should be clearly recognized, in order that it may be carefully pro- 
 vided against. 
 
 You must know, however, that great differences of opinion have existed, and, I 
 believe, still exist, in respect to the contagious quality of certain forms of peurperal 
 peritonitis ; just as great differences exist as to the contagiousness of continued fever, 
 of cholera, of the plague. There are parties who regard the whole notion of con- 
 tagion as a mere bugbear: and there are others who embrace in their allegations of 
 contagion many more diseases than can be proved to be so caused. Tlie same 
 strong assertions are made, the same kind of eagerness is displayed (the same party- 
 spirit, I had almost said) as mark the strife of ordinary politics. It is our serious 
 duty, however, to inquire what is the truth in this matter: for the safety of indivi- 
 duals, and the happiness of whole families, may often hang upon our opinions. I 
 must trouble j'ou, therefore, with a few facts that bear closely upon the subject. 
 
 We possess some valuable and highly instructive accounts of epidemics of the 
 kind I am alluding to. One by Dr. Gordon, on the epidemic peritonitis after child- 
 birth, which took place at Aberdeen, in the years 1789, 1790. Another by Mr. Hay, 
 on that Avhich happened at Leeds from 1809 to 1812. And a third by the late Dr. 
 Armstrong, on that which was observed in Sunderland and its neighbourhood in 
 1813. Dr. Robert Lee has also collected some very interesting facts in reference to 
 the spreading of thp peritonitis by contagion. Dr. Gordon had, he affirms, unques- 
 tionable proof that the cause of the disease was a specific contagion, and that it did 
 not arise from any noxious constitution of the atmosphere. The disease seized such 
 women only as were visited or delivered by a practitioner, or taken care of by a 
 nurse, who had previously attended patients affected with the same disorder. And 
 Dr. AriUitrong observed that forty out of the forty-three cases that happened at Sun- 
 derland, occurred in the practice of one surgeon and his assistant. 
 
 From among other histories — all tending to the same conclusion — brought together 
 by Dr. Lee, I take the following : — 
 
 "On the IGth of March, 1831, a medical practitioner, who resides in a populous 
 parish on the outskirts of London, examined the body of a woman who had died a 
 few days after delivery, from inflammation of the peritoneal coat of the uterus. On 
 the morning of the 17th of March (/. e., the next morning), he was called to attend a 
 private patient in labour, who was safely delivered on the same day. On the 19th, 
 she was attacked with severe rigors, great disturbance of the cerebral functions, rapid 
 feeble pulse, with acute pain of the hypogastrium, and a peculiar sallow colour of 
 the whole surface of the body. She died on the 4th daj^ after the attack, on the 22d 
 of March ; and between that period and the 6th of April, the same practitioner 
 attended fwo other patients, both of whom Avere attacked by the same disease in a 
 vnalignant form, and fell victims to it. On the 30th of March he bled a young woman 
 who had pleurisy : the wound became inflamed after a few days ; erysipelatous 
 redness and swelling extended from it up the arm; and in four or five days that 
 patient died of phlebitis." 
 
 Mr. Rooerion, of Manchester, states the following facts, in a paper in the Medical
 
 PUERPERAL PERITONITIS. 733 
 
 Gazette. — From the 3d of December, 1830, to the 4rh of January, 1831, a midwife 
 attended thirty patients for a public charity. Sixteen of these were attacked witii 
 puerperal fever, and they all ultimately died. In the same month, 380 women were 
 delivered by other midwives for that institution ; but none of the 380 suffered in the 
 smallest degree. All the sixteen had inflammation of the peritoneal surface of the 
 uterus. So, also, Dr. Robert Lee tells us that, in the last two weeks of September, 
 1827, five cases came under his observation. All the patients had been attended in 
 labour by the same midwife: and no example of a febrile or inflammatory disease 
 of a serious nature occurred during that period among the other patients of the 
 same dispensary, who had been attended" by the other midwives belonging to the 
 hislitution. 
 
 Statements of this kind — and they could be largely multipHed — furnish irresistible 
 evidence, that the peritonitis, which prevails epidemically among lying-in women, 
 is of a specific nature, and communicable from one person to another. It is observed, 
 also, to reign as an epidemic especially in lying-in hospitals, and that it recurs at 
 irregular intervals, sometimes leaving them quite exempt from its ravages for years 
 together. 
 
 Indeed, I beheve that these cases of puerperal fever occurring in succession to the 
 same practitioner, are examples of something more than ordinary contagion, operating 
 through the medium of a tainted atmosphere. I believe them to be instances of 
 direct inoculation. Recollect, that the hand of the accoucheur is brought, almost of 
 necessity, into frequent contact with the uterine fluids of the newly-made mother. 
 Recollect, — those among you who have examined the interior of the dead body with 
 your own hands, — recollect, with what tenacity the smell, which is thus contracted, 
 clings to the fingers in spite even of repeated washings ; and whilst this odour re- 
 mains, there must remain also the matter that produces it. Recollect how minute a 
 quantity of an animal poison may be sufficient to corrupt the whole mass of blood, and 
 fill the body with loathsome and fatal disease. Illustrations will occur to you in the 
 inoculated small-pox, in hydrophobia, in the viper-bite, in the scratches and punctures 
 of the dissecting-room. Recollect the raw and abraded state of the parts concerned 
 in parturition ; the interior of the uterus forming a large wound, and presenting, as 
 Dr. Ferguson observes, an exact analogy to the surface of a stump after amputation ; 
 the more external soft parts bruised and sore. Bear in mind the remarkable fact, 
 that this contagion does not affect other persons, but only lying-in women. Reflect- 
 ing upon these facts, you will see too much likelihood in the dreadful suspicion, that 
 the hand which is relied upon for succour in the painful and perilous hour of child- 
 birth, and which is intended to secure the safety of both mother and child, but espe- 
 cially of the mother, may literally become the innocent cause of her destruction ; 
 innocent no longer, however, if, after warning and knowledge of the risk, suitable 
 means are not used to avert a catastrophe so shocking. 
 
 I need scarcely point to the practical lesson which these facts inculcate. When- 
 ever puerperal fever is rife, or when a practitioner has attended any one instance of 
 it, he should use most diligent ablution ; he should even wash his hands with some 
 disinfecting fluid, a weak solution of chlorine for instancel he should avoid going in 
 the same dress to any other of his midwifery patients: in short, he should take all 
 those precautions which, when the danger is understood, common sense will suggest, 
 against his clothes or his body becoming a vehicle of contagion and death between 
 one patient and another. And this is a duty so solemn and binding, that I have 
 thought it right to bring it distinctly before you. 
 
 In these days of ready invention, a glove, I think, might be devised, which should 
 be impervious to fluids, and yet so thin and pliant as not to interfere materially with 
 the delicate sense of touch required in these manipulations. One such glove, if such 
 shall ever be fabricated and adopted, might well be sacrificed to the safety of the 
 mother, in every labour. Should these precautions all prove insufficient, the practi- 
 tioner is bound, in honour and conscience, to abandon, for a season, his vocation. 
 
 [The connection between puerperal peritonitis and erysipelas has recently attracted a good 
 deal of discussion. In a large number of instances, it has been shown that the two diseases 
 prevail simultaneously and in the same localities ; and facts have been adduced, which wo tiil 
 
 3m
 
 734 DISEASES OF THE ABDOMEN. 
 
 even appear to prove that a contagion of some kind may be communicated from a patient 
 labouring under erysipelas to the parturient female, and induce in her an attack of puerperal 
 fever. Until, however, a greater number of facts have been accumulated, and the whole 
 .subject more closely investigated, it will be premature to draw any positive conclusions. — C] 
 
 That variety of peritonitis which results from perforation of the stomach or intes- 
 tines, and the effusion of their contents into the cavity of the belly, is full of interest. 
 The inflammation is violent in degree ; universal (generally) in extent : and almost 
 always fatal. The attack is characterized by its suddenness. All at once intense 
 pain arises in some region of the abdomen, which soon becomes tender in every part. 
 The pain is incapable of removal, and generally even of mitigation, by medicine, 
 and death takes place in a short time. These are the general features of such cases. 
 Occasionally, the symptoms follow some different order. Thus, I have seen a case 
 in which no pain was complained of, and the source of the inflammation was not 
 suspected until the dead body was examined. This was a case oi fever ; and it had 
 been attended with much stupor, which was probably the reason that no indication 
 of suffering was made by the patient. Occasionally, but that is uncommon, the pain 
 intermits. For the most part, however, it resists all treatment, and ceases only with 
 life, or a short time before life is terminated. 
 
 Most of the instances of this kind of peritonitis that I have witnessed have resulted 
 from perforation of the ileum, in the progress of continued fever. You are already 
 aware, that the glandulfe agminatae, which are found only in that bowel, and the 
 glanduloe solitarise, which are scattered over nearly the whole inner surface of the 
 alimentary tube, are very liable, in continued fever, to inflammation, sloughing and 
 ulceration : and sometimes the ulcers go through : the contents of the gut are poured 
 into the cavity of the serous membrane, and intense inflammation is lighted up. I 
 purposely abstain from going into any particulars respecting these ulcers. We are 
 no further concerned with them at present than as they furnish the channel by which 
 the cause of the peritoneal disease is introduced. Once, and once only, as I stated 
 before, have I known perforation occur from th-e extension of scrofulous ulceration 
 of the same glands in phthisis. In general, in that disease, the ulcer runs a much 
 slower course. As it approaches the peritoneum, circumscribed chronic inflamma- 
 tion is set up in that membrane ; lymph is thrown out ; and the bowel becomes 
 adherent to some other portion of the canal, or to some of the other viscera of the 
 abdomen. In this way the perforation is prevented ; or, should it take place, the 
 escape of the contents of the bowel into the peritoneal sac is prevented. Occasion- 
 ally, when two portions of the tube thus adhere together, a communication is formed 
 between them, and the contents of the intestine either reach an advanced point of 
 their stated journey by a short cut, or are carried back again perhaps to a spot which 
 they had already passed. 
 
 A very curious instance of this latter event has been described by Dr. Abercrombie. 
 A man, fifty-six years old, who had shown no signs of serious illness, but had laboured 
 under impaired appetite, languor, and occasional pain in the abdomen, for two or 
 three weeks, was suddenly seized, while out walking, with vomiting ; and he ob- 
 served that what he brought up was stercoraceous ; and this occurred again and 
 again, at variable intervals ; the matter vomited being distinctly fecal, and sometimes 
 so solid that he was obliged to swallow warm water to soften it, that it might be ex 
 pelled from the stomach more easily. He never vomited his/oo(^; and no tumour 
 or other sign of organic disease, could be detected by external examination. He 
 lived about three months, and died at last of exhaustion ; and then it was discovered 
 that the stomach and the transverse arch of the colon were adherent to each other, 
 and that a ragged aperture of communication between them existed at the place of 
 adhesion. 
 
 It is a curious fact, that the vermiform appendage of the caecum is not unfrequently 
 tne seat of a penetrating ulcer. I have traced little groups of glands in that slender 
 tube : and I have known perforation to happen from the specific ulceration of con- 
 tinued fever ; and from the accidental ulceration caused by a cherry-stone lodged 
 ihetfl
 
 PERITONITIS FROM PERFORATION. 7i{5 
 
 [Many cases are related of peritonitis from ulceration of the apendicula vermiformis 
 caused by the impaction of some foreign substance within its cavity. A veiy interesting 
 case of the kind is detailed by Dr. Pepper, in the Transactions of the College of Physicians of 
 Philadelphia, vol. i., p. 296, in which a grape seed had passed into the apendicula, and was 
 the cause of its ulceration and perforation. — C] 
 
 Sometimes it is the stomach that is perforated, either by a common or by a spe- 
 cific ulcer ; and the symptoms are exactly the same as when the boivel gives way. 
 Sudden, unremitting pain, tenderness, and tympanitic distension of the abdomen ; and 
 early death. 
 
 Perforating ulcers of the stomach are of various kinds. It is not uncommon to 
 find one small roundish hole, with edges as smooth and clean as if a piece of the 
 stomach had been cut out by a punch, and without any surrounding hardness, or 
 other mark of disease. Occasionally the orifice is more irregular, and occupies the 
 centre of a thickened and indurated patch of the mucous membrane. Several in- 
 stances of this sort of perforation have occurred under my own eye ; two within the 
 last fourteen months (1839). Almost all the patients have been young women, 
 plump, and in good condition ; who, up to the moment of the fatal seizure, either 
 seemed to enjoy perfect health, or, at most, had complained of slight and vague feeHngs 
 of dyspepsia. Ulcers of the stomach are, however, mostly chronic ; and the diseased 
 viscus is commonly fenced about and protected by adhesion to the neighbouring 
 parts, before its coats are completely penetrated by the ulcer. You are probably 
 aware that this happened in the body of Napoleon Bonaparte. He died of cancer 
 of the stomach. That organ was strongly adherent to the concave surface of the left 
 lobe of the liver, which formed a part of the wall of the stomach ; and this adhesion, 
 no doubt, prolonged his life. 
 
 Usually the actual perforation, in cases such as we are now considering, takes 
 place merely from the natural progress of the ulcer; but sometimes it would appear 
 that the thin membrane which remains is broken by some accidental force applied to 
 it. Thus the symptoms have immediately followed the act of vomitinof, brought on 
 by an emetic. Bouillaud relates an instance in which the perforation happened 
 while the patient was straining at stool ; and it is conceivable enough, that rough 
 pressure of the abdomen might complete the rupture, when the ulcer had already 
 eaten through all the coats of the bowel except its peritoneal coat. 
 
 Less commonly than this, in my experience at least, the peritonitis is set up by 
 the escape of urine from the urinary bladder, through the extension of an ulcer, or 
 from a forcible rupture of that bag by a blow or a fall, when it was distended with 
 urine. Rupture of the gall-bladder, whether by violence or from ulceration, has the 
 same results ; so also has, in general, the rupture of the uterus, which sometimes 
 takes place during the efforts of parturition. Abscess of the liver, bursting into the 
 peritoneum, is another occasional source of severe and fatal inflammation of that 
 membrane. Acute and general peritonitis sometimes arises, also, in consequence of 
 penetration from without ; i. e., it succeeds the puncture made by the trocar in the 
 operation of tapping the belly : and these cases, too, are almost all of them mortal : 
 chiefly, I presume, because, in nine instances out of ten, they occur in an unhealthy 
 and debilitated subject. 
 
 I formerly offered you some observations respecting a form of hysteria which very 
 closely mimics peritonitis, and would most certainly deceive a medical man who was 
 not on his guard against it. We judge by the age and sex of the patient somewhat; 
 by the presence of hysteria in other forms, or of the hysteric diathesis; by the ex- 
 cessive tenderness of the abdomen, or rather of its surface ; by the co-existence of the 
 same exquisite sensibility in other parts ; and by the incongruity and shifting character 
 of the symptoms. The pulse and the tongue will perhaps be natural, while the 
 abdominal irriuation is at its height. Forewarned, you will seldom find much dif- 
 ficulty in establishing the diagnosis. Of the signs by which peritonitis may be dis- 
 '.inguished from enteritis, I shall speak when I come to the latter disease.
 
 736 ACUTE PERITONITIS. 
 
 LECTURE LXVI. 
 
 Treatment of Acute Peritonitis ; Bleeding, Mercury, Opium . Ch ronic Peritonitis -, 
 Gramdor Peritoneum. Ascites ; Ovarian Dropsy ; Diagnosis of these diseases. 
 Other forms of Abdominal Dropsy. 
 
 Acute peritonitis, in its simple form, is always a dangerous, yet frequently a 
 manageable disease. When it is complicated with other and earher organic mischief, 
 and especially when it has been excited by the entrance of foreign matters into the 
 civity of the belly, it is all but hopeless under any treatment. 
 
 In speaking of the mode of cure, I have again to repeat, mutatis mutandis, the 
 grand remedies for inflammation, and particularly for the adhesive inflammation 
 proper to serous membranes : blood-letting; mercury. 
 
 It is of the greatest importance in this, as in many other cases of inflammation, 
 that the blood-letting should be performed early. You must not be deterred from 
 bleeding by the mere smallness of the pulse : a quality which I have frequently 
 shown you to be characteristic of acute inflammation within the abdomen ; and which, 
 in the disease now in question, is often present from the very beginning. If the 
 pulse be wiry and hard, we disregard, in these cases, its smallness. Not uncom- 
 monly it is rendered more full, as well as softer, by venesection ; and this, when it 
 happens, gives assurance of the propriety of that measure. 
 
 Topical blood-letting is of much efficacy — of greater efficacy perhaps than in most 
 other forms of abdominal inflammation. Cupping is out of the question, from the 
 tender state of the abdomen. But in adults, after a full bleeding from the arm, such 
 as has produced some sensible impression upon the circulation, or brought the patient 
 to the vertre of syncope, the surface of the belly should be covered with leeches. 
 From twenty to forty may be applied at once ; and sometimes this will make any 
 further loss of blood unnecessary. But in severe cases, you may expect to find that 
 repetitions of at least the local bleeding will be requisite. 
 
 After the leeches have fallen off, a light poultice may be laid over the abdomen ; 
 or it may be assiduously fomented with flannels wrung out of hot water. These 
 means will encourage the bleeding from the leech bites ; and are generally found to 
 afford great comfort to the feelings of the patient. Cold applications have been 
 recommended by some practitioners of high authority. Dr. Sutton injected cold 
 enemata. and applied cloths, made wet with cold evaporating lotions, to the abdo- 
 men with good effect : and Dr. Abercrombie has since reported favourably of the 
 same kind of treatment. However, I should think this a more precarious plan 
 than the opposite : and I have always observed so much relief to be given by 
 warm epithems, that I have never had the inclination, or the courage, to employ 
 cold. 
 
 It is extremely desirable, in these cases, to obtain as speedily as possible the 
 specific influence of mercury upon the system ; by calomel and opium, or by 
 inunction. It cannot be necessary that I should again go over in detail the means 
 of following out this indication ; but it is an indication which we must diligently 
 pursue. 
 
 The treatment of puerperal peritonitis is much more uncertain and difficult : for 
 ■ his reason, that it springs out of an antecedent morbid condition more deeply seated, 
 more o-enerally diffused, and less accessible to remedies, than itself. Whenever in- 
 flammation arises here and there in the body, in consequence of a vitiated state of 
 the blood, we have not only the inflammation itself to deal with, but its physical 
 cause also, which may still be in uncontrolled operation. 
 
 Dr Fercjuson justly remarks that "inflammation being made up of vascular and 
 of nervous action, of "the afflux of blood to a part, and of pain, it is not irrational to 
 jict on both the elements of the malady at the same time, or in periods shortly con- 
 secutive of each other." "The abdominal pain that occurs in puerperal fever is 
 accompanied by two very different states of constitution : one in which little or no
 
 ACUTE PERITONITIS. 737 
 
 depletion is borne, another in which reHef is obtained only by very large evacua- 
 tions of blood." Between these two there is every conceivable gradation. " In no 
 malady are a cautious boldness, and a sagacious adaptation of remedy to constitu 
 tional power, more imperatively demanded." 
 
 " If lurge bleeding be determined on, it must, to be beneficial, be resorted to within 
 the first twenty-four hours from the attack. In the second stage of the disease it often 
 produces, rapidly, a fatal result." 
 
 In ambiguous cases he gives ten grains of Dover's powder, and covers the whole 
 of the abdomen with a large linseed-meal poultice, sufficiently thick to retain warmth 
 for four hours. At the end of that time, if the symptoms are alleviated, "ten grains 
 more of the Dover's powder, and a fresh poultice, should be prescribed. If within 
 four hours from this second medication, the practitioner is not satisfied that the 
 malady is yielding, he must at once resort to depletion." 
 
 Of all the means we possess of arresting this malady, bleeding, general or topical, 
 is, in Dr. Ferguson's experience, by far the most extensively applicable. " But," he 
 says, " while I admit this, I am equally certain that large bleeding has not been 
 borne in this complaint, generally speaking, during the last twelve years." 
 
 Another most important truth enunciated by our professor is, that "epidemic 
 puerperal fever has, invariably, the character common to the ordinary fevers raging 
 with it: if the latter require depletion, the presumption is that the former will also." 
 
 Undoubtedly the very same species of febrile disease is variously aflected by 
 a given remedy in different places: and during diflferent periods in the same place. 
 There is such a thing as an epidemic state of the human constitution, gradually pro- 
 duced by a gradual fluctuation in the influences whereby communities of men are 
 surrounded and impressed. The fevers that were cured in London ten or fifteen 
 years ago by copious blood-letting, would now be rendered by that measure, carried 
 to a like extent, irretrievably mortal. There is scarcely a more important object of 
 study to the practical physician than this different capacity, exhibited by the average 
 of constitutions at different limes and seasons, of bearing active depletion. "Nihil 
 mihi prius est," says the wary Sydenham, "quam quando novoe febres grassari in- 
 cipiant, cunclari paulisper, et ad magna prsesertim remedia non nisi suspenso 
 pede, ac tardius procedere ; diligenter interim illarum ingenium atque morem obser- 
 vare, quibus itidem prsesidiorum generibus ^gri juventur vel lasdantur, ut quam pri- 
 mum his repudiatis, illis utamur." The exciting cause of the fever remains the 
 same ; the system upon which it operates undergoes trom time to time great changes ; 
 which are brought to light partly by the altered phenomena of the disease, partly 
 and chiefly by the effects of remedial measures. 
 
 Unless you bear these differences in mind, you will be perplexed and disheartened 
 bj the discrepant accounts given by competent and faithful observers respecting the 
 success of difl"erent or even opposite plg,ns of treatment, in the same complaint. 
 
 Most writers, whose works I am acquainted with, recommend purgatives as highly 
 serviceable in peritonitis. I do not think the good which th<iy are calculated to do 
 as antiphlogistic remedies can at all be put in competition with the harm that I am 
 persuaded they may produce, by increasing the peristaltic action of the intestines, 
 and so causing additional friction and tension of the inflamed membrane. I believe 
 that in all cases of vvell-marked and pure peritonitis, when the inflammation is limited 
 to the serous membrane, it is far better and safer to restrain than to solicit the internal 
 movements of the alimentary tube. In a pamphlet published several years ago by 
 Mr. Bates, of Sudbury, some striking instances are recorded of recovery from severe 
 peritonitis, under large and frequent doses of opium, and a ri^id adherence to the 
 horizontal posture, until all pain had subsided. The patients were not allowed to 
 raise themselves, on any account, into a sitting position: and the opium was admi- 
 nistered sometimes by the mouth, sometimes by the rectum. These cases, related 
 in an unpretending manner by a practical observer, made a strong impression on 
 my mind when I read them. To simple inflammation of the peritoneum, to those 
 perilous forms of peritonitis which occur in women after delivery, and to those still 
 more terrible cases that follow perforation of the serous membrane, this principle of 
 keeping the intestines at rest is alike applicable. I stated a httle while ago, that the 
 47 3m2
 
 733 ACUTE PERITONITIS. 
 
 last-mentioned cases are all but hopeless. That all but I inserted on the strength of 
 some most interesting facts published by Dr. William Stokes, in the second number 
 of the Dublin Jour/ui' of Jiledical and Chemical Science. He trnlj'' remarks, that 
 in most of these accidents the powers of life sink so rapidly, that bleeding, either 
 local or general, cannot be attempted. Neither can we employ mercury interna II v, 
 for fear of excitintr the peristaltic action of the bowels, which action would tend to 
 tear asunder recent adhesions, to keep the communication between the mucous and 
 serous surfaces open, and to cause a fresh ingress of fecal or other extraneous mat- 
 ters into the sac. Yet in a few instances we find that the patients live for several 
 dajj-s, and that a process of organization commences in the effused lymph. It seems 
 that some years before Dr. Stokes wrote this paper, he had witnessed the admirable 
 efTects of opium in low forms of peritonitis, as administered by Dr. Graves ; who 
 thus saved, without abstracting a drop of blood, two individuals in Avhom that disease 
 followed paracentesis. I cannot refrain from quoting to you the particulars of one 
 instance, in which the efficacy of the opiate treatment was conspicuous. The well- 
 known symptoms of perforation of tlie intestines had existed for two days ; the 
 patient was apparently sinking, " his countenance was collapsed, anxious and 
 expressive of dreadful suffering; the extremities were cold, and the pulse hardly 
 perceptible. The exhibition of sixty drops, in the twentj'-four hours, of the pre- 
 paration called the black drop, was followed by the most signal improvement. The 
 pulse regained fullness and softness, the extremities became warm, and the counte- 
 nance had lost the Hippocratic expression. The patient could bear pressure on the 
 abdomen, which, the day before, was exquisitel_v painful. The same treatment was 
 continued for twenty-four hours longer; and by the end of that time every symptom 
 of abdominal inflammation had completely subsided. The belly felt natural, there 
 was no tenderness, the pulse was good, and the patient declared himself well." At 
 this period of the case. Dr. Stokes omitted the opium, and gave the mildest possible 
 saline laxative, as there had been no stool for forty-eight hours. Four evacuations 
 took place, followed by the immediate return of the symptoms of peritonitis, under 
 which the patient rapidly sank. 
 
 " The intestines were everywhere agglutinated together, and adherent to the parie- 
 tal peritoneum, except in the left iliac fossa, where a quantity of yellow puriform 
 matter was collected. On detaching the caput coli from the peritoneum lining the 
 right iliac fossa, a small perforation of the gut was discovered, b}'- the escape of the 
 contents of the intestines in a jet," &c. &c. 
 
 This example puts in a very strong light the good effects of opium ; the danger- 
 ous efft'cts of purgatives ; and the mode in which recovery from these frightful 
 accidents may sometimes be brought about. 
 
 Dr. Stokes gives another instance in which the patient did recover; after taking 
 105 grains of opium, besides what was administered in injections: and he alludes 
 to a third case, in which the employment of opium was successful, when peritonitis 
 had supervened upon the bursting of an hepatic abscess into the cavity of the abdo- 
 men. 
 
 Now I would earnestly recommend you to consider the expediency of applying 
 the same principle of treatment, as an auxiliar}% when the peritonitis does not grow 
 out of previous organic disease: in all cases, in short, of mo'e peritonitis. The 
 opmm is not to supersede the bleeding, or the mercury ; it is not incompatible with 
 either of those remedies ; and it may, I believe, be most advantageously adopted in 
 conjunction with them both. 
 
 1 shall relate one example, which has lately occurred to me, of the successful use 
 of opium in simple, but severe, peritonitis. Several of you saw this patient. His 
 cuse is published in the appendix to Dr. Ferguson's volume. 
 
 H. Middlehurst, a tailor, seventeen years old, was admitted into the JVIiddlesex 
 Hospital on the 17th of September : looking very ill. and complaining of pain in the 
 epigastriiun, with extreme tenderness over the whole abdomen, which was full and 
 tense. He had been ill several days; had shivered in the outset: and had vomited 
 fieqaently, up to the period of his admission. His bowels were confined ; his 
 tongue was dry and white.
 
 CHRONIC PERITONITIS. •fl^ 
 
 Twelve leeches were placed upon his abdomen, and calomel, in five-grain doses, 
 was given two or three times at intervals of four hours. An enema of warm water 
 was injected, and retained. In che evening sixteen more leeches were applied, and 
 a drachm of mercurial ointment was rubbed into his arm. 
 
 r first saw him on the 18th. His countenance was then pinched and anxious, 
 and he lay moaning with pain ; his knees being drawn up towards his belly, which 
 was tense, and exquisitely sensible to pressure. He complained of nausea and 
 retching, but had not vomited since his admission. His tongue was thickly coated ; 
 his pulse small, sharp, 108 in number. No permanent relief had been obtained 
 from the leeches. 
 
 I directed immediate venesection ; but not more than four ounces of blood could 
 be got from the arm. Thirty fresh leeches were therefore put upon the abdomen, 
 and afterwards a warm poultice to receive the blood from their bites. Three grains 
 of calomel, and three of blue pill, were ordered to be given every four hours. 
 
 The last leeches mitigated the pain ; but it returned in the evening, with in- 
 creased severity, and he vomited the pills. He appeared to be in great agony. In 
 this state the apothecary gave him twelve grains of calomel, and five grains of 
 opium, in one dose. Soon after this he fell asleep ; and slept during the greater 
 part of the night. Next morning his countenance had lost, in a great degree, its ex- 
 pression of anxiety ; his belly was less tender, but still tense ; and his tongue 
 cleaner. No stool. 
 
 Capiat pilulae saponis cum opio gr. v. 8va. quaq. bora. 
 
 On the 20th, the bowels were freely open, the dejections dark and watery ; the 
 abdomen was less tender. Pulse 114. He continued to take a grain of opium 
 thrice daily till the 3d of October: the bowels being every day moved; the pulse 
 and tongue gradually improving; and the abdomen painless even under firm pres- 
 sure. On the 3d, as the bowels had not acted for the last two days, I discontinued 
 the opium. On the 5lh, diarrhoea set in, with some renewed tenderness of the 
 belly ; and the pinched and anxious countenance returned. He had then an opiate 
 enema ; and resumed the opiate pills as before. Under this treatment he at length 
 got quite well ; and left the hospital on the 30th. 
 
 Chronic peritonitis is sometimes merely the sequel of that acute form of inflam- 
 mation of the peritoneum, which I have just been describing. Plastic lymph is 
 effused, and becomes organized ; serous fluid is poured out, and is not absorbed 
 again; the products of the original inflammation remain ; a low degree of inflamma- 
 tory action perhaps remains also, or is re-excited by slight causes^ the mischief 
 augments ; and the patient is slowly conducted to the grave. 
 
 There is, however, another, not at all uncommon, and equally formidable source 
 of chronic peritonitis ; the presence, I mean, of a multitude of little granules, lying 
 within or immediately beneath the membrane, or occupying, in counUess numbers, 
 those folds of the peritoneum which compose the omentum. These granules occur 
 principally, if not exclusively, in scrofulous persons. Louis, indeed, who considers 
 them to be tubercles, afiirms that they are never met with in the peritoneum, without 
 being met with also — and usually in a more advanced state and greater abundance — 
 in the lungs; but this rule is not universally true. I have seen more than one 
 instance of well-marked granular disease of the serous membrane of the abdomen, 
 without a single tubercle in the pulmonary tissues. Still the observation of Louis 
 holds good in a vast majority of cases : and when we have symptoms of chronic 
 peritonitis, which were not preceded by those of acute inflammation of the mem- 
 brane, and when we perceive at the same time indications of phthisis, or of any 
 other unequivocal form of scrofula, we shall seldom be wrong in connecting the 
 chronic peritonitis with the presence of these miliary granulations. Whether^'they 
 are truly scrofulous tubercles, or whether, as some suppose, they are sui generis, or 
 again, simply minute spherules of coagulable lymph, I do not undertake to detej 
 mine. I have been in the habit of regarding them as the cause, and not as th(! con 
 sequence, of the inflammation with which they are found associated
 
 740 ASCITES. 
 
 The symptoms of chronic inflammation of the peritoneum are more obscnre, m 
 general, than those of the acute disease. And when the disorder is primitive, not 
 the rehcs I mean of more active inflammation, it often begins, and steals on, in a very 
 insidious manner. The patient complains of abdominal pains: sometimes slight, 
 amounting to scarcely more than uneasiness, but abiding; sometimes occasional 
 only. Usually there is a sensation of fullness and tension in the heWj, although its 
 bulk may not be sensibly altered. Sometimes there is a sense of pricking felt. Dr. 
 Pcmberton remarks, that you may detect a sort of deep-seated tension ; that the skin 
 and muscles lie loosely on the peritoneum, which gives to the hand a sensation as of 
 a tight bandage underneath, over which the integuments appear to slide. The 
 uneasiness, or the pain, is augmented by pressure ; or perhaps is felt only when 
 pressure is made. Sometimes the functions of the intestinal canal are disturbed : 
 there are loss of appetite ; nausea and vomiting ; an irregular state of the bowels, 
 and unnatural evacuations from them. Sometimes, on the contrary, the digestive 
 organs perform their office in a tolerably healthy manner. These differences depend 
 apparently upon the circumstance of the inflammation visiting, or sparing, the peri- 
 toneal covering of the stomach and bowels; and of the parts concerned in the secre- 
 tion of bile. Sooner or later, in most cases, the abdomen enlarges, and fluctuation is 
 felt. All along there is some fever, more or less distinctly marked ; with progressive 
 emaciation and debility. The face is pale and sallow, and wears an expression of 
 languor. 
 
 Very much the same set of symptoms are apt to result from scrofulous disease and 
 enlargement of the mesenteric glands : and consecutive slow inflammation of the 
 peritoneal membrane. 
 
 Accordingly, after de?ih, we often find those glands swelled, and red, and hard ; 
 sometimes forming very large tumours : or we discover the whole surface of the 
 membrane thickly bestreAved with innumerable small, round, grayish or white 
 granules : sometimes it is covered, here and there, or everywhere, with false mem- 
 branes : the intestines are frequently agglutinated into one mass ; or they are ad- 
 herent to each other, or to the other parts of the peritoneum, in places only. The 
 omentum is generally thick, red, and fleshy, as if its component parts had been mat- 
 ted together ; and there is more or less fluid, commonly turbid and flaky, in so much 
 of the cavity as happens to be left. 
 
 These are very unpromising forms of disease ; and it is seldom that we can do 
 more than mitigate the most distressing of the symptoms, or retard, perhaps, the 
 march of the disorder. Leeches to the abdomen, in moderate numbers, and fre- 
 quently repeated, and followed by soft warm poultices. Blisters, when the pain is 
 not severe, and the tenderness less. Attention to the state of the bowels, which 
 should be regulated by mild laxatives, rather than by drastic purges. A nourishing, 
 but unstimulant diet. These are the measures to which we must look for benefit. 
 It has been thought that frictions upon the belly, with ointments containing iodine, 
 have done good ; so that it will be well to make trial of such. But, do what we 
 may, in nine cases out of ten, our best-directed efforts will be disappointed. 
 
 When there is much fluid collected in the abdominal cavity in these cases, they 
 take their character from this predominant symptom, and are called cases of ascites. 
 But this is only one form of ascites — that form which results from chronic inflam- 
 mation of the peritoneal membrane. I shall pass, however, by an easy transition, to 
 the other forms of dropsy of the belly. 
 
 There is another form of ascites, not very common, which approaches in its cha- 
 racter to inflammation, and which is therefore called active ascites. I mean that* we 
 sometimes see persons, who were previously in good health, become rapidly ascitic, 
 after exposure to cold and wet, and rapidly recover again under the remedies that 
 Sue used to subdue inflammation. Perhaps it may be said that these are cases of 
 inflammation ; and it may be so. But they want many of the ordinaiy symptoms 
 of peritonitis ; and if inflammation be present, it has no worse effect than the effusion 
 of serum, which, under depletion or mercury, is speedily taken up again. I should 
 rather conceive, however, that these cases are to be included in that category of drop-
 
 ASCITES. 741 
 
 sical effusions which I spoke of formerly, as resulting from the detention or absorp 
 tion, in the first place, of an undue quantity of watery fluid into the blood, and its 
 subsequent discharge, by a kind of secretion, either into shut cavities, or through 
 some one of the natural vents of the body. The balance of the circulation between 
 the skin and the internal surfaces appears to be destroyed, on these occasions, by the 
 operation of external cold upon the tegumentary membranes. 
 
 But by far the greater number of cases of ascites are cases of passive dropsy which 
 arise slowly from a mechanical obstacle to the free return of the venous blood 
 towards the heart. 
 
 Ascites occurs, as you know, in general dropsy, with anasarca of the universal 
 areolar tissue ; and this general effusion of fluid depends, in almost every case, either 
 upon a peculiar renal disorder, or upon organic disease of the viscera of the thorax ; 
 of the lungs, or of the heart, or of both ; and, above all, upon such disorder as is 
 attended with dilatation of the right chambers of the heart. 
 
 But I exclude this form of ascites, wherein the dropsy of the belly is only a por- 
 tion of more general disease of the same kind, and limit myself at present to that 
 kind of passive ascites which is unattended with dropsy elsewhere, or which at any 
 rate precedes the occurrence of serous accumulation in other parts. 
 
 The symptom which first leads us to suspect ascites, is the progressive enlarge- 
 ment of the abdomen. But the abdomen may grow gradually large and prominent 
 when there is no disease whatever: in pregnancy, for example, or in mere obesity. 
 It is necessary, therefore, to search for more definite signs of peritoneal dropsy. 
 
 In order to make an accurate diagnosis of ascites, we must know what are the 
 morbid conditions with which it is most liable to be confounded. Solid tumours and 
 simple corpulency are readily enough distinguished. But there are certain kinds 
 of encysted dropsy of the abdomen, of which the recognition is not so easy and 
 obvious. Of these, what is called ovarian dropsy is the chief. In some of its symp' 
 toms, this complaint closely resembles ascites ; in some, it differs from it widely. So, 
 also, the treatment of the two disorders is alike in some respects ; dissimilar in others. 
 For these reasons, and because I am more solicitous to be practical than to be me- 
 thodical, I shall consider these two maladies together ; turning first to the one, and 
 then to the other, and marking, as I go on, the various points of simihtude and con- 
 trast which they mutually offer. 
 
 Recollect that ascites signifies the accumulation of serous liquid in the bag of the 
 peritoneum ; whereas ovarian dropsy consists in the collection of fluid in one or 
 more cells within the ovary, or in a serous cyst connected with the uterine ap- 
 pendages. 
 
 One source of distinction between the two is furnished by the condition of the 
 abdomen during their early stages. 
 
 In ascites the enlargement is uniform and symmetrical, in reference to the two 
 sides of the body. When the patient lies on her back, the flanks bulge outwards, 
 or swag over, from the weight and lateral pressure of the augmenting fluid. This 
 increased breadth of the trunk is not observable in the case of an ovarian tumour ; 
 nor, I may add, in pregnancy. 
 
 When we are able to trace the early history of ovarian dropsy, we find, in most 
 instances, that the abdominal tumour was first perceived on one side ; in one or the 
 other of the iliac fossae, or somewhere between the ribs and the ilium. But when 
 the enlargement of the abdomen is great, the distinction between ascites and encysted 
 dropsy, drawn from the shape of the swelling, ceases. The ovarian tumour distends 
 the abdomen, if not uniformly, yet nearly or quite as much on one side as on the 
 other. 
 
 The next thing we do, when the visible bulk and shape of the abdomen have 
 suggested a suspicion of ascites, is to employ the sense of touch. 
 
 Examination by pressure will sometimes suffice to assure us that there is fluid in 
 the peritoneum. If you press suddenly with the tips of your fingers, in a direction 
 perpendicular to the surface, you will often become aware of a sensation which it is 
 difficult to describe in words, yet which is quite decisive, and not to be mistaken : a 
 .■sensation of the displacement of liquid, and of the impinging of your fingers upon
 
 742 ASCITES. 
 
 some solid substance below. So that, by this manoeuvre, you frequently detect, not 
 merely the presence of the liquid, but an enlarged liver, or spleen, or (it may be) an 
 ovarian or other tumour; ev-en when simple palpation, or handling in the ordinary 
 wa}', would not enable you to ascertain these enlargements. 
 
 A(ram, peratssion of the abdomen is fertile of information in these cases. First, 
 by the sense of fluctuation which it causes when hquid is collected within. The 
 left hand being laid flat against one side of the tumid abdomen, if a slight blow be 
 struck with the fingers of the right upon the opposite side, the impulse is conveyed 
 by a wave of the liquid to the open flat hand, which feels a little shock that is per- 
 fectly distinctive. The larger the amount of the accumulated liquid, and the thinner 
 and tighter the walls within which it is confined, the more sensible and decided is 
 this fluctuation. Even when the quantity is small, not exceeding a few ounces, a 
 little practice and management will enable you to detect it. Percuss with one finger 
 the most depending part of the cavit}^ and apply at the same time a finger of the 
 other hand, very near the part struck; and, if liquid be there, you will perceive a 
 limited j'et distinct fluctuation. In the same way, the presence of liquid in a small 
 cyst may sometimes be ascertained. Much more when the cyst is large. And the 
 cyst, in ovarian dropsy, is often very large, and the liquid it contains is often thin and 
 aqueous ; and then the fluctuation ma}^ be quite as perfect and perceptible as ever it 
 is in ascites. 
 
 Hence, mere fluctuation is not a discriminating symptom between ascites and 
 ovarian dropsy. 
 
 But, secondly, percussion is full of instruction in the somids it elicits. The sense 
 of hearing will generally supply what the sense of touch may leave wanting. 
 
 In true ascites, the relative place of the liquid and of the intestines is determined 
 by the posture of the patient. The bowels, which always contain some gas, float 
 to the upper part of the liquid, and there give out (when the finger, as a pleximeter, 
 is apphed to the corresponding surface, and struck) their peculiar resonance. Me- 
 diate percussion will thus follow the gravitating fluid, and discover always a dul. 
 sound in the lowermost, and a hollow sound in the uppermost, part of the abdomen. 
 
 But it is not so in ovarian dropsy. The cyst, in a diseased and enlarging ovary, 
 rises in front of the intestines, which, being tied down by the mesentery, cannot 
 embrace the tumour so as to reach its anterior aspect, but are in fact pressed back by 
 it towards the spine. Hence, if there be any resonance produced by percussion, it 
 is in one, or the other, or in both, of the flanks; and the umbilical region yields a 
 dull sound, whatever the position of the patient may be. The same is true of the 
 enlarging womb in pregnancy. 
 
 The simple expedient, then, is quite decisive. In ascites the epigastric and umbi- 
 lical regions' are tympanitic on percussion ; in ovarian dropsy the latter, at least, is 
 dull. To be quite sure it is well to make the patient assume difll^rent postures in 
 succession. If the person affl'Cted with ascites turns upon her side, the uppermost 
 flank will become resonant ; the umbilical region dull: whereas in ovarian dropsy, 
 the sounds remain severally where they were under every change of position. In 
 ascites, with a little care, you may ascertain the exact level at which the contained 
 hquid stands ; and measure its rise or fall from day to da3^ 
 
 This mode of diagnosis is scarcely open, under ordinary circumstances, to fallacy 
 or exception. Yet there are two or three possible conditions in which it may fail ; 
 and these it is right that I should briefly mention. 
 
 1. The distension, in true ascites, may be so great, that the mesentery shall not 
 b(! broad enough to allow the buoyant intestines to reach the surface, when the 
 patient is supine. This impediment to the efficacy of the proposed test I have met 
 with in practice. A woman came under my charge in the hospital with ascites. 
 Fluctuation of the belly was unequivocal. While she lay on her back, the umbili- 
 cal and epigastric regions were resonant when percussed ; the flanks were dull. 
 When she turned upon either side, the other side, previously'- dull, gave the hollow 
 sound; the umbilical and epigastric regions, previously resonant, gave the dull flat 
 sound. Under the treatment employed, the accumulated liquid was removed, and 
 sne lef^ the hospital.
 
 ASCITES. 
 
 Some time afterwards, as I was going round the wards, I recognized the same 
 iv'oman among the patients recently admitted by my colleague. Dr. Hawkins. The 
 ascites had returned. The abdomen, enormously distended, projected upwards, 
 , as she lay on her back, to an excessive height. I found that fluctuation was very 
 distinct, as before : but every part of the belly yielded a dull sound when struck by 
 the lingers. At length this patient died : and it was seen, after death, that there 
 was nothing to prevent the rising of the intestines. They had floated, at the utmost 
 tether of the mesenter}', as high as they could, without reaching the surface of the 
 prominent belly. 
 
 2. Another occasional source of fallacy I have just now hinted at. The intestines 
 may be tied down, and so prevented from ascending by their specific lightness, to 
 the upper part of the surrounding liquid. And this may happen, either in conse- 
 quence of the adhesion of the various coils of the intestines to each other, and to the 
 parts behind them : which is not an uncommon occurrence : — or the intestines, 
 though unadherent, may be swathed, as it were, and bandaged down, by a thickened 
 and diseased omentum. This also I have myself seen. A man died in the hospi- 
 tal, who had manifest ascites. Yet his whole abdomen, though not so much distended 
 as to hinder the intestines, had they been free to rise, from reaching its walls, 
 sounded dull on percussion. Ins])ection of the body explained this circumstance. 
 When the peritoneum was opened by an incision carried through the fore-part of 
 the abdomen, a quantit}^ of serous liquid gushed out. The floor of the cavity which 
 it had occupied was smooth and level ; and was found, on further examination, to be 
 formed by a tiiick cake of omentum, strapped tightly over the subjacent intestines. 
 Of course, the same diseased condition may occur in the female. 
 
 8. On the other hand, I have once known an ovarian cyst to exist, when the um- 
 bilical region was tympanitic under percussion. The case furnished just that kind of 
 exception which serves to prove a rule. This was also a hospital-patient. Her his- 
 tory was the history of ovarian dropsy. Some time previously she had discovered 
 a small tumour in one of the iliac regions. It increased without much disturbance 
 of her general health, until it became very inconvenient from its bulk. She was 
 then tapped in one of the Borough hospitals : and she staled distinctl}'- that it was 
 not a clear watery fluid that was evacuated; but a glutinous, mixed, and grumous 
 matter : such as belongs to ovarian disease. No doubt could be entertained that the 
 enlargement of the abdomen resulted from disease of that kind. Yet the umbilical 
 region, when percussed, always rendered a hollow sound. Upon the death of the 
 patient the mystery was solved. Air hissed forth from the opening made by the 
 scalpel through the abdominal parietes : and the source of it being traced, an ovarian 
 cyst, of considerable magnitude, was found adhering to the peritoneum in front of 
 the belly, and containing no liquid, but some yellowish shreds only ; the remains, 
 apparently, of some smaller included cysts. This ovarian bag had been filled with 
 air, and had given occasion to the equivocal sounds. 
 
 These sources of possible mistake or obscurity very seldom occur; and the phy- 
 sical diagnosis, as I have now pointed it out, is very sure and valuable. So com- 
 pletely physical, indeed, are these tests, that we recognize ascites by them as readily 
 and certainly in the dead, as in the living body. 
 
 Other points of distinction may frequently be derived from the history and progress 
 of the two disorders. 
 
 The equable enlargement of the abdomen, on both sides, in ascites , and its une- 
 qual prominence on one side in the early stages of ovarian disease ; I have already 
 mentioned. 
 
 Again, it is observable that in true ascites, there are almost always manifest indi- 
 cations of constitutional suffering and disturbance : a sallow complexion ; debility ; 
 emaciation. The morbid accumulation results (as we shall see) from disease in 
 some organ, of which the functions cannot be impaired without injury to the whole 
 system. 
 
 Ovarian dropsy, on the other hand, may last long, and be extreme m degree, 
 while the general health is scarcely affected. The very bulk and weight of the 
 swelHng, produce, indeed, much inconvenience and discomfort; but, in other re-
 
 /44 CHRONIC ASCITES. 
 
 spects, the patient often remains in good health. This appears to be owing to the 
 circumstance that the ovary is not directly necessary to the life or well-being of 
 the individual, but is merely subservient, for a limited time, to the purpose of repro- 
 duction. 
 
 Among the symptoms that are common to ascites and ovarian dropsy in their 
 advanced stages, are all those which are occasioned by weight and pressure : viz., 
 shortness of breath, from the resistance opposed to the descent of the diaphragm ; 
 anasarca of the legs and thighs, from pressure upon the inferior cava and its branches ; 
 and a peculiarity of carriage and gait, like those of a woman big with child, and de- 
 pending upon the same cause, the necessity of throwing the head and shoulders back- 
 wards, to balance the weight of the distended abdomen in front. 
 
 It is necessary to caution you against mistaking a distended bladder for dropsy of ■ 
 the abdomen. An old Frenchman was brought into the Middlesex Hospital, afdicted 
 (so his friends said) with dropsy. He had been treated for that complaint. The 
 abdomen was large, and dull under percussion from the pubes to above the umbili- 
 cus. In the hypogastric region I could detect an obscure sense of fluctuation. I 
 noticed a strong* smell of urine about this patient. Being interrogated, he said that 
 he had formerly had some "stoppage," but that he now passed plenty of water; 
 that it 'fven ran from him. It was obvious that his bladder was enormously distended, 
 unabl*^ to contract upon its contents, and overflowing. With some difficulty a cha- 
 theter was introduced, and some quarts, I forget the exact quantity, of turbid and 
 stinking urine were drawn off. The patient sunk at length, and the bladder was 
 found to be much diseased. I have known similar mistakes occur in private prac- 
 tice. You will not think the caution I am now giving you superfluous, when I tell 
 you, on the authority of Sir Everard Home, that John Hunter once actually tapped 
 a distended bladder, in the belief that the disorder was ascites. 
 
 Encysted dropsy, in the abdomen, is not always ovarian dropsy. Omental 
 dropsy is described : the omental cavity alone being unfolded, and full of liquid. 
 This I have never seen. Cysts containing a considerable quantity of a clear thin 
 liquid, and connected with the liver, are common. Probably these are in all cases 
 (they certainly are in many) the effects of the growth of hydatids. Dropsy of the 
 Fallopian tubes : dropsy of the uterus : large serous cysts in the kidney : constitute 
 other forms of abdominal encysted dropsy. Such states must be discovered by their 
 own particular circumstances. None of them are very common. 
 
 LECTURE LXVII. 
 
 Pathology of Chronic Jlscifes ; of Ovarian Dropsy. Treatment of these two 
 disorders. Internal remedies : Extirpation of the ovarian sac : Paracentesis 
 Abdominis. 
 
 In my last lecture I pointed out the means we possess of distinguishing ascites 
 from ovarian dropsy. Continuing the parallel between these two disorders, I have 
 still to consider their pathology ; and to prescribe their treatment. 
 
 I mentioned that chronic ascites is sometimes the sequel of acute inflammation of 
 the peritoneum. In such cases, the abdomen is usually uneasy, and tender under 
 pressure ; or at any rate, more sensible than common : and I believe more hot also 
 than common. Whereas when ascites is passive as well as chronic, you may make 
 the requisite examination without causing any distress to your patient. There is no 
 pain produced by palpation, by pressure, or by percussion. Even when the dropsy 
 has resulted from bygone inflammation, it does occasionally, though rarely, happen^ 
 that no other trace of such inflammation is discoverable in the living patient. The 
 absorbing function of the membrane having, however, been spoiled, the coflected 
 iK^uid remains. Such a condition, I beheve, I have witnessed. The history of siul-
 
 CHRONIC ASCITES. ' 745 
 
 den and sharp pain, and tenderness of the abdomen, with fever, immediately before 
 the dropsical swelling took place, made it probable that it was the consequence of 
 inflammatory effusion. But the fever had entirely subsided ; no tenderness was 
 left ; no large veins were visible on the surface of the belly, denoting internal ob- 
 struction ; and the general health was good. The patient had no other dropsy. 
 
 The main exciting cause, however, of true and uncombined ascites, Avhen no 
 inflammation is, or has been, at work, is some impediment to the venous circulation 
 in the abdomen. Whereabouts, and of what kind, is this impediment ? That is the 
 question which, in each particular instance, we ask ourselves. 
 
 The old doctrine respecting the causes of ascites, vaguely referred the collection 
 of liquid to obstruction ; and to organic diseases of the abdominal viscera; and, 
 above all, to hepatic disease. But as we are now better instructed, and know that 
 organic diseases produce the dropsy, ultimately, by retarding the flow of blood through 
 the system of the vena porlce, we see that the truth was only half perceived by the 
 ancient pathologists. We can now understand Avhy some organic diseases of the 
 abdomen lead to dropsy of the peritoneum, and others (even of the same viscus) do 
 not. And we have no difficulty in comprehending why, of all the abdominal viscera, 
 the liver is the one whose diseases are the most frequently connected with ascites: 
 that gland being traversed by the converging branches of the venous trunk, through 
 which passes by far the greater part of the serosity absorbed from the surface of the 
 vast membrane that enwraps most of the abdominal organs, and hnes the cavity con- 
 taining them. It is plain that an accumulation of serum in the peritoneal sac may 
 arise from a mechanical obstruction in the trunk of the vena portJB, or in some of the 
 principal branches that unite to form that vein ; or from certain diseases of the hver 
 itself. But we know that disease of the liver is of very common occurrence, and 
 oftentimes very obvious, while there is no ascites. And a further question arises — 
 With what kinds of disease of the liver is hepatic ascites most apt to be associated ? 
 
 In truth, there is one special form of liver-disease which, though not the sole, is 
 the grand cause, of passive and simple ascites. It has long been noticed that mere 
 enlargement is not the most common condition of the liver met with in hepatic 
 dropsy ; but rather the small, hard, contracted viscus. Mere increase in the size 
 of the organ may interfere but little with the portal circulation ; whereas a shrink- 
 ing and diminution of its bulk must needs do so. In point of fact, that particular 
 state of the liver which the French have termed cirrhose, and which is familiar to 
 morbid anatomists in this country as the hobnail liver, is the great source of passive 
 ascites. 
 
 The true character of this remarkable condition of the liver is of modern discovery. 
 The credit of correcting the erroneous opinions which had been entertained respect- 
 ing it is due, I beheve, to Mr. Kiernan. The change undergone by the organ has 
 also been clearly described by Dr. Carswell; whose delineations of its physical 
 appearance are now before you. The change results from chronic inflammation, and 
 chronic thickening (miscalled hypertrophy) of Glisson's capsule. Since Mr. Kier- 
 nan's admirable exposition of the minute anatomy of the liver has been given to the 
 world, few can be ignorant that the areolar tissue, termed the capsule of Glisson, 
 accompanies the portal vein, the hepatic artery, and the biliary ducts ; and forms a 
 sheath around these vessels in their course through the liver: while the hepatic vein 
 and its branches are lodged in the proper substance of the gland without any such 
 investing membrane. It follows that a general thickening of this tissue must produce 
 a general pressure upon the portal veins, and hinder the return of the venous blood 
 from the intestines. Hence, as in analogous cases, congestion of the capillaries, 
 arrested absorption, mechanical transudation of serous liquid. The pressure affects 
 also the nutrient vessel, the artery of the liver ; so that, in most instances, there are 
 atrophy and shrinking of the organ. And sometimes, but not always, from pressure 
 upon the biliary vessels, there is jaundice also. By degrees, the areolar tissue 
 itself begins to shrink ; and the spaces in which it ramifies on the surface of the h rer 
 are pulled inwards; the lobules appear to be promment ; and the surface becomes 
 irregular and knobby, and studded with little roundish eminences like the head« 
 
 3n
 
 74G CHRONIC ASCITES. 
 
 of nails. Tlie constricted lobules are very conspicuous in the cut surface also of the 
 liver. 
 
 In the living body the presence of this hepatic disease is, for the most part, a 
 matter of inference only. It is rendered probable by its ascertained frequency in 
 connection with ascites, and by the absence of any other obvious cause for tho 
 dropsy. But sometimes the irregular surface can be felt through the walls of the 
 abdomen. 
 
 The nature of this morbid change affords a reason for the intractable and unpro- 
 mising character of ascites in general. The obstructed blood seeks, indeed, new 
 channels ; but the compensation they furnish is rarely sufficient. The superficial 
 veins become obvious, numerous, large ; and wander with many inosculations over 
 the surface of the belly. Large veins, significant of the same compensating effort, 
 have been met with also in the adhesions which previous inflammation had left be- 
 tween the liver and the diaphragm. 
 
 Among the causes to which the thickening of the capsule of Glisson may be as- 
 cribed, habitual intemperance holds the chief place. 
 
 But this condition of Glisson's capsule, though it is the principal, and by far the 
 most frequent, is not the only cause of obstruction to the current of the blood in the 
 portal vessels, and of consequent ascites. In those specific forms of liver disease in 
 which separate tumours are scattered through its substance, one of these tumours 
 may be so placed as to press upon the trunk of the vein. So, obviously, may ab- 
 dominal tumours of any kind ; enlarged mesenteric glands; cancer of the pylorus ; 
 cancer of the head of the pancreas ; and the like. 
 
 Ascites is found to be not unfrequently associated with disease and enlargement 
 of the spleen also ; but in most instances of this kind, the enlargement of the spleen 
 and the peritoneal dropsy are not connected as cause and effect ; but are both conse- 
 quences of portal obstruction. 
 
 When, after death preceded by ascites, the cavity of the abdomen is laid open, its 
 contents present a bleached and sodden appearance. It has been made a question 
 whether this be the result of the long-continued immersion of the living tissues in 
 the accumulated water ; or of their short maceration after death. The question has 
 no practical importance. 
 
 Dropsy of the ovary, in its ordinary form, consists (I believe) in disease and 
 enlargement of one, or more, of the Graafian vesicles ; or of the ova which they 
 inclose. 
 
 The actual condition of the dropsical ovary is subject to much variety. Sometimes 
 there is but one cyst ; and this may be no bigger than a pea ; or it may be large 
 enough to contain many gallons. Its walls may be as thin and flexible as those of 
 the healthy urinary bladder; or they may be firm, and half an inch or more in thick- 
 ness. It may spring from a small pedicle, and he free and unattached to the cavity 
 of the peritoneum ; or it may adhere, partially or at all points, to the contiguous 
 parts ; or it rnay be tied down by bands of coagulable lymph. Its inner surface may 
 be smooih and even, or knobby and irregular. Lastly, the fluid contained in the 
 cyst may be thin, or consistent ; limpid, or glutinous ; opaque, or transparent ; and 
 of various tints ; so that, in different cases, it may be colourless, green, purple, red ; 
 and more or less resemble in appearance pure water, white of egg, jelly, glue, bird- 
 Hme, or treacle. Most commonly, however, wheri the cyst is single, its contents are 
 thin and aqueous. 
 
 Again, the dropsical ovary may be multilocular, composed of many cysts, which 
 are usually distinct, but which sometimes communicate together; and these cysts, 
 in the same ovary, while they vary much in size, may differ also from each other in 
 any or all the particulars just enumerated as being mcidental to a solitary C3'^st. 
 
 Commonly one of the cysts is much more capacious than the rest; and some part 
 ol its inner surface is frequently embossed, as it were, by the projecting outline of 
 d. group of small nodules, which seem to lie within the parietes of the larg.'r cyst, 
 but which, in truth, are cysts of similar origin with it, but of more stunted growth. 
 
 The externa! surface also of the multilocular ovary is generallj'- lobulated ; and its
 
 OVARIAN DROPSY. 747 
 
 inequalities may often be discovered by a careful examination of the abdomen in the 
 living subject. 
 
 Sometimes the tumour is sohd throughout ; in which case the term dropsy is alto- 
 gether misapplied. 
 
 These differences are not without occasional importance, in reference to some 
 points in the treatment of the disease. 
 
 The proa;ress of ovarian dropsy is no less wanting in uniformity. Sometimes it 
 is very rapid ; sometimes it is very slow. It may destroy life in a few months ; it 
 may continue, a mere burden, with scarcely any fatal tendency, for many years. Not 
 unfrequently, after a period of active increase in the tumour, the morbid process, 
 without any obvious cause, suddenly stops : and the pause may be final ; or, after 
 an uncertain interval, the disease may j-esume its former activity. 
 
 Under all circumstances the malady is a serious one : for its possible grievances 
 are many ; and its issue is precarious and unpromising. Although, in some cases, 
 the general health for a long time is but slightly or not at all impaired, in others 
 the disease runs a short course; the tumour increasing rapidly and proving ulti- 
 mately fatal by its bulk and pressure ; or embittering and abridging the unhappy 
 patient's existence by some accident of growth or position. Even when of no vast 
 magnitude, it may be so situated as to impede or prevent the expulsion of the 
 feces from the bowel, of the urine from the bladder, or of the foetus from the gravid 
 uterus. 
 
 The single cysts, having thin parietes, and containing a serous liquid, are not 
 always produced by disease and distension of a Graafian vesicle ; for they sometimes 
 have no connection with the ovary, but spring from some other part of the uterine 
 appendages. 
 
 Neither, perhaps, can it be demonslraled that the complaint originated within the 
 Graafian vesicles, when it exists in its more complicated form ; when the cysts are 
 many, and their contents various. But the shape of the cysts, which are more or 
 less spherical, their number, their isolation in most cases, and the diversity in the 
 matters by which they are filled, render this view of their origin at least a probable 
 one. 
 
 This form of the disorder has been considered as belonging to the category of 
 malignant diseases ; but, in my judgment, without sufficient reason. It is true tlia* 
 the tumour does sometimes involve one or more of those morbid conditions, which 
 have been denominated scirrhus, fungus hsemalodes, cerebriform disease, or mela- 
 nosis, and which all, or nearly all, appear to be varying results of the same morbid 
 process, and to be referable to the genus carcinoma : but whenever this is observed 
 to be the case, other structures also are found to be infested with analogous changes. 
 The so-called malignant disease occupies the ovary in common with other parts ; and 
 this is one of its most constant characters, namely, that proceeding from some vice 
 in the constitution, or disseminated from some local germ, it pervades different organs 
 of the body at the same time, or in succession ; whereas, in by far the majority of 
 instances of ovarian dropsy, these peculiar products are met with neither in the 
 diseased gland, nor in any other place. It has already been remarked that many 
 women, labouring under ovarian dropsy, enjoy, nevertheless, in all other respects, 
 very good health, even for many years. The victims of malignant disease are not 
 so fortunate. They either are soon cut off, or if they linger, they seldom fail to ex- 
 hibit, in their complexion and general condition, notable indications of the mischief 
 which is in progress, and gradually undermining the powers of life. 
 
 If it be admitted, as a reasonable conjecture, that the Graafian vesicles, or the ova 
 they contain, are the seat of the primary changes, we may push our speculations a 
 litUe further. These ova are destined, under the peculiar stimulus of impregnation, 
 10 Duild up the fabric of the body in all its parts and qualities. And we may sup- 
 pose that, in consequence of some unnatural and morbid stimulus, perverted and 
 erring action may be set up, and strange products resuU. It is not uncommon to 
 find fat, hair, cholesterine, teeth, and other bones, in the diseased ovaria, even of 
 virgins. 
 
 This view of the matter is strei gthened by the fact, that dropsy of the ovary, of
 
 748 TREATMENT OF OVARIAN DROPSY. 
 
 the orJinary kind, has not been known to commence before the age of puberty ; noi 
 often after the capability of child-bearing had ceased; but only, or chiefly, during 
 that period in which the organ, if healthy, is susceptible of its proper and temporary 
 functions. Virgins, and barren and fruitful wives, are alike subject to the disease ; 
 but in what relative proportions, statistical inquiry has not yet (so far as I know) 
 determined. Where it accompanies, it may also account for, sterility. 
 
 The catamenia during the progress af the malady sometimes appear with more oi 
 less of regularity and quantity ; sometimes are entirely suspended. This function 
 is so often interrupted under other circumstances, that its derangements shed bui 
 little light upon cases that are otherwise obscure. When the discharge continues 
 to recur, we may presume that one, at least, of the ovaries is in a tolerably healthy 
 state : when both are sensibly diseased, the catamenia may be expected to be 
 wanting. 
 
 The treatment of these two forms of abdominal dropsy must, up to a certain point, 
 at which the operation of tapping becomes expedient, be considered separately. Of 
 both it may be said, that their cure is seldom accomplished ; yet, for reasons already 
 assigned, ascites has, upon the whole, a more certain progress towards the destruc- 
 tion of life than ovarian disease : while, perhaps, it is oftener cured. 
 
 In passive ascites, when the distension of the peritoneum has crept on without 
 pain, fever, or other marks of inflammatory action, our first and best hope of evacuat- 
 ing the collected liquid will rest upon diuretics. Hepatic ascites and. renal disease 
 may be sometimes found in conjunction, but according to my experience, they seldom 
 are so : and except that both may probably owe their occasional origin to habits of 
 intemperance, there appears no reason why they should be. Diuretics may be ad- 
 ministered, therefore, without scruple. The hydragogue purgatives are to be em- 
 ployed, also, when diuretics fail to act, or to reduce the swelHng; and when the 
 disease is not already complicated with diarrhcea. And inferring with more or less 
 certainty the existence of hepatic disease — sometimes from palpation of the enlarged 
 or altered liver, sometimes from the coincidence of jaundice, but most of all from the 
 result of accumulated experience respecting the morbid anatomy of such cases — we 
 give the patient the chance of the remedial influence of mercury. The disorder 
 being chronic, the introduction of that drug should be gradual. Th^ iodide of potas- 
 s'um is held by some physicians to be especially serviceable in hepatic ascites. 
 Compounds of mercury and iodine may be applied, by inunction, to the surface of 
 the abdomen, and to the right hypochondrium m particular. In Germany, the 
 muriate of ammonia is in much repute as a therapeutic agent. This diuretic salt, 
 though seldom administered internally in this country, is believed by some practical 
 men who have employed it, to exercise the same beneficial influence upon the func 
 lions of the liver, as is commonly attributed to preparations of mercury ; while it is 
 less prethictive of distress or inconvenience. My own experience upon this point ia 
 too limited to justify me in expressing any confident opinion about it; but in some 
 recent instances I certainl}^ have noticed a remarkable improvement in the character 
 of the biliary excretion, afier the daily exhibition of sal-ammoniac combined with the 
 extract of taraxacum. 
 
 You will generally be obliged to try, in their turn, all the diuretics within your 
 reach, and frequently to no purpose. Our efforts to remove by medicine the accu- 
 mulated liquid, or to cure the morbid condition on which the accumulation depends, 
 are too often made in vain. The distension of the peritoneum continues to augment ; 
 the distress arising therefrom becomes urgent and extreme ; and at length, to aflbrd 
 temporary ease to the patient, and in the faint hope also of giving him permanent 
 relief, we resort to the mechanical expedient oi paracentesis. 
 
 When we have the opportunity of treating ovarian dropsy from its commence- 
 ment, we sometimes find that the enlarging ovary is painful, or tender. This is an 
 indication for antiphlogistic measures. But from such remedies, or from any reme- 
 dies, little more than temporary relief is to be expected. My position as physician 
 to a hospital, has brought under my notice several cases of ovarian swelling, at a very 
 early period of its development ; when all that could be detected by careful exami
 
 TREATMENT OF OVARIAN DROPSY. 749 
 
 nation of the abdomen was a small tumour, not larger, perhaps, than an egg, and 
 occupying the situation of the ovary; to which the attention of the patient had been 
 drawn by some pain or uneasy feehng in that part. I have treated such cases assi- 
 duously, with the remedies of chronic inflammation, frequent topical bleedings, and 
 the use of mercury till the gums were affected ; with the remedies of ordinary dropsy, 
 diuretics and drastic purgatives ; and with remedies accounted specific, the liquor 
 potassse, the various preparations of iodine ; and I must honestly confess to you that 
 I am unable to reckon one single instance of success. Yet these are the measures 
 that we are bound to try. They have succeeded — as we are assured by competent 
 and credible w^itnesses ; they may therefore succeed again. The amount of my own 
 experience, however, tends to the persuasion that medicine has, in general, very 
 small influence over the progress of this disorder. The cases that do well, do well 
 we scarcely know how or w^hy ; the cases that prove fatal run their course in spite 
 of us. 
 
 Sometimes, as has been stated, these ovarian tumours reach a certain magnitude, 
 and then (wherefore we cannot tell), enlarge no more ; but remain a mere inconve- 
 nience and deformity, for many years. Occasionally, either spontaneously, or in 
 consequence of some accidental violence, they burst into the cavity of the perito- 
 neum, whence the effused fluid may be absorbed ; but more commonly it causes fatal 
 inflammation. Or the bursting tumour may empty itself harmlessly (adhesion having 
 previously taken place), through some channel of communication with the bowels or 
 with the bladder; or externally through the parietes of the abdomen. 
 
 Tumours, supposed to be ovarian, do sometimes disappear entirely. It may, 
 however, be doubted whether all, or even many, of the enlargements which have 
 had this fortunate issue, were really connected with the ovary. One source of mis- 
 take 1 have myself more than once encountered, and I believe it to be not uncom- 
 mon. A brief statement of the circumstances under which I first observed the falla- 
 cious symptom, will show you at once what 1 mean. Some years ago I was sent 
 for by a lady, who for many days had been labouring under an ordinary attack of 
 continued fever. While examining the abdomen by pressure, I discovered, on the 
 right side, between the ilium and umbilicus, a round, hard, painless tumour, as big 
 as a swan's egg. The patient was aware of it ; and thought it had existed for some 
 time. At the next visit it was gone. In the interim, very abundant discharges from 
 the bowels had followed the administration of purgative medicine. The tumour had 
 obviously been formed by the accumulation of fecal matters in the csecum. 
 
 Similar collections take place, less frequently, on the left side, just above the sigmoid 
 flexure. 
 
 The parts concerned in this disorder are not essential to life, or to the enjoyment 
 of health. On some of the lower animals the operation of spaying is as customary 
 in the one sex, and is performed with as little risk, as that of castration in the other. 
 The ovaries have in several instances been extracted from the living human body, 
 without any ill consequences. These facts, and the intractable character of the dis- 
 ease, have naturally suggested the expediency of extirpating the tumour in cases of 
 ovarian dropsy. 
 
 But although the ovary, when healthy, or when not much enlarged, may be re- 
 moved without much difficulty or hazard, the operation becomes always perilous, and 
 often impracticable, when the altered gland has attained any considerable magnitude. 
 Yet these are the very cases for which the remedy is needed. A large ovarian 
 tumour is usually multilocular, with firm parietes, and thick internal septa ; and is 
 therefore incapable of collapsing much when punctured. To extirpate such a tumour, 
 the abdomen must be (as it frequently has been) laid open from the sternum to the 
 pubes. Most commonly, also, a large ovarian swelling is adherent to the contiguous 
 parts ; a circumstance which either makes the proposed removal of the tumour im- 
 possible, or, if the connections admit of being broken down, augments in a fearful 
 manner the jeopardy of the patient. It is not surprising, therefore, that the results 
 of experience have been so discouraging as well nigh, in most minds, to prohibit 
 such attempts in future. The operation has, indeed, in several authentic cases, 
 been auite successful. In other instances, the surgeon, after exposing the adhereiu 
 
 3n2
 
 750 TREATMENT OF OVARIAN DROPSY. 
 
 mass, has been fain to replace the effused bowels, and to sew up the abdomen, a? 
 speedily as possible; and the patient, having suffered all this in vain, has sometimes 
 been fortunate enough to escape with life ; but not always. In others, the adhering 
 tumour has been separated, and the object achieved ; and the woman has lived there 
 after for some hours. Three times, at least (one of the cases is recorded b}'^ Mr. 
 Lizars, another by Mr. King, the third fell under the cognizance of Dr. Richard 
 Bright), the abdominal muscles and the peritoneum have been slit open, for the pur 
 pose of extracting a diseased ovary, — when no disease existed. 
 
 But of late, a modification of the process of excision — whereby it is adapted to 
 certain forms or conditions of the disease — has been proposed and practised; and 
 holds out somewhat more of promise. 
 
 It consists in making, not a long, but a small incision through the walls of the 
 abdomen, and through the peritoneum, so as to bring the surface of the diseased 
 ovary into view. The cyst is then secured, by means of a tenaculum, or of a ligature, 
 from receding inwards, and punctured, and its contents are suffered to escape. When 
 the sac has emptied itself, it is withdrawn through the external orifice by gentle 
 traction, until its stalk, or place of attachment to the broad ligament, comes near the 
 wound. A thread is tied round this stalk, the cyst is cut off", the uterine appendages 
 are put back into the cavity of the abdomen, and the lips of the wound are brought 
 together. 
 
 Although this method does not appear to have been actually performed till very 
 recently, it had been suggested as long ago, at least, as the time of Dr. William 
 Hunter, who, in a paper on the disease, has these remarks : — "If it be proposed, 
 indeed, to make such a wound in the belly as will admit only two fingers or so, and 
 then to tap the bag, and draw it out, so as to bring its root or peduncle close to the 
 wound of the belly, that the surgeon may cut it without introducing his hand, surely 
 in a case otherwise so desperate, it might be advisable to do it, could we beforehand 
 know that the circumstances would admit of that treatment." 
 
 In these few words, Dr. William Hunter not only describes the mode of excision, 
 but alludes to circumstances that may render it inadmissible, as well as to the uncer- 
 tainty that may arise about the existence of those circumstances. What the circum- 
 stances are is sufficiently obvious. 
 
 However, this suggestion has been carried into successful practice by Mr. West, 
 Mr. King, and others. To an interesting paper on the subject, published by Mr. 
 Gorham, in the Lancet, is appended a summary account of ten cases ; by which 
 account it appears, that five of the ten patients were cured by the operation ; two 
 recovered from the attempt to extract, which wac unsuccessful ; two died very soon 
 after the operation, and evidently in consequence of it. The remaining patient, 
 whose case has already been adverted to, recovered also from the incision : but there 
 was no diseased ovary to amputate : so fallacious, sometimes, is the diagnosis. 
 
 This mode of operating merits careful consideration, and further trial. Its recom- 
 mendations are — 
 
 1. That the first steps — the incision and the puncture — are the same in kind as 
 the first steps in ordinary paracentesis, and not much more severe or dangerous ; the 
 only difl^erence being that the incision requires to be somewhat larger in the one case 
 than in the other. 
 
 2. That, when successful, it affords a complete and permanent cure, which can 
 hardly be hoped for from any other plan. 
 
 The objections to its general use are — 
 
 1. That the single sacs, with thin and flexible walls, do not, commonly, reach a 
 very large size. When small, or of moderate dimensions, they produce so httle 
 distress or inconvenience, that an operation, which must always be uncertain and 
 tentative, ought not to be recommended. 
 
 2. That the multilocular tumours, with solid walls and partitions, can scarcely be 
 BO drawn through the opening made into the abdomen. 
 
 3. And above all, that adhesion of the tumour to the neighbouring parts would 
 mterfere with and prevent the success of the operation. 
 
 In mosc, nowerer, of the five cases of cure referred to by Mr. Gorham, the sacs
 
 TREATMExNT OF OVARIAN DROPSY. 75J 
 
 thus removed were large. From one of them 12 pints of fluid were let 3ut ; from 
 another, 27 pints ; from a third, upwards of 20 ; and from a fourth, 24 pints. 
 
 It is difficult to guess beforehand, whether the tumour be attached to the parts 
 surrounding it or no. If it be readily movable by the fingers applied to the surface 
 of the belly, so as to admit of being pushed hither and thither without pain or dis- 
 tress to the patient, it is probably unadherent. In one of the same five cases, the 
 patient being in labour, Mr. West found that the tumour lay between the uterus and 
 the brim of the pelvis. By gentle pressure, per vaginam, it was made to recede 
 into the cavity of the abdomen. This afforded a presumption that it wa.s free from 
 adhesion ; accordingly the sac was afterwards easily excised. The tumour is at- 
 tached anteriorly to the peritoneum lining the front of the abdomen more frequently 
 than to any other part. This Mr. Gorham attributes to partial inflammation pro- 
 duced by the puncture in the operation of tapping; hence the presumption that the 
 cyst is loose is, cacferis paribus, the stronger, when paracentesis has never been 
 performed. 
 
 If this mode of excision should be thought advisable, it ought to be attempted 
 while the tumour is yet of moderate bulk, before the peritoneum has been much 
 stretched, and while the chance of adhesion is the least. When any distinct history 
 of bygone peritonitis can be traced, the existence of adhesions may be confidently 
 reckoned upon.* 
 
 To the simpler operation of tapping, the contrary precept applies. Neither in 
 ascites, nor in ovarian dropsy, should paracentesis be resorted to, until it seems abso- 
 lutely indispensable. To this rule there are, in my opinion, very few exceptions. 
 
 The operation itself, though commonly esteemed a trivial one, is not without its 
 dangers. The instances are not few in which it has been followed by fatal peritonitis, 
 excited either by the mere passage of the lancet or trocar through a previously un- 
 healthy membrane, or, (in the case of ovarian dropsy,) by the escape of some portion 
 of the contents of the cyst into the cavity of the abdomen. Formerly, the rapid 
 evacuation of a large quantity of liquid from the belly was often attended by terrify- 
 ing efl^ects ; fainting, convulsions, almost instant death. This made the ancient 
 physicians afraid of the operation : and when they could no longer avoid it, they 
 let the accumulated fluid out by little and httle, and at short intervals. 
 
 The cause of these alarming symptoms is now well understood, and easily obviated. 
 They were owing, doubtless, to the sudden removal of the pressure to which the 
 viscera and large blood-vessels had been for some time submitted and accustomed. 
 For this explanation of the fact we are indebted to the sagacity of our celebrated 
 countrj'^man. Dr. Mead, who was the first to suggest that external compression should 
 be substituted, in lieu of the tension taken off by the operation. The complete 
 success of that expedient fully justified his ingenious opinion. We now drain the 
 cavity of its liquid contents without scruple or delay. A sheet, or broad roller, is 
 thrown round the patient's body, and tightened as the fluid escapes, so as to main- 
 
 • Since this lecture was first printed, an interesting paper by Mr. Phillips vipon the ques- 
 tion of extirpating ovarian cysts has been published in the 27th volume of the Mcdico-Ckirur- 
 gical Transactions. 
 
 Mr. Phillips exhibits, in a tabular form, "the results of 81 operations, performed for the 
 purpose of extracting ovarian tumours. In 61 cases the tumour was extracted; in 15 cases 
 adhesions, or other circumstances, prevented its removal ; in 5 instances no tumour was 
 found. Of the cases in which the operation was completed, the tumour being extracted, 35 
 terminated favourably; the patient recovered. In 26 instances the termination was unfa- 
 vourable ; the patient died. Of the five cases in which no tumour was discovered, all 
 recovered. 5 
 
 "Of the 15 cases in which adhesions or other circumstances prevented the extraction of 
 the tumour, 9 recovered, 6 died." 
 
 In two other tables Mr. Phillips collects together : — 
 
 I. Cases in which a large incision was made, 55 in all : and among these cases there wi^ri? 
 26 deaths, 23 cures, and 6 recoveries which were not cures. 
 
 II. Cases in which the incision was small (usually under six inches), amounting in all to 
 27. Among these there were 7 deaths, 13 cures, and 7 recoveries from the tmsuooessfui 
 operation
 
 752 TREATMENT OF OVARIAN DROPSY. 
 
 tain an equable pressure, which is continued for a while, and at length gradually- 
 withdrawn. 
 
 Other casualties occasionally happen ; the trocar has sometimes pierced the intes- 
 tine. In one instance wliich I myself witnessed, clear serum issued for some time 
 through the canula, but at length pure blood ; not less than a pint. The patient 
 sank ; and no opportunity was given to investigate the cause of the bleeding. In 
 another strange but well-authenticated case, the almost incredible quantity, twenty- 
 six pints, of blood flowed out at the orifice made by the trocar, and afterwards sepa- 
 rated into clot and serum. To the wonder of those who saw the incident, this 
 patient recovered from the tapping ; and the source of the hemorrhage is still a mat- 
 ter of conjecture. 
 
 And apart from these mischances — which, after all, are not of frequent occurrence 
 — you must bear in mind that paracentesis can seldom be contemplated as a mode 
 of cure, but simply of temporary relief from distress. A few instances have hap- 
 pened where the hquid has been drawn off', and has not again collected : but such 
 cases are very few. So, also, according to my experience, are those, much talked 
 of by authors, in which the kidneys resume their activity upon the removal of the 
 dropsical fluid. Ordinarily, the hquid re-accumulates, often with more rapidity than 
 before ; and again, and again, the pain and the hazard of the operation must be 
 repeated : wherefore, in my judgment, paracentesis in abdominal dropsy ought 
 seldom to be performed, unless the quantity of liquid is so great as to occasion pain- 
 ful distension ; or causes great distress of breathing by its upward pressure against 
 the diaphragm ; or gives rise to some positive suffering or urgent inconvenience, 
 which the evacuation of the water may be expected to remedy. 
 
 Acupuncture of the dropsical abdomen has of late been recommended ; and 
 cures, thus efl^ected, have been announced. It is said, or supposed, that the inclosed 
 liquid, oozing gradually into the areolar tissue of the integuments of the abdomen, 
 is thence removed, gradually, by absorption. Of this method of treatment I have 
 no practical knowledge. 
 
 It is seldom that tapping is many times performed upon the same person, when 
 the complaint is mere passive ascites. The dropsy returns indeed, and again the 
 operation is required ; meanwhile, in most cases, the health and strength rapidly 
 deteriorate, and the patient sinks. 
 
 The same speedy declension and early death occur sometimes in ovarian dropsy 
 ako ; yet the operation commonly bears to be repeated more often than in ascites, 
 without serious detriment to the general health. Sometimes the liquid re-accumu- 
 lates in the cyst very quickly, sometimes slowly ; in a very few instances not at all. 
 I have had under my own care a patient who had been tapped for this disease thirty- 
 eight or thirtj^-nine times. Extraordinary examples of a similar kind are on record ; 
 one or two I may mention as specimens. 
 
 Dr. Mead narrates the case of a lady, who, " for the information of posterity, 
 ordered bj^ her will that the following English inscription should be engraved on her 
 monument, in Bunhill Fields: — 
 
 Here lies Dame Mary Page, 
 
 Relict of Sir Gregory Page, Bart. 
 
 She departed this life, March 4, 1728, 
 
 In the 56th year of her age. 
 
 In G7 months she was tapped 66 times : 
 
 Had taken away 240 gallons of water, 
 
 without ever repining at her case, 
 
 or ever fearing the operation." 
 
 Among authenticated instances, the most remarkable that I have met with )» 
 detailed in the Philosophical Transactions for 1784, by Mr. Martineau, who was at 
 that time surgeon to the Norfolk and Norwich Hospital. An abstract of the case is 
 given in the printed catalogue of the Hunterian Museum, where the cyst is pre- 
 served : it belonged to the left ovary of Sarah Kippus, a w^idow, fifty-five years old. 
 " The complaint began after a miscarriage, at the age of twenty-seven. From the 
 year 1757, to August, 1783, when she died, she had been tapped eighty times, and
 
 ACUTE GASTRITIS. 753 
 
 had, in all, had taken from ber 6631 pints of fluid, or upwards of thirteen hocrs- 
 heads. 108 pints was the largest quantity ever taken away at any one time. But 
 after death Mr. Martineau could not make the sac contain more than fifty pints." 
 
 Upon the whole, it may be stated of this operation, as applied to ovarian dropsy, 
 
 1. That when it is essential to the comfort and continued existence of the patient, 
 it brings sensible rehef to her distress, and often materially prolongs her life. 
 
 But, 2. That when it is performed under less pressing circumstances, it tends to 
 shorten the patient's days. Dr. Bright is of opinion that the number is small of 
 those who survive the first tapping more than four years. A respectable woman 
 having very large ovarian dropsy, entered the Middlesex Hospital, under my care, 
 for the express purpose of being tapped. The tumour incommoded her by its bulk 
 and weight, but in no other way ; and she had carried it for thirteen years. I felt 
 that I should not be justifi^^d in sanctioning the operation in such a case. The 
 patient was made to understand that the performance of it would not be altogether 
 free from immediate danger: and that if she went through it safely, the swelling 
 would return, and the same kind of remedy again become equally necessary. She 
 was instructed how to suspend the heavy overhanging abdomen by a sling passing 
 over her shoulders. There appeared no reason why she should not continue m 
 good health for another period of thirteen years. 
 
 I am aware of another instance, in which a woman, similarly burdened, but other- 
 wise in comfortable health, has lived, not without enjoying Hfe, between twenty and 
 thirty years. Had she been tapped when the mere enlargement might have seemed 
 to justify the operation, she would probably have been for twenty years in her grave. 
 
 LECTURE LXVIII. 
 
 Acute. Gastritis : symptoms ; anatomical characters ; treatment. Chronic Injlam 
 mation of the Stomach; thickening of the Mucous Membrane; Ulceration; 
 symptoms and treatment of the disorder. Cancer of the stomach. 
 
 Acute inflammation, when it afTects the peritoneum, usually spreads with rapidity 
 over the whole surface of the membrane. This is characteristic of inflammation of 
 the serous membranes generally. But it is not so with the other tissues that com- 
 pose the alimentary canal. Inflammation of the mucous membrane may be, and 
 often is, very limited in extent : and the different portions of the intestinal tube, as 
 they differ in function, so also they differ somewhat in their diseases, and still more 
 in the symptoms by which those diseases are revealed. Not being fettered by any 
 artificial system of arrangement, I shall take the course which promises to be prac- 
 tically most useful, and consider separately the maladies of the several parts of ihe 
 alimentary canal in the abdomen, extending my remarks occasionally to the whole 
 of the tube, when speaking of disorders that are common to all portions of it. 
 
 Let me, then, in the first place, draw your attention to the organic diseases, and 
 the morbid conditions, of the stomach. 
 
 It is remarkable, all things considered, how seldom the stomach is affected with 
 acute infianimation. Scarcely ever do we find either the organ as a whole, or any 
 one of its tissues separately, the subject of spontaneous acute inflammation. What 
 is described in books as gastritis, means inflammation of the mucous membrane of 
 the stomach ; and almost all that we know, for certain, of this disease, we derive 
 from observation of the effects of strongly irritant substances upon that membrane. 
 Idiopathic gastritis, in an acute form, I never saw. Acute gastritis, fnjm the contact 
 of corrosive or acrid poisons, I have frequently seen : and a highly interesting afl^ec 
 tion it then becomes. This is a subject that cannot be thoroughly discussed in thjs 
 course of lectures : neither may it be altogether omitted. 
 4S
 
 754 ACUTE GASTRITIS. 
 
 When an irritant poison has been received into the stomach and excites inflam- 
 mation there — or when acute inflammation arises from any cause — the symptoms 
 which mark that inflammation are pain, usually of a burning character, in the epi- 
 gastrium; with frequent vomiting, especially upon the entrance of anything into the 
 stomach ; and often with hiccup, and with tension of the upper part of the abdomen. 
 To these local symptoms are added fever of a low type ; and a small and weak pulse. 
 At first, indeed, the pulse, although small, is generally sharp and hard ; but it soon 
 becomes thready and feeble. The muscular power undergoes a corresponding de- 
 pression ; the patient is pale and faint, with collapsed features, cold extremities, and 
 a damp skin. 
 
 In all this we see a strong tendency to death by asthenia. It is clear that the 
 subdued state of the circulation is dependent upon the inflammation, for it is often 
 relieved by the remedies of inflammation. In acute gastritis, as well as in peritonitis, 
 you will find that the pulse expands, becomes more distinct and full, under early 
 bleeding: sometimes even while the blood is flowing. 
 
 Upon this remarkable sympathy between the heart and the stomach I have fr& 
 quently had occasion to insist. You are aware that a smart blow upon the epigas- 
 trium may put a sudden stop to the movements of the heart, and induce mortal 
 syncope, without leaving any local trace of its operation. On the other hand, a 
 person in a state of extreme exhaustion and faintness, will sometimes revive at once, 
 upon swallowing into the stomach an ounce or two of brandy, and recover his pulse 
 and colour much too speedily to allow of our ascribing these effects to the absorption 
 of the alcohol into the blood. Dr. Alison suggests that the depression of the circu- 
 lation may be attributable to the peculiar sickening pain which accompanies inflam- 
 mation or sudden injury of the stomach. It appears, however, more probable (as 
 has been intimated to me by an obliging correspondent) that the remarkable sympathy 
 in qttestion is governed by the nerves of organic life. The great solar plexus of the 
 ganglionic system lies upon the spinal column immediately behind the stomach. 
 The heart is largely supplied with nervous filaments from the same system. Hence 
 we might almost expect that any sudden stimulus applied to this important plexus 
 would excite, and that any sudden depressing influence would subdue, the natural 
 action of the heart. Upon the same principle may be explained the facts that deadly 
 faintness and nausea are apt to result from injury of the testes, which are also 
 abundantly endowed with influence from the nerves of organic life. Be this as it 
 may, it is important for you to know that the mode of dying in these cases is pre- 
 cisel}'- what Bichat describes as death beginning at the heart. 
 
 The pain that accompanies gastritis is augmented by pressure upon the epigas- 
 trium. It is increased also by the full descent of the diaphragm, and the breathing 
 IS consequently short and constrained. In the most exquisite cases of gastritis, pro- 
 duced by chemical or mechanical irritants applied to the interior of the stomach, the 
 inflammation probabl} reaches and involves, more or less, the peritoneum. The 
 patients speak of the pain as a pricking and burning sensation ; it is attended with 
 great anxiety and restlessness. The sufferer is tormented with extreme thirst, while 
 all that he drinks, even cold water, is almost instantly rejected by vomiting. 
 
 Hiccup does not always accompany acute gastritis. It sometimes occurs early ; 
 but more generally it comes on late in the disease, when the patient is sunk and 
 much debilitated. 
 
 The bowels, in this complaint, are sometimes bound : sometimes, on the contrary — 
 uspeciaUy when the inflammation has been caused by corrosive poison — dysenteric 
 diarrhoea ensues, with much griping and tenesmus. 
 
 Such, then, are the symptoms that indicate the existence of acute gastritis ; but 
 you ought to be aware that they occur in varying combinations, and with different 
 degrees of severity ; and consequently that the course of the disease is not uniformly 
 the sanr>e in all cases. When the symptoms are the most violent, and the progress 
 of th'j complaint is the most rapid, the peritoneal coat of the stomach is usually, I 
 belie /e, more or less implicated. 
 
 Intense inflammation of the stomach may be expected to be rapid in its progress. 
 I' mav destroy Hfe within twenty -four, or even twelve hours. When it is fatal, it
 
 GASTRITIS. 755 
 
 generally is so within a few days ; and death takes place by fainting : with a remis- 
 sion of the pain, sometimes verj sudden, and sometimes occurring only just before 
 dissolution. But as idiopathic gastritis is rave, fatal idiopathic gastritis is, of course, 
 still more so. Louis states, that during six years' experience at La Charite, in which 
 period he noted the details of 6000 cases of disease, and of 500 dissections, he did 
 not meet with a single instance of fatal idiopathic gastritis. The subject derives 
 almost all its importance, therefore, from its connection Avith poisoning ; and the many 
 mteresting points of inquiry which arise out of that connection will be brought before 
 you by the Professor of Forensic Medicine. This consideration is a great satisfac- 
 tion and relief to me ; because I find that the limits of my own course will not 
 permit me to go into any detail in this matter. 
 
 The morbid appearances to be looked for after death by acute gastritis, are redness 
 of the mucous membrane, softening, sloughing, and even (after the action of strongly 
 corrosive poisons) perforation of all the coats of the stomach. 
 
 I wish particularly to caution you against being misled by mere redness of the 
 interior of the stomach ; or of the inner surface of the alimentary canal in general ; 
 or of any mucous membrane ; and indeed I may add, of any serous membrane also. 
 Redness and inflammation have been made, too often, convertible terms. Persons 
 finding the inner surface of the stomach red, have instantly concluded, from that cir- 
 cumstance, that suspicions of poisoning, which had arisen, were well founded. We 
 are indebted to Dr. Yclloly, in the first instance, and to M. Billard and some other 
 Frenchmen, in the second, for correcting this error — an error which not only was of 
 importance in questions of imputed poisoning, but has run through and vitiated 
 almost the whole of pathology, both lately and heretofore. iVIistaking mere redness 
 for evidence of inflammation, Cullen divided gastritis into two species — one of which 
 he called gastritis erythematica ; and he inferred from the observation of cases in 
 which redness of the membrane had been met with after death, that this peculiar 
 kind of inflammation of the mucous coat of the stomach might take place, without 
 fever, pain, or vomiting, or any other symptom indicative of gastritis : whereas it is 
 almost certain that, in the cases to which he refers, there really was no inflammation 
 at all. So also Morgagni, puzzled by intestinal vascularity, was disposed to attribute 
 the absence of pain, in what he beheved to have been inflammation of the bowels, 
 to a paralytic afl!ection, which blunted the sensibility of the parts ; and Haller con- 
 ceived, from so constantly meeting with this vascularity in his inspections of the body, 
 that inflammation of the bowels was almost always present in fevers of all kinds ; 
 and was frequent in every other complaint. And the same doctrine has been strenu- 
 ously inculcated of late years, as I dare say you know, by Broussais, in France, and 
 adopted by a Tast host of his disciples. Finding the lining membrane of the stomach 
 and intestines red and vascular in most of the bodies of patients who had died of 
 fever, Broussais concluded that fever depends, in all cases, upon inflammation of the 
 gastro-enteric mucous membrane. You will perceive that this doctrine must exer- 
 cise a vast influence upon the practice of those who entertain it. If inflammation 
 constitute an essential part of any disorder, it follows that the remedies of inflamma- 
 tion will be adapted to that disorder ; and thus, even so slight a mistake as that may 
 appear to be, against which I am now cautioning you, of regarding every surface 
 which is red as being inflamed also, may lead to very mischievous views in respect 
 to treatment. 
 
 The redness that is zndependent of inflammation may be of various kinds ; but 
 the principal cause of it is venous congestion. " The appearances of vascular full- 
 ness (says Dr. Yelloly) in the villous coat of the stomach, whether florid or dark- 
 coloured, in distinct vessels, or in extravasations of difl^erent sizes, are not to be 
 regarded as unequivocal marks of disease, inasmuch as they occur in every variety 
 of degree and character, under every circumstance of previous indisposition, and in 
 situations where the most heakhy aspect of the organ may be expected." To the 
 truth of this statement I can bear witness, having at one time of my hfe carefully 
 examined, with a view to this matter, a great number of stomachs in succession, iu 
 the dead-housG )f a large hospital. " The vascularity (according to Dr. Yelloly) is 
 entirely vennus, and depends on a power capable of being exercised on the artery
 
 756 GASTRITIS. 
 
 itself at the close of life, which carries on the blood to the veins, after the further 
 supply of fresh blood from the heart is stopped. The branched or stellated form of 
 vessels, under which the vascularity usually appears, is capable of being imitated, 
 either by injecting the veins with fine injection, or by forcing back with the finger, 
 or the back of a scalpel, the blood from the larger branches of veins into the smaller." 
 " And this vascularity soon becomes difl^used redness, by transudation of the blood 
 through the coats of the containing vessels, just as happens with the bile in the gall 
 bladder." 
 
 Redness, from mere repletion of the smaller veins, is usually extensive and unde- 
 fined ; except that, being influenced by the force of gx-avity, it settles into the most 
 depending parts of the organ, which are either its exclusive seat, or, at any rate, are 
 of a deeper colour than the parts more elevated. It is attended with an empty state 
 of the arteries, and with a full state of the larger veins. Hence, the condition of the 
 venous and arterial trunks, and especially of the vena portse, should, in doubtful 
 cases, be ascertained before the main blood-vessels are laid open and drained of their 
 contents. 
 
 The redness that belongs to inflammation is generally circumscribed, and of limited 
 extent ; it occupies indiscriminately the upper or the lower side of the tube (for these 
 remarks apply alike to the stomach and to the intestines) ; it is attended with some 
 fullness of the corresponding arterial trunks: and it may or may not be coincident 
 with comparative emptiness of the venous system within the abdomen. Much will 
 depend, in this respect, upon the mode of dying, as I have fully explained to you 
 on a former occasion. 
 
 You will please to remember, then, in all your future investigations into morbid 
 anatomy, that it is generally difficuk, and often impossible, to determine, from the 
 aspect of the vessels of a dead part, from its redness, that inflammation had been 
 present in that part during life, unless the unequivocal products or effects of inflam- 
 matory action are present also. 
 
 A much more certain evidence of inflammation of the mucous membrane of the 
 stomach and intestines, is its softening. This can be attributed to nothing else, 
 except it be to decomposition ; and it is well known that this membrane is slow and 
 late in passing into the state of putrefaction after death. To certain questions respect- 
 ing perforations of the stomach, I shall by and by return. 
 
 I say that gastritis is most commonly the eflect of poisons applied to the mucous 
 surface of the stomach ; but I must include under that head certain substances which, 
 to most people, are not poisonous or injurious at all, and which only become so to 
 some persons under particular circumstances. Thus, large draughts of cold drink, 
 taken when the body is hot, and rapidly parting with its heat, and especially large 
 draughts of cold sour liquors, as cider or stale beer, are apt to give rise to acute gas- 
 tritis. Another occasional cause of gastritis is the ingestion of very large quantities 
 of food at one time, especially during convalescence from any serious disorder. It 
 is an exceedingly curious fact, too, but one which I merely mention without dwelling 
 upon, that certain poisons introduced into the body through some other channel, will 
 cause mflammation of the mucous membrane of the stomach, with which they have 
 not been in contact. Corrosive subhmate and arsenic excite inflammation, with 
 ulceration or sloughing of the mucous membrane, even when they are merely 
 rubbed, in a certain quantity, upon the skin, or when they are inserted into the 
 rectum. 
 
 The treatment of acute gastritis is simple. The chief nicety respects the employ- 
 ment of blood-letting. Early in the disease, if the pain be severe, you must trylhe 
 fiffect of venesection, notwithstanding the smallness and feebleness of the pulse. 
 How much blood you are to abstract cannot be told beforehand. Take away a small 
 teacupful, keeping, meanwhile, your finger on the wrist. If the beat of the artery 
 does not grow weaker, and still more if it becomes fuller and stronger, go on with 
 the bleedmg, and take another cupful, and another, according to the circumstances 
 of the case and to the effects produced. Apply leeches to the epigastrium, and cover 
 ihe bleeding bites with a soft, light pouUice. Keep the patient as strictly as you can 
 in the horizontal posture ; in other words, see thft thr depressing influence of tbn)
 
 CHRONIC INFLAMMATION OF THE STOMACH. 757 
 
 Msi lise upon the action of the heart is not aided and augmented by the position of 
 the body. If cold water is retained, that is the best medicine which you can give by 
 the mouth; purgatives so administered would be almost sure to be rejected, and, if 
 nut rejected, they would be likely to increase the existing inflammation of the organ. 
 En-imata are, however, extremely useful: of warm water, if the bowels are not 
 mu(,h confined ; of purgative materials, if they are. After the intestines have been 
 thuij cleared — or when they are loose and irritable — opiate injections (thirty or forty 
 drops of laudanum, with three or four ounces of starch or gruel) do much good. 
 They often have a very tranquillizing effect upon the irritable stomnch, and check 
 the vomiting. These measures are to be pursued until the inflammation has 
 subsided. 
 
 When any corrosive substance has been swallowed, I scarcely need say that painj 
 should be taken to remove it as speedily as possible from the stomach, or to admin- 
 ister such remedies as are known to be capable of decomposing the poison, or of 
 affording a specific antidote to it. Not that the stomach-pump should be employed 
 in such cases, as it too often is. These, however, are points that must be fully treated 
 of in the lectures on forensic medicine, and therefore I shall dwell upon them no 
 longer here. 
 
 Chronic inflammation of the stomach is probably a very common disorder. It 
 does not put life in immediate jeopardy, and it is often recovered from. It deranges, 
 however, the functions, and perverts the feelings of the stomach : it gives rise to the 
 manifold and multiform symptoms of dyspepsia. But dyspepsia, with its manifold 
 and multiform symptoms, may be, and often is, entirely independent of inflamma- 
 tion. You see, then, why the efTects of chronic gastritis are various, and why the 
 symptoms that are supposed to denote its presence are apt to be obscure, uncertain, 
 and equivocal. I intend, before I quit the subject of the stomach, to investigate the 
 principal circumstances that mark its functional disorders, and to describe the means 
 which we sometimes find effectual for their relief. I shall therefore restrict myself 
 at present to a kw points which seem to have been fairly ascertained respecting 
 chronic gastritis. 
 
 We know that chronic inflammation had been going on in the stomach when, after 
 death, we see that its coats are thickened, or when we perceive that a portion of one 
 or more of them has been removed by ulceration. 
 
 It is not at all uncommon to find the mucous membrane of the stomach, over a 
 larger or smaller space, thick, granular, uneven, and of an unnatural colour. Gray, 
 or slate-coloured, it often is. This slate-colour is much dwelt upon by the French 
 writers, as being a sure and unequivocal impress of chronic inflammation. The 
 colour proceeds, I believe, from the operation of the gastric acids upon the blood, 
 which, under habitual congestion or slow inflammation, is detained in the vessels of 
 the altered part. The ulcers that result from chronic inflammatory action are usually 
 small, varying from the size of a split pea to that of a shilling; sometimes with no 
 surrounding vascularity or thickening at all, but looking exactly as though a piece 
 of the mucous membrane had been struck out by a stamp ; sometimes with rounded 
 and elevated edges only; and sometimes they occupy patches of thickening and 
 induration of the parietes of the stomach. There may be one solitary ulcer, or a 
 few, or many. It is seldom, however, that they are numerous. 
 
 Ulcerative disease of the stomach may prove fatal in various ways. The ulcer 
 may penetrate as far as the peritoneum, and excite inflammation of that membrane, 
 whereby the stomach becomes adherent to the neighbouring parts. In these cases, 
 prior or subsequently to adhesion, death may at length ensue, from gradual ex- 
 haustion and protracted suffering. 
 
 If an ulcer happen to lie over the track of a large blood-vessel in the stomacn, it 
 may eat its way into that vessel, and give rise to fatal hemorrhage. 
 
 Or the ulcer may perforate the walls of the stomach, without any previous adho 
 sion, and suffer the food, or the secretions of the stomach, to pass into the peritoneal 
 cavity, where intense inflammation is lighted up, and the patient soon perishes 
 
 So
 
 758 CHRONIC INFLAMMATION 
 
 Or the ulcers may at length heal. Of this we are certain, because, we sometimes 
 find cicatrices marking the spots which the ulcers had occupied. 
 
 The symptoms of chronic gastritis are pain or uneasiness in the epigastrium, 
 increased by pressure ; increased also on the introduction of food, or perhaps fell 
 only while digestion is in progress; flatulence and eructation; vomiting of mucus, and 
 of the meals; loss of sleep; languor and debility. 
 
 Not that even these symptoms are constant in all cases. Sometimes there is no 
 actual pain, but a sense of heat or of acidity. The vomiting, too, in the outset, is occa- 
 sional only ; and is then attributable, often, to some error or imprudence in respect 
 to diet. And sometimes the complaint may run nearly its whole course, up to one 
 of the fatal terminations just now mentioned, with scarcely any other sign of its ex- 
 istence than uneasiness after meals, which subsides in two or three hours entirely. 
 With the local symptoms I have been describing there are often conjoined some 
 acceleration and hardness of the pulse : more or less thirst : a dry skin : scanty and 
 deep-coloured urine: a red tongue; red especially at its tips and edges; patchy and 
 fissured perhaps ; or smooth and glossy, like a slice of raw meat. The throat is also 
 frequently tender; and the phaiynx and palate unnaturally vascular. 
 
 In attempting to relieve or cure chronic gastritis we have to guard against apply- 
 ing anything to the inflamed surface which may be likely to add to the existing 
 mischief, or which has been found, upon trial, to give pain. We employ at the 
 same time the ordinary remedies of chronic inflammation. Leeches may be put 
 upon the epigastrium, and repeated day by day, or every other day, in small num- 
 bers, so long as there is much tenderness on pressure. When the tenderness is less, 
 counter-irritation is very useful: repeated blisters; or friction with the tartar emetic 
 ointment over the region of the stomach. But, after all, the main dependence must 
 be placed in the due regulation of the food, which should be mild and unstimulating 
 in quality, and sparing in quantity. The well-known farinaceous substances which 
 figure in the bill of fire of a sick chamber : arrow-root ; sago ; tapioca ; gruel ; milk 
 also ; and jellies. And even these bland articles of nourishment must be given in 
 moderation, so as neve to distend the stomach or to stretch its coats by their bulk, 
 or to overtask its power of digestion. It is difficult, in such cases, to give precise 
 rules for the management of the diet, which must be left to the common sense of the 
 practitioner. 
 
 With respect to internal medicines, they must be such as appear to be called for 
 by ])arlicular symptoms. Of these, which are in fact the symptoms of dyspepsia, I 
 postpone the further consideration. Appropriate means must be used for the regu- 
 lation of the bowels : mild laxatives by the mouth ; emollient or purgative enemata 
 by the rectum. 
 
 When I say that a good deal must be left, in these cases of chronic disease o-f the 
 stomach, to the judgment and good sense of the practitioner, I am forcibly reminded 
 of a most striking and instructive case, beautifully told by the celebrated Dr. Wm. 
 Hunter, in the sixth volume of the Medical Observations and Inquiries. The 
 perusal of that history has afforded me hints upon which I have ofien acted with 
 great advantage to my patients, and with some credit to myself. As I doubt whether 
 many of you would find immediate opportunity or leisure for referring to the narra- 
 tive, and as I should spoil it by attempting to give you an abstract of it, I am tempted 
 to read it here in Dr. Hunter's own words. 
 
 " Many years ago (he says) a gentleman came to me from the eastern part of the 
 city, with his son, about eight or nine years old, to ask my advice for him. The 
 complaint was pain in the stomach, frequent and violent vomitings, great weak|[iess, 
 and wasting of flesh. I think I hardly ever saw a human creature more emaciated, 
 or with a look more expressive of being near the end of all the miseries of life. The 
 disorder was of some months' standing, and from the beginning to that time had been 
 daily growing more desperate. He was at school when first taken ill, and concealed 
 nis disorder for some time : but growing much worse he was compelled to complain, 
 and was brought home to be more carefully attended. From his sickly look, his 
 v?tal loss of appetite, besides what he said of the pain which he suffered, but espe
 
 OF THE STOMACH. 759 
 
 cially from his vomiting up almost everything which he swallowed, it was evident 
 that his disorder was very serious. 
 
 "Three of the most eminent physicians of that time attended him in succession : 
 and tried a variety of medicines without the least good effect. They had all, as the 
 father told me, after sufficient trial, given the patient up, having nothing further to 
 propose. The last prescription was a pill of solid opium ; for in the fluid state, 
 though at first the opiate had stayed some time upon his stomach, and brought a 
 temporary relief, it failed at length, and like food, drink, and every medicine which 
 had been given, was presently brought up again by vomiting. The opiate ^;z7/ was 
 therefore given in hopes that it would elude the expulsive efforts of the stomach. It 
 did so for a time ; but after a little use, that likewise brought on vomiting. Then it 
 was that his physician was consulted for the last time, who said that he had nothing 
 further to propose. 
 
 ♦' Though at first the boy professed that he could assign no cause for his complaint, 
 being strictly interrogated by his father, if he had ever swallowed anything that 
 could hurt his stomach, or received any injury by a blow, or otherwise, he confessed 
 that the usher in the school had grasped him by the waistcoat at the pit of the sto- 
 mach, in a peevish fit, and shaken him rudel}^ for not having come up to the usher's 
 expectation in a school-exercise. That though it was not very painful at the time, 
 the disorder came on soon after. This account disposed the father to suspect that the 
 rude grasp and shake had hurt the stomach. With that idea he brought him to me, 
 as an anatomist, that an accurate examination might if possible discover the cause or 
 nature of the disorder. 
 
 " He was stripped before the fire, and examined with attention in various situa- 
 tions and postures; but no fulness, hardness, or tumour whatever could be discovered ; 
 on the contrary, he appeared everywhere like a skeleton covered with a mere skin ; 
 and the abdomen was as flat, or rather as much drawn inwards, as if it had not con- 
 tained half the usual quantity of bowels. 
 
 "Having received all the information that I could expect, and reflected some little 
 time upon the case, I wished to speak with the father alone, in another room ; and 
 to give my patient some employment as well as refreshment, asked him to lake a 
 liule milk in the mean time. But his father begged that taking any thing into his 
 stomach might be put off till he got home, because he was certain that it would 
 make him sick ; ' just before we set out (said he) I gave him a little milk ; but he 
 was sick, and brought it all up in the coach, before we had got many paces from the 
 house.' 
 
 " In the adjacent room I said to the father. This case, sir, appears to me so despe 
 rate, that I could not tell you my thoughts before your son. I think it most probable, 
 no doubt, that he will sink under it ; I believe that no human sagacity or experience 
 could pretend to ascertain the cause of his complaint : and without supposing a par- 
 ticular or specific cause, there is hardly any thing to be aimed at in the way of a cure. 
 Yet, dreadful as this language must be to your ear, I think you are not to be without 
 hope. As we do not know the cause, it may happen to be of a temporary nature, 
 and may of itself take a favourable turn ; we see such wonderful changes every day, 
 in cases that appear the most desperate, and especially in young people. In them 
 the resources of nature are astonishing. 
 
 "Then he asked me if T could communicate any rules or directions, for givincr 
 l.im a better chance of getting that cure from nature, which he saw he must despair 
 of from art. 
 
 " I told him that there were two things which I w^ould recommend. The first was 
 not so important indeed, yet I thought it might be useful, and certainly could do no 
 harm. It was to have his son well rubbed, for half an hour together, with warm oil 
 and a warm hand, before a fire, over and all around his stomach, every morning and 
 evening. The oil, perhaps, would do little more than make the friction harmles;-;, 
 as well as easy ; and the friction would both soothe pain, and be a healthful exercise 
 to a weak body, 
 
 "The second thing that I had to propose, I imagined to be of the utmost conse- 
 quence It was something which I had particularly attended to in the disorders o '
 
 760 CHRONIC INFLAMMATION 
 
 the stomach, especially vomitings. It was, carefully to avoid offending a very weak 
 stomach, either with the quantity, or quality, of what is taken down ; and yet to get 
 enough retained for supporting life. I need not tell you, sir, said I, that your son 
 cannot live long, without taking so7ne nourishment ; he must be supported to allow 
 of any chance m his favour. You think that for some time he has kept nothing of 
 what he has swallowed ; but a small part must have remained, else he could not 
 have lived till now. Do you not think, then, that it would have been better for him 
 if he had only taken the very small quantity which remained with him, and was 
 converted to nourishment '. It would have answered the end of supporting life as 
 well, and perhaps have saved him such constant distress of being sick, and of vomit- 
 ing. The nourishment which he takes should not only be in very small quantity at 
 a time, but in quantity the most inoffensive to a weak stomach that can be found. 
 Milk is that kind of nourishment. It is what Providence has contrived for support- 
 ing animals in the most tender stage of life. Take your son home, and as soon as 
 he has rested a httle, give him one spoonful of milk. If he keeps it some time, 
 without sickness or vomiting, repeat the meal, and so on. If he vomits it, after a 
 little rest, try him with a smaller quantity, viz., with a dessert, or even a leaspoonful. 
 If he can but bear the smallest quantity, you will be sure of being able to give him 
 nourishment. Let it be the sole business of one person to feed him. If you succeed 
 in the beginning, persevere with great caution, and proceed very gradually to a 
 greater quantity, and to other ^uid food, especially to what his own fancy may invite 
 him ; such as smooth gruel, or panada, milk boiled with a little flour of wheat or 
 rice ; thin chocolate and milk ; any broth without fat, or with a little jelly or rice or 
 barley in it, (fee. &c. 
 
 " We then went in to our patient again ; and that he might be encouraged with 
 hope, and ac\ his part with resolution, I repeated the directions with an air of being 
 confident of success. The plan was simple, and perfectly understood. They 
 left me. 
 
 " I heard nothing of the case till, I believe, between two and three months after. 
 His father came to me with a most joyful countenance, and with kind expressions 
 of gratitude told me, that the plan had been pursued with scrupulous exaclrness, and 
 with astonishing success ; that his son had never vomited since I had seen him; that 
 he was daily gaining flesh, and strength, and colour, and spirits, and now grown 
 very importunate to have more substantial food. I recommended a change to be 
 made by degrees. He recovered completely ; and many years ago he was a healthy 
 and a very strong young man." 
 
 [Acute gastritis is a disease of by no means unfrequent occurrence during infancy, and 
 then frequently causes a softening of the mucous membrane of the- stomacli, to which much 
 attention has of late years been directed by the observations of Cruveilheir, Louis, Laisne, 
 Billard, and others; by several of whom it is described as a specific disease. It is to this 
 particular lesion that we wish to direct attention in the pfresent note, referring the reader fur 
 information on the subject of the inflammatory affections of the stomach generally, that occur 
 during the early period of life, to the Editors Treatise on the Diseases of Children. 
 
 The symptoms of the particular form of acute gastritis, to which we have reference, are 
 ■'ery accurately described by Billard. The disease commences with tlie phenomena of a 
 violent inflammation of the stomach ; as tension of the epigastrium, which is painful to 
 tlie touch ; frequent vomiting, not only of the milk and drinks taken, but also of a green or 
 yellow fluid; the vomiting occurring every moment, without any reference to the period 
 when the child has taken food or drink. There is, sometimes, diarrha'a, varying in diflerent 
 subjects, and returning after having ceased for a day or two; the matters discharged from 
 the bowels being often green, and similar to those brought up from the stomach by vomiting. 
 The extremities are cold; the pulse is generally irregular ; the countenance has a permanent 
 expression of sufiering, the face remaining furrowed, as if the infant were crying; the cry 
 is expressive of pain ; the respiration is interrupted, and the general agitation so great that 
 Ihe existence of a cerebral affection might be suspected. At the end of six, eight, or fifteen 
 (lays 'he patient sinks exhaiisted from the want of sleep, constant vomiting, and pain : in 
 very young infants the disease is attended with little or no fever. 
 
 Dr. Iselin, of IMuhlheim, who had an opportunity of studying the disease during its exten- 
 sive prevalence as an epidemic at Gottingen, gives the following description of its phe- 
 ocmena : 
 
 Previous to the attack, the child is often, for several days, unusually restless and fretful —
 
 OF THE STOMACH. 761 
 
 finally, a decided febrile attack occurs, attended with a quick pulse, hot and dry skin, intense 
 thirst, sleeplessness, and constant vomiting, increased upon food or drink being taken into the 
 stomach. To these symptoms is speedily added a copious diarrhoea — the dejections being, 
 at first, of a grayish colour, and of some degree of consistence, but subsequently of a yellow- 
 ish or greenish serum, decidedly acid. The evacuations are usually preceded by contortions 
 of the countenance indicative of pain, which are likewise induced by pressure on the abdo 
 men. The latter is always much, often enormously distended, and its temperature, especially 
 at the epigastrium, is often considerably elevated, while the extremities are cool, or even de- 
 cidedly cold. The patient exhibits great prostration of strength, and a profuse partial per- 
 spiration soon breaks out, particularly about the head. 
 
 The disease varies in its duration — proving fatal, in some cases, within twenty-four hours, 
 and in others, not until after a continuance of several days, or even weeks. 
 
 In the more violent cases, its onset is very sudden — and it is attended with frequent faint- 
 ing, and an irregular and very quick pulse — the eyes and features are sunken — the body is 
 bathed in a profuse perspiration. Convulsions, more or less severe, often attended with stra- 
 bismus, sooner or later, occur ; the face becomes of a bluish tint; the diarrhoea or vomiting, 
 or both, soon become suspended ; the accessions of fainting and convulsions become more 
 frequent, and during one of these, death usually takes place. 
 
 The intumescence and augmented heat of the abdomen, particularly of the epigastric 
 region, and the coldness of the extremities, are, according to Dr. Iselin, to be considered a3 
 among the most constant and characteristic symptoms of the disease. The agonized expres- 
 sion of countenance, and sunken appearance of the eyes, are likewise almost invariably pre- 
 sent, even from its earliest stages. 
 
 The age at which this form of gastritis usually occurs is within the first year ; it is 
 not, however, necessarily restricted to this period of life. 
 
 The most constant lesion discovered after death is a softening of the mucous membrane 
 of the stomach, and often of the small and great intestines; the membrane being reduced to 
 a disorganized and gelatinous pulp ; or, the softening may extend to all the tissues of the 
 stomach, rendering them liable to be perforated by the slightest force. In the stomach these 
 softenings occur especially, according to Baron, Billard, and Iselin, at the great curvature, sel- 
 dom extending beyond the most depending parts. Distinct traces of inflammation are occa- 
 sionally observed, surrounding the softened parts, and patches of inflammation often exist, 
 also, in diflerent portions of the intestinal canal, especially in the small intestines. The pa- 
 rietes of the stomach frequently present a serous infiltration. 
 
 Carswell, Burns, Gairdner, Carwell, Hope, and other pathologists, deny the connection in 
 tliese cases, of the softening of the gastro-intestinal mucous membrane and inflammation, and 
 maintain that, in general, it is to be viewed as a cadaveric phenomenon, resulting from the 
 action of the gastric juice upon the tissues of the stomach ; others, with Jaeger, Zeller, and 
 Camerer, refer it to a paralysis of the nerves of the stomach, with increased acidity of the 
 gastric juices, by which the tissues of the organ are dissolved during the lifetime of the pa- 
 tient. A somewhat similar opinion is entertained by Laisne, Chaussier, Desbarreaux, Ber- 
 nard, and others. Without denying that the softening observed after death in the stomachs 
 of children may be, in many cases, strictly a cadaveric phenomenon, and that, in other cases, 
 it may result, during the lifetime of the patient, from other causes than inflammation, we are, 
 nevertheless, well convinced from the result of repeated and cautious observations, that the 
 gelatinous softening so frequently met with in the stomach of those infants who die after 
 exhibiting all the symptoms of acute gastritis, is invariably the efl'ect of an intense inflamma- 
 tion commencing in the mucous tissue of the organ. 
 
 Softening of the parietes of the stomach, as well as of the intestines, unquestionably often 
 takes place previously to the death of the patient, in cases where it cannot be sujjposed to be 
 trie result of inflammation. Thus, we not unfrequently observe in infants brought up by the 
 hand, or improperly fed subsequently to weaning, a loss of appetite, peevishness, great rest- 
 lessness, and want of sleep ; the tongue becomes coated with a layer of white or yellowish 
 mucus ; and in some instances aphthte appear upon the parietes of the mouth, and the breath 
 has usually a decidedly acid odour. There are a constant diarrhcea, and intense thirst. The 
 diarrhcea, after a time, frequently diminishes, or entirely ceases — but soon returns again with 
 increased violence — the discharges being a thin serous fluid of a yellow or greenish hue, and 
 having a very strong acid smell ; great emaciation and exhaustion soon ensue ; the face and 
 extremities become cold ; the pulse small and irregular ; the resjiiration quick and short. 
 The child utters continually a low piteous moan, or lies upon his back with the eyes fixed, 
 glassy, and half closed. No pain or tenderness is indicated upon gentle pressure of the ab- 
 domen ; the latter is, however, often greatly swollen and tyuipanitic. The child becomes 
 more and more exhausted, and, finally, expires quietly, and without convulsions. 
 
 This train of symptoms, with slight variations, marks that form of disease described by 
 Camerer, Pommer, Hergt, Romberg, Droste and others, as gastro-malacia, and in which the 
 stomach, and often the intestines likewise,' present a gelatinous softening of their parietes, to 
 a greater or less exter t, but without the slightest indication of inflammation ; the soitenirg 
 
 3o2
 
 7C2 CARCINOMA OF THE STOMACH. 
 
 appearing to depend upon a diminished cohesion of the tissues — the result probably of dis* 
 ordered or suspended nutrition. 
 
 Acute gastritis as it occurs in the infant, is under all circumstances, and throughout all its 
 stages, difficult to manage, and but little luider the control of remedies. At its very onset 
 leeches to the epigastrium, followed by warm fomentations or soft emollient poultices, assi 
 duonsly applied, will be found advantageous. Internally, minute doses of calomel vi'il often 
 remain upon the stomach and allay the excessive irritability of that organ; we have occa- 
 .■sionally combined the calomel with the acetate of lead; one-fotirth of a grain of the first 
 ■with half a grain to a grain of theN second, will, in a large number of instances, very speedily 
 control the vomiting and purging, and atibrd us time to reduce the local inflammation by 
 leeches to the epigastrium, followed by blisters, kept on for one or two hours, and then re- 
 placed by an emollient poultice. The thirst of the child should be allayed by small quanti 
 ties of some bland mucilaginous fluid, given cold, and repeated at short intervals. Slightly 
 astringent and bitter infusions are recommended by some practitioners during the period of 
 convalescence, and we think that we have seen very decided benefit result at this period 
 from the j^roto-carbonate of iron in moderate doses. — C] 
 
 The stomach is very frequently the seat of specific inahgnant disease ; of cancer, 
 in its various forms and denominations. The fatal nature of this complaint ; the 
 obscurity in which it is sometimes wrapped ; the possibility of overlooking it alto- 
 gether, or of confounding it with disease of a more innocent character, combine to 
 invest it with peculiar interest. 
 
 Carcinoma of the stomach has sometimes no symptoms at all, or none which the 
 most sagacious practitioner would refer to the organ affected. Not long since I saw, 
 in consultation, an elderly clergyman, m4io complained of pains in his back, which 
 were brought on or aggravated by certain movements of the body. His bowels 
 were costive ; and purgatives always relieved his pains. He was passing lithic acid 
 gravel. The pains were felt in or near the renal region. Several years before he 
 had suffered in a similar manner; and had then been cured by being cupped in the 
 loins. What was the matter here ? Was it lumbago ? Was there a calculus in one of 
 his kidneys ? These were the best guesses that I could make. The eminent phy- 
 sician whom I met, and a surgeon of no less eminence, Avho had seen the patient 
 previously, had not been able to obtain any more exact diagnosis. Upon this gen- 
 tleman's death, which occurred not long afterwards, his disorder was discovered to 
 have been cancer of the stomach. Excepting slight sickness a day or two before he 
 died, there had been no symptom to direct attention to that part. 
 
 A young woman came into the xMiddlesex Hospital, under one of my colleagues, 
 with a pulsating tumour in her epigastrium. It was thought, at first, to be an aneu- 
 rism, and the case attracted, on that account, a good deal of notice. But the tumour 
 subsided very much after free purgation. This led some to suppose that it was formed 
 by accumulated feces in the transverse colon. There was no sickness; nor indaed 
 any one symptoin referable to the stomach. She died. The tumour was cancerous; 
 and in the stomach. Lying in front of the abdominal aorta, it had been hfted by its 
 pulsations. 
 
 Cases to the same effect are related by Dr. Seymour in the Medico-Chirurgical 
 Transactions ; and by M. Andral in his Cliniqiie Medicale. 
 
 But even when the stomach is the organ pointed out, by the symptoms, as the 
 probable seat of the malady, those symptoms fail, often, to indicate with any cer- 
 tainty its nature. The effects of the carcinomatous disease exhibit no uniformity. 
 The ingestion of food is apt to produce great distress ; but differently in different 
 cases : sometimes as soon as the food is swallowed ; sometimes not for an hour 
 or two afterwards. Some cases are attended with much pain ; some with none 
 at all. One patient vomits continually: another has httle or no vomiting from first 
 to last. 
 
 Can the.?e differences be in any way accoimted for ? Partly they may. By ana- 
 •yzmg case after case, we approximate to a knowledge of their causes. But this 
 knowledge is yet far from being complete. 
 
 One circumstance that has a considerable influence upon the symptoms, is the 
 situation of the disease. In respect to this. point there are certain general rules 
 which are for the most part true. Still we can speak of them only as applicable on 
 the average; they are not absolute or infalhble.
 
 CARCINOMA OF THE STOMACH. 763 
 
 The rules I mean are these : 
 
 1st. That there is more suffering, caeteris paribus, when the cancerous disease is 
 situated at, or very near, either extremity or orifice of the stomach, than when it 
 occupies the intermediate parts ; whether in the greater or in the lesser curvature. 
 
 2d. That when the cardia, and its immediate neighbourhood, is the part solely or 
 principally diseased, the food and drink find a hinderance in passing into the sto- 
 mach ; but being once there, the distress is over. The symptoms are very like those 
 of stricture of the oesophagus. The morsel reaches the bottom of that tube, and there 
 causes uneasiness, till at length it is brought up again through the mouth, or passes 
 gradually in the natural direction. 
 
 8d. That when, on the other hand, the disease is limited to the pyloric end of the 
 stomach, the food enters that bag readily enough, and remains there for a certain 
 time ; then uneasy sensations arise, and the imperfectly digested meal is apt to be 
 rejected by vomiting. 
 
 It is the difficulty of passing the doorway in these cases, that gives rise to the 
 principal suffering; the difficulty of getting into, or the difficulty of getting out of 
 the stomach. But when the disease is confined to the intermediate space, no such 
 difficulty occurs ; and therefore little or no pain. 
 
 You must expect, I say, to meet with individual variations from these rules. A 
 remarkable example of such variation was presented by one of my hospital pa- 
 tients, in the year 1837. I have the notes of that case before me, which I will read 
 sJiort. 
 
 Simon Ailes, aged thirty-six, admitted March 14. His main complaint was of pain 
 in the epigastrium, always present, but augmented in frequent paroxysms, to an ex- 
 treme degree of severity. At first, pressure gave him some relief. The pain was 
 most violent an hour or two after he ate. He was troubled also with flatulence, and 
 with sour eructations. Occasionally a clear tasteless fluid, looking like water, rose 
 into his mouth. His bowels were costive. 
 
 At this time his countenance was natural and placid ; but it gradually assumed 
 that pinched and anxious expression, and that peculiar yellowish hue, which are so 
 significant of organic visceral disease. He wasted fast. At length the epigastrium 
 became tender as well as painful: but no tumour, except the left edge of the liver, 
 could be felt there. He died on the 11th of May, about eight months from the 
 commencement of the pain. A week before his death he vomited some dark, 
 grumous, offensive fluid, evidently containing blood. With this exception he had 
 CO vomiting. 
 
 Many remedies were tried, which I do not specify, for none of them gave him any 
 sensible or continued relief. 
 
 In the smaller curvature of the stomach we found a ragged, sloughy surface, as 
 big as the palm of one's hand, and extending to within half an inch from the pylorus. 
 A section of this diseased portion exhibited the characters of true scirrhus: a white 
 and hard mass, nearly half an inch across at its thickest part. The mucous mem- 
 brane of the duodenum was congested, and dark-coloured. The I'est of the intestines 
 VA'ere healthy except the rectum, which was surrounded, towards the anus, by scir- 
 rhus and thickened areolar tissue, intermixed in laminas. The gut itself was not 
 affected. 
 
 The diseased stomach was removed, and examined by Mr. Kiernan, who found, 
 upon careful dissection, that the trunk of the gastric branch of the par vagum run 
 directly into, and was lost in, the scirrhous mass. This sufficiently accounted for 
 the dreadful sufferings of the patient. 
 
 And I am here reminded that, with regard to the structural akeration itself, there 
 are some circumstances well worth attending to. 
 
 Andral places all these organic affections of the stomach in the class of chronio 
 gastritis. But it is clear that he is wrong : and you will perceive at once that it •'» 
 of immense importance to recognize the specific disease from the mere result of 
 common inflammation. 
 
 But though cancer is not, in any case, a mere product of common inflammation 
 neither is all that is called cancer really such. Specimens of morbid texture, nus*
 
 764 CARCINOMA OF THE STOMACH. 
 
 named scirrhus of the pylorus, are not uncommon in anatomical museums. I shciv 
 you some from our own ; not so denominated, however. The correct labeling would 
 be hypertrophy. You may perceive that the areolar and the muscular tissues near 
 the p3-lorus, are very much thickened. A section of the thickened parts presents 
 an appearance somewhat like horn ; and is crossed by whitish Hnes that run nearly 
 parallel to each other. The morbid structure is quite definite and uniform ; and 
 ver}" dissimilar, in that respect, to the irregular masses of scirrhus, and to the amor- 
 phous deposits of encephaloid cancer. Neither does it at all resemble that of the 
 colloid variety of carcinoma. Changes of this kind are liable to occur in the mus- 
 cular tissue of this, as of other organs, whenever a permanent obstacle is opposed to 
 the onward progress of the contents of the hollow viscus. The impediment may 
 have been originally produced by inflammatory thickening of the textures composing 
 the pylorus ; and then the hypertrophy may, in a certain sense, be accounted a con- 
 sequence of inflammation. To that extent alone is M. Andral right. He has un- 
 questionably pushed his theory on this subject too far. Whatever narrows the 
 pyloric orifice leads to increased effort of the propelling muscle, and to augmenta- 
 tion of its bulk and power. Now cancer itself, situated at, or close upon, the pylorus, 
 may impede the exit of the digested aliment ; and then it causes a gradual hyper- 
 trophy of the muscular coat. In these cases there is a mixture of the two changes ; 
 of the cancerous growth, with the muscular hypertrophy : and this is one reason 
 why they have been confounded together. Here are several preparations, exhibiting 
 true cancer of the stomach. At the bottom of each bottle may be seen a sort of 
 whitish powder, or sediment, consisting of some of the matters peculiar to cancer. 
 This fact has been pointed out to me by Mr. Kiernan in the numerous specimens 
 contained in his private collection. But there is no such deposit when the hyper- 
 trophy is not combined with malignant disease. 
 
 It has long been thought and asserted, that cancer of the stomach is not so apt to 
 be attended, as cancer of other parts, with a disposition to present itself in various 
 organs of the body at the same time, or in succession. Now I believe — and I am 
 glad to add the weight of Mr. Kiernan's authority to my statement — that this is not 
 really so. Cancer is a constitutional affection: or, if local and solitary in the outset, 
 is prone to disseminate itself. The error has arisen out of that confounding of one 
 morbid condition with another, against which I have been warning you. Instances 
 are not at all uncommon of thickening of the areolar and mucous tissues about the 
 pylorus, producing first a mechanical impediment to the passage of the food, then 
 more energetic muscular efforts towards its expulsion from the stomach, and at last 
 hypertrophy of the muscular tunic. In these cases, you do not find cancer in other 
 organs : because, in fact, there is no cancer in the stomach. 
 
 You may say that as both forms of disease are alike fatal, it signifies nothing 
 whether there be really cancer or not. But it is always satisfactory to clear away 
 an apparent anomaly, and to show that it has no real existence. Besides, you know 
 with how much anxiety the relatives of the dead inquire concerning these matters. 
 That cancer "runs in families" is well understood even by the public: and the dis- 
 tinctions I have been pointing out are surely worth learning, if they do no more than 
 enable us to comfort the minds of survivors, and to relieve them from the apprehen- 
 sion that they also may be doomed or likely to become the victims of cancer. 
 
 Notwithstanding what I have now been saying, it must be allowed that genuine 
 cancer of the stomach is accompanied less frequently than some other modes of car- 
 cinomatous disease, by cancer elsewhere. In fact cancer of the stomach is most 
 often of the scirrhous variety, which until it softens is not so readily disseminated as 
 the others, and which is apt to prove fatal before it softens. 
 
 When primary cancer of the stomach is of the encephaloid kind, or when, being 
 scirrhous, it begins to grow soft, — you would expect, after what was stated respecting 
 suppurative phlebitis, that its secondary manifestation should occur chiefly in the 
 liver. And it is so: the reason being that the veins of the stomach conuTiunicate 
 with the general system not directly, but through the hepatic capillary system. 
 
 But to return to the symptoms of carcinoma of the stomach. In some cases, I say, 
 the food is rejected by vomiting : in some cases it is not. Now it has been argued
 
 CARCINOMA OF THE STOMACH. 765 
 
 that this difference depends upon the condition of the pyloric outlet ; whether it be 
 free and open, or contracted and shut. The explanation is more plausible than 
 sound. It is not strictly consistent with facts. Vomiting of the food has been an ur 
 gent symptom, when there was no mechanical bar to its passage into the duodenum, 
 The pylorus is a sphincter muscle, of which the natural and habitual state is that of 
 contraction. It yields, however, in health, to the pressure of the digested aliment, 
 whicn is driven forwards by the muscular fibres that surround, and compress by their 
 action, the pyloric end of the stomach. If there be a mechanical impediment, that 
 affords a sufficient reason why the food should be thrown up again. But sometimes, 
 I repeat, the orifice is wide open, and yet the food is rejected : and it is rejected be- 
 cause the disease so involves the pyloric end of the stomach, that the propelling force 
 cannot be exercised. 
 
 When there is a mechanical obstacle, the disposition to hypertrophy of the mus- 
 cular coat is conservative. But in feeble and delicate persons, the baffled muscles 
 may never acquire strength enough to overcome the impediment ; and then the very 
 opposite condition is apt to take place : the coats all become very thin ; meal after 
 meal is retained ; the stomach is enormously distended, and relieves itself now and 
 then, at distant intervals, by copious vomiting ; until at last it is unequal to that efTort, 
 and the patient dies. 
 
 Sometimes the sickness and vomiting are urgent even when the stomach contains 
 no food : and the matters rejected are of various character and appearance. They 
 often resemble coffee-grounds, and consist, no doubt, of altered blood. Vomiting of 
 this kind is a vexy pregnant sign of organic mischief in the stomach. 
 
 Emaciation is another ugly circumstance in these cases ; and forms a strong grouno* 
 of presumption that the symptoms depend upon structural disease. Yet it is not a 
 uniform consequence, even of malignant disorganization of the stomach. Napoleon 
 Bonaparte was very fat when he died. His omentum is described as having been 
 "remarkably fat;" and the "fat was upwards of an inch thick upon his sternum, 
 and one inch and a half upon his abdomen." 
 
 The existence of a palpable tumour strengthens the unfavourable diagnosis. But 
 this is far from being a constant phenomenon. It is not even pathognomonic when 
 it does occur. The diseased head of the pancreas has been mistaken for a thickened 
 pylorus. The stomach is liable also to be dragged much out of its place ; and then 
 a thickened pylorus may be mistaken for something else. Sometimes the form of 
 the stomach may be distinctly traced. In the person of a medical practitioner who 
 died lately in this neighbourhood, the shape of the organ, its occasional peristaltic 
 motions, and the irregular and hardened pylorus, were plainly to be felt. They 
 might indeed almost be seen, in the hollow and attenuated abdomen. When a 
 tumour is ascertained to belong to the stomach, it indicates disease of the pylorus 
 rather than of the cardia. 
 
 It is a curious feature in these malignant diseases of the stomach, that the symp- 
 toms sometimes remit, in a remarkable manner, so as to excite a hope in the mind 
 of the patient, and in that of his medical attendant, that the nature of the malady 
 had been mistaken, and that recovery is about to take place. But the truce is not 
 for long. Frightful disorganization is at length produced, ragged ulceration, perfora 
 tion of the coats of the stomach, adhesion to the parts adjacent, which thus are con 
 stituted adventitious walls ; — and inevitable death at last. 
 
 The treatment of this dreadful complaint can only be palliative. If there be pain, 
 we are driven, sooner or later, to opium. Anodyne enemata have often as good an 
 effect in relieving the pain as opium given by the mouth ; and they have this advan- 
 tage, that their constipating properties are more easily obviated than when that drug 
 is put into the stomach. Nutritive injections are proper when food taken through 
 the natural channel is not retained. 
 
 Other palliative measures may be aimed at particular symptoms ; of these I pro- 
 pose to speak when I come tc the symptoms and remedies of dyspepsia.
 
 766 H^MATEMESIS. 
 
 LECTURE LXIX. 
 
 Hemorrhage from the Stomach: sometimes from a large vessel, usually by exha 
 lation. Idiopathic Hxmatemesis. Vicarious Hxrnatemesis : Hsematemesis 
 from Gastric disease or injury: from disease in other organs. Melxna. 
 Ila^matemesis from a morbid state of the blood. General phenomena of Haema- 
 temesis. Diagnosis. Treatment. 
 
 Hemorrhage from the stomach, to which I wish next to direct your attention, is 
 of much more frequent occurrence than acute gastritis. It is a complaint, or a symp- 
 tom, that presents several points of interest and importance. I use the phrase 
 "hemorrhage from the stomach," rather than the single term " hasmatemesis," be- 
 cause that term, signifying strictly a vomiting of blood, does not necessarily imply 
 hemorrhage y)'om the stomach; nor, indeed, does it always accompany such hemor- 
 rhage, although it is one of its most common and most striking symptoms. 
 
 What I have so frequently mentioned in respect to hemorrhages from me mucous 
 membranes generallj', viz., that the efllux of the blood is seldom jwing to tne rupture 
 of a large blood-vessel, holds true in this. It can rarely happen tnat any vein or 
 artery belonging to the stomach is divided or laid open by accidental injury, so as to 
 pour forth its blood. When hemorrhage does proceed from one or more of the 
 larger blood-vessels, the opening by which the blood escapes is commonly the result 
 of chronic ulceration ; such as I spoke of yesterday. 1 have not, myself, met with 
 an instance of that kind. Andral states, that, ai most, there are but five or six such 
 eases to be found in the records of medicine. Since his work on Pathological 
 Anatomy was published, another example of the same lesion has been detailed in 
 the Journal Hebdomadairz for May, 1S30. I show you a drawing after Dr. Cars- 
 well, representing an ulcer which Idid open the coronary artery of the stomach, ana 
 caused fatal hemorrhage. In these cases, we have, first, the symptoms of chronic 
 gastritis ; next, faintness, or actual syncope, from the sudden abstraction of a large 
 quantity of the vual fiuid ; and lastly, the visible eruption of the blood itself; foi 
 vomiting seldom occurs until a large quantity of blood has accumulated in the sto- 
 mach. 
 
 As this variety of gastric hemorrhage is rare, I will briefly relate an instance of it, 
 which occurred in the year 1831, at St. Bartholomew's Hospital. Dr. Latham, who 
 had charge of the case, was good enough, some time ago, to give me the following 
 history of it. The subject of the disorder was a man thirty-eight years old. He was 
 admitted on tne 19th Januarj'. His countenance was dusky, but exsanguine ; his 
 pulse 100, and weak ; his tongue pale, and shghtly furred. He made no complaint 
 of pain anywhere. 
 
 He had been ailing for two years ; had suffered much pain across the epigastric 
 region ; and had frequently vomited his meals. Two days before, he had been 
 suddenly attacked with faintness and giddiness, and then vomited about two quarts 
 0^ blood. He was an habitual spirit drinker. 
 
 In the afternoon of the day on which he entered the hospital, he was again seized 
 with giddiness ; and fell into a state of syncope, in which he remained for several 
 minutes. Upon recovering, he vomited a large quantity of blood, not less than 
 three pints. The next morning, early, he brought up a like quantity, under similar 
 circumstances ; and he passed three evacuations from the bowels, all of them black. 
 He w'as gradually sinking during the whole of that day, the 20th. Towards the 
 evening, he vomited about half a pint more blood. He died quietly the next 
 morning. 
 
 When the abdomen was laid open, the stomach was seen to be distended. The 
 intestines had. in several places, a black appearance, from the colour of their con 
 tents. The siomach contained about two pints of coagula, and of a dirty red liquid. 
 At the upper part of its lesser arch was a small excavated ulcer, with hardened
 
 HiEMATEMESIS. 767 
 
 edges. In the centre of this ulcer there were visible the orifices of three or four 
 arteries, filled with minute clots of blood. 
 
 Tt would seem as if gastric hemorrhage, having this origin, were capable of being 
 stanched by some natural process ; and as if the injury done to the stomach were 
 susceptible of repair. Andral describes a curious case, in which an open blood- 
 vessel was found in an ulcer of the stomach ; but no hemorrhage had occurred. 
 That mere ulcers in the stomach may heal, there can be no doubt : two or three 
 scars of healed ulcers are represented in Dr. Carswell's drawing. The patient 
 whose case is related in the Journal Hebdomadaire had vomited considerable 
 quantities of blood for eight days in succession, five years previously to the attack 
 which terminated his life. So that hsematemesis from this cause is not absolutely 
 hopeless. 
 
 But (as I have already said) hemorrhage from the mucous membrane of the sto- 
 mach, and from that of the alimentary canal generally, takes place far more com- 
 monly by exhalation. The evidence that the blood really does ooze from the 
 membrane is the same as that to which I have so often had occasion to advert ; and 
 it is very satisfactory and conclusive in these cases, because we are able to scrutinize 
 closely the whole extent of the mucous surface. This cannot so well be done in 
 regard to the mucous membrane of the lungs. When death has followed imme- 
 diately upon the hemorrhage, and has indeed been its rapid effect, the membrane 
 has been found quite entire, and of its natural consistence and texture throughout. 
 Sometimes partially red and pulpy, and vascular; sometimes universally so, the 
 submucous capillary net-work of vessels being still gorged with blood ; sometimes 
 quite pale, the same system of vessels having been completely emptied by the last 
 attack of hemorrhage ; and sometimes studded with minute dark points, which could 
 be made, by slight pressure, to start from the surface, and looked like grains of 
 black sand. This latter appearance, as I once before remarked, is very corroborative 
 of the opinion that the blood escapes through the natural pores or channels : which 
 it cannot enter so long as the solids and fluids of the body retain their healthy con- 
 dition. These sand-like bodies are, doubtless, small portions of blooa, which have 
 coagulated in the exhalant orifices of the membrane, and received from them their 
 shape. 
 
 This kind of hemorrhage happens under various circumstances ; and is attended 
 with different degrees of danger. 1. The bleeding may be idiopathic. 2. It may 
 bo vicarious of some other habitual hemorrhage. 3. It may depend upon disease 
 or injury of the stomach itself. 4. It may be the consequence of disease situated 
 elsewhere, and producing, mechanically, a plethora of the veins of the stomach. 
 5. It may result from a morbid condition of the blood, and form one sjariptom of a 
 more general disease ; as in the passive hemorrhages of purpura and sea-scurvy. 
 Each of these varieties requires a short notice. 
 
 1. Hemorrhage strictly idiopathic — i. e., independent of any apparent change 
 of texture, whether in the surface itself, or in any part obviously capable of influ- 
 encing its blood-vessels — is as rare, I believe, from the mucous membrane of the 
 stomach, as from that of the lungs. I have never seen, nor do I recollect to have 
 read of, any instance of hsematemesis analogous to the epistaxis which is so common 
 in children and young persons ; and which affords the most familiar example of idio- 
 pathic hemorrhage. 
 
 2. But hemorrhage from the stomach, occurring in connection with other consti- 
 tutional hemorrhages, or in their stead — and above all, occuring vicarioiislt/ of men- 
 struation — is abundantly common. It is the most common, indeed, of all the species 
 of hemorrhage by deviation. I told you, in a former lecture, that patients will 
 sometimes menstruate for years together through the lungs ; without any apjxirent 
 injury to their general health. More commonly still do they menstruate through 
 the stomach. I will mention one concise but singular example of this which I had 
 from Dr. Latham, and which came within his own knowledge. A young woman 
 became the subject of haematemesis, recurring at monthly periods, about the age of 
 fourteen. She had never menstruated. This continued until she married, and in 
 due time, fell with child. Thereupon the hsematemesis ceased. She brought forth
 
 768 HiEMATEMESIS. 
 
 and suckled her infant. During lactation tlie hennorrhage did not recur. It came 
 on again soon after she ceased to nurse the child ; no regular menstruation by the 
 uterus having ever happened. This was the woman's own account, and there ap- 
 peared no reason to question its accurac3\ 
 
 Gastric hemorrhage of this kind, vicarious of regular menstruation, is not generally 
 thought to have any tendency to shorten the existence of those who are afflicted with 
 it. Cujlen states broadly that this species of hsmatemesis is hardly ever a dangerous 
 disorder: and this is true. Yet it is not so entirely free from peril as to preclude 
 the necessity of some caution and qualification in stating the prognosis. The ex- 
 haustion from the mere loss of blood is sometimes so great as to create serious alarm 
 for the patient's safety. And Mr. North has recorded (in the London Medical and 
 Physical Journal) two instances in which suppressed menstruation was followed by 
 repeated and at length fatal hsematemesis. In neither of these women was the 
 health seriously deranged ; nor, previously to the hemorrhage, did there exist 
 debility, or any other symptom calculated to excite the apprehension of danger. In 
 fact, in both of these cases, a strongly favourable prognosis was given by experienced 
 physicians, a very short time only before the fatal event. 
 
 3. Gastric hemorrhage, by the w^ay of exhalation, is often a consequence of dis- 
 ease or injury of the stomach itself. It is sometimes one of the earliest declaratory 
 symptoms of scirrhus or cancer of that organ — occurring long prior to ulceration. 
 Hsematemesis attends, also, very commonly, the ultimate stages of that fatal disease : 
 and then it may be owing to the erosion of some vessel of notable magnitude, in the 
 course of the process of disorganization, as in the examples already spoken of: or 
 (what I believe is far more common) it may result from a kind of general oozing or 
 exhalation from the ulcerating surface. Blood is often vomited soon after the recep- 
 tion of strongly irritant poisons into the stomach. I show you again Dr. Roupel's 
 plate, representing the crimson surface of a portion of the stomach of a dog which 
 had been killed shortly after the administration of a dose of alcohol. The intense 
 congestion thus produced is doubtless active congestion ; congestion belonging to 
 inordinate arterial action. Pushed a degree further, such congestion passes into 
 hemorrhage. 
 
 4. On the other hand, intense passive congestion — congestion arising from the 
 detention of blood in the veins by some mechanical obstacle to its progress — is a very 
 common source of gastric hemorrhage. Hfematemesis is therefore an occasional 
 symptom of obstructive disease of the heart. Much more frequently, however, it 
 depends upon abdominal changes. The hemorrhage is symptomatic of disease 
 situated not in the stomach itself, but elsew'here. And the viscera, with the diseases 
 or morbid conditions of which, bleeding from the stomach is most often connected, 
 are the liver and the spleen. 
 
 All this is well known : and it is easy to see, from the peculiar construction of thff 
 venous apparatus in the abdomen, how disease of one or both of these viscera may 
 produce mechanical congestion of the submucous capillary tissue; and how chai 
 congestion may be relieved, under certain circumstances, by the effusion of seious 
 fluid on the one or the other surface, constituting ascites or diarrhoea, as the case 
 may be ; or under other circumstances, not perhaps easily discriminated or well 
 understood, by the extravasation of the collected blood itself. It would be saper- 
 fluous to describe the peculiar distribution and functions of the vessels which leturn 
 the main portion of the venous blood from the stomach and intestines towards thd 
 'heart. It seems to m''. highly probable that one at least of the offices of the spleen 
 is to provide a receptacle or reservoir for this blood when its free passage through 
 the portal vessels is temporarily obstructed. It then becomes a sort of safety-valve 
 (if such an illustration be allowable), which obviates the danger that might otherwise 
 arise to more vital parts from any great or sudden disturbance of the venous circu- 
 lation. The stress of the congestion is continually feh in the submucous capillary 
 system ; and the hemorrhage, which is apt in such cases to occur from the loaded 
 membrane, receives a simple solution upon principles almost purely mechanical. 
 Nay, the very circumstances which lead to the effiision of the blood from the mucous 
 eurface on the one side, rather than from the serous on the other, may perhaps (as I
 
 HiEMATEMESIS. 760 
 
 Stated more at large in an early part of the course) be themselves susceptible or 
 mechanical explanation. 
 
 Gastric hemorrhage, symptomatic of hepatic disease, is chiefly to be looked for in 
 those morbid conditions of the liver which imply obstruction of the portal vein and 
 of its ramifications. We are not surprised, therefore, to find it coincident, often, 
 with a contracted and shrunken state of that organ. The state of the spleen, on the 
 contrary, for reasons that must be obvious to you, is uniformly, in the cases we are 
 now considering, a state of enlargement. And the augmentation of bulk is not so 
 much to be ascribed to disease inherent in its proper texture, as to distension by the 
 mere quantity of blood which it holds. The internal structure of the spleen furnishes 
 a credible presumption in favour of that view of one of its uses to which I just now 
 alluded ; and this structure, and this presumed function, when considered together, 
 throw a strong light upon some of the pathological relations of the spleen which well 
 deserve attention. 
 
 Numerous instances are on record of hsematemesis going along with evident 
 enlargement of the spleen ; and in some of them that organ has been observed to 
 diminish in bulk, in proportion as blood was poured out by the stomach. If I am 
 not greatly mistaken, I have more than once seen this myself. In such lases the 
 tumid condition of the spleen may be regarded as an evidence of venous obstruction 
 elsewhere; and, as depending, sometimes at least, upon disease of a less striking 
 and prominent character in the liver, impeding the progress of the blood through the 
 vena portaa. Of this kind would seem to have been a case related by Morgagni, 
 wherein, after repeated attacks of haematemesis, under which the patient sank at 
 last, the spleen was found to weigh four pounds, and to be gorged with dark blood ; 
 while the liver was pale and exsanguine. Frank gives the history of a patient, who 
 had vomitings of blood, and whose spleen, taken from the body after death, weighed 
 sixteen pounds: the ordinary weight of the spleen in a healthy adult being from 
 eight to ten ounces. In Latour's work on Hemorrhage, which is remarkable for the 
 number of examples it contains, collected from various sources, and amounting to 
 nearly a thousand, several instances are detailed of this combination of splenic en- 
 largement with hasmatemesis. One of these occurred in the person of a friend of 
 his, who had been living in a malarious district, and who had laboured for nearly 
 iwo years under obstinate intermittent fever. This was followed by an immense 
 enlargement of the spleen — a great ague-cake — which came to occupy almost tht 
 whole of the abdomen. Latour's experience enabled him to predict that hasmate- 
 mesis would probably supervene upon this condition of the spleen ; and, accord- 
 ingly, one night he was called in a hurry to his friend, and found that he had 
 vomited an enormous quantity of clotted blood. A great deal passed away through 
 the bowels also. The hemorrhage recurred from time to time, till in the course 
 of a month the spleen was so far reduced in bulk, that it could no longer be felt in 
 the belly ; and the patient lived and enjoyed good health, for twenty-five yeara 
 afterwards. 
 
 It is necessary, therefore, in marking the connection which frequently subsists 
 between hsematemesis and enlargement of the spleen, to guard ourselves against con- 
 cluding that these two circumstances hold always the relation of cause and effect. 
 In many such cases, probably in most of them, they are simply concurrent effects of 
 one common cause ; and that cause is chiefly to be sought in such morbid conditions 
 of the liver — or of other parts within the abdomen — as are competent to produce a 
 considerable impediment to the free transmission of blood through the system of tha 
 vena portse. 
 
 When gastric hemorrhage results from hepatic obstruction, there is almost always 
 intestinal hemorrhage also. At any rate there are almost always black alvme 
 evacuations, like tar or dark paint. This form of disease has there^'ore been 
 called mdxna. The ancients supposed that the unnatural stools consisted of black 
 bile. 
 
 Hemorrhage from the stomach, independent of disease in that or any other part, 
 sometimes happens in the advanced periods of utero-gestation. Yet, though it does 
 not result in these cases from disease, it is difficult to class it among idiopatUl 
 49 3p
 
 770 HiEMATEMESIS. 
 
 hemorrhages. The want of periodical recurrence, and the absence of the hemor- 
 rhage during the earlier months of pregnancy, are circumstances which sufficiently 
 refute the old notion, that this form of hoematemesis depends also upon the suspen- 
 sion of the catamenia. It is caused, no doubt, b}^ the pressure of the gravid uterus, 
 which impedes mechanically the venous circulation in the abdomen. 
 
 5. Gastric hemorrhage, resulting from changes in the blood itself, occurs in sea- 
 scurvy, in purpura hemorrhagica, and in the yellow fever. Being merely a symp- 
 tom in these cases, it requires no separate consideration here. 
 
 When a large quantity of blood is poured into the stomach, whatever may have 
 been its source, it appears to have a nauseating and emetic effect. At least the blood 
 ejected in hcematemesis is almost always considerable in amount. The vomiting 
 may, for aught I know, be dependent on the m.ere distension of the stomach, which 
 appears to be tolerant of the presence of the blood up to a certain point, but no further. 
 A small quantity may, doubtless, pass all of it onwards through the pylorus, after 
 undergoing, more or less completely, the process of digestion in the stomach; and a 
 portion of the blood pursues that course in most instances. But when it is vomited, 
 it comes up in large quantities, usually of a dark colour, and more or less coagulated. 
 Sometimes the coagula have evidentl}'' been moulded in the stomach ; and sometimes 
 clots are thrown up, partially deprived of the colouring matter of the blood, and re- 
 sembling the fibrinous polypi so often met with in the cavities of the heart. Of course 
 the degree of coagulation of the blood, and of its separation into serum and crassa- 
 mentum, will depend upon the time that it remains in the stomach ; and this again 
 would seem to bear a proportion to the rate of its effusion. 
 
 The blood that is vomited is almost always of a dark colour ; while that Avhich is 
 coughed up is most frequently florid and bright. Why is this ? We are told that 
 the blood which comes from the lungs is rendered florid by the admixture of atmo- 
 spheric air. But this is not the Avhole of the matter. Neither can we saj'' that the 
 dark hue of the blood ejected in hoematemesis is always, or solely due to some morbid 
 alteration effected in that fluid while yet circulating in its proper vessels. There is 
 another cause, which till of late years, was much overlooked, but which frequently 
 changes the colour and appearance of the blood after it has been extravasated into the 
 stomach ; and that in so great a degree as sometimes to render doubtful, or to disguise 
 altogether, the real nature of the fluid vomited. I mean the chemical agency of the 
 gastric acid. The effect of acids in blackening the blood out of the body is well 
 known ; and it is somewhat singular that the ascertained existence of an acid secre- 
 tion in the stom.ach, varying in quantity at different times and under different circum- 
 stances, was not sooner apphed in explanation of the dark colour of the blood, and 
 its occasional blackness, when vomited. The degree of blackness will be in propor- 
 tion to the relative quantity of acid which it meets with in the stomach, and the inti- 
 macy of the admixture. Sometimes the blood is clotted and not very much altered 
 in colour; sometimes it is grumous, brown, of a chocolate tint, or like coffee-grounds. 
 This generally denotes the existence of organic disease; and the appearance of the 
 blood is probably modified in some degree by the morbid process that leads to its 
 effusion. There is good reason for believing that in the black vomit of the yellow 
 fever, the colour of the blood undergoes alteration, even while it is yet circulating 
 through the blood-vessels : but that the black appearance of the matter vomited is in 
 great part owing to the chemical action of the gastric acid, may be inferred from the 
 fact, that the fluid so discharged is always (so I am informed) intensely acid. Andral 
 has described an eff^usion of black liquid into the stomach, as an example of mela- 
 nosis. He states at the same time that an accurate analysis of the liquid showed 
 its composition to be very nearly the same with that of the blood. May we not sus- 
 pect that this inky fluid really consisted of blood that had been blackened, subse- 
 quently to its extravasation, by the acid with which it mixed in the stomach ? Upon 
 the same principle may be explained the dark brown or almost black colour of the 
 spots which are sometimes seen (I presume when there has been a great predomi- 
 nance of acid) in the substance of the mucous membrane of the stomach, or even 
 Deneath it ; and which have also been set down as melanotic. They are so like, in
 
 DIAGNOSIS OF GASTRIC HEMORRHAGE. 771 
 
 all circumstances, except in the single particular of colour, to the crimson spots which 
 are obviously formed by minute extravasations of blood in the same parts, that we 
 can scarcely refer them to any other source. The slate-coloured patches, which I 
 spoke of yesterday as being vestiges of chronic gastritis, depend likewise upon the 
 blackening effect of the gastric acid upon the congested surface. We have the same 
 dark colour of the effused blood, in many cases, when it is poured out in the intes- 
 tines. Here, of course, its colour is not referable to the gastric juice ; but it is black- 
 ened by some of the intestinal gases : probably b}'' the sulphuretted hydrogen, for 
 example, or the carbonic acid that enters into their composition. 
 
 There can be no doubt that this gastric acid, when intense in strength, or copious 
 in quantity, is capable of changing the colour of the blood, after death, even while 
 it is contained in the sub-mucous blood-vessels. In these cases it must be conveyed 
 to the blood by imbibition. And the very same thing takes place when strong acids 
 are introduced into the stomach from without. When, for instance, the sulphuric 
 acid, or what is perhaps more to our present purpose, the vegetable oxalic acid, has 
 been taken as a poison, it has the effect of blackening, and, as it were, charring the 
 blood, with which the membrane becomes loaded in consequence of the irritation 
 produced by the poison. It does this when no destruction of the mucous membrane 
 has been produced. 
 
 It is but justice to observe, that the credit of having been the first to perceive, and 
 to explain, this cause of the blackened state of the blood, while yet remaining in its 
 proper vessels, is due to Dr. Carswell. 
 
 When the blood is injected through the oesophagus and mouth, we have demon- 
 strative evidence of the existence of hemorrhage ; and the diagnosis of hsematemesis 
 may appear to be so simple as to admit of neither mistake nor doubt. The diagno- 
 sis of hemorrhage from the stomach, however, is really oftentimes difficult and ob- 
 scure, and to be established by presumptive evidence alone. 
 
 In the first place, bleeding may take place from the mucous membrane of the 
 stomach, and no hcematemesis ensue, especially when the blood is poured forth in 
 small quantities and slowly. In these cases the blood becomes visible only in the 
 stools, where it may not be looked for, and where, if seen, it may not always be 
 recognized, in consequence of the changes it has undergone during its passage 
 through the intestinal canal. And even supposing that its presence is detected in 
 the alvine evacuations, it will remain uncertain in what part of that long canal it 
 was effused. The hemorrhage may even be profuse, and the patient may die, with- 
 out any escape of the blood externally. There is a case related by Frank, in which 
 death took place from hemorrhage of the stomach without hsematemesis; and both 
 the stomach and the intestines were found distended by an enormous coagulum of 
 blood which had assumed their form. 
 
 Even when the blood is ejected by the mouth, the exercise of some care and 
 sagacity is occasionally, though not always required, in order to determine the part 
 from which it was originally poured out. 
 
 Thus blood may be swallowed, and afterwards vomited : and so we may have 
 hsematemesis without hemorrhage from the stomach ; just as we may have hemor- 
 rhage from the stomach without hsematemesis. There are cases of slow bleeding 
 from the lungs, the fauces, the mouth, or the nasal cavities, where the blood, col- 
 lecting in the pharynx, provokes, from time to time, an instinctive and involuntary 
 act of deglutition; and thus is gradually accumulated in the stomach up to that 
 point at which the organ becomes impatient of its contents, and ejects them by vo- 
 miting. This is very apt to happen during sleep, and especially to young children : 
 and as the blood, ivhen vomited, is coagulated, and in considerable quantity, it is 
 scarcely possible to conclude, from its mere appearance, that it has proceeded frono 
 any other source than the stomach itself. If, however, we mistake such cases, our 
 error is likely to produce much needless alarm, and to lead us to unnecessary acti 
 vity in treating them. We are assisted towards forming a right judgment (when 
 our attention happens to be directed to this source of fallacy), partly by the general 
 history and symptoms, and partly by an examination of the mouth, fauces and nos-
 
 772 DIAGNOSIS OF GASTRIC HEMORRHAGE. 
 
 trils, to ascertain whether any coagula, or other marks of hemorrhage, are visible on 
 the mucous membrane belonging to those parts. 
 
 But blood may be swallowed knowingly and purposely by impostors, and after- 
 waids vomited. Hsematemesis is one of the complaints which have frequently been 
 feigned ; either for the sake of avoiding some imminent punishment, or distasteful 
 service ; or with the view of exciting compassion, and of profiting by the contribu' 
 lions of the charitable and the credulous ; or sometimes from a kind of wilful per- 
 versity, akin to insanity. In treatises on forensic medicine, you will generally find 
 reference made to an instance of this kind recorded by Sauvages, in his Nosology. 
 A young girl, who was anxious at all hazards to escape the constraints of a convent, 
 pretended that she was suffering from violent heematemesis. In fact she did, for 
 several days in succession, vomit large quantities of blood in the presence of the 
 physician who had been summoned to her assistance. It Avas afterwards discovered 
 that on each of those days she had swallowed blood which had been secretly con- 
 veyed to her from the neighbouring shambles. A case of precisely the same kind 
 occurred (as I was informed by a gentleman who witnessed it) in the Bristol Infirm- 
 ary some years ago. A girl had long been a patient there, labouring (as was sup- 
 posed) under hsematemesis ; but it was at length discovered that she was a mahn- 
 gerer. She was in the habit of assisting the nurses in their work ; and this afforded 
 her opportunities — of which she availed herself — of drinking the blood which had 
 been drawn from the veins of other patients: and this blood she afterwards vomited. 
 
 And even where no fraud is attempted, nor any blood swallowed, it occasionally 
 becomes a nice matter to determine the origin of the hemorrhage, when blood is 
 ejected in large quantities from the mouth: to decide, namely, whether the blood 
 has come originally from the lungs or from the stomach. In copious hsemoptysis, 
 the blood issues from the mouth in gushes as it does in hcematemesis ; and the reflux 
 of the blood into the phar}-nx, the tickling sensation it there produces, and the cough 
 (which we know, even when the expectoration is not of blood, frequently excites 
 retchings); these causes, acting singly, or together, occasion sometimes a convulsive 
 contraction of the muscles of the thorax, which looks like the effort of vomiting : and 
 they often indeed give rise to actual vomiting. On the other hand, in sudden and 
 profuse hsematemesis, the irritation caused by the blood as it passes over the upper 
 part of the larynx, is apt to provoke a paroxysm of choking cough. 
 
 Now when I was speaking, some lectures back, of hcemoptysis, I promised that I 
 would point out the means of distinguishing it from hasmatemesis, when I came to 
 the consideration of the latter complaint. I have now therefore to redeem my 
 promise. 
 
 However equivocal certain cases may be at first sight, we may generally guide 
 ourselves to a correct decision by a careful investigation of the circumstances that 
 precede, accompany, and folloiv the hemorrhage. Vomiting of blood is commonly 
 preceded by a sensation of weight and uneasiness in the epigastrium ; and by nausea. 
 Ilsematemesis is also, more frequently than htemoptysis, ushered in by paleness of 
 the face, dimness of vision, and an approach to syncope, or even actual fainting. 
 These symptoms are not to be regarded (I apprehend) as premonitory of the hemor- 
 rhage, although they have been so considered by some ; they are rather a sign that 
 it has already taken place ; and yet they are preliminary of the hsematemesis. 
 Occurring before the blood comes up, they cannot be ascribed to alarm at the sight 
 of it. On the other hand, haemoptysis is wont to be announced by dyspnoea, cough, 
 tickling in the throat, and a sensation as if of bubbling within the thorax. Most 
 commonly, too, before the expulsion of much blood from the lungs, some sputa are 
 coughed up, composed more or less of that fluid. The symptoms that usually suc- 
 ceed the hemorrhage, in either case, afford equallv valuable assistance to our judg- 
 ment, in cases that might otherwise be doubtful. Generally copious hsemoptysis 
 goes on, in a succession of mouthfuls, for some time : whereas there is, mostly, only 
 one access of full vomiting. At any rate, at the close of abundant pulmonary he- 
 morrhage, the patient manifestly coughs up, and expectorates, smaller quantities of 
 blood , while we usually may observe that, a few hours after hsematemesis has
 
 DIAGNOSIS OF GASTRIC HEMORRHAGE. 773 
 
 occurred, slight griping pains come on in the abdomen, and a portion of blood is got 
 rid of from the bowels. 
 
 Other questions, often of much importance in regard to the ultimate diagnosis, 
 when the blood is traceable with certainty to the stomach, are, whether it be idio- 
 pathic, if, indeed, it ever be so : whether it be supplemental of some other discharge : 
 whether it depend on disease of the stomach itself; of one, or more, of the contigu- 
 ous viscera ; or of the system at large. Certainly, in a very great majority of ca.es, 
 gastric hemorrhage is symptomatic; and the nature and seat of the disease of which 
 the bleeding is a symptom, may, in many instances, be determined without much 
 difficulty. That which depends upon incipient cancer of the stomach, while it is 
 by no means of rare occurrence, is also, (I think,) more frequently than other forms 
 of hemorrhage from that organ, obscure. It must be obvious to you, and therefore 
 I need not dwell upon this part of the subject, that a httle attention to the symptoms 
 and past history of the patient will usually suffice to elucidate the nature of the case, 
 where hsematemesis supervenes immediately upon the introduction of corrosive poi- 
 sons, or within a certain interval after they have been swallowed : where it depends 
 upon the bursting of a large aneurism : where it breaks forth among other symp- 
 toms of scurvy or purpura : where it is the result of an advanced stage of cancer of 
 the stomach : where it accompanies organic disease of the liver, spleen, or heart : 
 where it occurs as a symptom of yellow fever : where it takes the place of suppressed 
 or imperfect menstruation ; or where it is occasioned by the pressure of the gravid 
 uterus. In all these cases, there is, ordinarily, no room for mistaking the one dis- 
 ease for the other; or for regarding the hemorrhage as idiopathic. 
 
 With respect to the treatment that should be adopted in cases of hemorrhage from 
 the stomach, it must be apparent, from what has just been said of the many different 
 morbid conditions u]5on which it may depend, or with which it may be essentially 
 connected, that remedies are, in most cases, rather to be directed against the disease 
 of which the ha^matemesis is a symptom, than against that symptom itself. But 
 sometimes we are obliged to treat the symptom, either because we are not certain of 
 the exact nature of its cause, or because the condition out of which it springs is not 
 within our reach. 
 
 Cases 0^ melxna (I have told you what is meant by that term) require hard purg- 
 ing ; and many patients recover thoroughly under that mode of treatment. You 
 may prescribe five grains of calomel every night, and a black dose every morning, 
 till the stools lose their pitchy colour. Do not be afraid of purging your patients in 
 such cases. If they are curable at all, that is the way to cure them. I have pur- 
 sued that plan with perfect success, even with patients whom the previous hemor- 
 rhages had blanched, and whose pulse was feeble and irregular. You may sustain 
 them, at the same time, by a full allowance of nourishing broths. The portal system 
 is drained and unburdened by this active depletion. And if there be no irremediable 
 change of texture in the liver, the recurrence of the hemorrhage may often, by a 
 proper regulation of the habits and diet, be obviated. The ancients had learned by 
 observation the efficacy of treatment of this kind ; but they used a different form of 
 medicine, and purged away the atra bilis with hellebore. 
 
 It is plain that for melcena, dependent on mechanical congestion, styptic substances 
 would be worse than useless. They are more adapted to those cases (could w^e but 
 surely distinguish them) in which the hemorrhage proceeds from a bleeding vessel. 
 This is indeed the mode whereby w^e often succeed in stanching external hemor- 
 rhages ; namely, by applying astringents to the very part. Similar means may bv^ 
 employed when ha^matemesis, of a purely passive character, depends upon some 
 modification of the circulating blood. There is one remedy which is thought to 
 have a sort of specific eflt^ct upon hemorrhages of the gastro-intestinal canal • I mean 
 the oil of turpentine, given in small doses; from twenty minims to half a drachm, 
 every four or six hours. I cannot say that I have had much experience of it. Of 
 course the patient must be kept cool and quiet; whatever he drinks, he should drink 
 cold ; even ice is often both grateful and effectual. If ordinary measures fail, recourse 
 may be had to the acetate of lead ; or even to the quack medicine, Ruspini's styptic 
 Not that I think you will often find the latter expedient successful, when mor« 
 
 3p2
 
 774 DYSPEPSIA. 
 
 rational treatment has failed ; but in obstinate and dangerous cases it ought to be 
 tried. If, with the hasmatemesis, there be any fever, it may be proper and necessary 
 to abstract blood from a vein, and to employ refrigerant substances as remedies ; and 
 if, with or without much fever, there be tenderness at the epigastrium, leeches, or a 
 bhster, should be applied. In cases where the catamenia desert their natural chan- 
 nel, and seek an outlet through the mucous membrane of the stomach, it will be 
 well, while means are taken to discourage the hcematemesis, as iced drintt and so 
 forth, to endeavour to solicit the discharge in the right direction. And we often sue 
 ceed in this object by placing leeches upon the groins of these patients immediate^ 
 before the period when the vicarious menstruation is expected, and by putting theii 
 feet at the same time into hot water, or even laying them in a warm hip bath. 
 
 LECTURE LXX. 
 
 Dyspepsia. Physiology of Digestion. Symptoms of Dyspepsia. Treatment 
 and Prevention, Dietetic and Medicinal. 
 
 It is my intention to appropriate this evening's lecture to a cursory account of 
 dyspepsia; by which I mean some evident derangement in the natural process of 
 digesting and assimilating our food, and, more especially, a faulty performance of the 
 functions of the stomach. Indigestion is the prevailing malady of civilized hfe. 
 We are more often consulted about the disorders that belong to eating and drinking, 
 than perhaps about any others ; and I know of no medical topic concerning which 
 there is afloat, both within and beyond the profession, so much ignorant dogmatism 
 and quackery. 
 
 Cullen, in his definition of dyspepsia, enumerates the various symptoms, by the 
 occurrence of more or fewer of which that complaint is most commonly manifested : 
 "Anorexia, nausea, vomitus, inflatio, ructus, ruminatio, cardialgia, gastrodynia : pau- 
 ciora saltem vel phira horum simul concurrentia, plerumque cum alvo adstricta, et 
 sine alio vel ventricuh ipsius, vel aliarum partium, morbo." 
 
 The variety in the actual presence and combinations of these symptoms is very 
 great ; and any attempt to give a perfect or complete history of dyspepsia in these 
 lectures is quite out of the question. But I will endeavour to draw such a general 
 outline of the disorder as may assist and direct your observation of it hereafter. 
 
 I shall first take a brief view of the pathology of indigestion, so far as it is under- 
 stood ; and to make this intelligible, it will be necessary to interweave something of 
 the physiology of the subject. To these preliminary considerations, I shall ad»^ a 
 short comment upon the several symptoms of dyspepsia, enumerated in Cullen's 
 definition ; and, lastly, I shall state what I know respecting the means of curing and 
 preventing this familiar disorder. 
 
 The conditions of healthy digestion are these : that the food should be masticated, 
 mixed with saliva, and swallowed into the stomach ; that in the stomach it should be 
 reduced to a semi-fluid consistence, and converted into a uniform pulp, called chyme ; 
 that the chyme should be transmitted through the pylorus into the duodenum, and 
 there mixed with the bile, the pancreatic secretion, and the intestinal mucus : in 
 consequence, as it would seem, of which admixture, the whole is separated into two 
 parts, viz. : the chyle, or the nutritive portion of the food, now in a fit state to be 
 taken up by the lacteals which open upon the mucous surface of the intestines, and 
 to be carried by them into the blood ; and the excrementitious portion, which at 
 length is conveyed out of the body. 
 
 The food js dissolved and transformed, in the stomach, by the chemical agency 
 of the gastric juice. This is a secretion peculiar to the stomach. All that need be 
 stated of it h'^re — almosi all, indeed, that is known — is, first, that it oozes forth in 
 minute drop* from the mucous surface ; but only when food (or some solid sub*
 
 DYSPEPSIA. 775 
 
 stance) is present in the stomach; and, secondly, that it is always aclJ. It appears 
 to owe its solvent power to a special principle, which chemists have named pepsin. 
 
 The food, having arrived in the stomach, is moved about by a sort of churning or 
 revolving movement, and mixed with the gastric juice, and gradually changed into 
 chyme, which also is acid. Finally, the chyme is propelled by degrees into the 
 duodenum by the pressure of the transverse band of muscular fibres which embraces 
 the pyloric extremity of the stomach. The time in which the whole operation is 
 completed varies from two to four or five hours. 
 
 Liquids introduced into the stomach disappear much more speedily ; either by 
 direct absorption, or through the pylorus. 
 
 All this we know, not from mere speculation on the anatomy and uses of the 
 organ, but from actual observation. An American physician had, for several months 
 in succession, the curious privilege of looking, whenever he pleased, into a healthy 
 human stomach, and of watching its condition, its movements, and its contents, during 
 the process of digestion. A young Canadian had a portion of the skin, muscles 
 and ribs of the left side of the body blown away in a gunshot wound, which laid 
 open the stomach also. He recovered from this frightful injury with a permanent 
 aperture in the side, communicating directly wiih the stomach. Through this loop- 
 hole Dr. Beaumont was allowed to introduce various articles of food ; and to with- 
 draw from time to time the gastric secretions ; and the aliment, in the different stages 
 of its digestion. He has published a very interesting account of these experiments, 
 which have set at rest some points in the physiology of the stomach that were pre- 
 viously uncertain. I shall embody his deductions in what I have further to say on 
 the subject. 
 
 In order that digestion may be perfect and easy, it is requisite that the food be irj 
 a state of minute division. This object is attained by mastication. A weak dys- 
 peptic stomach acts slowly, or not.at all, on solid lumps and tough masses of food. 
 The delayed morsels undergo spontaneous changes, promoted by the mere warmth 
 and moisture of the stomach : gases are extricated : acids are formed : perhaps the 
 half-digested mass is at length expelled by vomiting ; or it passes undissolved into 
 the duodenum, and becomes a source of irritation and disturbance during the whole 
 of its journey through the intestines. Here then we have one common cause of 
 dyspepsia ; and an easy and obvious preventive. Dyspeptic persons should not eat 
 in a hurry, as busy men, and studious and solitary men, are apt to eat. They are 
 to be cautioned against bolting their food : it must be well ground in the mill that 
 nature has provided for that purpose. I am not at all sure that the increased lon- 
 gevity of modern generations is not, in some degree, attributable to the capability 
 of chewing their food which the skill of the dentist prolongs to persons far advanced 
 in life. 
 
 There are certain things upon which the gastric juice has no power. The green 
 colouring matter of certain vegetables ; the husks of seeds ; the rinds of many fruits. 
 You may perhaps have observed that dry currants, and the pips of apples, swallowed 
 entire, reappear, unchanged, among the egesta. Whatever passes the stomach un- 
 touched by the gastric liquor, passes undissolved through the whole of the alimentary 
 canal ; provoking disorder sometimes in its transit; forming sometimes a nucleus for 
 intestinal concretions. These substances are therefore unfit for a weak stomach. 
 When the digestive powers are active, and the bowels slow, they may perhaps ccca- 
 sionally be even useful. Thus brown bread — i. e., the indigestible bran, or tegu- 
 ment of the kernel of wheat — stimulates the peristaltic motions of the intestines, 
 and averts, in certain persons, the necessity of more direct purgatives. Unbruised 
 mustard-seed, once so much in vogue, owed much of whatever virtue it possessed to 
 this principle. But if these intractable substances fail to excite the proper action 
 of the bowels, they are apt to accumulate, and to lay the foundation of serious 
 disease. 
 
 Indigestible matters, to which the pylorus refuses a passage, may remain in the 
 stomach, and disturb its functions, for days, or even sometimes for weeks, together. 
 If we could ascertain their presence, an emetic would be the remedy. And sooner 
 or later vomiting is set up, and the offending substance expelled. I lately saw h
 
 776 DYSPEPSIA. 
 
 mass of hard curd — a small cream cheese in respect to consistence — which was 
 thrown up after several days of severe gastric pain and disorder. The relief was 
 immediate and complete. The patient had been taking large quantities of cream 
 with his tea and coffee. In another person a similar fit of indigestion terminated m 
 the ejection of a mass of snuff". This is no unusual source of derangement of the 
 stomach among those who use lavishly that nasty luxury. 
 
 The essential change which the chyme undergoes after leaving the stomach, ap- 
 pears to consist in its separation into two parts : namely, into chyle, which is taken 
 up by the lacteals ; and into excrement, which is discharged from the body. Any 
 undissolved portions of the food become attached to this last part. We do not know 
 exactly what is the function or agencjr of the pancreatic liquor ; but with regard to 
 the bile our knowledge is somewhat more definite. The acid developed in the 
 stomach combines in the duodenum with the alkali of the bile, and is more or less 
 neutralized. Dr. Prnut conjectures that in a healthy state of the organs it is entirely 
 neutrahzed. Bile is, moreover, the natural stimulus of the intestines: when its 
 secretion is stopped, or its passage into the duodenum prevented, digestion and assi- 
 milation may go on, but the bowels are usually sluggish. The hepatic secretion has, 
 doubtless, other important uses ; but with these we are not at present concerned. It 
 is pretty evident that the state of the biliary functions can have no direct influence in 
 the production of mere dyspepsia. When the constituents of the bile are imper- 
 fectly eliminated from the blood, various parts of the body may suffer detriment. 
 And when the functions of the stomach and the functions of the liver are both disor- 
 dered, it may be that the former organ sympathizes indirectly with the morbid state 
 of the latter : or it may be that one and the same cause operates in producing the 
 derangement of both organs. 
 
 Let us now review the symptoms of dyspepsia which are mentioned in Cuilen's 
 definition. The first of these is anorexia: want of- the natural appetite. Sometimes 
 this is almost the only symptom observable. The patient is warned, by loss of appe- 
 tite, not to take too much food ; he refrains instinctively from certain kinds of food ; 
 or he feels perhaps absolute repugnance and disgust at the very thought of eating. 
 Various have been the speculations respecting the immediate cause ot hunger. It 
 has been ascribed to the action of the gastric juice upon the surface of the empty 
 stomach. But during health the gastric juice is never present in an empty stomacli. 
 Neither can the appetite depend upon contraction of the muscular fibres of the 
 3tomach ; for the emptj^ stomach, during health, is always contracted upon itself. No 
 doubt the sensation of hunger, like all other sensations, arises from some particular 
 condition of the nerves of the part. It returns periodically, acknowledging in this 
 respect the influence of habit. It is sensibly aff'ected by agencies which operate upon 
 and through the nervous system. The receipt of a piece of bad news Avill destroy, 
 in a moment, the keenest appetite. 
 
 Sometimes there is no anorexia. The appetite may even be morbidly craving and 
 ravenous ; or capricious and uncertain. 
 
 When defect of appetite is the only symptom, it may be remedied, often, by the 
 employment of bitters, or of the mineral acids, taken twice or thrice daily, for some 
 lime together. It would be out of place for me to speak in detail of particular me- 
 Jicines of this kind ; it is enough if I indicate quina, columbo, gentian, quassia ; the 
 Jiluie sulphuric and nitric acids; or a mixture of the nitric and muriatic. 
 
 Nausea — vomitus. These are, in some instances, the most distressing results and 
 ligns of the dyspepsia. Sometimes nausea comes on soon after the food is swal- 
 lowed. Sometimes there is no nausea ; but after the lapse of a certain period, an 
 liour or two generally, the food is rejected by vomiting. The matters thus thrown 
 up are most frequently sour. Not seldom they are mixed also with bile, especially 
 if the rutching has been violent, or long continued ; and then the patient is apt to 
 ascribe the whole of his complaint to "an overflow of bile," although in fact the 
 secretions of the liver have nothing whatever to do with it; the appearance of bile 
 in the fluids ejected from the stomach proceeding from an inverted action of the 
 duodenum. The effort of vomiting, however induced, will, if often repeated, be 
 nllended with the expulsion of yellow bile. I have more than once referred you, fur
 
 DYSPEPSIA. 777 
 
 an illustration of this fact, to the phenomena of sea-sickness. The fallacy I now 
 point out has been one cause of the notion that is prevalent among patients, and the 
 pubHc — and not unfrequently perhaps among practitioners — that dyspepsia very 
 commonly depends upon a disordered state of the biliary organs. 
 
 The vomiting which occurs in dyspepsia is often connected with a morbid irrita- 
 bility of 'the stomach; and it is sometimes a very troublesome symptom to treat. 
 The carbonic acid has certainly a marked effect in allaying it, in many cases. We 
 give it, as you know, in the effervescing saline draught, made wiih the carbonate of 
 potash, or soda, and lemon-juice. Sometimes the mineral acids answer better. Some- 
 times, on the other hand, alkalies — the liquor potasses, for example — or hme-water, 
 are more effectual. In these latter cases we may presume that there is a morbid 
 acidity of the stomach. Small doses of opium are occasionally successful when 
 other means fail. Opiates thrown into the rectum — opium plasters to the epigastri- 
 um — blisters to the same part : these are measures which you will sometimes have 
 to try one after another. There are two special remedies which have been greatly 
 extolled for their virtue in abating sickness : the hydrocyanic acid is one of them ; 
 creasote is the other. The hydrocyanic acid I have found exceedingly useful in 
 obstinate cases. It may be given alone — or mixed with the effervescing draught- — 
 or combined with a few grains of the sesquicarbonate of soda. The creasote has 
 disappointed me oftener than it has answered my hopes from it. Yet it has a de- 
 cided influence in checking some forms of nausea ; and it is the more likely to suc- 
 ceed, in proportion as the condition of the stomach is remote from inflammation. 
 
 But after all, the grand principle on which to treat chronic vomiting — not depend 
 ent upon disease in other parts, as the head, the kidney, or the uterus — is that laid 
 down by Dr. William Hunter ; of reducing the quantity of food to that amount, 
 whatever it may be, which the stomach is able and willing to retain, and of making 
 its quality as bland and nutritious as possible. The most satisfactory case which I 
 have had to treat upon this principle occurred some years ago, in the person of one 
 of my hospital patients. She was brought out of Kent by her father. She had 
 been under the care of several medical men, one of whom had been a pupil at the 
 hospital, and recommended her as a proper patient for admission there. Her age 
 was sixteen. She and her father both agreed in the same story ; viz., that she con 
 stantly vomited her meals ; the food generally coming up again immediately after it 
 was swallowed, and never remaining longer in her stomach than ten minutes. The 
 vomiting was described as being easy ; and was neither preceded nor accompanied 
 by nausea. 
 
 She had been ill for four years : ever since a severe attack of scarlet fever. At 
 first she vomited her meals now and then — three or four times a week — but the 
 vomiting gradually became more and more frequent ; and at the time of her admis- 
 sion she had vomited after every meal, for three months in succession. She had 
 grown considerably in the four years ; and was tolerably plump ; and looked healthy ; 
 and the catamenia had begun to appear, though scantily, in the same period : but 
 they had been altogether suspended for a year. 
 
 It was clear that a good deal of her food must have remained ; and, bearing Wil 
 liam Hunter's case in mind, I directed that she should have a very small quantity of 
 roast meat for dinner, and a coffee cup of milk occasionally during the day ; and no 
 other food. I prescribed also some pills consisting of aloes and soap, to act mode- 
 rately on the bowels. I expected to have been obliged still further to limit her food; 
 but she never vomited again, from that time. This distressful and protracted disor- 
 der, after long and fruitless treatment previously, yielded thus at once and easily to 
 very simple means. 
 
 Injlalio — ruclus. Flatulence, and belching. The gas that produces these symp- 
 toms is sometimes extricated from undigested food detained in the stomach, and' in a 
 state of fermentation : sometimes secreted, apparently, by the stomach itself ; for the 
 flatulence comes on when the stomach is empty of food. It is apt to arise, in dys- 
 peptic persons, if a meal happens to be delayed beyond the accustomed hour. Pa- 
 tients complain grievously of these symptoms, and accuse the " wind in their stomach," 
 as being at once the essence and the cause of all their complaint^. They ask tor
 
 778 DYSPEPSIA. 
 
 medicines to get rid of the wind ; and its escape may indeed be promoted by warm 
 aromatics, and carminatives, as they are called : the relief thus afforded to the dis- 
 tended stomach being so sudden, and for the time so complete, that the sufferer 
 ascribes to the medicine vi7n curminis, the power of a charm. One of the most 
 effectual and popular of these carminatives is peppermint water. A due regulation 
 of the periods for taking food will often suffice to obviate the flatulence that belongs 
 to emptiness. That which follows eating may, in many cases, be prevented, by 
 swallowing, immediately before the meal, five or six grains of the extract of rhubarb, 
 with or without a grain of cayenne pepper. If the ascending wind brings into ihe 
 throat and mouth a portion of the solid contents of the stomach, the patient is said 
 to ruminate. The regurgitated matters are often intensely acid ; and then an alkali 
 may remedy the flatulence ; a teaspoonful of sal volatile, for example. 
 
 Indigestion is, in many instances, attended with scarcely any pain; while in 
 others the pain is very tormenting. Cullen speaks of it under the terms car dial gia ; 
 and gastrodynia. Cardialgia is that less violent and more permanent uneasiness 
 which in popular language is called heart-burn. Gastrodynia is that more severe, and 
 usually more transient pain, which is commonly denominated spasm or cramp of 
 the stomach. 
 
 Dr. Abercrombie has some useful practical observations in respect to pain of the 
 stomach. He speaks of it as occurring under four different forms, and I am able to 
 bear witness to the reality of the distinctions that he has drawn. In the first place, 
 some persons suffer pain, occasionally, when the stomach is empty, even when there 
 is no flatulence ; and they are comforted and relieved by taking food. It is reason- 
 able to suppose that this kind of pain depends upon some degree of acrimony of the 
 fluids of the stomach itself. It is often removed at once by alkalies, or absorbent 
 medicines. A teaspoonful of the aromatic spirit of ammonia, or a tablespoonful of 
 the liquid magnesia, in a wineglass of camphor julep, will still the whole uneasiness 
 sometimes in a moment, as if by magic. 
 
 A second form of pain in the stomach is when it occurs immediately after taking 
 food, and continues during the whole process of digestion, or until vomiting ensues, 
 which gives instant ease. In such cases we have reason to suspect the existence 
 of chronic inflammation, or of some undue sensibility of the mucous membrane of 
 the stomach. The suitable remedies are such as I spoke of in the last lecture. I 
 might have mentioned a form of medicine which Dr. James Johnson has found espe- 
 cially serviceable against this morbid sensibility ; I mean the nitrate of silver, in 
 small doses. 
 
 In a third species of painful disorder of the stomach the pain does not begin till 
 from two to four hours after a meal, but continues for several hours. This is a very 
 common form of complaint. Dr. Abercrombie is of opinion that the pain is seated 
 in the duodenum, and connected with inflammatory action, or with morbid sensitive- 
 ness of the mucous lining of that bowel. He says it is frequently accompanied by 
 pain and tenderness of the right hypochondrium ; and that the hver is often blamed 
 when it really is not in fault. This last remark I well believe ; but I am not so 
 easily persuaded that the pain is duodenal. I believe it depends upon acidity in the 
 prinice vias. It has been ascertained by several chemists, that the acid which is pre- 
 sent in the gastric juice is the muriatic. Dr. Prout holds that the source of this 
 muriatic acid is the common salt which exists in the blood, and that the decomposi- 
 tion of this salt is owing to the immediate agency of some modification of electricity; 
 and he conceives that the principal digestive organs represent a kind of galvanic 
 apparatus, of which the mucous membrane of the stomach and intestinal canal may be 
 considered as the acid or positive pole, while the hepatic system is the alkaline or 
 negative pole. However this may be, it is certain that the muriatic acid contained 
 in the stomach is often in excess : other acids are ako found there — the acetic, and 
 more especially the lactic; and when the food, now converted into chyme, passes 
 into the duodenum, the remaining superfluous acid teazes the stomach. I think this 
 explanation of the cause of the pain is a more probable one than Dr. Abercrombie's, 
 because jou may generally mitigate or remove the pain by introducing an alkan mto 
 the stomach, whereby the acid is neutralized : even the swallowing a cup of
 
 DYSPEPSIA. 779 
 
 warm tea, by which the acid is diluted or w^ashed away, often stops the pain. And 
 I have in numerous instances succeeded in preventing the recurrence of this pain, 
 by directing the patient to take a small quantity of alkali, in some aromatic water, 
 immediately after his dinner. According to Dr. Abercrombie's theory, the pain 
 ought not to be so immediately allayed by these remedies ; and, since the food is gra- 
 dually propellea into the duodenum as it is digested, the pain should begin, I think 
 (supposing him right), earlier than it does. Dr. Abercrombie has found nothing of 
 more general utility in these cases than the sulphate of iron, combined with one 
 grain of aloes, and five grains of aromatic powder, taken three times a day. He 
 praises lime-water, also, and small opiates, and a combination of bismuth and rhu- 
 barb. What its modus operandi is I know not, but I am sure that bismuth is a very 
 effectual remedy for some kinds of gastric distress. 
 
 Cases now and then occur in which this pain, succeeding a meal, and the deposit 
 of lithates in the urine, would seem to indicate the propriety of an alkaline treatment, 
 but which really are more benefited by the mineral acids. How to distinguish these 
 exceptional cases, unless by trial, 1 have not yet learned. Any detected admixture 
 of phosphates might perhaps furnish the requisite clue. 
 
 Pain in the stomach occurs in a fourth form, coming on at uncertain intervals in 
 most violent paroxysms, and properly called gastrodynia. It is often accompanied 
 by a sensation of distension, much anxiety, and extreme restlessness. In females it 
 is frequently combined w^ilh hysterical symptoms. This form Dr. Abercrombie 
 supposes to depend upon over distension of the stomach ; and it may be so; certainly 
 great quantities of air are sometimes extricated ; and the pain is not confined to the 
 stomach, but shoots through to the back and between the shoulders. I suspect that 
 the pain is sometimes neuralgic. It is often very intractable ; occasionally it yields 
 to carminatives, • Dr. Abercrombie states that he has observed ihe most effectual 
 relief in such cases to have been obtained from exciting a brisk action of the bowels by 
 means of a strong purgative enema. He makes this practical remark, which is 
 worth attending to. From the facilities with which such affections often yield to the 
 remedy just mentioned, it appears not improbable that the pain may be sometimes 
 situated in the arch of the colon. Wherever its seat may be, I know that it is fre- 
 quently removed by a mustard poultice laid upon the epigastrium. Opium also is 
 of eminent use in many of these cases ; and bismuth ; and cordials : but I have seen 
 more rapid and decided rehef afforded by the prussic acid than by anything else ; 
 and the cure so wrought is often permanent. It does not bring ease in all cases, nor 
 is it a medicine that is any particular favourite of mine, yet its good effect is in some 
 instances so striking, that if this were its only virtue I should esteem the hydrocyanic 
 acid a most valuable remedy. 
 
 You will meet sometimes with what is called spasm of the stomach (and I sup- 
 pose it is such) in gouty people ; who are then said to have gout in the stomach. 
 The pain comes on in sudden and severe paroxysms ; and is removable in general 
 by laudanum and stimulants, brandy, for example; or by the mustard poultice. 
 On these cases, however, we look with jealousy and apprehension. In some in- 
 stances the attack is really inflammatory, and would then be aggravated by a stimu- 
 lant treatment. 
 
 There is yet another modification of uneasiness and disorder of the stomach, of 
 which the distinguishing characteristic is the vomiting, or rather the eructation of a 
 thin watery liquid, sometimes sourish, but usually insipid and tasteless, and often 
 described by the patients themselves as being cold. This is what Cullen calls 
 pyrosis, the water-brash. It is a disorder much more frequent in the lower ranks 
 of society than in others. It is particularly common in Scotland, and is there ascribed 
 to the large employment of farinaceous substances as food, and especially of oat-meal. 
 But it is said to be still more common in Lapland. Dr. Cullen, w^ho saw a great 
 deal of it, says that its paroxysms " usually come on in the morning and forenoon, 
 when the stomach is empty. The first symptom of it is a pain at the pit of tho 
 stomach, with a sense of constriction, as if the stomach was drawn towards Hie back. 
 The pain is increased by raising the body into an erect posture, and tnerefore tnc 
 body is bended forward. The pain is often very severe ; and after continuing for
 
 780 DYSPEPSIA. 
 
 some time, it brings on an eructation of a thin watery fluid inconsiderable quantity." 
 Such is Cullen's description of pyrosis. He states that the complaint often occurs 
 without other evidence of dj^spepsia ; but this is not consistent with the experience 
 of subsequent observers. It is a symptom sometimes of organic disease of the 
 stomach. In one remarkable case of pyrosis which I saw, and in which not less 
 than three pints of this thin tasteless liquid was brought up every day, the stomach, 
 after death, was found to all appearance healthy ; but it had been pressed upon by 
 an enormous liver. I mention these facts that you may not suppose pyrosis to be 
 ahvays, as Cullen has described it, a substantive and idiopathic malady. 
 
 When pyrosis is not caused by organic disease in the stomach or in the liver, it 
 will yield in general to opium, and especially to opium in combination with astrin 
 gents. The pulvis kino compositiis of the Pharmacopoeia is an admirable remedy 
 for it. But we often have to contend with this difficulty, that the bowels, in case.s 
 of pyrosis, are generally confined, and that the opium tends to aggravate this unna- 
 tural condition; so that it becomes necessary to administer some aperient daily 
 while the kino and opium are given: castor oil, or confection of senna, or cathartic 
 extract. 
 
 Cosliveness is, in fact, a very frequent concomitant of dj-spepsia, as Cullen's defi- 
 nition affirms (plerumque cum alvo adstricta). And this sluggish state of the bowels 
 often aggravates, if it does not produce, the dyspepsia. At anj'' rate the defective 
 powers and uneasy sensations of the stomach are rectified, in many instances, by 
 measures which promote the regular and healthy evacuation of the intestines. 
 AVithout professing to go into detail in this matter, I may state that, in our remedial 
 attempts, we should imitate, as much as we can, the processes of nature. The 
 mixed contents of the small intestines furnish the natural stimulus of their peristalic 
 movements ; and the excrement excites the larger bowels. When this natural stimu- 
 lus is insufficient, the want may be supplied by some substance which is involved in 
 the food, and accompanies it in its progress — as the bran of brown bread, already 
 mentioned, or a few grains of rhubarb or of aloes swallowed immediately before 
 dinner. In adjusting the proper quantity of the drug the patient must assist the 
 physician. It should be just so much as suffices to effect what nature neglects to 
 do, and no more. With some persons an aperient pill acts more comfortablj^ and 
 opportunely if taken at bed-time. Sometimes diarrhoea is associated with indigestion. 
 This is usually connected with an excess of acid in the primse vise. The principle 
 of treatment in such cases is obvious. 
 
 There are innumerable sympathies of distant parts with a dyspeptic stomach, .n 
 respect to which lean do little more than barely enumerate a few. Thus indigestion 
 is often accompanied by pain in the head, with some confusion of thought : or. at all 
 events, with a loss of mental energy^ and alertness. Together with a violent headache 
 there are frequently nausea and vomiting ; and the complaint is popularly known by 
 the name of the sick-headache : or, in the fashionable jargon of the da}', as a bilious 
 headache. I must refer you to a paper of Dr. Fothergill's, in the sixth volume of 
 the Medical Observations and Inquiries, for a very good account of this troublesome 
 complication. 
 
 I shall hereafter have a good deal to say respecting certain morbid conditions 
 of the urine, which take their rise sometimes from faulty digestion in the stomach, 
 sometimes from faulty assimilation of the digested aliment in the more advanced 
 stages of the process of nutrition. These conditions of the urine, indicating grave 
 derangements of the whole system, furnish the characters and the names of several 
 distinct maladies. 
 
 I told j'ou, in a former lecture, that certain affections of the viscera of the thorax 
 are liable to be produced by mere indigestion. Palpitations of the heart, irregulari- 
 ties of the pulse, fits of asthma, are no uncommon accompaniments of a disordered 
 stomach. This is partly to be ascribed to that reflex sympathy between the parts 
 concerned, which I have so frequently mentioned ; partly to the effect of flatulence, 
 which, by resisting the descent of the diaphragm, impedes the free working of the 
 lungs and of the heart. I told you, at the same time, that these symptoms torment 
 mnny persons with the belief that they spring from organic disease. This notion is
 
 DYSPEPSIA. 781 
 
 particularly apt to infest the minds of medical students. I suppose most teachers in 
 our profession partake of that sort of experience which Dr. James Gregory, of Edin- 
 burgh, used to speak of in his lectures. He said that scarcely a winter passed over 
 in which several of his pupils did not apply to him on account of palpitations sup- 
 posed by them to depend upon structural disease of the heart : and in no single in- 
 stance were their apprehensions well founded. They were all cases of mere dys- 
 pepsia and hypochondriasis. 
 
 D3'^spepsia is often connected with phthisis, with leucorrhoea, with amenorrhosa 
 and chlorosis : and some persons imagine that these diseases are caused by the 
 dyspepsia. Indigestion may lead indirectly to the development of consumption, by 
 producing debihty ; but the truer view of the matter seems to be that the dyspepsia 
 is a consequence, rather than an exciting cause, of these complaints. When, for 
 instance, leucorrhoea is cured by topical astringents, as it often may be, the indiges- 
 tion frequently is cured too. 
 
 One of the worst occasional concomitants of dyspepsia is that peculiar state of the 
 mind to which I just now alluded under the term hypochondriasis. This is, in truth, 
 a species of insanity : but it is so often connected with disorder of the digestive 
 organs, that Cullen, whose descriptions of disease are admirably clear and true, 
 however faulty many of his theories may be, defines hypochondriasis to be ^^Dys- 
 pepsia — cum languore, ma^stitia, et metu, ex causis non sequis." In the following 
 short paragraph he completes the picture. " In certain persons there is a state of 
 mind distinguished by the concurrence of the following circumstances. A languor, 
 listlessness, or want of resolution and activity with respect to all undertakings : a 
 disposition to seriousness, sadness, and timidity : as to all future events, an appre- 
 hension of the worst or most unhappy state of them ; and therefore, often upon 
 slight grounds, an. apprehension of great evil. Such persons are particularly atten- 
 tive to the state of their own health, to every the smallest change of feeling in their 
 bodies : and from any unusual feeling perhaps of the slightest kind, they apprehend 
 great danger, and even death itself. In respect to all these feelings and apprehen- 
 sions, there is commonly the most obstinate belief and persuasion." 
 
 Now when the attention of the hypochondriac is thus morbidly fixed upon the 
 states and sensations of his digestive organs (as it is very apt to be) the patient be- 
 comes a plague to his physicians as well as to himself. 
 
 There are a few simple rules which ought always to be kept in mind in our treat' 
 rnent of dyspepsia ; although we can seldom enforce them, as they ought to be en- 
 forced, upon our padents. What patients want, in general, is some medicine that 
 will relieve them from their discomfort and uneasy feelings, and allow them, at the 
 same time, to go on in the indulgence of those habits which have generated the dis- 
 comfort. And such remedies have not yet been discovered. 
 
 One great and indispensable principle in the treatment of indigestion, is that of 
 restricting the quantity of food taken at any one time. The gastric juice is probably 
 secreted in a tolerably uniform quantity. The muscular contractions of the stomach 
 must needs be impaired or impeded by much distension of thai organ. For both 
 these reasons the amount of food introduced into the stomach should be kept within 
 the limits of its capacity and powers. The great good which the late Mr. Abernethy 
 unquestionably did to a host of dyspeptic patients, was owing much more, I am per- 
 suaded, to the rules of diet, and the restrictions as to quantity, which he laid down, 
 than to his eternal blue pill. 
 
 Again, as Dr. Abercrombie has well remarked, and as Dr. Beaumont actually saw, 
 various articles of food are soluble in the stomach with various degrees of readine.'s. 
 Therefore, when the digestion is liable to be easily impaired, it is of great import- 
 ance, not only to refrain from those substances which are known to be soluble with 
 difficulty, but also to avoid mixing together in the stomach different substances which 
 are of different degrees of solubility. Hence there are two reasons why it is salutary 
 to dine off one dish. 1st. Because we avoid the injurious admixture just adverted 
 to ; and, 2dly, because we escape that appetite, and desire to eat too larjge a quantit},, 
 which is provoked by new and various flavours. 
 
 3q
 
 782 DYSPEPSIA. 
 
 And another very important principle, f^reatly insisted on by Mr. Abernetliy, is, 
 that the stomach should have time to perforna one task before another is imposed 
 upon it. He always made his patients (at least he always strongly exhorted them) 
 to interpose not less than six hours between one meal and another. Allowing from 
 threy to five hours for the digestion of a meal, and one hour over for the stomach to 
 rest in, Mr. Abernethy's rule seems as much founded in reason as it is justified by 
 experience. But we preach in vain on these topics. Mr. Abernethy was in the 
 habit of saying that no person could be persuaded to pay due attention to his digestive 
 organs, till death, or the dread of death, was staring him in the face. I have now 
 in my mind a family consisting of a mother and three grown-up daughters, who are 
 continually ailing and valetudinary. They profess to have great respect for my pro- 
 fessional advice : yet I never can induce them to think that their plan of eating is a 
 bad one. They are not early risers. They get to breakfast about half after ten or 
 eleven. At two they think it absolutely necessary to eat luncheon, which consists 
 of a mutton chop or some hashed meat, with vegetables. At six they dine : and at 
 eight they drink tea : and then they eat no more till the next breakfast. And this 
 is just a picture of the habits of scores of famihes. They huddle all their food into 
 the stomach, at four periods, within seven or eight hours ; and leave it idle for six- 
 teen or seventeen. 
 
 D3'speptic patients are very importunate to know ivhat they may eat, and (more 
 so still) what they ma}^ drink. It is of course impossible to lay down any general 
 rules which will suit every case. The stomach has its idiosyncrasies. I remember 
 seeing a publication some years ago, one section of which had this startling title, — 
 " Cases of poisoning by a Mutton Chop." Dr. Prout knew a person who could not 
 eat mutton in any form. He was thought to be whimsical, and mutton was frequently 
 served up to him under some other guise, without his knowing it ; but it invariably 
 caused violent vomiting and diarrhosa. Yet, for the average of stomachs, mutton is 
 probably the most digestible of all meats. And for the average of stomachs some 
 useful general directions may doubtless be given. 
 
 In fevers and inflammatory disorders, experience has taught us to forbid or limit 
 the use of flesh meat on account of its stimulating qualities. And when the stomach 
 itself is affected with chronic inflammation, or with morbid sensibility, a diet restricted 
 to farinaceous substances, and milk, is sometimes attended with the happiest conse- 
 quences. I suspect that a false analogy has led some into the mistake of supposing 
 that animal food ought to be refrained from, or taken in a scanty proportion, in merely 
 dyspeptic complaints. Animal food is easier of digestion, in the human stomach, 
 than vegetable food. It is nearer, in its composition, to the textures into which it is 
 to be incorporated by assimilation. There is less of " conversion" requisite. Indeed 
 we may look upon the appropriation of vegetable matter, by granivorous and grami- 
 nivorous animals, as one stage of the process by which such vegetable matter is 
 prepared for the sustenance of carnivorous animals : even as one great end of vege- 
 table life seems to be that of generating or concocting matter for the nutrition of the 
 former class, out of inorganic materials, not fitted for that purpose. A more elaborate 
 digesting apparatus is provided for the vegetable eaters. Man, indeed, is omnivorous. 
 But his organs of digestion are more like those of the carnivorous than of the grani- 
 vorous races. And it is notorious that vegetable food, when the stomach is weak, is 
 followed by more flatulence, that is, is digested with niore tardiness and difficulty, 
 ihan animal food. Nevertheless, a mixture of the two, of well roasted or boiled flesh 
 or fowl, with a moderate portion of thoroughly cooked vegetables, is better suited, 
 in my opinion, for a feeble stomach, than a rigid adhesion to either kind of aliment 
 singly Each of the four great classes of alimentary principles specified by Dr. 
 Prout should be represented; the aqueous, the saccharine, the albuminous, and the 
 oleaginous. All meats that have been hardened by culinary art, or by condiments, 
 should be avoided by him, who, as the vulgar express it, has "a bad digester;" all 
 cured meats I mean — ham, tongue, sausages, and so forth. Mutton is thought to be 
 ..lore readily digestible than beef. Pork, its lean part at least, is much less so than 
 either. All raw vegetables also must be eschewed ; salads, cucumbers, pickles. 
 But if we press our prohibitions much more strictly than this, we incur the risk of
 
 DYSPEPSIA. 783 
 
 fixing the patient's attention too curiously upon his diet, and upon the sensations of 
 his stomach ; and of rendering him hypochondriacally ahve to the miserable subject 
 of his feeding. 
 
 Again, you will be continually asked whether you recommend malt liquor or 
 wine, wine or brandy and water, vvhite wine or port, sherry or madeira. Now it 
 would be very easy to propound some positive rules in this matter, but it would not 
 be so easy to vindicate them. Some allowance must be made, no doubt, for custom. 
 I believe, however, that most dyspeptic persons would be better without any of these 
 drinks. But it is very difficult to persuade them that the habitual use of strong- 
 liquors in small quantities can have any injurious effects. "It is not easy (says 
 Cullen) to engage men to break in upon established habits, or to renounce the pur- 
 suits of pleasure ; and particularly to persuade men that those practices are truly 
 hurtful, which they have often practised with seeming impunity." They are too 
 ready to believe that it is unsafe to abandon their accustomed indulgence. A friend 
 of mine, who visited, some years since, many of the American prisons, tells me that 
 the health of even the most inveterate spirit-drinkers improves, instead of suffering, 
 upon the sudden and total abstinence from spirits, which the regulations of those 
 prisons enforce. There certainly are cases in which the digestion seems to be helped 
 by a moderate quantity of wine, or beer, or spirits ; yet no one can say before-hand 
 — at least I cannot — which of them is to be preferred. Upon these points patients 
 should interrogate their own sensations and experience, instead of seeking the oracu- 
 lar counsel of a physician. Drinks which are followed by evident disturbance and 
 discomfort are manifestly unfit. And even when a favourable effect, for the time, 
 appears to be produced, there is always a risk of ultimate detriment to the powers of 
 the stomach from this habitual excitement. 
 
 There are states of mind and habits of life, which, having no direct relation to the 
 organs of digestion, yet exercise a material influence over their functions. Mental 
 distress; mental solicitude ; mental toil ; over-much study ; Avant of exercise : these 
 are all prohfic sources of dyspepsia. Sedentary habits, when their injurious effects 
 are known, may be altered : excessive intellectual labour may be abandoned : but it 
 is seldom that we can minister to a wounded or an anxious spirit. Our task is 
 hardest of all when the patient's anxiety relates to his own complaints ; when he is 
 morbidly engrossed by his bodily feelings, and despondent about its recovery. The 
 management of the mind of a hypochondriac is peculiarly nice and difficult. It wilt 
 not do to treat him as if his ailments were imaginar}^ He disbelieves you, contemns 
 your judgment, and deserts you: to be fleeced perhaps by some villanous quack. 
 You must hear what he has to say ; show an interest in his case ; and prescribe for 
 him : assuring him that you understand his malady, that it is curable, and that he 
 will be cured provided he follows your directions. If you can succeed in gaining 
 his confidence, and in persuading him of this, the battle is half won. To tell such a 
 person, however, not to think of his grievances would be worse than useless. The 
 very effort to drive a subject from our thoughts fixes it there more surely. But you 
 must endeavour to turn his attention to other things ; and to awaken in him some 
 new interest. Prescribe change: change of air; change of place and of scenery; 
 change of society. Get him to travel in search of health ; and the chances are in 
 favour of his finding it. A tour, in fine weather, and through a pleasant country, 
 combines almost all the ingredients which are, seperately even, desirable : the with- 
 drawal of the mind from its ordinary pursuits and cares ; the diversion of the atten- 
 tion from one's self, by new and varied objects ; exercise carried on in the open air ; 
 a holiday from intellectual toil. Six weeks among the mountains of Switzerland, or 
 upon the rivers of Germany, Avill often do more towards restoring a dyspeptic hypo- 
 chondriac than a twelvemonth's regimen and physicking at home. 
 
 With these disjointed hints, gentlemen, I must request j^ou to be satified in respect 
 to the principles upon which dyspepsia — and the hypochondriasis, which is in gene- 
 ral so closely linked with dyspepsia — are to be managed. A full discussion of "the.<=« 
 subjects in detail would furnish matter for several lectures.
 
 784 ENTERITIS. 
 
 LECTURE LXXI. 
 
 Enteritis: its symptoms ; causes; treatment. Mechanical occlusion of the Intes 
 tinal Tube. Culic. Colica Fictonum : its symptoms, complications, treatment, 
 and prevention. 
 
 Some of the diseased states of the intestinal canal, while they difTer a good deal in 
 their essential nature, have yet many characters in common. Colic ; ileus ; enteritis ; 
 mechanical obstruction of the tube. It will be convenient, therefore, to consider these 
 disorders in succession, and, in some degree, in connection with each other. 
 
 In colic we have pain of the abdomen ; pain of a twisting or wringing kind, occu- 
 pying generally the umbilical region ; vomiting ; and costive bowels. Similar pains 
 are apt to occur in diarrhoea ; but they are transitory, and are then termed gripings, 
 or more learnedly, tormina. When they are violent, and more permanent, and 
 above all, when attended with constipation, they constitute colic. 
 
 You have not forgotten the symptoms of peritonitis. They are, briefly, pain in 
 the abdomen, increased on pressure ; and fever. 
 
 Now, if to the symptoms of colic, you add the symptoms of peritonitis, you have 
 the symptoms of enteritis : by which word I desire to express the disease that is 
 commonly called inflammation of the bowels. The term has lately been extended 
 so as to signify any and every form of inflammation which any portion or tissue of 
 the intestinal canal within the belly may suffer; but I use it in the old-fashioned 
 meaning. Cullen makes two species of enteritis. One of these consists in inflam- 
 mation of the mucous membrane of the intestinal tube : he calls it enteritis erythe 
 matica. That is not the disorder I am about to speak of; but the other of his spe- 
 cies, the enteritis phlegmonodea. I say that in colic, we have abdominal pain, 
 constipation, and vomiting. In peritonitis, the functions of the stomach and intestines 
 are not, necessarily, affected : in enteritis they are. There is inflammation, not 
 merely of the peritoneal coat, but of the areolar tissue uniting the several tunics, 
 probably of the muscular tissue also, and often of the whole substance of the bowel 
 at the inflamed part. 
 
 When the intestinal channel is any how closed up, and a bar placed to the pass- 
 age of its contents, the symptoms of coHc are very apt to ensue ; and at length, the 
 obstacle continuing, fatal inflammation is set up. 
 
 The term ileus is applied, I believe, to those cases, whether inflammatory or not, 
 in which, by an inverted action of the intestines, their contents are carried, in 3 
 retrograde course, into the stomach, and thence out of the body by vomiting. 
 
 Having made these explanations, I shall now address myself more especially to 
 Jhe consideration of enteritis. 
 
 It is of much practical importance to discriminate between enteritis and the dis- 
 orders that resemble it ; and particularly to distinguish it from colic. When it com- 
 mences, as it sometimes does, with distinct rigors, and is attended by thirst, a hot skin, 
 and a hard and frequent pulse, there is no room for doubt. But it often begins in- 
 sidiously, with mere colicky symptoms ; the pain, at first, is not much augmented, 
 It may even be somewhat eased, by steady pressure. If we mistake colic for enteritis, 
 the error is of no great moment ; but the opposite mistake, which is more common, 
 may be fatal. Blood-letting, and the other remedies of enteritis, will not aggra- 
 vate the mere colic ; they may even, though unnecessary, relieve the patient. — 
 Some of the remedies of mere cohc are, however, highly dangerous when there is 
 inflammation of the bowel. Physicians may fall into this error : patients who choose 
 to prescribe for themselves, commonly do so. They take stimulants, cordials, car- 
 minatives — the pleasantest and nearest at hand is a glass of brandy, or of gin. And 
 in true colic these means are frequently of great service ; but they exasperate the 
 6>yniptoms, and increase the mischief when the disease is enteritis. Indeed, treat- 
 ment of this kind will sometimes urge colic into enteritis. If the case be ambiguous,
 
 ENTERITIS. 78o. 
 
 you must act upon the most unfavourable supposition, and treat the complaint as if 
 you were sure that inflammation was present. 
 
 The pain of enteritis is increased by pressure. The pain of coHc is not only not 
 made worse, but it is actually mitigated often, by pressure ; and it usually intermits 
 entirely. I know that when there is simply flatulent distension of the intestines, 
 pressure does sometimes increase the patient's uneasiness ; but the uneasy sensation 
 is very different from that acute sensibility which belongs to inflammation of their 
 peritoneal covering. In enteritis there are also paroxysms of severe pain, determined, 
 probably, by the peristaltic movements, or by the temporary distension of the inflamed 
 parts of the bowel ; and the pain has frequently a twisting character : but there is 
 not any thorough intermission. There is a duller abiding pain between the sharper 
 fits. It is to be observed also, as a diagnostic circumstance, that, as in peritonitis, the 
 patient lies on his back, with his knees drawn up, and is fixed in that position, and 
 for the very same reasons. If, in his agony, he tosses about his arms, the trunk is 
 kept motionless, and the respiration is thoracic : whereas in mere colic the mode of 
 breathing is not altered, and the patient is apt to be turning and writhing in all pos- 
 tures, and out of one posture into another. 
 
 The nausea and vomiting are often most distressing. The patient not only rejects 
 immediately whatever food, drink, or medicine he swallows, but he has fits of retch- 
 ing when the stomach is empty. In some instances, matters are cast up having the 
 appearance, and something of the odour, of liquid feces : or resembling, at any rate, 
 the offensive fluids which are found in the small intestines after death in these cases. 
 I cannot say that I have ever seen genuine excrement ejected, unequivocal ordure: 
 yet this may well happen if it be true that clysters, introduced into the rectum, have 
 been voided through the mouth. Such a phenomenon would show that the whole 
 tube was pervious ; that there was no mechanical obstruction. 
 
 Although the fever, in the outset, may be high, and the pulse strong and hard, it 
 soon becomes (as in all acute abdominal inflammations) small and wiry ; or weak, 
 and like a thread. In bad cases, as the disease proceeds, the abdomen begins to 
 swell, becomes tympanitic ; hiccup sometimes comes on ; the pulse intermits or beats 
 irregularly ; the extremities grow cold ; the features are sharpened and ghastly ; 
 cold sweats break out ; the pain ceases perhaps ; and the sphincters relax. The 
 head is generally unaffected. Now and then delirium occurs late in the disease ; 
 but much more frequently the intellect remains clear to the very last. Death begins 
 at the heart, and takes place in the way of asthenia. 
 
 You may probably have observed that the symptoms which I have been describ- 
 ing are just the symptoms which the surgeon so frequently encounters in cases of 
 strangulated hernia. The symptoms of that surgical complaint are, in truth, most 
 commonly at least, the symptoms of enteritis, caused by the forcible closure of the 
 bowel. Obstruction to the passage of the contents of the gut gives rise to its inflam 
 mation. And we often find, after death preceded by the signs of enteritis, an internal 
 mechanical obstruction — an internal strangulated hernia. In some cases bands or 
 strings of coagulable lymph, the products of bygone inflammation, have formed 
 snares (so to speak) for the gut, which at length they catch and constrict. They do 
 no harm till some coil of intestine gets beneath or beyond them; and then they 
 strangle it, as the phrase is. I have twice seen (as I think I formerly stated) the 
 appendix vermiformis prove the immediate cause of fatal internal hernia. In one of 
 these cases, the person had been a private patient of Dr. Macmichael ; and I went 
 with him to examine the body. The free end of the appendix had become adherent 
 to the mesocolon ; and so a loop was made, through which a portion of the gut had 
 passed. In the other instance, which I saw in Edinburgh, the appendix was lite- 
 rally tied round a piece of the intestine. Sometimes, again, there is intussusception : 
 the upper part of the tube slips into the lower, fills it up; obstructs it; and inflam- 
 mation fixes it there. Or it may be that a chronic thickening of the coats of the in- 
 testine has narrowed its channel ; or a tumour presses upon the intestine from with- 
 out ; or some foreign substance, or morbid accumulation, plugs it up within ; in all 
 which cases a chronic dfsorder passes at length into acute inflammation. A very 
 small hernia at one of the usual orifices — not large enough to manifest itself ext^r 
 50 3 Q 2
 
 786 ENTERITIS. 
 
 nally — is sometimes the cause of the obstruction ; even though only a portion of one 
 side of the gut may be nipped in the aperture. 
 
 Sometimes, but according to my experience less frequently, there is no mechanical 
 impedime>it to account for the constipation. In all cases, whether there be mechanical 
 obstruction or not, the inflamed portion of the gut is of a red or dark colour ; distended 
 by its gaseous or liquid contents ; covered often, on its peritoneal surface, with co- 
 agulable lymph ; or adherent to the contiguous organs. When the gut is mechani- 
 cally closed, the part which lies on this side the obstacle, as we follow the natural 
 course of the channel, is inflamed ; the part which lies beyond it is pale, contracted, 
 and to all appearance, healthy. The line of demarcation is abrupt and strong; and 
 it is determined by the obstacle. And the distinction between the healthy and in- 
 flamed portions is usually as sudden and decided, when there is no apparent obstacle. 
 I mean that up to a certain spot the intestine is red like a cherry, or dark like a grape, 
 large, and smeared (perhaps) -with lymph or with pus ; while immediately beyond 
 that point, and throughout the remainder of its course, it is white, empt}', and shrunk 
 up into the semblance of a cord. The pathology of these last forms of the disease 
 is full of difficulty. Some have held that the contracted part was the original seat 
 of disease, namely, of spasm; and that the upper adjoining portion of intestine be- 
 cime distended and inflamed in consequence of such spasm. Without attempting 
 to explain these phenomena, which are comparatively unfrequent, I content myself 
 with observing that it is the distended part which is ihe really inflamed part, and 
 that its muscular coat appears to have lost its natural contractile power — not (I fanc}-^) 
 from over-stretching, as now and then happens to the urinary bladder — but from the 
 efl^ect of the inflammation. 
 
 The inflamed portion of bowel is often of a very dark colour, and even almost 
 black, from the great congestion of blood in its tissues. Now this black colour has 
 sometimes been erroneously set down as an evidence of gangrene. You must not 
 trust to the mere colour, however. If the coats of the bowel be firm, and if the pe- 
 culiar odour of gangrene be wanting, you are not to conclude that mortification has 
 taken place, simply from the dark appearance of the intestine. 
 
 Enteritis, not dependent upon any mechanical occlusion of the bowel, may arise 
 under the operation of the ordinary causes of internal inflammation : cold and wet, 
 for instance, applied externally, and especially to tha feet and legs. Cold is thought 
 to be particularly injurious in this way when the exposure happens soon after a 
 meal : probably because at that time the digestive organs, being in activity, receive 
 a more copious supply of blood. 
 
 The mechanical impediments that occur within the bowel, are still more various 
 in kind than those which constrict it from withotd. Hardened fecal matters: intestinal 
 concretions. Some of these are curious, and I shall hereafter have a word or two 
 to say respecting their composition. Persons who are in the habit of taking a good 
 deal of magnesia, or of chalk, to relieve acidity and heartburn, are liable to have 
 these substances accumulate, and become indurated in the intestines. They generally 
 begin to collect, I believe, around some accidental nucleus : and such a nucleus may 
 very readily be supplied. A cherry-stone, a fish-bone, a gall-stone that has found 
 its way into the bowei. Even a pill, prescribed to cure, may thus come to kill one's 
 patient. Dr. Prout was asked to analyze certain odd-shaped, triangular bodies which 
 had been voided at stool, and were supposed to be gall-stones: but he found that 
 they were specimens of Plummer's pill, which had defied the solv>!nt action of the 
 gastric juice, and had passed into, and lingered in, the bowels. Unbruised mustard- 
 seed, and carbonate of iron, are other remedial substances which, injudiciously ad- 
 ministered, have collected in hard masses, and caused intestinal disease. It is seldom 
 that we can discover, during life, what is the exact nature of the mechanical obstacle : 
 but I have observed this peculiarity in most of the cases in which I have known it 
 produced by intussusception, that after severe and sudden symptoms of obstruction 
 and inflammation, blood has been passed by stool. Sometimes the included portion 
 of bowel itself sloughs away, and is expelled ^;er anum. 
 
 Inflammation of the bowels requires very much the same kind of treatment as 
 penionitis : indeed, the disease is in most cases peritonitis and something more. The
 
 ENTERITIS. , ' 787 
 
 patient must strictly abstain from every sort of stimulus, and confine himself as much 
 as possible to the horizontal position. He must lose blood also from the arm, and 
 the earlier the better. The lancet is not to be withheld merely because the pulse 
 is small. If the artery becomes fuller, and its beating more distinct, under venesec- 
 tion — nay, if the patient does not become faint — the first bleeding should be a large 
 one. This is not only the safer plan, but in the long run it is the most economical 
 of the blood and strength of the patient. As in simple peritonitis, the abdomen must 
 be covered with leeches, and afterwards with fomentation cloths. Should one spot 
 or region be more painful and tender than another, on that part the leeches are to be 
 accumulated. It may be requisite to repeat the venesection and the leeching once, 
 or twice, or many times ; the propriety of such repetition depending upon the 
 urgency and obstinacy of the symptoms, and upon the age and state of the patient. 
 I am speaking of idiopathic enteritis, and of its earher stages. In the advanced 
 periods, when feebleness of the pulse is associated with tympany of the belly and 
 coldness of the surface, it betokens weakness and sinking, and the tendency to death 
 by asthenia; and, consequently, it then indicates support rather than depletion. So 
 also when the enteritis is not idiopathic, but consecutive — when we have reason to 
 believe that it arises out of a firm mechanical impediment — our employment of blood- 
 letting must needs be modified by that circumstance. 
 
 One point in the management of enteritis, requiring great caution and judgment, 
 relates to the exhibition of purgative medicines. The costive state of the bowels is 
 apt to be looked upon as the main evil, and their evacuation as the chief indication 
 of treatment; but great mischief, I apprehend, is likely to arise from the exclusive 
 pursuit of that indication. I am still speaking of the idiopathic disease, where it is 
 presumable that no mechanical obstacle exists to render the passage of the feces im- 
 possible. Purgatives given by the mouth are often rejected by the stomach, with 
 great distress to the patient. If they are retained, and fail to operate, they must do 
 more harm than good. Certainly they should not precede the venesection. I well 
 remember, though it is now many years ago, being myself badly treated for enteritis. 
 Being ill, in a strange place, I sent for the nearest practitioner, who happened to be 
 a very ignorant man. Finding that I was sick, and that my bowels did not act, he 
 gave me, for two or three days in succession, strong drastic purges, with no other 
 effect than that of increasing my sickness, and adding to the abdominal pain I suf- 
 fered. I was then seen by a most intelligent physician (this was before I had paid 
 miy attention to physic myself), and the first thing he did was to have me copiously 
 bled ; and the immediate effect of that bleeding was to send me to the night-chair. 
 And I am persuaded that when evacuations follow the administration of purgatives in 
 such cases, they are often owing to the blood-letting and other antiphlogistic measures 
 that are employed at the same time. These are the opinions of Dr. Abercrombie 
 also, who says, " I confess my own impression distinctly to be, that the use of pur- 
 gatives makes no part of the treatment of the early stages of enteritis ; on the con- 
 trary, that they are rather likely to be hurtful until the inflammation has been sub- 
 dued." It is an instructive fact, that when purgative medicines do operate during 
 the height of the inflammation, the stools they produce are merely watery ; and it is 
 only after the inflammation has been reduced that feces are discharged, and then in 
 such quantity sometimes as to show that they must have been shut up in the bowels 
 during the period of active inflammation. 
 
 You should wait, then, for the effect of other measures, blood-letting, leeching, 
 fomentation, before you give active purgatives by the mouth; and in all stages of the 
 disease, whatever laxatives are given should be of the mildest kind, such as are least 
 likely to excite irritation of either the stomach or bowels. 
 
 The same objections do not apply to enemata, which soothe while they evacuate 
 the lower parts of the canal. You will read or hear of great service done by an 
 infusion of tobacco, or by the smoke of tobacco, thrown into the bowels Uhrough the 
 rectum. Dr. Abercrombie speaks of a weak infusion of the leaves as being a remedy 
 of very general utility. It should, I apprehend, be a weak infusion to be at all safe; 
 but, of my own knowledge, I can tell you little or nothing about it. I do Know, 
 however, that the injection of a large quantity of merely warm water is often of mucl-
 
 788 MECHANICAL OCCLUSION OF THE INTESTINAL TUBE. 
 
 use : from two to six pints, for example, thrown up gradually and gently. Indurated 
 feces are softened and brought away in this manner, and the warm water acts as an 
 internal fomentation. 
 
 Of internal medicines I believe the best you can give is a combination of calomel 
 and opium, in such proportions as will restrain the purgative qualities of the calomel. 
 The opium allays pain, and, perhaps, relaxes spasm ; mercury tends to arrest the 
 inflammatory action ; and the more immediate effects of this combination are often 
 found to be, a setthng of the irritable stomach, a disposition to diaphoresis, and an 
 improved pulse. 
 
 To sum up, then, bleeding, and calomel and opium are to be resorted to for 
 checking the inflammation : and when that is in great measure abated (and probably 
 not before), it will be right to give some mild laxative to clear out the bowels. 
 There can be none more suitable or convenient than castor oil. But before we ven- 
 ture upon purgatives by the mouth it will be proper to wash out the bowels by 
 lavements of tepid water. These injections may sometimes have mechanically a 
 beneficial effect upon the parts concerned in the inflammatior) ; untwisting, for ex- 
 ample, a twisted bowel ; or setting free the half-incarcerated intestine. It is often 
 expedient to administer them through a long tube passed as far as possible into the 
 rectum. 
 
 There is one very important point in the treatment of enteritis that I have yet to 
 mention. I have told you that in the advanced stage of the disease symptoms of 
 sinking often come on ; a total cessation of pain, failure of the vital powers, and 
 coldness of the body. These symptoms, this collapse and approach to syncope, are 
 generally considered to denote grangrene, and, therefore, a hopeless state of disease. 
 Yet in many cases which have proved fatal after similar symptoms, not a trace of 
 gangrene has been discoverable. So that this unpromising change in the symptoms 
 does not always indicate a morbid condition which is necessarily mortal. And if the 
 patients are to be saved at ail, they are to be saved by wine and support. We must 
 combat the obvious tendency to death by asthenia. 
 
 " A man, aged forty, was affected with enteritis in the usual form, for which ho 
 was treated in the most judicious manner by a respectable practitioner. On the fifth 
 day the pain ceased: the pulse was 140, and extremely feeble and irregular; his 
 face was pale, the features were collapsed, and his whole body was covered with 
 cold perspiration ; his bowels had been moved. In this condition (says Dr. Aber- 
 crombie, from whom I quote the case) I saw him for the first time. Wine was then 
 given him, at first in large quantities, and upon the whole, to the extent of from two 
 to three bottles during the next twenty-four hours. On the following day his ap- 
 pearance was improved; his pulse 120, and regular; the wine was continued in 
 diminished quantity. On the third day his pulse was 112, and of good strength, and 
 in a few days more he was well." 
 
 Dr. Abercrombie relates other cases to the same effect ; and most physicians, I 
 suppose, have occasionally seen such. They teach us that we must not abandon our 
 patients in despair, even under the most adverse circumstances. If diarrhoea should 
 supervene with this state of collapse, opiates must be joined with the wine. External 
 warmth is also a powerful auxiliary. 
 
 I know of no cases of disease more painful to witness or to treat than those which 
 result from invincible obstruction of the intestinal lube. They are usually attended, 
 at length, with enteritis ; but they differ much in some respects from what I have 
 called idiopathic enteritis. The inflammation is an accident or consequence of the 
 obstruction ; or of the means used to overcome it. They happen usually somewhat 
 in this manner. A person thinks it expedient to take some aperient medicine. It 
 has no effect. He repeats the dose. It causes pain and gripings, and probably sick- 
 ness also ; but still the bowels are not moved. Enemata are employed. They 
 bring away, perhaps, some hardened feces, but there is no further relief. Mean- 
 while' i-ne patient may have a clean tongue, a quiet pulse,. a cool and soft skin, and a 
 supple and painless abdomen. Purgatives of a more drastic kind are tried, but tried 
 .n vain ; and the physician is summoned.
 
 MECHANICAL OCCLUSION OF THE INTESTINAL TUBE. 789 
 
 Now the first thing which you have to do, when called to a case of " obstruction 
 of the bowels," is to search narrowly whether there be not some unsuspected exter- 
 nal hernia. All delicacy must be waived ; and every part of the body, where hernia 
 may possibly show itself, must be submitted to inspection. If none be found, the 
 rectum, and in women the vagina, must be severally explored. Stricture, or a 
 quarry of impacted feces, may possibly be detected in the one : a uterine or other 
 tumour, pressing upon the bowel, may perchance be felt through the other. I shall 
 never forget the shock I once experienced on being sent for to see a woman, of mid- 
 dle age, who was in articulo mortis, and who, as I was told, had for some days been 
 labouring under sickness, pain in the abdomen, and constipation. In her left groin 
 there was a large palpable strangulated hernia, which had not been detected by the 
 practitioner in attendance, simply because it had not been looked for ; and which was 
 discovered only when it was too late. 
 
 Remember, therefore, that in every case of obstinate costiveness, with signs of 
 inflammation within the abdomen, it is absolutely necessary, for y,our own credit and 
 subsequent comfort, as well as for your patient's safety, to make diligent and thorough 
 inquiry after such hernia as may be recognized externally. 
 
 But often you find nothing of the sort, and then you are at liberty to prosecute 
 with more energy and decision the purgative plan ,of treatment. You prescribe 
 strong doses of jalap and calomel ; black draughts. The stomach being irritable, 
 you give pills of cathartic extract, and repeat them at short intervals ; or large doses 
 of calomel, ten grains or a scruple, three or four times in succession. You inject 
 stimulating clysters. Then you are driven to croton oil : and at last, in some vague 
 hope of relaxing spasm, to opiates. If symptoms of inflammation spring up, you 
 put fairly in force the remedies of inflammation ; and especially blood-letting. But 
 all is in vain. The medicines are vomited ; or, if retained, they serve but to aug- 
 ment the patient's distress, producing or renewing the pain and the nausea. It is 
 extraordinary how comfortable the patient sometimes becomes upon the intermission 
 of these active attempts. Now and then he suffers tormina, or has fits of retching; 
 but in the intervening periods his sensations and outward condition may be those of 
 perfect health ; only there is no alvine discharge. 
 
 Now, under these afflicting circumstances, the question will force itself upon you 
 —-how long am I to pursue the purgative system? Common sense, and commorr 
 humanity, answer — you must stop it the instant you are convinced that there is a 
 mechanical obstacle, which cannot be overcome. To persist in the use of drastic 
 purgatives after that conviction, is to inflict wanton and needless torture upon the 
 patient. But how are you to know this ? That is one difficulty. And how are 
 you, beheving that it is so, to satisfy the patient's friends that his disorder is irreme- 
 diable ; and to resist their importunity to try this and that : how persuade them to 
 look passively on, while their relative is slowly perhaps, but surely, perishing? 
 These are great and terrible difficulties. 
 
 You will be urged by all imaginable suggestions : even the most absurd. Crude 
 mercury may perhaps be one. Pounds of this metal have been swallowed in such 
 cases ; in the hope, I suppose, that it would force a passage by its weight. But the 
 obstacle may be in an ascending coil of intestine. And if not, experience does not 
 teach us to put any faith in this rude mechanical remedy. It has often done mis- 
 chief, and seldom or never done any good. The metal is apt to become oxidized in 
 the body, and then to produce very distressing salivation. This is an evil which I 
 have known to occur, and to trouble the patient greatly, some time after the ineffect- 
 ual exhibition of large doses of calomel. 
 
 Dashing cold water over the abdomen, and the lower extremities, is another i-nugii 
 expedient, which is sometimes successful in producing evacuations. It was adopted, 
 after various other measures had failed, in the case in which the bowel was tied 
 down by the adherent appendix vermiformis ; and it caused the empiymgot that part 
 of the canal which lay beyond or below the internal hernia. It is plain that this 
 partial success can be of little or no use ; certainly of none that can compensate for 
 the shock and annoyance of the cold affusion. 
 
 Let me not, however, be misunderstood. I do not say that you are to aDanaon ail
 
 790 MECHAMCAL OCCLUSION OF THE INTESTINAL TUBE. 
 
 hope when purgatives (and, if need be, blood-letting) have failed, after a fe\v trials, 
 to obtain evacuations from the bowels. Nor even that you are necessarily, for that 
 reason, to give up the use of purgatives. The intestines may be torpid and insen- 
 sible to ordinary stimuli, and really require strong rousing. Dr. Abercrombie men- 
 tions the case of a gentleman whose bowels were locked up by an accumulation, as 
 the result showed, of black hardened feces. The obstruction, which had resisted 
 the most active purgatives, and was accompanied by an evident and painful disten- 
 sion of a part of the abdomen, yielded at once to the repeated application of galva- 
 nism to that part : each application being immediately followed by a copious evacua- 
 tion. Here the flagging muscular action was restored apparently by the galvanic 
 stimulus. Very lately I attended an elderly lady, who from Wednesday morning 
 to the next Monday noon, had had no alvine relief, notwithstanding the employment 
 of the most active cathartics. She suffered frequent paroxysms of pain and vomiting : 
 but the abdomen was scarcely, if at all, distended ; nor was it tender. At length she 
 complained that what she vomited was stercoraceous — to use her own words, "what 
 came upwards ought to have passed the other way." It was a thin, brown-coloured, 
 ill-smelling fluid. Dr. Mayo and Mr. Arnott were now associated with me in this 
 case, and they touched and felt the abdomen as I had previously done. The lady 
 observed that their hands were heavy; and she fancied that the pressure they made 
 had displaced something within. And I believe that it was so: for before our consul- 
 tation in the next room was over, word was brought us that the bowels had acted. 
 She had passed a liquid motion precisely resembling the stuff she had last vomited. 
 The next day, with one of several similar stools, a hard lump was voided, which 
 proved to be a gall-stone, as big as a small walnut. 
 
 As large quantities of warm water had without difficulty been injected, I infer that 
 the concretion had been impacted high up in the bowel, probably at the valve of the 
 cajcum. Some years previously the lady had suffered severe abdominal pains, 
 which at the time were ascribed to the passage of a biliary calculus through the 
 gall-ducts. 
 
 In this instance there was no evidence of any strong contractile efforts of the bowel 
 above the place of obstruction. 
 
 Large enemata — as much as the intestines will patiently receive — gradually and 
 gently introduced, and repeated three or four times a day, may sometimes succeed 
 in breaking down and washing away masses of hardened excrement. And if these 
 enemata are composed of milk or beef-tea, and are suffered to remain as long as they 
 will, they may answer another important purpose; they may contribute sensibly to 
 the nourishment of a patient who cannot retain food in his stomach. They are 
 generally very soothing and comfortable ; allaying tormina, and abating sickness : 
 and they are adapted to every stage and variety of the complaint. 
 
 There are, however, cases in which we arrive at the melancholy but sure convic- 
 tion that some mechanical impediment has rendered the bowel absolutely and hope- 
 lessly impassable. We fear this when, the constipation being obstinate, we discover 
 a tumour, or hardness, in some part of the belly : or when we receive a history of 
 some former inflammatory attack, since which the bowels have been habitually diffi- 
 cult to regulate. Our fears are strengthened when the patient feels that the injec- 
 tions reach a certain spot, and there always stop ; and that the intestines rumble, 
 and roll, and propel their contents downwards to the same spot, and no further. 
 And this is the distinctive symptom upon which I desire to fix your attention. The 
 abdomen gradually enlarges, especially if the patient is able to retain food. The 
 intestines fill up above the obstacle ; and then throes of pain occur, spasms the suf- 
 ferers usually call them, attended with sickness ; and during these pangs you may 
 feel, and if the abdomen be uncovered, you may see, immense coils of intestine, as 
 big perhaps as one's arm, rise and roll over, like some huge snake, with loud roar- 
 ings and flatulence. When this takes place, the time for giving purgatii-es is cer- 
 tainly over. The distended bowel requires no stimulus ; it acts, and strives with all 
 its power, but strives in vain, to overcome the opposing barrier. If you would con- 
 sult your patient's ease, if you would not embitter and abbreviates his slender rem- 
 nant of life, harass him no further with active remedies. In some cases violent
 
 COLIC. 791 
 
 .nflammation quickly supervenes, and death arrives in a few days : in others, the 
 patient survives, without any evacuation from his bowels, but with long intervals 
 of ease and comfort, for four, or five, or six weeks. Even a brief respite may be of 
 infinite value ; giving time for the arrival of distant friends — for the settlement of 
 worldly concerns — and for preparation of the spirit against the inevitable hour. 
 
 It is to these circumstances of irremediable disease that opiates are eminently 
 adapted. Even when the symptoms are less desperate, they are not without their 
 use. I cannot better express what I think upon this point than in the words of the 
 first Heberden, who says : " The probability of advantage from anodynes has deter- 
 mined me to recommend them; and experience has strongly confirmed this judg- 
 ment. Under the protection of an opiate I have successfully given more and stronger 
 purges than v/ould have stayed without its help. The patient's strength has been 
 kept up by some refreshing sleeps : and even in hopeless cases, in which the dying 
 person is harassed by unspeakable inquietude, he may be lulled into some compo- 
 sure ; and without dying at all sooner, may be well enabled to die more easily. 
 Lord Verulam blames physicians for not making the euthanasia a part of their 
 studies : and surely, though the recovery of the patient be the grand aim of their 
 profession, yet, where that cannot be obtained, they should try to disarm death of 
 some of its terror : and if they cannot make him quit his prey, and the life must 
 be lost, they may still prevail to have it taken away in the most merciful manner." 
 
 1 have spoken of these cases as being irremediable : but perhaps I have spoken 
 somewhat too absolutely. Life may sometimes be saved by a surgical operation. 
 The gut may be punctured above the seat of obstruction, and suffered to discharge 
 its contents through what is called an artificial amis. This expedient is feasible, 
 however, in those cases 07ily in which the obstacle is situated near the termination 
 of the large intestine ; i. e., in the rectum, or in the lower part of the descending 
 colon : for here only can we ascertain, with any thing like certainty, the exact place 
 of the impediment, and here only may the colon be pierced, from behind, without 
 injury to the peritoneum. Under no other circumstances, in my opinion, would an 
 attempt to reheve the patient, by cutting down upon and opening the bowel, be justi- 
 fiable. An artificial outlet in the loin would probably be less disgusting to the pa- 
 tient, and less offensive to others, than if it were in front of the body. I am not 
 aware that the operation has ever been done in this country. It has been practised 
 successfully in France. The mode of performing it I am not competent to teach 
 you. In an appropriate case I should think it right to mention, though I should be 
 slow to recommend, this anceps remedium. The risk of failure, and the penalty of 
 success, should both be set fairly before the patient. The choice between certain 
 death, on the one hand, and the chance of living with a very loathsome bodily 
 infirmity, on the other, must be made by himself. 
 
 For further information upon this subject, I would refer you to an interesting essay, 
 by Mr. Erichsen, published in the 28th volume of the Medical Gazette. 
 
 It remains that I should say something more respecting colic: which may exist 
 independently of enteritis, and of mechanical occlusion of the bowel ; although the 
 three are very often combined and intermixed in the course of the same disease. 
 
 In colic there is pain in the abdomen, constipation of the bowels, vomiting often : 
 and these are symptoms which occur also in enteritis. The pain is a twisting or 
 wringing pain generally, round the navel ; and such is the character of the exacer- 
 bations of pain experienced when the bowels are inflamed. These are the points 
 of resemblance between the two maladies : and it is of much importance, as 1 told 
 you before, to observe their differences ; and to note the marks by which the one 
 may be distinguished from the other. It is, then, an essential difference that enteritis 
 is attended with fever, and with tenderness of the belly. The pain is increased by 
 all kinds and every degree of pressure ; and the patient, fixed in the supine position, 
 breathes with the intercostal muscles only, and carefully avoids any movement whicli 
 would call the abdominal muscles into action, and so "^rimpress the inflamed bowel. 
 In colic, on the other hand, the circulation is tranquil ; there Js no fever ; and the 
 pain is even mitigated by pressure. The patient will lie on his belly lor ease : nay,
 
 792 COLICA PICTONUM 
 
 he will press it, with the whole weight of his body, across the back of a chair, and 
 obtain comfort by that manoeuvre. During the paroxysms the pain is often most 
 violent : what the old writers call dolor atrox — atrocious pain : but there are inter- 
 vals of complete ease. Even when the pain is worst, the patient tosses and shifts 
 from one posture to another in search of relief: and he does not wear that anxious 
 and apprehensive aspect which we see in those who are labouring under enteritis. 
 The pain arises, I imagine, from the distension of the bowel, here and there, by gas ; 
 or, it may be, from spasm ; or from both these states at once. At any rate, it is 
 often associated with audible flatulence, and with evident outward spasm. The 
 abdomen is hard, and drawn spasmodically inwards towards the vertebral column ; 
 and its muscles are partially and strongly contracted, gathered up into lumps and 
 knots. None of these circumstances belong to enteritis. 
 
 However, there is good reason for believing that, even in mere colic, the pain may 
 sometimes be augmented by pressure. When a portion of the gut has become 
 rapidly distended, considerable uneasiness may result from its forcible compression; 
 although, as Dr. Abercrombie states, the kind of pain can generally, by attention, 
 be distinguished from the sensitive tenderness of an inflamed peritoneum. 
 Luckily, if such pain on pressure should lead us to mistake a case of pure colic for 
 a case of enteritis, the error is on the safe side : and we must always bear in mind 
 the tendency remarked in colic, when the complaint is neglected, or badly treated, 
 to run into actual inflammation. In fact, as any obstacle to the passage of the ali- 
 mentary matters through the bowels may give rise to colic, colic is sometimes merely 
 the first step towards acute inflammation arising out of a continuance of the obstruc- 
 tion. And having told you that colic may be thus produced, I have at once intro- 
 duced you to a large class of its causes which have already been spoken of in the 
 present lecture as frequent causes of inflammation also. 
 
 But colic, like inflammation of the bowels, sometimes arites without any appa- 
 rent or detectable obstruction, of a mechanical kind, to the free transit of the contents 
 of the alimentary tube. And there is one particular form of colic that requires a 
 separate notice. The colica Pictonum — so called from its great frequency, hereto- 
 fore, among the Pictones, or inhabitants of Poictou — is produced by the slow intro- 
 duction of the poison of lead into the system.. 
 
 Now, the colic which has this origin is not to be distinguished, in its ordinary 
 symptoms, from any other kind of colic. But the abdominal pain is usually, in such 
 cases, a part only of more general disease. It has received, in different places, a 
 variety of names — colica Pictonum, the painter's colic, the Devonshire colic, the 
 bfUain of Derbyshire, the dry belly-ache of the West Indies. In all cases it acknow- 
 ledges the same cause — the gradual entrance of lead into the body. 
 
 In this country, we see the disease more often in painters than in any other per- 
 sons. They use, as you know, white lead in the preparation of their colours ; and 
 they are perfectly familiar with this terrible cohc. We see it, also, in all workmen 
 whose occupations bring them habitually into contact with preparations of lead. No 
 doubt there are very great differences in the susceptibility of this effect of the poison 
 of lead. Persons have been known to suffer colica Pictonum, in consequence of 
 their sleeping for a night or two in a recently painted room. On the other hand, I 
 have myself seen a patient who became affected with the disease, for the first time, 
 after working with white lead for nineteen years. Generally the first attacks of colic 
 are well recovered from. The obstinate constipation of the bowels is at length over- 
 come ; the patient obtains ease, and forthwith recurs to his previous habits ; and after 
 a period, which varies in different individuals, he is again laid up with the cohc. 
 Even the primary attacks are usually attended with pains in the head, and in the 
 limbs ; sometimes with cramps ; sometimes even with epilepsy and coma. At 
 length, in one of these attacks of colic, or after one of them, when the violence of 
 :he pain and the costiveness have yielded to treatment, the patient finds that he has 
 lost the full power of using one or both of his hands. The wrists, as the patients 
 express it, drop. You see at once what is the matter, by the characteristic state of 
 the arms and hands. The extensor muscles of the hands and fingers are palsied ; 
 so that, when the arms are stretched out, the hands hang dangling down by their
 
 COLICA PICTONUM. 793 
 
 own weight, and the patient is unable, by any effort of his will, to raise them. The 
 palsy is local ; it does not proceed from any diseased condition of the nervous cen- 
 tres. The affected muscles waste, and the atrophy is very remarkably seen in the 
 bundle of muscles composing the ball of the thumb. Even from this condition, the 
 patients often are capable of complete recovery. But if they persist in following their 
 former calling — or if, without knowing it, they continue to be habitually exposed to 
 the exciting cause of the disease — they become miserable cripples, fall into a state 
 of general cachexia, and sink at length under some visceral disease. The poison 
 accumulates in the body, and saps the powers of life. Francis Citois, a native of 
 Poictou, who published an excellent and one of the earliest accounts of the disease, 
 in the year 1617, has drawn the follovving graphic picture of its effects. Its cause 
 was not at that time suspected. Speaking of the wretched sufferers, he says, "Per 
 vicos, veluti larvos, aul arte progredientes statuse, pallidi, squalidi, macilenti conspici- 
 untur; manibus incurvis, et suo pondere pendulis, nee nisi arte ad os et coeteras 
 supernas partes sublatis, et pedibus non suis sed crurum musculis, ad ridiculum ni 
 miserandum incassum compositis, voce clangosa et strepera." 
 
 The course of the disease is usually such as I have just described it. The colic 
 happens first, perhaps several times, and then arrives the palsy. But in a few 
 instances I have known this order reversed. The wrists have dropped, when there 
 tiad been no preceding colic. 
 
 The great cause of this fearful malady Avas first made out by our distinguished 
 countryman. Sir George Baker. He set on foot an inquiry into the origin of what 
 was called the Devonshire colic, so common was it in that county. He found, first, 
 that it occurred chiefly in persons who drank the cider manufactured there ; and, by 
 degrees, he traced the source of the malady to the admixture of lead with the cider ; 
 cither designedly, for the purpose of sweetening it, or by the inadvertent employment 
 of lead in the construction of the cider-mills and vats. It was under circumstances 
 of the same kind that the colic of Poictou originated. Preparations of lead were 
 used — not fraudulently, but openly and honestly — to prevent the wines of the coun- 
 try from turning sour; the injurious influence of lead upon the human body not 
 having then been ascertained. So, also, equally convincing proofs of the adultera- 
 tion of rum by means of lead, giving rise to frequent attacks of dry belly-ache, in 
 the West Indies, are given by Dr. John Hunter, in the Medical Transactions. I 
 invite your attention to his papers, and to Sir George Baker's, on this subject. They 
 afford a capital specimen of medical research and reasoning. Various causes, as you 
 may suppose, had been assigned for this disorder. These are one by one investi- 
 gated and set aside, until, by this method of exclusion, the real source of all the mis- 
 chief is detected. Sir George Baker's papers contain a great deal of curious and 
 useful information in respect to the various modes in which this poison of lead may 
 find its way, without being suspected, into the animal economy. The subject is one 
 of vast importance in its relation to medical police ; but my limits will not allow me 
 to follow it beyond the point where it ceases to be directly connected with the prac- 
 tice of physic. 
 
 Colica Pictonum is seldom fatal as colic, or during the persistence of the abdomi- 
 nal symptoms ; yet instances enough of death occurring while the colic was present, 
 but from other accidental causes, have now been collected, to enable us to say, that 
 no appearances have been met with in the intestinal canal, calculated to explain the 
 pain or the constipation. Andral relates five cases, in which the body was carefully 
 examined after death preceded by the painter's colic. He found neither inflamma- 
 tion, nor any remaining trace of spasm. The intestines were neither dilated no' 
 contracted, but of their natural texture and appearance. Merat, who has written t. 
 good treatise on this form of colic, gives the dissections in four fatal cases : fatal, as I 
 mentioned that they sometimes are, by the supervention of coma. There was no 
 discoverable mark of disease ; the alimentary canal was -empty, and the large bowels 
 contracted ; as they were also found to be in rabbits which had died of lead colic. 
 For animals are susceptible of the disease, and it ma}'' be produced in them by the 
 slow impresrnation of their bodies with the specific poison. Dogs, cats and rats, thai 
 inhabit houses and manufactories wherein lead is much used or prepared, are known 
 
 3r
 
 7D4 COLICA PICTONUM. 
 
 to be attacked both with colic and with palsy. With respect to the contraction of tiie 
 large intestines in these cases, we must not be too ready to attribute it to spasm ; for 
 the bowel, when empty, is apt to be contracted. 
 
 When the palsy has been of any continuance, the affected muscles not only shrink 
 and waste, but undergo a structural change, which is obvious to the sight. They 
 become pale, almost white, dry. John Hunter examined the muscles of the hand 
 and arm of a house-painter, who died, while thus paralytic, in St. George's Hospital. 
 He found them of a cream colour, and opaque, instead of being of a purplish red, 
 and semi-transparent. And, since his time, lead has been detected in the palsied 
 muscles, and in the brain, by chemical analysis. It is doubtless conveyed by the 
 blood to all parts of the body. Why it fastens solely or chiefly on particular mus- 
 cles or particular nerves, nobody knows. The pain it occasions, whether in the 
 abdomen or in the hmbs, is generally thought to be neuralgic. It is one of the poi- 
 sons that do not appear to find a ready exit from the body. Very recently, a most 
 curious symptom, pathognomonic, I believe, of the presence of lead in the system, has 
 been pointed out by Dr. Burton ; and now that it has been pointed out, one can 
 hardly understand how it escaped discovery so long. It is a blue or purplish line 
 running along the edges of the gums, just where they meet the teeth. Dr. Burton 
 first noticed this six years ago, but wisely refrained from making his observations 
 public until he had had time and opportunity enough to satisfy his mind that he was 
 not mistaken. A paper of his on the subject was read at the Medical and Chirur- 
 gical Society last January (1840). I cannot resist the temptation to read to you the 
 notes of a case which has subsequently occurred to me in the hospital. Mary Anne 
 Davis, a middle-aged woman, presented herself with dropped wrists. It was an 
 exquisite example of palsy of the extensor muscles of the hands and fingers. She 
 could raise her arms, but her hands hung down like the talons of a bird, or like the 
 fore paws of an erect kangaroo. This began nine weeks before. She complained 
 of pain, beginning under the nails, stretching up the backs of her hands, and reach- 
 ing sometimes to the elbows. The bottoms of her feet had also been tender, and at 
 night were burning hot. 
 
 Seeing the dropped wrists, we thought immediately of the poison of lead. But 
 the patient was a female. We do not often see these effects of that poison in women ; 
 for obvious reasons. At first we could get no clue to the mode in which lead could 
 have found its way into her system. Her husband was a broker. She had not 
 been living in a newly-painted house : and had (she said) no concern with lead in 
 any way. Lead often creeps in, however, through undetected channels, and I could 
 not help suspecting it here. Mr. Pyper, my clinical assistant, soon elicited another 
 part of her history, which added to our suspicions ; namely, that before the palsy 
 occurred, she had had pains in the abdomen, and costive bowels, for five days toge- 
 ther. Nay, she had a recurrence of colic after her admission. This was a strongly 
 corroborating fact; but what clenched the proof was the discovery of a decided blue 
 rim along the edges of nearly ail her gums. This conclusive evidence led to further 
 cross-examination ; and at last it came out that some of her sons (she had seven) had 
 occupied their leisure time in the preceding summer with making bird-cages, and 
 painting them green, in the one room in which she habitually lived. The case alto- 
 gether was a very neat one. 
 
 Mr. Tomes pointed out to me some interesting circumstances, which led him, at 
 one time, to think it probable that the colour might be produced by some chemical 
 action between the tartar that forms on the teeth, where they meet the gums, and 
 the lead which pervades the system. This woman's teeth, like those of man)^ in 
 her rank of life, were loaded with tartar. In one place was visible a stump, level 
 with the gum, and surrounded by a ring of tartar; and there was also a correspond- 
 ing border of blue. In other places there were gaps, where teeth once were ; here 
 there was, of course, no tartar; and here there was no blue line on the edge of the 
 gum The blueness may however appear when there is no tartar at all. I do not 
 know exactly m what manner the chemical union arises, but the colour depends, I 
 beheve, upon a sulphuret of lead, formed somehow by the action of sulphuretted 
 hydrogen upon the metal. It is curious that the edge of the gum should always be
 
 COLICA PICTONUM. 795 
 
 the part thus marked ; that very part which first exhibits the influence of another 
 metal, mercury, when ptyalism is about to ensue. 
 
 This discovery of Dr. Burton's is not a mere piece of curiosity, but is likely to 
 be of use in various ways. In the first place, it may settle the nature and cause of 
 many doubtful cases; as it did, indeed, of the one just narrated. The poison of 
 lead produces pains which resemble, und no doubt are sometimes mistaken for, the 
 pains of rheumatism; it has other obscure consequences too: and an inspection of 
 the gums may often greatly elucidate such cases. Dr. Burton finds that small 
 quantities of lead given as a medicine will produce the phenomenon. In two in- 
 stances it occurred within two days. One of these patieiid^iad taken fifteen grains 
 of the acetate of lead in that time ; the other twenty-four grains. A correspondent 
 of his produced the blue rim in twenty-four hours ; viz., by four doses, of five grains 
 each, exhibited every six hours. He finds too that the line remains distinct after 
 death ; even more so than during life. It may atford valuable inibrraution therefore 
 to the medical jurist in cases of suspected poisoning with the salts of lead. It is, I 
 say, an early consequence of the absorption of lead. It will teach us, as the mercu- 
 rial affection of the gums teaches us, that the medicine is pervading the system ; and 
 admonish us to look out for, and guard against, colic. It may apprise workers in 
 lead that their caution has been insufficient ; that the poison has entered ; and that 
 they are in peril of belly-aches and palsy. It is a capital diagnostic sign also be- 
 tween colic so arising, and colic from other causes ; and between cohca Pictonum, 
 and the pain of inflammation of the bowels. 
 
 [The symptoms of colica pictonum, or lead colic, are in some respects different from those 
 of ordinary colic. There is usually, at first, a loss of appetite, ^vith some degree, more or 
 less in different cases, of nausea, and very commonly an increased discharge of saliva. The 
 patient's sleep is disturbed, or more frequently, there is an inability to sleep ; according to 
 M. Ranque, of Orleans, he exhibits various other symptoms of a disordered condition of the 
 nervous system. The attack of colic usually commences with vomiting ; the matter dis- 
 charged being, at first, whatever has been taken into the stomach mixed with bile and the 
 gastric secretions, very generally changed from their healthy condition; if the vomiting con- 
 tinue, these latter are alone discharged. Pain of the abdomen is next complained of; it is 
 most severe about the navel, the epigastrium, the hypochondria, the loins, and above the crest 
 of the ileum. The pain, in general, commences at the hypogastric region, or, as a cramp, at 
 the pit of the stomach, and from thence extends, in a short time, over the rest of the abdo- 
 men. The pain is at first paroxysmal, with intervals of ease ; these intervals being the 
 longest at the commencement of the attack. More commonly there occur remissions ratlier 
 than intermissions of the pain; and it is remarked, that both the remissions and exacerba- 
 tions are much longer than those of ordinary colic. As the disease advances the pain is 
 almost constant, but is usually most severe at night. It is not increased by pressure; on the 
 contrary, pressure very generally, but not invariably, affords relief, provided it be not made 
 upon the epigastrium ; according to Merat, patients have been known to bear, with relief JD 
 tlie paroxysms, the weiglit of two or tliree persons standing on the belly. The abdomen is 
 almost invariably hard and flat from a contraction of its niuscles ; the navel is sometimes 
 drawn in so as almost to approach the spine; in a kw instances there exists some fiUlness of 
 the abdomen, and occasionally it has an irregular, knotty feel. There generally occur, within 
 the first day or two, sometimes within the first few hours of the attack, headache, and a dull, 
 anxious, or depressed expression of the countenance ; to these symptoms are soon added, 
 pains of the limbs, especially of the inside of the thighs, calves of the legs, ankles, and soles 
 of the feet; these pains are worst at night; they are often accompanied with cramps, and 
 according to Tanquerel, are relieved by pressure. The disease is seldom attended with febrile 
 excitement. The skin is of a dull, dirty cadaverous appearance ; it is frequently hot, and 
 almost invariably bedewed with irregular, clammy, and often cold, perspiration. The pulse, 
 according to SIM. Ranque and Merat, is rarely accelerated, but often below G0° in a minute ; 
 others, however, notice a considerable acceleration of the pulse, which we have remarked in 
 many cases, the pulse being at the same time hard, and communicating to the finger a pecu- 
 liar thrill. Obstinate constipation of the bowels is an almost invariable symptom; although 
 it does not always occur at the very commencement of the attack ; in a few instances, it is 
 said that the attack has been attended with diarrhcea; such an occurrence, howe' er, we have 
 never observed. On the contrary, in all the cases that have fallen under our -otice, either 
 no discharge has taken place from the bowels, or a scanty stool has occurred composed of a 
 few lumps of dry, hardened feces, passed with much straining and pain. The urine, 
 though generally natural in appearance, is often diminished in quantity. 
 
 From an attack of colica pictonum, particularly a first attack, the patient may, under a
 
 796 COLICA PICTONUM. 
 
 judicious and timely treatment, recover perfectly ; and with a careful avoidance of any oi 
 its exciting causes, and of the poison of lead, he may remain ever after free from a recur 
 rence of the disease. When the disease, however, is neglected, or badly managed, or the 
 patient is constantly or repeatedly exposed to the influence of lead, he becomes affected either 
 with a peculiar form of partial palsy, which is well described by Dr. Watson in the text; or, 
 instead of this gradual loss of voluntary motion in the muscles of the extremities, there occur 
 another set of symptoms, which very generally terzninate speedily in death. The patient 
 after a few days becomes affected with giddiness, great debility, torpor, and sometimes deli- 
 rium : as the torpor advances, the pains in the abdomen and extremities abate ; at length 
 convulsions, and a comatose condition ensue, from which very few recover. Cases are 
 recorded by Louis and others, in which death suddenly occurred during the first stage of the 
 disease, without the occurrence of any symptoms that would cause such a result to be sus- 
 pected. Drs. Elliotson and Copland each relate a case in which death was caused by per- 
 foration of the stomach. To a paralytic affection of the muscles of the extremities, as a 
 very common eftect of repeated attacks of colica pictonum, we have already referred ; and 
 two cases are related by Dr. Alderson, of Hull, England, in which the disease was attended 
 with paralysis of the nerves of vision ; Tanquerel states that this is not uncommon in Paris, 
 the paralysis being attended with dilated and immovable pupils ; he met, also, with one in- 
 stance in which deafness was present, no doubt from paralysis of the auditory nerve. — C ] 
 
 In the treatment of colic — and especially of the lead colic — the great indication is 
 to get the bowels to act. If the pain of the belly be increased on pressure, if the 
 pulse be at all accelerated, if the face be flushed, and there be the shghtest approach 
 to fever, it will be right to take blood from the arm. It is a measure of safety as 
 regards the possible existence of inflammation : and if there be no inflammation pre- 
 sent or impending, it will tend to remove the spasmodic state of the muscles which 
 goes along with, and perhaps chiefly constitutes, the disease. External warmth 
 should also be applied ; dihgent friction, with some stimulating liniment ; or, what 
 is much better, a mustard poultice, or a turpentine stupe. My colleague. Dr. Wil- 
 son, has been very successful in relieving these patients, by putting them into a hot 
 bath, and having a large quantity of the water in which they are immersed, thrown 
 gradually into their bowels by means of a proper syringe. The bath presently be- 
 comes polluted, to the great satisfaction and refreshment of the patient. It will 
 generally be expedient to give a full dose of calomel and opium ; ten grains of the 
 one with two of the other. Sometimes the effect of the opiate is to suffer the bowels 
 to empty themselves ; showing that the previous difficulty was probably spasmodic. 
 Usually the calomel and opium will soothe the vomiting, the restlessness and the 
 pain ; and then a full dose of neutral salts, or of castor oil ; or (if these do not suc- 
 ceed) of the last named remedy, castor oil, quickened by one or two drops of the oil 
 of croton, will produce free evacuations from the bowels; and the patient soon re- 
 turns to his ordinary state of health. It is sometimes necessary to repeat this prac- 
 tice, this alternation of purgatives and anodynes: but when once the bowels have 
 been freely moved, the disease, in general, becomes very tractable. 
 
 At La Charite, in Paris, there is what is called a specific mode of treatment fol- 
 lowed. It is complicated and rough, bu't not a whit more successful than the simpler 
 plan which is universally adopted in this country. You may see it described, if 
 you are curious on the subject, in most of the French books. I think it is given in 
 detail in Ratier's Formulary of Hospital Practice. 
 
 Some have recommended salivation for the cure of the painter's colic, on the 
 principle, I conjecture, of driving out one metallic poison by another. But the two 
 may combine, for aught I know, to plague the patient. The practice is quite unne- 
 cessary. 
 
 You will be consulted about the palsy which arises from lead, and especially to 
 remedy the dropped wrists, which render the patient incapable of earning his liveli- 
 hood. Now in the early stages of the palsy, and in its primary attacks, you may 
 often succeed in effecting a cure. Electricity has long been thought useful, apphed 
 in the way of sparks at first, and of shght shocks afterwards, along the muscular 
 parts of the extensors of the fingers. It accelerates the recovery to give the hand 
 and fingers the mechanical support of a splint, made for that express purpose, and 
 so contrived that the hand and fingers are kept extended through the greater part of 
 the day. Patients labouring under this kind of palsy resort to the Bath waters for
 
 COLICA PICTONUM. 797 
 
 a cure : and I learn from a gentleman who once held the office of house-surgeon to 
 the hospital there, that the physicians have much more faith in the use of the baths, 
 with shampooing, and in splints and blisters to the palsied muscles, than in electricity. 
 The warm douche is a promising expedient : the electro-magnetic apparatus, per- 
 haps, still more so. 
 
 According to Andral and others, who have had more experience of that drug than 
 I have, there is no form of palsy so Hkely to be benefited by strychnine as this which 
 proceeds from the poison of lead. I should recommend you to try the safer methods 
 of binding the hand to a splint, and stimulating the muscles by friction, shampooing, 
 or electricity, before you resort to that active poison. 
 
 It is observable of this disease, as of many, and, indeed, of most others, except 
 certain contagious febrile diseases, that when once it has occurred, it is much more 
 liable to occur again, upon a repetition of the exciting cause, than before. It is of 
 very great moment, therefore, that they who are necessarily exposed to the poison 
 of lead — as painters, plumbers, printers (who handle leaden types), colour-grinders, 
 potters, and glass-blowers (who use the oxide of lead in their respective manufacto- 
 ries), shot-makers, workers in lead mines, and so on — it is of great importance that 
 these persons should be made aware of the means which are best adapted for their 
 protection against the injurious agency of the poison : and we ought to be able to 
 give them advice in that matter. The rules for their guidance are short and simple ; 
 and, if carefully observed, I believe they will generally prove successful. They 
 resolve themselves into cautions against the admission of the metal or its compounds 
 into the body through any channel. 
 
 1. To prevent its introduction through the skin minute attention to cleanliness is 
 necessary. The face and hands should be washed, the mouth rinsed, and the hair 
 combed, several times in the day ; and bathing and ablution of the whole body should 
 be frequently performed : also, the working-clothes should not be made of woolen, 
 but of strong compact linen ; and they should be washed once or twice a week at 
 least ; and they should be worn as little as possible out of the workshop : and some 
 light impervious cap mi^ht protect the head while the person is at work. 
 
 2. Care should be taken that none of the poison be admitted into the system with 
 the food. The workmen, therefore, should not take their meals in the workroom, 
 and should be scrupulous in cleansing their hands and lips before eating. 
 
 3. The entrance of the poison into the air-passages during respiration should be 
 guarded against as much as possible. Masks have been recommended for this pur- 
 pose : none, probably, would be more convenient or more effectual, than Mr. Jeffrey's 
 orinasal respirator. 
 
 There is a notion prevalent in some places, which apparently has some founda- 
 tion, that the free use of fat, and of oily substances, as food, is a preservative against 
 the colic. A physician, near Breda, informed Sir George Baker that the village in 
 which he lived contained a great number of potters, among whom he did not witness 
 a single case of lead colic in the course of 'fifteen years; and he attributed their 
 immunity to their having lived very much on butter and bacon, and other fat kinds 
 of food. De Haen also was told by a physician, the proprietor of a lead mine in 
 Styria, that the labourers there were once very subject to colic and palsy ; but that 
 after they were exhorted by a quack doctor to eat a good deal of fat, especially at 
 breakfast, they were exempt from these disorders for three years. This is a kind 
 of prophylaxis that is very easily adopted. 
 
 More recently Liebig has asserted that " the disease called painter's colic is un- 
 known in all manufactories of white lead in which the workmen are accustomed to 
 take, as a preservative, sulphuric acid lemonade, a solution of sugar rendered acid 
 by sulphuric acid." 
 
 If this be so, the lemonade must protect the system by converting any other salt 
 of lead, which might find entrance, into an insoluble sulphate : solubility being 
 requisite to give efficacy to any poisonous substance. 
 
 Mr. Benson, the manager of the British white-lead works, in Birmingham, states 
 (in the Lancet) that he has tried this method of prevention. Under his direction 
 sulphuric acid was first added to the treacle-beer, used as a beverage by the work- 
 
 3r2
 
 798 DIARRHCEA. 
 
 men, in the summer of 1841. Lead colic, which had prevailed before " to a dis 
 tressmg extent," soon began to diminish in frequency : and from October in the 
 same year, up to the date of Mr. Benson's communication in December, 1842 — a 
 period of fifteen month? — not a single instance of the disorder had occurred amongst 
 them. This is very encouraging. 
 
 LECTURE LXXII. 
 
 Diarrhoea. Sporadic Cholera, Epidemic Cholera 
 
 Tke morbid fluxes which proceed from the long tract of mucous membrane that 
 lies between the stomach and the anus are many in number: and they vary much 
 both in kind and in cause. Hemorrhages are not uncommon. I have already de- 
 scribed the disease called melsena, which is characterized by the discharge of black 
 semifluid matters, resembling tar, from the bowels, and in most instances from the 
 stomach also by vomiting. The matters vomited, and the matters passed by stools, 
 are composed principally of blood, Avhich has been rendered black, and otherwise 
 modified in appearance, during its progress onwards in the one direction and in the 
 other. Again, hemorrhage from the bowels is apt to occur in continued fever ; as I 
 shall show j'ou when we come to that disease. Hemorrhage takes place also from 
 the rectum in hsemorrhois, or bleeding piles : a malady that falls chiefly to the care 
 of the surgeon. Blood comes awa}^, too, mixed with a greater or less quantity of 
 mucus, in dysentery. 
 
 The remaining forms of profluvia from the intestinal canal I shall proceed to con- 
 sider seriatim ; at least the most important of them. 
 
 There are several very different affections classed together under the head of 
 diarrhcea: by which term is usually signified the occurrence of frequent, loose or 
 liquid alvine evacuations. Thus diarrhcea is a very common sj-mptom of pulmo- 
 nary phthisis ; and this form of the disorder has been already mentioned. It is very 
 oiten met with also in continued fever, and during the decline of the febrile exanthe- 
 mata, of which I have yet to speak. But diarrhcea is not unfrequently the main 
 symptom of the illness under which the patient labours; and constitutes, at any rate 
 the chief object of our treatment. I shall touch briefly on some of its varieties. 
 
 In the first place, there is that common form of the complaint which proceeds 
 from over-repletion of the stomach ; or from the ingestion of food that is not whole- 
 some : food that disagrees (as the phrase is) with the patient's stomach and bowels 
 at that particular time. We may call it, with Cullen, by way of distinction, diarrhoea 
 crapnlosa: in which feces are discharged in a more liquid state, and more copiously, 
 and more often, than is natural. These cases are in truth slight cases of irritant 
 poisoning. The ingesta irritate the mucous surface, and probably the muscular coat 
 also ; the secretions of the inner membrane are poured forth in unusual abundance, 
 and the peristaltic motions of the intestines become more strong and active ; the ob- 
 ject of these changes being that of getting rid of the offending substances: a salutary 
 and conservative effort, which we assist and imitate in our treatment of this form of 
 diarrhoea. 
 
 The symptoms by which this species of diarrhoea is marked, must be well known 
 to us all. There are often nausea; flatulence; griping pains in the bowels, suc- 
 ceeded by stools of unnatural appearance and odour, and of fluid or watery consist- 
 ence. There are often, also, a furred tongue and a foul breath : but the disorder is 
 attended with little or no fever ; the pulse remains of the ordinary frequency ; and 
 the temperature of the body does not rise. 
 
 There are certain things which, more than others, tend, when taken into the sto- 
 mach, to cause this crapulous diarrhoea : and there are certain circumstances which 
 increase the disposition to be affected by the ordinary exciting causes.
 
 DIARRHCEA. 799 
 
 We frequently see this disorder supervene upon a debauch, in which case the 
 mixture of various articles of food, and of drink, each of which in itself might have 
 been perfectly innocent — and the actual quantify of the mixed ingesta — have occa- 
 sioned the irritation and disturbance, Byjt Avhere there has been no intemperance in 
 eating or drinking, some kinds of food are more likely than others, cxteris paribus, 
 to provoke diarrhoea. I do not speak of idiosyncrasies, which show the truth of the 
 old proverb, that what is one man's meat is another man's poison, and which cannot 
 be reckoned upon beforehand ; but I refer to the average of systems and stomachs. 
 And among these indigestible and irritating substances we may place raw vege- 
 tables of many kmds ; such as cucumbers and salads, sundry kinds of fruit, espe- 
 cially if they be hard, immature and acid ; plums, melons, pine-apples, nuts, and so 
 forth. Mushrooms may be added to the hst, even when they are cooked. Putrid 
 food, or food which, in the more refined phraseology of gastronomers, is termed 
 high, has the same effect upon some persons : and so, in a particular manner, have 
 some kinds oafish ; shell-fish, crabs and muscles, for instance, in this country ; and 
 in other countries, in the West Indies, there are several species of fish which are 
 actually poisonous, and cannot be safely eaten at all. And similar disorder is fre- 
 quently produced in children by any sort of food, other than the natural sustenance 
 furnished by the mother. The new kind of nutriment disagrees with them : and the 
 very same thing is apt to occur in adult persons. An article of diet which is per- 
 fectly wholesome and digestible, and which the stomach bears well after a little habit, 
 will sometimes cause griping and purging, when it is taken for the first time. It is 
 upon this principle that the diarrhoea to which Englishmen are subject upon first 
 visiting the towns upon the continent, is to be explained. I do not know that it is 
 so, but I think it very likely that Frenchmen, and Germans, and Italians, suffer 
 in the same way when they first come to this country, and adopt our habits and 
 regimen. 
 
 Another curious exciting cause is to be found in certain mental emotions, and 
 especially the depressing passions; grief, and above all, fear. A sudden panic will 
 operate on the bowels of some persons as surely as a black dose, and much more 
 speedily. Among the circumstances which predispose most persons to this kind of 
 malady, we may particularly specify season — the hot weather of summer and au- 
 tumn. And it is probably consistent with the experience of most of you, that the 
 atmosphere of the dissecting-room has a similar tendency. 
 
 Now this diarrhoea, from occasional irritation, produced by the presence of sub- 
 stances that offend the stomach or bowels, will generally cease of itself. The purging 
 is the natural way of getting rid of the irritant cause. We may favour the recovery 
 by diluent drinks, and by making the patient abstain from all further use of food 
 which is not perfectly easy of digestion ; and we may often accelerate the recovery 
 by sweeping out the alimentary canal by some safe purgative, and then soothing it 
 by an opiate. Or we may give the aperient and the anodyne together, and the one 
 will not interfere with the operation of the other. A table-spoonful of castor-oil, 
 wAh. six or eight minims of laudanum dropped upon it : or from fifteen grains to a 
 scruple of powdered rhubarb, with half as much of the pulvis cretse cumpositus cum 
 opio. By some such medication as this, emptying the bowels, and quieting them, 
 the cure is generally accomplished with ease, and speedily: tutd, cito, etjucunde. 
 
 We sometimes, however, meet with cases in which diarrhoea runs on ; the stooL< 
 being composed of fecal matter in an unnaturally fluid state ; and the precise condi 
 tion on which this disposition to an over-loose slate of the bowels depends, escaping 
 detection. If the disorder be slight, it will often yield to the astringent and bitter 
 medicines. The infusion of cusparia, with the tincture of cinnamon, supplies a con- 
 venient formula. If it be more severe, or obstinate, we have recourse to a chalk 
 mixture, which neutralizes acidity ; com-bined with catechu, which is a direct astrin- 
 gent of the tissues ; and with laudanum, which calms irritation. And in extreme 
 cases the sulphate of copper has been found to have a powerful efiect in restraining 
 the flux. It is apt to gripe, and should be combined therefore with opium. A quar 
 ter of a grain of each, in a pill, given three or four times a day, I have frequently 
 found successful, when previous attempts to remove the diarrhoea had failed.
 
 800 DIARRHOEA. 
 
 [A much more effectual remedy is the acetate of lead, combined with opium and ipecacu- 
 anha ; one grain of the first, from a fourth to the half of a grain of the second, and from 
 half a grain to a grain of the latter, combined in the form of a pill, or in a powder, mixed 
 with a little simple syrup, may be given to an adult, and repeated every three or four hours 
 according to circumstances. 
 
 Diarrhrea in a chronic form is that which the practitioner will be the most frequently 
 called upon to treat in the adult; and it, in general, requires for its complete removal a cau- 
 tious and judicious course of treatment persevered in for a length of time. The slightest 
 deviation from the strict diet and regimen required in each case, will often very considerably 
 protract the cure ; while a too early abandonment of the appropriate remedies ■will fre 
 quently be quickly followed by a return of all the worst symptoms of the disease. 
 
 In chronic diarrhoea there exists a morbid excitability of the intestinal canal, so that almost 
 everything taken into the stomach, as food or drink, brings on quickly repeated discharges by 
 stool consisting of the ordinary secretions of the digestive tube, more or less changed in cha- 
 racter, mixed with portions of half digested aliment ; and the looseness continues, often un- 
 attended with griping, or any other uneasy sensation save those connected with the debility 
 and emaciation produced by the interruption to the digestive and nutritive functions generally, 
 which the rapid passage of the aliment through the bowels occasions. There is no doubt, 
 that frequently the morbid excitability of the digestive canal is due to a chronic inflamma- 
 tion, often follicular, and attended with ulceration of some portion of its mucous membrane; 
 when this is the case, we have repeated discharges by stool without apparently any exciting 
 cause other than the morbid secretions of the liver, pancreas, or of the stomach and intes- 
 tines themselves. The discharges are, in general, dark-coloured and offensive, very fluid, and 
 small in quantity, and are often preceded and accompanied by griping pains more or less 
 severe. There is, very commonly, some degree of nausea, and occasionally vomiting, the 
 appetite for food is generally destroyed, though in many cases it continues unimpaired. The 
 patient becomes more and more emaciated and debilitated ; his skin assumes a dirty sallow 
 hue and a dry harsh feel; the palms of the hands become hot and dry; the countenance has, 
 in many cases, a dull, desponding expression; the features acquire considerable sharpness, 
 and the eyes become sunken and surrounded by a broad leaden-coloured ring. The abdo- 
 n^n is frequently flaccid, and exhibits no tenderness upon moderate pressure; occasionally, 
 however, it becomes swollen and tympanitic, and is now and then decitledly tender to the 
 touch. We have known in cases of chronic diarrhcea, an effusion of serum to occur within 
 the peritoneal cavity, and to produce a very decided intumescence of the abdomen. In pro- 
 tracted cases, the body exhales a peculiar sickly odour, the tongue becomes of a dark maho- 
 gany hue, and often, together with the parietes of the mouth, is covered with aphthas. The 
 pulse is usually small and feeble, often quick and frequent. Febrile symptoms are not gene 
 rally present; in many cases, however, there is observed some degree of febrile excitement 
 towards evening — very protracted cases we have repeatedly known to be accompanied with 
 well-marked hectic symptoms — more or less pufliness of the face, and cedematous swelling 
 of the extremities, very commonly occur in the course of the disease. The discharges by 
 'jtool, while they are always fluid and vitiated, exhibit considerable variety in their appear- 
 ance ; most gencraUy they are dark-coloured, and exhale a rancid or fetid odour; occasion- 
 ally, however, they have a jelly-like consistence, and very little smell; at other times they 
 consist of a small quantity of a dirty yellow fluid, and when they contain solid matter this 
 will generally be found to consist of portions of half-digested aliment. All these changes in the 
 character of the discharges may present themselves in the same case, and often within a very 
 short period. In protracted cases, the discharges would appear to acquire an acrid property, pro- 
 ducing an erythematous inflammation of the verge of the anus, and often of the nates. The 
 frequency of the stools varies very much in different cases, and at different periods in the 
 same case. Occasionally, the diarrhoea takes place only after the ingestion of food or drinks, 
 or of particular kinds of food, and the discharges from the bowels continue to recur at short 
 intervals until the offending matters are got rid of; in many cases, repeated stools occur in 
 the course of the day, whether food is taken or not, and are suspended during the night ; in 
 other instances the evacuations from the bowels often cease for a day, or even longer, and 
 then return, and for a short period with increased frequency. 
 
 The duration of chronic diarrhoea is very various ; unless arrested by a proper course of 
 treatment — its spontaneous cessation being a thing of very rare occurrence — it will run on 
 for weeks, often for months, and the patient finally sinks from extreme exhaustion. Occa- 
 sionally perforation of the intestines occurs from ulceration or softening, and the fatal event 
 is preceded by peritonitis. 
 
 Tne causes of chronic diarrhoea are the same as those of the acute or simple form of the 
 disease ; frequent attacks, within a short period, of an ordinary bowel complaint, will very 
 commonly induce a chronic affection. — Improper articles of diet, and acescent drinks, habit 
 ually mdulged in ; exposure to a cold, and, at the same time, humid atmosphere ; the abuse 
 *f purgatives, and intemperate habits generally, are among the most common causes of
 
 DIARRHCEA. 801 
 
 chronic diarrhoea. It is an affection much more readily induced in those of a lax, and feeble, 
 excitable and broken-down constitution, than in tho.se of an opposite condition. 
 
 The state of the intestinal tube in those who have fallen victims to the disease is very 
 various. In some cases, the mucous coat, particularly of the large intestines, is somewhai 
 thickened, spongy, and pale — in others its anatomical characters are entirely changed, large 
 portions of it presenting a smooth, glassy, mottled appearance, as though its surface had been 
 covered with a thin coating of dirty varnish. Occasionally large patches of the mucous mem- 
 brane of the colon or rectum are of a dark mahogany or of a slate colour — • the traces of 
 follicular inflammation, or of ulcerations, more or less extensive, are not unfrequently met 
 with, especially in the ileum and colon. Dr. Stokes notices a form of chronic diarrhcBa as 
 of common occurrence, dependent upon ulcers situated close to the verge of the anus ; these 
 ulcers occur chiefly in persons of a broken-down constitution, and those who have taken a 
 great deal of mercury ; we have repeatedly observed them, also, in individuals, who have 
 been in the habit of using almost daily the various pills composed chiefly of aloes, soap, and 
 Bcamniony, or gamboge, vast quantities of which are vended in the United States as a popu- 
 lar remedy for almost every ailment. The ulcers situated just within the anus produce irri- 
 tation in the colon, tenesmus, griping, frequent discharges by stool, and most commonly dur- 
 ing the straining a little blood is passed. The presence of the ulcers may be at once detected 
 by an examination of the rectum ; which examination, as Dr. Stokes very correctly remarks, 
 should invariably be made in all cases where the diarrhoea has been of long standing, and 
 has resisted a great variety of treatment ; where it is attended with tenesmus, and a desire 
 of sitting on the night chair after a stool has been passed ; and, finally, where the patient's 
 health does not appear to be so much affected as it naturally would be from long-continued 
 disease of a large portion of the great intestine. 
 
 In the treatment of chronic diarrhoea our leading indications are, to control the morbid 
 irritability or excitability of the intestinal mucous membrane, and restore it as quickly as 
 possible to its healthy condition and functions. To effect these objects is not always, how- 
 ever, a very easy task, and always demands considerable judgment on the part of the prac- 
 titioner, and considerable patience, and an implicit obedience on the part of the patient to 
 the medicinal direc^tions and dietetic rules laid down. The first and all-important considera- 
 tion is that of diet — so that, while the patient is supplied with aliment caleulateii for his 
 support, as little irritation as possible of the intestines shall be excited by it. The food taken 
 by an individual labouring under chronic diarrhcEa should be easy of digestion, of the mildest 
 quality, and such as leaves, after undergoing digestion, but a small quantity of excrementi- 
 tious matter ; and even of such food but a small portion shoiHd be taken at a time. Rice is 
 probably the best article of diet in the generality of cases of chronic diarrhoea; when well 
 boiled, with the addition of a little salt, while it is sufficiently nourishing it is extremely mild 
 and unirritating, by no means difficult of digestion, and scarcely affords any excrementitious 
 matter to be transmitted along the intestines. It may, generally, be eaten mixed with a 
 very moderate quantity of plain beef or mutton broth ; plain meat broths prepared whh the 
 addition of a large amount of rice, will often furnish a very suitable food in chronic diarrhoea, 
 and are to many stomachs more palatable ; rice, also, boiled with milk and sweetened, but 
 not too heavily, with the best of loaf sugar, or fresh milk thickened with rice flour, may be 
 occasionally given. Should either preparation, however, be found to disagree with the 
 patient, or to augment or keep up the diarrhoea, it should be at once relinquished. We have 
 indeed, in numerous instances, found plain broths, when well prepared, or the juice of 
 roasted meats with a portion of stale bread or cracker broken into it, agree better than any 
 preparation of rice. Tapioca, sago, or arrow-root, we have seldom found an appropriate ali- 
 ment for persons labouring under the chronic form of diarrhcEa. As soon as it can be borne, 
 and this can only be ascertained by a cautious trial, a small portion of tender chicken, tur- 
 key, or mutton, plainly boiled or roasted, may be eaten with rice. Pure water, toast water, 
 or rice water, taken cold and in very moderate quantities at a time, should be the only drink 
 allowed. 
 
 Next, or more properly perhaps, equal in importance to a well-regulated diet, is an atten 
 tion to the clothing and regimen of the patient. Individuals affected with chronic diarrhosa 
 are particularly susceptible to the influence of a cold and damp atmosphere — a slight ex- 
 posure to which will often increase their disease, or when we have succeeded in diminish- 
 ing the frequency of the discharges, causes them to return as before. It is essential, thens- 
 fore, that independent of cautiously avoiding every species of exposure, the patient should bo 
 suitably lodged and clothed. The chamber he occupies at night, as well as during the day, 
 iiliould be dry, of a comfortable and equable temperature, perfectly clean, and well ventilated ■ 
 his clothing should be adapted to the season and state of the weather — flannel next the skin 
 should always be worn; a belt of flannel around the abdomen, or enveloping this part with 
 a flannel roller nicely adjusted, and renewed daily, will always be found advantageous. In 
 obstinate and protracted cases, the removal of the patient from a cold, damp, and changeable, 
 to a more equable, warmer, and drier climate, whenever praoiicable, is a measure fioiv. 
 51
 
 802 DIARRHCEA. 
 
 which the very best results are to be anticijiated ; it has, in numerous instances, been known 
 to effect a speedy cure, when all other means have failed. 
 
 In regard to exercise, even the gentlest kind, whether passive or active, cannot sometimes 
 Le undertaken, from the frequent and pressing calls to evacuate the bowels which occasion- 
 ally are found to be excited by motion of every kind : in other cases, short walks in the open 
 air, in suitable weather, or a gentle ride in an open carriage, or sailing in a boat, are advan- 
 tageous, and should be repeated daily if the patient's strength will admit of it. 
 
 The warm bath, followed by brisk friction of the surface, is a remedy from whicli the best 
 effects are to be anticipated in most cases of chronic diarrhoea; it maybe repeated daily, the 
 temperature of the water being carefully graduated by the condition of the patient's surface; 
 when this is dry and warm, a tepid bath should be preferred, but if the surface is cool, or 
 its heat is not well sustained, the water should be decidedly warm. The temperature of 
 the bath should never be so low as to cause the patient when innnersed in it the slightest 
 sensation of chilliness on the one hand, nor so high on the other, nor the continuance in it 
 so long, as to produce profuse perspiration. 
 
 By a few physicians the effects of leeches to the abdomen or to the anus, in cases of chro- 
 nic diarrhoea, are spoken of in the highest terms of commendation. Drs. Crampton and 
 Forbes, in their very excellent essay on the disease under consideration, contained in the 
 Cyclopsedia of Practical Medicine, {Philadelphia Edition, vol. i., p. 640,) speak of leeclies ap- 
 plied to the anus, as a remedy " possessed of remarkable powers — often working,'' according 
 to the common expression, "like a charm, even in cases of diarrhcEa of vej'y long standing, 
 and of different external characters. Combined with proper diet, indeed, we are per- 
 suaded," tliey remark, "that the greater number of diarrheas, both acute and chronic, will 
 yield to this method, with little or no aid from other medicine.'' — "Although, in our prac- 
 tice, we always," they add, "combine with the use of leeches, in the cases where they are 
 indicated, a proper diet, yet we have had ample evidence of their unassisted powers in 
 checking or removing diarrhcea of great severity and obstinacy." 
 
 It is certain that many of the most obstinate cases of chronic diarrhoea are kept up by a 
 subacute inflammation of some portion of mucous membrane of the large intestines, and in 
 such cases a well-timed application of leeches to the anus will be productive of the best 
 effects. In such cases, the earlier the leeches are applied the better. In detectinT; the cases 
 in which leeching is indicated, will demand a good deal of tact, and close habits of observa- 
 tion on the part of the practitioner — his judgment must be made up from an inquiry into the 
 history, and a careful analysis of all the circumstances of each case, for we know of no lead- 
 ing phenomena by which those cases where leeches are calculated to do good can be distin- 
 guished from those to which they are not adapted ; as a general rule, however, we are per- 
 suaded that in well-marked cases of chronic diarrhcea, particularly when the disease has 
 existed for any length of time, leeches are at best a doubtful, if not an improper remedy. 
 
 Blisters to the abdomen will, we apprehend, be found more generally advantageous than 
 leeches ; we have found them to produce a speedy, marked, and prompt amelioration in the 
 l^rominent symptoms of the case; the frequency of the stools, under their use, being siseedily 
 diminished, and the discharges assuming a more natural appearance. In many instances, 
 however, we confess that no benefit whatever has resulted from repeated blisters. They are 
 a remedy, nevertheless, which so generally do good that they should not be overlooked. 
 Keeping on the blister for a few hours, and then replacing it by a soft emollient poultice; 
 repeating it as soon as the vesicated surface has healed, is a preferable plan to allowing the 
 blister to remain on until complete vesication is produced, and keeping up the irritation thus 
 produced by stimulating dressings. 
 
 The principal internal remedies from which any good effects are to be anticipated are, 
 opiates and astringents. Opium, either by the mouth, or introduced into the rectum, in the 
 form of an injection, acts beneficially by quieting the pain and other uneasy sensations under 
 which the patient labours, as well as by allaying the irritability of the bowels, and thus sus- 
 pending the frequency of the stools ; it aids in this manner the efficacy of whatever astringent 
 is r,«.ade use of. The Dover's powder will frequently be the best form in which the opium 
 can be administered ; or, if this be found to disagree with the stomach, as will sometimes 
 be the case, the opium may be given in the form of a pill; combining it with a small por- 
 tion of ipecacuanha, we have generally found advantageous : or the opium may be given as 
 an enema rubbed up with starch. The dose of the opium, and the period of its repetition, 
 must be left to the judgment of the practitioner. — We have not derived the same advantage 
 in cases of chronic diarrhoea, from the salts of morphium as from the opium itself. 
 
 Of astringents, nearly the whole list, both vegetable and mineral, has been recommended, 
 and each one is praised by different practitioners as particularly efficacious in the disease 
 under consideration. The vegetable astringents most deserving of attention are, the catechu, 
 kino, galls, logwood, blackberry root, and the root of the geranium maculatum. The first 
 may "up given in t'.s form cf the infus. catechu comp. Dr. Pemberton prefers the kino tc all 
 other astringents, in chrome diarrhoea; he gave it in doses cf a scruple made in a bolus with 
 opiate confection (on Diseases of jib dam. Viscera'). More recently, an extensive series of ex
 
 DIARRHCEA. 803 
 
 periinents on the effects of kino in diarrhoea were made in the hospital La Pitie, in Paris, by 
 M. Bally. In chronic diarrhoea, unaccompanied by fever or marks of inflammation in the 
 mucous membrane, the continued use of the remedy, even for a short time, was found almost 
 invariably to be effectual in stopping the diarrhoea. In one case of three years standing it 
 effected a cure. But the most remarkable result of M. Bally's experiments is the alleged 
 fact — that the kino, given in doses of twelve or fifteen grains, for several days in succession, 
 succeeded in curing diarrhoea attended by febrile and inflammatory symptoms. (Crampton 
 and Forbes, from Med. Gazette, v. 70D.) We have repeatedly employed both the catechu and 
 kino in cases of chronic diarrhoea where astringents were evidently indicated, and although 
 their beneficial effects were often promptly exhibited, they have, nevertheless, repeatedly 
 failed in diminishing the frequency of the discharges ; we have found the galls, either in 
 powder — combined with camphor or opium, and not unfrequently with both — or in decoc- 
 tion, a much more effective astringent in protracted and obstinate cases of diarrhoea, than 
 either the kino or catechu. The logwood in decoction is a favourite remedy with many prac 
 titioners ; we have, however, been disappointed in its effects ; it may serve as a useful vehi 
 cle for more active remedies. The dewberry-root is unquestionably a very powerful astrin 
 gent, and well adapted to the disease under consideration; in infusion or decoction it is 
 extensively employed by the physicians of the United States, as is also the root of the gera- 
 nium maculatum, the efi'ects of which latter, in chronic discharges from the bowels, are very 
 highly spoken of by many practitioners. 
 
 Of the mineral astringents, we know of none superior, in cases of chronic diarrhcEa, to the 
 acetate of lead ; in the dose of one grain, combined widi a quarter of a grain of opium and 
 the same quantity of ipecacuanha, repeated every three hours, it will, in a large number of 
 cases, promi^tly arrest the disease. The alum will, also, be found a good astringent in chro- 
 nic diarrhoea; it may be administered in the form of alum whey, or in substance, combined 
 with opium. We have given it in conjunction with powdered galls and with the best effects. 
 The sulphate of copper, which has been employed in combination with opium by Dr. Elliots 
 son with the most decided success, has repeatedly succeeded in our hands in arresting the 
 disease under circumstances the most unpromising. The mode in which we have generally 
 employed it, has been in a quarter or one-third of a grain doses combined with two grains 
 of extract of quina and a fourth of a grain of opium every three hours. The protocarbonate 
 of iron, the tincture of the chloride of iron, and the solution of the persesquinitrate of iron, 
 we have repeatedly employed, and in cases of long standing have found them, especially the 
 first two, very efficacious. They are particularly well adapted to protracted cases of the dis- 
 ease, attended with great prostration, and more or less infiltration of the subcutaneous cellu- 
 lar tissue. 
 
 The balsam copaiba and spirits of turpentine are among the remedies from which, in nu- 
 merous cases of chronic diarrhoea, the very best eflects may be anticipated. When the dis- 
 charges from the bowels are small in quantity, and resemble in consistence thin starch or 
 mucilage, or when they are dark-coloured and of a rank offensive odour, we are acquainted 
 with no remedies from which the same amount of good may be anticiiJated. They may be 
 combined with opiates and astringents where these are considered necessary. The sjiirits 
 of turpentine we employ more frequently than the copaiba; it is, we believe, equally effica- 
 cious, while it is more easily taken by the patient, and agrees better with the stomach; it 
 may be combined widi simple syrup and water, by adding a few grains of magnesia. 
 
 A variety of other remedies are recommended by different writers, the eflicacy of which 
 is highly extolled. The most prominent are Hope's Mixture, which is a mixture of nitrous 
 acid, camphor water and laudanum — the nux vomica and its active principle ; the ferrocya- 
 nuret of iron ; the nitrate of silver, and the resinous extract of the artemisia vulgaris. Of the 
 effects of these we have had no experience. 
 
 In those cases in which the diarrhoea appears to be kept up by ulceration seated just 
 within the verge of the anus, very speedy and permanent relief will always be obtained by 
 touching the ulcers with nitrate of silver. 
 
 We have given above an outline of the treatment demanded in the chronic form of diar- 
 rhoea ; in conclusion, we would remark, that the management of this disease ahvays requires 
 the exercise of great judgment and discretion on the part of the practitioner. Nothing would 
 appear more easy tlian by opiates and astringent remedies to arrest the inordinate discharges 
 from the bowels, and thus to effect the cure of the patient, but it will be found that, in many 
 cases, when astringents are too early resorted to, the disease, instead of being removed, is 
 aggravated ; or if by our astringents we do succeed in suspending the discharges from tlie 
 bowels, a swollen and painful state of the abdomen quickly succeeds, producing greater dis- 
 tress to the patient, and terminating more promptly in death, than had the diarrhoea been 
 allowed to run its course. In numerous instances, chronic diarrhoea may be very effectually 
 cured by a proper regulation of diet and regimen, the warm bath, blisters to the abdomen, 
 and internally the blue pill or calomel combined with opium and ipecacuanha, and, pei haps, 
 the use, at the same time, of moderate doses of copaiba or turpentine, without astrint;ento. 
 There are, however, unquestionably, many cases, in the course of which astringents, az.u al'
 
 804 SPORADIC CHOLERA. 
 
 the most powerful kind, are demanded in order to effect a removal of the disease, and others, 
 in Mdiich mild astringents, early administered, will very materially shorten its duration; and 
 it is in rightly determining the cases and period of the disease, in which astringents are in- 
 dicated, that the success of the practitioner in effecting its cure will frequently depend. — C] 
 
 I have alluded to the influence of hot weather in predisposing the system to be 
 affected by the exciting causes of diarrhcEa. And there is a complaint of which 
 diarrhcea is one prominent symptom, but which is sopiething more than mere diar- 
 rhoea — that shows itself in this country more or less, every autumn, and prevails 
 extensively in some years, as a minor epidemic. It is rightly enough named cho' 
 lera ; for it is attended with, and consists mainly of, a remarkable flux of bile. Sy- 
 denham held that the disease is limited to the month of August ; and that bowel affec- 
 tions, with vomiting, occurring at other times, are not genuine cases of cholera. But 
 this was one of that great man's crotchets. The symptoms that mark this complaint 
 are vomiting and purging of liquid matter, deeply tinged with, and principally com- 
 posed of, bile ; violent pains in the stomach and bowels ; cramps of the legs and of 
 the abdominal muscles ; a great depression of the vital powers, and a tendency to 
 syncope or collapse. 
 
 The attack is generally sudden. At first the contents of the alimentary canal are 
 evacuated; and then a quantity, an enormous quantity sometimes, of a turbid, yel- 
 lowish, acrid fluid, is expelled with violence both from the bowels, and by vomiting. 
 The patients complain of a burning sensation in the epigastrium. As the vomiting 
 and purging go on, clonic spasms of the lower extremities, and especially of the 
 gastrocnemii, occur ; the surface of the belly is drawn up into knots : and after a 
 while, the patient, exhausted by the pain and the spasms, and still more so by the 
 copious discharges, grows cold and faint. Sometimes actual syncope happens : and 
 sometimes death. 
 
 Death, however, is an uncommon event of this form of cholera, in this country. 
 
 The chief cause of cholera, such as has now been described, appears to be casual 
 exposure to cold, after a continued high temperature of the atmosphere : and the 
 great irritation of the stomach and bowels evinced by the symptoms, proceeds 
 from the presence of bile in the intestines in undue quantity, and rendered more 
 acrid than usual by some morbid alteration of its quality. The attack seems to 
 be often determined by some of those causes of irritation which I just now men- 
 tioned when speaking of simple diarrhoea; and particularly by imprudence in eating 
 and drinking. 
 
 I believe that no better treatment can be followed in this disease than that long 
 ago laid down by Sydenham. He observes that any attempt to stop the purging and 
 vomiting by strong drastic aperients, under the notion of expelling the irritant matter, 
 would be like endeavouring to extinguish fire by pouring oil upon it; and that to 
 try to lock up the acrid discharges in the ahmentary canal by means of narcotics or 
 astringents, would be equally hurtful. He therefore was accustomed to dilute the 
 contents of the stomach and bowels by emollient drinks, and injections, especially by 
 chicken broth ; and so to favour their expulsion ; and when any faintness or sign of 
 sinking began to show itself, to administer laudanum in full doses. We are seldom 
 summoned to these cases in the outset. Generally the vomiting and diarrhoea have 
 continued for some hours before we see the patient : so that it is expedient to give 
 the opiate as soon as we can. If the stomach be very irritable, solid opium in the 
 form of pill may be preferable to laudanum ; or an opiate clyster — or an opiate sup- 
 pository — may be introduced into the rectum. 
 
 [In such cases we know of no remedy more effectual than a pill composed of opium, 
 eamphor and acetate of lead, in the proportion of one grain each. When the stomach is sa 
 Ijritable that the pill is quickly rejected, a solution of acetate of lead, eight grains ta 
 two ounces of water, with the addition of one grain of the acetate of morphia, in the dosa 
 of a teaspoonful, repeated at proper intervals, will very generally be retained. — C] 
 
 When the skin is cold, and the pulse sinking or irregular, carbonate of ammonia, 
 or brandy and water, may be given by the mouth ; and a mustard poultice, or a bag 
 of hot salt, or a moist and hot flannel sprinkled with oil of turpentine, should be 
 applied to the abdomen. The cramps of the extremities may be relieved by dili
 
 EPIDEMIC CHOLERA. 805 
 
 gent friction with, the hand ; or some stimulating liniment may be rubbed upon the 
 affected muscles. When the collapse is great, the patient should not be allowed to 
 raise himself out of the horizontal posture, lest fatal syncope should follow. Opium, 
 however, is our sheet-anchor in this complaint : it sustains the flagging powers, while 
 it quiets the gastro-inteslinal irritation. 
 
 After an attack of severe cholera, the patient is apt to be left extremely feeble ; 
 with soreness of the muscles of the trunk and limbs : and sometimes, symptoms of 
 viflammation of the mucous membranes will supervene ; pain and tenderness of the 
 belly, a white tongue, thirst, and fever. And these symptoms may require some of 
 the remedies of inflammation. 
 
 Such is the disease which has long been familiar to English practitioners, as cho- 
 lera : but about twelve or thirteen years ago, this country was visited by a severe 
 epidemic disorder, which was also called cholera ; or by way of emphasis, the cho- 
 lera ; or sometimes spasmodic cholera ; or Jlsialic cholera ; or malignant cholera. 
 The symptoms of this new disease resembled, in some points, those of the old- 
 fashioned cholera : but differed from them in more, and in more important, particu- 
 lars. So that the application of the term cholera, or cholera morbus, to both these 
 morbid affections, is very much to be regretted, for it has produced a great deal of 
 confusion and inconvenience. 
 
 I scarcely know how to name the newer and severer disorder. I have no right 
 to alter the received nomenclature ; and choosing from among the many appella- 
 tions which have been given to the complaint, that epithet which seems the least 
 objectionable, I may call it epidemic cholera : although this term is objectionable, 
 since the other malady, the English or sporadic cholera, is sometimes also epi- 
 demic. 
 
 The epidemic cholera so far resembled the sporadic, that it was attended by pro- 
 fuse vomiting and purging, by extreme prostration of strength, and by cramps. But 
 it differed remarkably in these respects; in the circumstance that the matters ejected 
 from the stomach and bowels contained no bile (and this alone is a good reason 
 against calling the disease cholera) ; in the early supervention of the symptoms of 
 collapse ; and in the great mortality of the disorder. 
 
 The amount of the fluid matters thrown up from the stomach and discharged by 
 the bowels, was really in many cases wonderful. At first, perhaps, the j)atient would 
 have so copious a stool — a consistent dejection it might be, but so large in quantity — 
 as to lead him to conclude that the whole contents of the intestines had been evacu- 
 ated at once. Yet soon afterwards a turbid whitish liquid would again and again 
 pour from his bowels in streams ; and be spouted from his mouth as if from a puuip : 
 not in general with much effort, but easily and abundantly. The matters thus dis- 
 charged were thin, and for the most part of a whitish colour, like water in which rice 
 has been boiled ; without fecal smell ; and containing small white albuminous flakes. 
 There were some varieties in the evacuations, but the kind I have mentioned, resem- 
 bling rice-water, was the most common and the most characteristic : and however 
 else their sensible qualities might vary, this circumstance was universal, that they 
 contained no bile. 
 
 With all this there was early sinking, and collapse, as it was called. This term 
 collapse expressed a general condition, made up, in the most exquisite cases, of the 
 following particulars : — A remarkable change took place in the circulation, and a 
 striking alteration in the appearance of the patient. The pulse became frequent, 
 very small and feeble, and at last, even for hours, sometimes, extinct at the wrists. 
 The surface grew cold ; and in most, or in many instances, blue as well as cold. The 
 lips were purple; the tongue was of the colour of lead, and sensibly and unplea- 
 sandy cold to the touch, like a frog's belly ; and the breath could be felt to be cold. 
 With this coldness and blueness there were a manifest shrinking and diminution of 
 the bulk of the body. The eyes appeared sunk deep in their sockets; the cheeks 
 fallen : in short, the countenance became as withered and ghastly as that of a corpse. 
 The cadaverous aspect that sometimes precedes death in long-standing aiseases, 
 would come on in the course of an hour or two, in this complaint. 11 the physi 
 
 3s
 
 806 EPIDE3IIC CHOLERA. 
 
 cian left his patient for half an hour, he found him visibly thinner on his return. 
 The finger nails became blue ; the hands and fingers shriveled, white, corrugated, 
 and sodden, like those of a washerwoman after a long day's work. The, skin was 
 bathed in a cold sweat. The voice became husky and faint. So peculiar was this 
 change, that the sound was spoken of as the vox cholerica. These are the symp- 
 toms which the single word collapse was meant to express. 
 
 Another very striking feature of the disorder was the muscular cramp ; affecting 
 the muscles of the thighs and calves of the legs, rendering them as hard and rigid 
 as wood ; and drawing up into kno'ts the muscles of the abdomen. These spasmodic 
 contractions were attended with severe pain, and constituted the greater part of the 
 patient's suffering. During the continuance of the symptoms that I have been en- 
 deavouring to describe, not a drop of urine was passed or secreted. One man, who 
 was under my own observation and care, and who recovered, did not void a drop of 
 water from Sunday morning till the afternoon of the following Wednesday. 
 
 Even in the extreme state of collapse the intellect remained quite clear : the 
 patients would continue to talk rationally to the last moment of their lives ; and, 
 for the most part, they seemed singularly indifferent and apathetic about their 
 condition. 
 
 In the fatal cases — and a very fearful proportion of the whole number were fatal — 
 death took place sometimes in the course of two or three hours ; and it was seldom 
 delayed beyond twelve or fifteen. In those that recovered, the favourable symptoms 
 were the cessation of the vomiting, purging, and cramp; the return of the pulse, and 
 of warmth to the surface ; the disappearance of the blueness of the skin, and of the 
 hippocratic countenance; the re-appearance of bile in the al vine evacuations; and 
 the restoration of the secretion of urine. 
 
 The course of the symptoms varied a good deal in different persons Sometimes 
 the vomiting and purging soon ceased, and sometimes there was neither sickness nor 
 diarrheea at all, but rapid collapse and sinking. These were thought the most formi- 
 dable cases. However, the peculiar secretions were poured forth, in some, at least, 
 of the instances in which none of them were eject-ed from the body. A patient died 
 of cholera in the Middlesex Hospital without any vomiting or purging : but on ex- 
 amming the dead body, we found the intestines quite full of the rice-water serous 
 fluid. Sometimes the cramps were not very troublesome. The cutaneous bluen^'ss 
 was not a universal phenomenon. The patients were in general tormented by thirst: 
 and when attempts were made to bleed them, the blood was found dark and thick, 
 like treacle, and scarcely moving, if moving at all, in the veins : in some cases it 
 could not be made to flow out. Considerable hurry and anxiety of the breathing 
 were also symptoms that I omitted to mention before. 
 
 Examination of the dead bodies threw no light, that I know of, upon the nature 
 of this frightful disease. The alimentary canal generally was found to contain a 
 white liquid, having whiter flakes in it ; such as had previously issued from the 
 bowels: and the mucous glands of the intestines, both the solitary and the agmi- 
 nated, were usually large and conspicuous. The veins were loaded with thick, black, 
 far-hke blood ; and the urinary bladder was always found empty, and contracted into 
 the size of a walnut. Even when the blue colour had existed in a marked degree 
 during life, it often quickly disappeared after death. And another most singular 
 phenomenon was occasionally remarked in the dead body. A quarter or half an 
 hour, or even longer, after the breathing had ceased, and all other signs of animation 
 had departed, slight, tremulous, spasmodic twitchings and quiverings, and vermicular 
 motions of the muscles would take place ; and even distinct movements of the limbs, 
 n consequence of these spasms. 
 
 The disease, of which I have drawn but a faint outline, was not known in this 
 country till the autumn of the year 1831. There are persons, I am aware, who hold 
 that it has always existed among us ; only not in such numerous instances as at that 
 period ; and they appeal to Morton, and other early writers on the diseases of this 
 country, in support of their opinion. But the malady was too striking to be over- 
 looked, or ever forgotten, by any one who had once seen it. Certainly, till that year 
 1 never saw anything hke it. To be sure, I had not at that time been very many
 
 EPIDEMIC CHOLERA. 807 
 
 years in practice here. The late Dr. Babington, however, told me that it was quite 
 new to him. He had, for a very long period, been in extensive practice, in those 
 parts of the metropolis and its vicinity where the epidemic cholera raged most ; and 
 when it first came among us he had the curiosity to ask every medical man whom 
 he met, whether he had seen any case of the cholera ; and if the answer was "yes," 
 he went on to inquire, whether, before that year, the person had ever met with the 
 same complaint; and the reply was always, without a single exception, "no." Yet 
 I say there were, and are, a few practitioners who denied, and deny, that it was any- 
 thing more than the common and well-known English complaint, raging with unusual 
 frequency and violence. 
 
 But we have evidence of a different kind of the newness of the epidemic cholera 
 to these kingdoms. Its approach was discerned afar off, as distinctly as a storm is 
 foreseen by the rising of the clouds from the horizon in the direction of the wir>d. 
 The disorder began to rage with terrible severity, in India, in the year 1817. I do 
 not mean that it then broke out there for the first time. It had visited those regions 
 again and again before. But from its eruption in the year I have mentioned, when 
 it committed frightful devastation in the armies in the north-eastern districts of India, 
 its course can be distinctly traced to our own thores ; towards which it approached 
 with slow and hailing, but with sure steps, in a north-western direction. From India 
 it spread to Persia ; and thence to Russia ; and across through Poland to Germany : 
 and at length it was found at Hamburgh. It was predicted before that time, that the 
 distemper would at length reach Great Britain. (Dur government had even sent two 
 physicians into Russia to investigate its nature, in the fearful anticipation that its 
 march across the earth would continue progressive ; and accordingly, at the expira- 
 tion of fourteen years, it made its appearance on the eastern coast of this country ; 
 in Sunderland : and in due time extended over every part of these islands. I say 
 its arrival had been foreseen and foretold ; and it is absurd to suppose that a vast 
 number of persons would fall sick and die, with symptoms quite strange to the great 
 mass of practitioners here, merely to fulfil this prediction. 
 
 The progress of the disorder did not end here. Crossing the Atlantic, it invaded 
 America ; turning, at the same time, in a south-easterly direction, it ravaged France 
 and Spain, and the north coast of Africa, and Italy. 
 
 Moving thus onward, as it did, in defiance of all natural or artificial barriers, 
 under opposite extremes of temperature and climate, in the teeth of adverse winds, 
 over lofty mountain chains, across wide seas, through " hot, cold, moist, and dry" — 
 in what manner, you will probably ask, was this wasting pestilence propagated? 
 
 Upon this point various and discordant opinions are entertained. Many persons 
 believe that the complaint spread by contagion ; more, however, that it was not con- 
 tagious at all, but arose from some deleterious cause with which the general atmo- 
 sphere of the place was pregnant. Now 1 cannot reconcile the phenomena of the 
 appearance and extension of the malady with either of these hypotheses exclusively. 
 It must, I think, be granted that the complaint, in every instance, was excited by the 
 apphcation of some noxious material to the body, some positive poison. It is certain, 
 also, whichever hypothesis may be chosen, that many more individuals were exposed 
 to the agency of this poison, than were injuriously affected by it. This exemption 
 from the disease no more invalidates the doctrine of contagion, than it invalidates the 
 doctrine of some diffused atmospheric influence ; nay, it is more explicable upon the 
 former than upon the latter supposition ; for while many may avoid a specific conta- 
 gion, all are immersed in, and all breathe, the common atmosphere. But the ex- 
 emption shows this: that the exciting cause, to be effective, required a fit recipient: 
 that the susceptibility of being hurt by the poison in its ordinary dose and intensity 
 varied much in different persons; and in the majority was very faint, or wanting. 
 It is clear that the poison travelled. It is equally clear to my mind, that it was 
 portable ; and therefore communicable from person to person. I even believe thai 
 it was capable of being conveyed, and was actually conveyed, from one spot to 
 another, by persons who were themselves proof against its effects. The innumerable 
 authentic instances of coincidence, in point of time, between the first outbreak of th«' 
 disorder in a particular place, and the arrival at that place of some person or persona
 
 808 EPIDEMIC CHOLERA. 
 
 from an infected locality, prove that the poison could be thus carried. Of this direct 
 importation of the disorder into new and distant places, by infected individuals, and 
 of its subsequent extension from those individuals to others who had intercourse with 
 them, you may see a vast number of examples, collected by Dr. James Simpson, in 
 the 4yth volume of the Edinburgh Medical and Surgical Journcd. The evidence 
 there adduced of the portability of the poison is abundant, and to my mind, irresist- 
 ible. Whether the malady was contagious in the same sense in which small-pox is 
 contagious — whether, I mean, the cholera poison had the power of multiplying and 
 reproducing itself in the human body, as yeast multiplies itself during the fermenta- 
 tion of beer — is a ditTerent and a much more doubtful question. A disorder may be 
 contagious, without this property of reproduction in the animal fluids. The itch is 
 contagious. The itch is produced by a minute parasitic animalcule, whose existence 
 has, of late years only, been assured to us by the microscope. Suppose that these 
 iich insects could fl)', or were capable of being wafted through the air — they would 
 then represent what is conceivable enough of the subtle exciting cause of cholera. 
 Between the two epidemic distempers, influenza and cholera, there were numerous 
 and striking points of similitude or analogy. They have observed the same, or very 
 nearly the same, geographical route.' Both, issuing from their cradle in the east, 
 have traversed the northern countries of Europe, till, arriving at its western boundary, 
 they have divided into two great branches ; the one proceeding onwards, across the 
 Atlantic, the other turning in a retrograde direction, towards the south and east. 
 The main difierences between them have been, that whereas the poison of influenza 
 spared very few of the community, inflicting a disease which, of itself, was seldom 
 fatal — the poison of cholera, on the contrary, smote very few, but with so deadly a 
 stroke that as many sank beneath it, probably, as recovered. Both were general 
 disorders, affecting the whole system, but in both the most prominent of the symp- 
 toms had reference, in the majority of cases, to the mucous membranes ; to those of 
 the air-passages in the influenza ; to those of the alimentary passages in the cholera. 
 Now this strong analogy has been made use of as an argument that the cholera 
 was not contagious. " The influenza (say the objectors) had no contagious proper- 
 ties ; therefore it is, a priori, likely that the cholera had none." But 1 demur to the 
 major proposition. Cuilen thought the influenza was contagious, and I adverted, in 
 a former lecture, to some facts which favour that belief. Supposing it, however, to 
 be so, the proof of its contagious property must, from the very nature of the case, be 
 extremely difficult. Its visitations are so rapid, widely spread, and multitudinous, 
 that there is no time for its transference from house to house, or from person to per- 
 son ; yet it may be nevertheless transferable. Its inherent rate of locomotion outstrips 
 and precludes the tardier conveyance of ihe poison by man. Its contagious qualities 
 (granting them to exist) are hidden in its universality, and can seldom be traced but 
 by accident. I therefore esteem this argument from analogy as worthless ; and my 
 own creed respecting the cholera is, that it u'as contagious, in the hmited sense 
 already explained ; but that its contagious power was not very great : that a com- 
 paratively small part of the population, of this country at least, was susceptible of its 
 operation ; and that few were in much danger of suffering from exposure to the 
 physical cause of the disease, except under circumstances of predisposition. At the 
 san)e time I believe that a great majority of the cases of cholera were not attributable 
 to direct contagion, but to the poison diffused through the atmosphere. There is no- 
 thing inconsistent in the supposition thot this noxious matter travelled sometimes by 
 its own peculiar powers, sometimes made use of vehicles. 
 
 [During the prevalence of the cholera in Philadelphia, in 1832, we closely investigated 
 every fact calculated to throw light upon the question of its contagious or non-contagious 
 character, and for this investigation, our position in the Board of Health and as chief of a 
 large hospital, afibrded us ample opportunities — hut we were unable to discover the slightest 
 evidence of the disease having been in any one instance comraunicated from the sick to the 
 well.— C] 
 
 This, I say, is my creed upon the vexed question of contagion. Respecting the 
 special nature of the poison I can only guess ; and my guessing, as you may have 
 perceived, takes the same direction as before. I adverted, when speaking of the
 
 EPIDEMIC CHOLERA. 809 
 
 influenza, to what Dr. Holland has called " the hypothesis of insect life as a cause 
 of disease." I shall not repeat the observations I then made ; but I would refer you, 
 for much curious thought and information upon the subject, to Dr. Holland's very 
 interesting essay. The hypothesis in question squares more readily than any other 
 that I know of, with the ascertained history of the disorder: with its origin, after an 
 unusually wet season, in the low marshy country, and hot atmosphere of Bengal : 
 with its irregular but continuous migrations : with its dying away after a while, and 
 its occasional and partial revivals. But still, remember that we are deahng merely 
 with an hypothesis. 
 
 Whatever obscurity may overhang the exciting causes of the epidemic cholera, 
 we are quite sure that certain circumstances exercised a strong predisposing influence 
 upon the human body, to render it more than usually susceptible of the disease. 
 The predisposing causes, as might well be imagined, were such as tended to debili- 
 tate the system : and therefore poverty, which implies scanty nourishment, and 
 frequently also the confinement of several persons to a narrow space, and want of 
 fresh air; poverty, which includes these and other evils, was found to predispose the 
 body to a ready reception of the malady. But to intemperance, more than to any 
 other single cause, may the proclivity to become affected by this species of cholera 
 be ascribed ; and especially to the intemperate and habitual use of distilled spirits. 
 This fact was peculiarly manifested in the selection, by the disease, of its victims in 
 this country ; and it has been remarked almost everywhere else. 
 
 I have all along spoken of the visitation of epidemic cholera in the past tense, 
 because, for the last eleven or twelve years, we have heard but httle of it. Yet we 
 can scarcely venture to hope that the stranger pest has altogether forsaken us, for we 
 have had slight sprinklings of the disease in and near London, every summer, I be- 
 lieve, since 1832; but it has never again been extensively prevalent or epidemic. 
 Certainly it dealt lightly, upon the whole, with our country. It was much more 
 general, and more widely fatal, in France, which it visited subsequently to its arriving 
 here : it was very destructive also in its subsequent course, both westward and to- 
 ward the south-east. 
 
 The epidemic cholera made its attack in two different modes, [n one it seized 
 upon the patient suddenly, and without warning. This was comparatively rare. 
 Much more commonly the specific symptoms were preceded, for some little time, 
 even for some days perhaps, by diarrhcEa. And this I take to be the most important 
 practical fact that was ascertained during its prevalence among us. When the dis- 
 ease was once fairly formed, medicine had very httle power over it ; but in the pre- 
 liminary stage of diarrhcsa it was easily manageable. Unfortunately people are 
 inclined (especially those classes of the community among whom the cholera most 
 raged), to regard a loose state of the bowels as salutary ; and to make no complaint 
 of it, and to do nothing for it : or, in other cases, they conceive it to proceed from 
 some peccant matter within, which requires to be carried off, and they take purgative 
 medicines to get rid of it. Both of these are serious and often fatal mistakes. Mere 
 neglect of the diarrhoea frequently permitted it to run into well-marked and uncon- 
 trollable cholera; and the employment of purgatives hastened or insured that cata- 
 strophe. The proper plan of proceeding, I am convinced, was, to arrest the diarrhoea 
 as soon as possible after its commencement, by astringents, aromatics, and opiates. 
 You may object, perhaps, that the cases that were cured in this way were not cases 
 of cholera at all, and never would have been; but simple ordinary diarrhoea. It is 
 impossible to prove the contrary, no doubt; but the presumption is strong that the 
 diarrhoea would in many, and, perhaps, in most instances, have run on, if not check- 
 ed, into the more perilous form of the disease. In many places, when, taught by 
 experience, the authorities estabhshed diarrhcea dispensaries, to which those attacked 
 by looseness of the bowels were warned and invited to apply, that the looseness 
 might forthwith be corrected ; in many such places the cholera, which had before 
 been cuiting the inhabitants off by scores, and hundreds, began instantly to declinv) 
 in frequency. I venture to advise you, supposing the disease should reappear, of 
 whenever in the autumn a suspicion arises that this form of cholera is pr" ^cnt in the 
 
 3s2
 
 810 EPIDEMIC CHOLERA. 
 
 community, not to try, in cases of diarrhoea, to carr)^ off the presumed offending 
 matter, but to quiet the irritation, and stop the flux as soon as you can. 
 
 But when the regular symptoms, peculiar to the severe form of cholera, had set 
 in, medicine, I repeat, had very little influence upon it : and accordingly, as might 
 have been expected, a hundred different cures of the disease were announced, most 
 of them all but infallible. Some persons held that timely bleeding would save the 
 patient ; others relied confidently upon mustard emetics. Hot air baths were manu- 
 factured, and sold to a great extent, to meet the apprehended attack in that manner 
 without delay. Certain practitioners maintained that the disease was to be remedied 
 by introducing into the system a large quantity of neutral salts, which were to liquefy 
 and redden the blood, and to restore the functions of the circulation. But of this 
 practice it was said in a sorry but true jest, that however it might be with pigs or 
 herrings, salting a patient in cholera was not always the same thing as curing him. 
 In a great number of the sick the blood was mechanically diluted by pouring warm 
 water, or salt and water, into their veins. Some physicians put their trust in brandy, 
 some in opium, some in cajeput oil, which rose to I know not what price in the 
 market ; some again, in calomel alone. 
 
 Now, I would not willingly mislead or deceive you on this point, by speaking 
 with a confidence which I really have no warrant for, of the success or propriety of 
 any of these expedients. I believe that each in some cases did good, or seeincd to do 
 so ; but I cannot doubt that some of them did sometimes also harm. I had not more 
 than six severe cases under my own charge : and I congratulated myself that the 
 mortality among them was not greater than the average mortality. Three died, and 
 three (I will not say were cured, but) recovered. The three that died I was called 
 in to see w^ien the disorder was at its height : and in each case it went on with 
 frightful rapidity, in spite of all the means adopted, and proved fatal a few hours 
 afterwards. The three that recovered I saw somewhat earlier, but still not till the 
 specific symptoms were present : one was a girl in the hospital. They all recovered 
 under large and repeated doses of calomel. Yet (as I said before) I do not venture 
 to affirm that the calomel cured them. In the first case which was treated in that 
 way, I merely followed up the plan that had been begun by Dr. Latham, who had 
 visited the patient for me when I was accidentally absent. I found that he had fell 
 better, less sick and less faint, after taking half a drachm of calomel at a dose ; and I 
 repeated the same dose many times, for after every dose his pulse rose somewhat, 
 and he appeared to rally. This was the same man whom I mentioned before as 
 having made no urine from the Sunday to the Wednesday : all that time he kept 
 discharging rice-water stools. At last, on the fourth day he passed a little water, 
 and his alvine evacuations became rather more consistent, and began to look green: 
 and from that time he graduall}- got well. Afterwards I treated my hospital patient 
 in the same way, and with the same event. Yet I will not pretend to sa\' that these 
 persons might not have done quite as well if they had been left entirely to them 
 selves. 
 
 [Soon after the appearance of the cholera in Philadelphia, we were persuaded that had 
 we a remedy capable of arresting the inordinate serous discharge, which in this disease is 
 poured out by the mucous membrane of the alimentary canal, we should very readily suc- 
 ceed in its cure. We were, therefore, induced to try the effects of the acetate of lead, with 
 the remedial powers of which in a somewhat analogous disease, the cholera of infants, we 
 'vere familiar. We administered it in pills, combined with opium and camphor, or when 
 ihe stomach rejected it in this form, in solution with the acetate of morphia, and at the same 
 ttrne, by the rectum, in injections composed of a strong solution with the addition of lauda- 
 num. Under this plan of treatment, the discharges were in numerous instances promptly 
 arrested, and the patients recovered, even after the stage of collapse had ensued. From our 
 subsequent experience with this plan of treatment, we are convinced, that had the remedy 
 been generally resorted to from the commencement of the epidemic, the mortalit}' of the 
 disease would have been materially reduced. Since 1832 many cases of the cholera have 
 occurred every year: all that have fallen under our notice were treated by the acetate of 
 l^ad, and we have lost ftone. — Dr. Graves has subsequently recommended the same remedy, 
 auii speaks of its effects in the highest terms. — We usually administer the acetate of lead in 
 the dose of one grain, combined with one of opium and the same quantity of camphor, 
 «very hour, or two, or three, according to the violence of the attack. The thirst of tb«
 
 CHOLERA INFANTUM. 811 
 
 patient was assuaged by small portions of ice held in the mouth and allowed slowly i«> dis 
 solve — large and frequent draughts of cold water we always found to be injurious. — Cups to 
 the abdomen were frequently employed, and we have reason to believe always with advan 
 tage. — From warm bathing, dry heat to the surface, sinapisms, stimulating pediiuvia, we 
 never saw any good effects result. — C] 
 
 Some of the expedients recommended had certainly a very marked and immediate 
 effect upon the condition of the patients, especially the injection of warm water into 
 the veins. Many instances of this were related at the time. One I myself saw. 
 The patient was a young man, who was nearly moribund apparently. His pulse 
 had almost, if not quite disappeared from the wrist ; he was very blue, and his visage 
 was ghastly and cadaverous : in one word, he was in an extreme state of collapse. 
 Out of this he was brought in a few minutes by injecting warm water into one of 
 the veins in the arm. The pulse again became distinct and full ; and he sat up, and 
 looked once more like one alive, and spoke in a strong voice. But he soon relapsed*, 
 and a repetition of the injection again rallied him, but not so thoroughly : and in the 
 end he sunk irretrievably. Dr. Babington told me of a patient whom he saw speech- 
 less, and all but dead, and whose veins were injected. He then recovered so as to 
 sit up, and talk, and even joke, with the bystanders: but this amendment did not 
 last either. Yet even this temporary recovery might sometimes be of great import- 
 ance : might allow a dying man to execute a will for example. And some of the 
 persons thus revived got ultimately well. We had for some time a woman in the 
 Middlesex Hospital acting as nurse, who had been rescued, when at the verge of 
 death in cholera, by the injection of warm water into her veins. 
 
 It was remarked of those who recovered that some got well rapidly, and at once ; 
 while others fell into a state of continued fever, which frequently proved fatal some 
 time after the violent and peculiar symptoms had ceased. Some, after the vomiting 
 and purging and cramps had departed, died comatose ; over-drugged sometimes, it 
 is to be feared, by opium. The rude discipline to which they were subjected might 
 account for some of the cases of fever. And the process of artificially replenishing 
 the veins was certainly attended with much danger. The injection of air with the 
 water — inflammation of the vein from the violence done to it — an over-repletion and 
 distension of the vessels by the hquid — might, any one of them, and sometimes, I 
 suppose, did, occasion the death of the patient. Never, certainly, was the artillery 
 of medicine more vigorously plied — never were her troops, regular and volunteer, 
 more meritoriously active. To many patients, no doubt, this busy interference made 
 all the difference between life and death. But if the balance could be fairly struck, 
 and the exact truth ascertained, I question whether we should find that the agorecrate 
 mortality from cholera in this country, was any way disturbed by our craft. Except- 
 ing always the cases in which preliminary diarrhnea was checked, just as many, 
 though not, perhaps, the very same individuals, would, probably, have survived had 
 no medication whatever been practised. 
 
 I do not know that I have any thing more to say that could be of any use to you, 
 in respect to the epidemic cholera. 
 
 [Of the diseases to which children are liable in the middle and southern portions of tno 
 United States, k-w produce a greater amount of mortality than Cholera Infantum, or 
 the Summer Complaint. It is an endemic of all our larger cities, during the season of the 
 greatest heat; attacking children between four and twenty months of age, or at the period of the 
 first dentition. So generally is it confined to this period, that an infant's second summer ia 
 considered by mothers as one of unusual peril, and should it escape an attack at diis period, 
 or pass safely through the disease, it is considered to have a fair chance of surviving the 
 period of infancy. 
 
 The first symptom of the disease is usually a profuse diarrhoea, the stool being very fluid, 
 generally of a very light colour, though often of a pale yellow or green; to the diarrhoea is 
 soon added an extreme irritability of the stomach, everything taken into it being rejected 
 immediately, and with violence. The irritability of stomach, in most cases, continues through 
 out the attack, and in many frequent spontaneous vomiting is a pronrinent symptom. 
 
 After the disease has continued for a short time, the discharges from the bowels are ordi 
 narily composed entirely of a perfectly colourless and inodorous fluid, containing often minutu 
 mucous flocculi, and are disch-arged without the least eflbrt. They are occasionaMv .however,
 
 812 CHOLERA INFANTUM. 
 
 very small in quantity, and squirted, as it were, from the anus. Li these cases, there is usually 
 more or less tormina and tenesmus. 
 
 Very frequently the vomiting becomes suspended, even at an early period of the attack, 
 ■while the discharges froin the bowels continue, or augment in frequency and in quantity, 
 the irritability of the intestinal canal being often such, as to cause whatever food or drink 
 is taken to pass off rapidly, without having undergone the slightest change. 
 
 The infant becomes quickly afl'ected with extreme langour and prostration, and is rapidly 
 emaciated — being reduced in a few days, often hours, to an extent that would scarcely be 
 credited by those unacquainted with the disease. 
 
 The pulse, from the very commencement of the attack, is usually quick, frequent, small, 
 and often tense. The skin is dry and harsh, the head and abdomen are often hot, while the 
 extremities retain their natural temperature, or are even decidedly cold. The tongue ia 
 moist, and covered with a white slimy mucus. There is always intense thirst — whatever 
 fluid is taken being almost immediately ejected from the stomach. The child sulfers more 
 or less pain in the abdomen, as indicated by its fretful ness, low moaning cries, frequent 
 change of posture, the drawing up of its knees, and its occasional acute screams. The abdo- 
 men is sometimes tumid, and generally tender to the touch. Towards evening, there occurs, 
 in most cases, a decided febrile reaction. 
 
 In many cases, some degree of delirium, with an injected and wild appearance of the 
 eyes, and a tossing of the head backwards and forwards, is early manifested. When this is the 
 case, we have frequently seen the patient attemjot to bite or scratch his attendants. 
 
 The disease usually runs a protracted course. The discharges from the bowels continue 
 to be frequent and profuse, but dark-coloured, like dirty water, or the washings of stale mea^ 
 and often very offensive. They not unfrequently, however, are small in quantity, and composed 
 entirely of a dark-coloured mucus, mixed with the food and drinks that have been taken. 
 The emaciation of the patient becomes extreme; his eyes are languid, hollow, and glassy; his 
 countenance pale and shrunken; his nose sharp and pointed; and the lips thin, dry and 
 shrivelled. The surface of the body becomes cool and clammy, of a dirty brownish hue, and 
 often covered with petechiffi. The tongue is dark-coloured, smooth and shining, or covered, 
 as well as the parieties of the mouth, with aphtha. In many cases the child lies constantly 
 in an imperfect doze, with half-closed eyelids, and so insensible to external impressions, that 
 flies will frequently light upon the half-closed eyeballs without the patient exhibiting the 
 least consciousness- of their presence. The abdomen becomes more or less tympanitic, and 
 tlie hands and feet of a leaden hue, or pallid and cedematous. The fauces, becoming dry, 
 causes a sense of uneasiness, which induces the patient to thrust his hand deep in the mouth, 
 as if to remove some offending substance. 
 
 In many of the protracted cases, an eruption of very minute white vesicles occurs upon 
 the neck and breast. This Dr. Dewees considered to be invariably a fatal symptom ; but we 
 have seen many patients recover, even when this eruption has been the most extensive and 
 distinct. 
 
 The patient, unless relieved from his suffering by a judicious treatment, becomes daily 
 more and more exhausted, rolls his head about when awake, and utters constantly short, 
 plaintive, scarcely audible cries. He falls at length into a state of complete coma, death being 
 frequently preceded by a convulsive attack. Not unfrequently, at a much earlier period of 
 tlie disease, the brain becomes affected, and the child dies with all the symptoms of acute 
 meningitis. 
 
 Cholera infantum is of very variable duration. In violent attacks, the prostration which 
 suddenly ensues is occasionally so extreme, that the patient is destroyed within the first 
 twenty-four hours. Usually, however, the disease is of many days, or even weeks' con- 
 tinuance, and the patient generally sinks, apparently from a total cessation of the nutrition 
 of the system. 
 
 The lesions exhibited by the post-mortem examination of those who have died from cholera 
 infantum, vary according to the period of the disease when death takes place. When the dis- 
 ease has been of short continuance, the mucous membrane of the alimentary canal presents 
 often an abnormal paleness, and the liver is more or less congested. When the case has been 
 of a more protracted character, increased redness in points or patches, in different parts of the 
 stomach and intestines, is often present. The red points are sometimes very minute and 
 isGiated, and spread over a considerable portion of the stomach and duodenum, or over the 
 fcmall intestines only. They have the appearance, generally, of minute extravasations of 
 blood. In the lower intestines the points occur in clusters, so as to form patches of redness, 
 varying in size, though never of any great extent, and often slightly elevated, from a thick- 
 ening of the mucous tissue at the parts occupied by them. Occasionally, portions of the 
 mucous membrane are more or less softened — often witliout the slightest inflammation. In 
 other instances, increased redness of some portion of the intestines exists, with contractions, 
 often extreme, of its calibre. 
 
 The mucous follicles of the intestines are very generally enlarged, often in a state of 
 inflammation, and occasionally of ulceration. Dr. Horner describes the appearance of the
 
 CHOLERA INFANTUM. 813 
 
 enlarged follicles, as resembling a sprinkling of white sand upon the surface of the mucous 
 membrane. The intestines are generally empty, or contain merely a small amount of thick 
 tenacious mucus. Drs. Page and Lindsly describe an appearance of dark spots upon the 
 mucous membrane of the stomach, above its pyloric oriiice. We have never detected it. 
 
 The liver is almost invariably enlarged, and more or less congested ; while the gall-bladder 
 is filled with dark-green bile, or a pale and almost colourless fluid. Dr. Page tlescribes 
 the liver as being in some cases large, soft, and spongy ; and Dr. Horner, as being usually of 
 a light yellow or mottled colour. 
 
 In the more protracted cases, indications of inflammation of the meninges of the brain are 
 very frequently present. 
 
 The prognosis in cholera infantum will depend very much upon our ability to remove the 
 patient from the influence of the impure and heated air by which the disease has been pro- 
 duced and is kept up, as well as upon the period of the attack at which the treatment is com- 
 menced. Without this removal, it is scarcely possible to effect, in any case, a permanent cure ; 
 while in most cases — in their commencement, at least — little else is required to arrest the dis- 
 ease: even at a later period, its effects are often strikingly evinced in the rapid improvement 
 of the patient, from almost the very moment the removal takes place. In cases where the dis- 
 ease has continued for many days, and reduced the patient to a state in which a fatal termina- 
 tion would seem inevitable, by removal to the free open air of the country, and an appropriate 
 course of treatment, a very rapid recovery is often effected. 
 
 Cholera infantum is evidently produced by the action of a heated, impure, and stagnant 
 atmosphere, directly upon the skin, and indirectly upon the digestive mucous surface, at an 
 age when the latter is strongly predisposed to disease from the effects of dentition, and fiom 
 the increased development and activity of the muciparous follicles which takes place at that 
 period. 
 
 The dependence of cholera infantum upon a high degree of atmospheric temperature is 
 shown by the fact, that its prevalence is always in proportion to the heat of the summer ; 
 the disease increasing and becoming more fatal with the rise of the thermometer, and 
 declining with the first appearance of cool weather in the autumn. That, however, the dis 
 ease is not produced by heat alone, in its more aggravated forms, is proved by its occurring 
 almost exclusively in the larger and more crowded cities of the Middle and Southern States, 
 and by its especially prevailing, and being most destructive to life, among the children of the 
 poorer classes, inhabiting small, ill-ventilated houses, situated in narrow, confined lanes, 
 courts, and alleys, or in situations abounding with accumulations of filth. When it occurs m 
 the country, which is rarely the case, it is almost exclusively in low, damp, and otherwise 
 unhealthy situations. 
 
 The process of dentition is unquestionably a predisposing cause of the disease ; while 
 premature weaning and errors in diet act often as exciting causes. 
 
 In regard to the treatment of the disease, this is very simple, and generally successful, 
 whenever we are able to remove the patient from the heated, confined, and impure atmo- 
 sphere by which the disease has been generated, to a situation where he may enjoy the 
 advantages of a cool air and free ventilation. 
 
 The infant should be confined to the breast, or, if weaned, to a diet of fresh rennet-whey, 
 with the addition of gum acacia, rice-water, tapioca, or plain meat broths, with some cool, 
 perfectly bland, and sliglitly mucilaginous fiuid for drink. He should be immersed daily in 
 a bath, warm or tei:)id, according as the temperature of the skin is deficient or increased. 
 
 If the removal of the patient is impracticable, he should be placed in as pure, cool, and 
 free an atmosphere as possible, and carried frequently abroad in any open and healthy situa- 
 tion in the neighbourhood of his residence, in a carriage, or in the arms — or where his resi- 
 dence is near a large river, he should be taken on the water in a boat. His clothing should 
 be perfectly clean and dry, and sufficient to guard against the influence of sudden changes 
 of temperature, but not so warm as to overheat tlie patient : flne soft flannel, or soft, coarse 
 ■muslin, worn next the skin, will be proper in all cases. His sleeping apartment should be, 
 if possible, large and airy. He should sleep upon a mattrass, or on a blanket folded and 
 laid upon the sacking-bottom of the bedstead, or upon the floor of the crib, his body being 
 defended by a light, loose covering. 
 
 The gums should be carefully examined, and if they are hot, swollen and inflamed, they 
 should be freely lanced. 
 
 When the disease commences as a simple diarrhoea, the warm bath, repeated daily, or 
 even night and morning, and followed by gentle friction over the surface of the body, with 
 a hand or soft dry cloth ; cold mucilaginous drinks, and a combination of a sixth of a grain 
 of calomel, about four grains of prepared chalk, and a half a grain of acetate of lead, 
 repeated every three or four hours, will ordinarily arrest it. 
 
 To subdue the irritability of the stomach, from a sixth to a fourth of a grain of calomel, 
 rubbed up with a little dry loaf-sugar, and sprinkled npon the tongue, will very generally bo 
 found suiRcient. When, however, this fails, a few drops of the spirits of turpentine, <v a 
 solution of camphor in sulphuric asther, repeated at short intervals, will usually succeed
 
 814 DYSENTERY. 
 
 Wlien tlie vomiting is violent and frequent, particularly if there is any pain or tenderness 
 of the abdomen, a few leeches to the epigastrium, followed by a light emollient cataplasm 
 or warm fomentations, will be found decidedly beneficial. The eflects of fomentations to 
 the abdomen, with a strong decoction of hops, have been spoken of by many practitioners as 
 peculiarly soothing. 
 
 A teaspoonful of cold water may be allowed every fifteen or twenty minutes ; it is grate- 
 ful to the f)atient, and will assist in allaying the gastric irritability. 
 
 When the irritability of the stomach is so far quieted as to allow of the remedy being 
 retained, the disordered action of the bowels will in most cases be promptly restrained by a 
 combination of a fourth of a grain of calomel, three grains of prepared chalk, one grain of 
 acetate of lead, and a fourth of a grain of ipecacuanha, given every three hours. Under the 
 use of this prescription, the inordinate discharges will be quickly suspended, and replaced 
 by regular, natural stools. The acetate of lead should be omitted as soon as the watery dis- 
 charges are arrested, and the calomel, prepared chalk, and ipecacuanha, in the same pro- 
 portion as above, continued until regular and healthy stools are procured. The use of some 
 one of the liglit vegetable astringents will complete the cure. The full restoration of the 
 patient to strength will be greatly promoted by a mild unirritating diet, daily exercise in the 
 open air, and the most scrupulous cleanliness of person and clothing. 
 
 In cases where much heat of the head, a wild injected state of the eyes, aversion from 
 light, with delirium, or other symptoms of cerebral disease ensue, leeches should be applied 
 to the temples or behind the ears, cold lotions to the scalp, and warm sinapisms, pediluvia, or 
 some stimulating embrocation to the lower extremities. In these cases, blisters behind the 
 ears, kept open by the use of some irritating ointment, will often be found beneficial. 
 
 In the chronic stage of cholera infantum, the most efiicacious remedies are the warm bat'.!, 
 repeated daily; blisters to the abdomen, kept on until the skin is reddened and then removed, 
 the part being covered with a soft emollient poidtice ; injections composed of starch and a 
 few drops of laudanum ; small doses of Dover's powder at night, with light astringents, as 
 kino, decoction of dewberry-root or of the geranium maculatum, with change of air, and a 
 diet of boiled milk thickened with rice-flour, or of plain meat broths with the addition oi 
 rice. A solution of die tartrate of iron, twenty grains to the ounce of water, with the addi 
 tion of a drachm or two of ginger syrup, or the persesquinitrate of iron, maybe administered 
 with good eflects. In many cases the sulphate of quinia in solution, besides exeriing a bene 
 ficial influence upon the disordered condition of the bowels, will be found useful in restoring 
 strength to the patient, who is always in a state of extreme prostration. 
 
 When the stools are thin, small in quantity, dark-coloured, and highly offensive, with flatu- 
 lence, and a tendency to a tympanitic condition of the abdomen, or when frequent griping 
 pains are experienced, the best effects will be derived from the use of turpentine. It may 
 be given in the following mixture: — H. Mucil. g. acaciip S'ij- j sacch. alb. pur. 5ij. ; spir. 
 tether nit. 3iij- j spir- terebinth. 3ij- ; magnes. calc. gr. xiij. ; lavend. spir. comp. 3ij- — M. The 
 dose of which is a teaspoonful three times a day — or oftener, when the child is over two 
 years of age. The addition of 3'^- of the tincture of kino, and the same quantity of the 
 camphorated tincture of opium, will be proper in cases attended with great irritability of the 
 bowels. 
 
 When the discharges are acrid, offensive, and dark-coloured, we have administered with 
 advantage pulverized charcoal, two to eight grains, in combination with two or three grains 
 of powdered rhubarb, a fourth to a half a grain of ipecacuanha, and a grain of extract of 
 hyosciamus every three or four hours. 
 
 The umost attention must be paid to the diet of the patient ; he should be confined to meat 
 broths — the juice of roasted meats, with boiled rice — rice milk and tapioca in moderate 
 quantities at a time — with toast or rice water, or rennet-whey, with the addition of a portion 
 C'f gum acacia, for drink. — C] 
 
 LECTURE LXXIII. 
 
 Dysentery. Diarrhoea Adiposa. Intestinal Concretions. Worms. 
 
 Another of the morbid fluxes from the alimentary tube, of which I have yet to 
 epeak, is dysentery. 
 
 Its characteristic symptoms are, griping pains in the abdomen, followed by fre- 
 quent, mucous or bloody stools, straining and tenesmus. In chronic cases pus is 
 sometimes discharged from the bowels. The acute form or stage of the disease is 
 attended with fever.
 
 DYSENTERY. 815 
 
 The difTerences between dysentery and diarrhoea are obvious enough. Both of 
 them may be accompanied by griping pains : in both the stools are frequent and 
 loose : but in diarrhoea they are fecal ; in dysentery there is retention of the natural 
 feces, or they are expelled from time to time, in small, hard, separate lumps, termed 
 scybala. Again, straining, and tenesmus, and the excretion of mucus, which is often 
 tinged with blood, form no necessary features in diarrhoea ; whereas in dysentery 
 these symptoms are prominent and constant. These nosological distinctions are true 
 and useful, although in our actual intercourse with the sick, we do not find them 
 always or strictly observed. Some of the worst forms of dysentery commence with 
 the ordinary symptoms of diarrhoea. 
 
 Dysentery consists, essentially, in inflammation of the mucous membrane of the 
 large intestines; yet not, I apprehend, of the whole of that long surface indiscrimi- 
 nately. Observation of the course of the disorder, during life, and of the morbid 
 appearances visible after death, leads to the conclusion that in simple dysentery, 
 marked by tormina and tenesmus, and frequent dejections of sanguinolent mucus 
 without fecal matter, the inflammation chiefly affects the rectum and the descending 
 colon. When the earlier portions of the large mtestines are involved in the diseased 
 process, the stools at the outset are often composed, in great measure, of excrement 
 in an unnaturally fluid state, and mmgled with blood and slime. We generally 
 speak of these circumstances as constituting dysenteric diarrhoea. 
 
 Slight and simple dysentery may occur and run its course with very httle or no 
 disturbance of the circulation. When it is acute and severe, it is attended with more 
 or Jess pyrexia. The acute disease may terminate in recovery ; or in early death ; 
 or in chronic dysentery, which usually, in the end, is fatal. 
 
 The wards of our metropolitan hospitals place frequently under our notice severe 
 cases of chronic dysentery in the persons of soldiers and sailors, who bring the dis- 
 ease home with them from hot climates. With these exceptions, dysentery is, now- 
 a-days, neither a very common, nor a verj'' serious disorder in this country, I say 
 now-a-days, for the time was when it raged in London like a plague. The present 
 Dr. Heberden, in his valuable essay, On the Increase and Decrease of different 
 Diseases., shows, that in the seventeenth century the number of deaths set down, in 
 the weekly bills of mortality, under the titles bloody Jliix, and griping in the guts, 
 was never less than 1000 annually, and in some years exceeded 4000, For five- 
 and-twenty years together, viz., from 1667 to 1692, they every year amounted to 
 above 2000. During the last century, the number gradually dwindled down lo 
 twenty. Dysentery is one of the pests of hot climates. In all tropical regions, at 
 certain seasons of the year, it is very prevalent and destructive. But it is in fleets 
 and armies, and especially among troops in actual service, that the distemper most 
 displays its terrible power. There is no single malady which is so crippling to an 
 army in the field as this. Sir James M'Grigor, to whom was entrusted the superin- 
 tendence of the medical department of the army, on "the two greatest services on 
 which the military force of this country has, of late years, been employed, namely, 
 that in Walcheren, and that in the Peninsula," calls dysentery "the scourge of 
 arimes," and the " most fatal of all" their diseases. In two years and a half, the 
 British army in Spain lost no less than 4717 men by this complaint. 
 
 How are these facts lo be explamed 1 Wherefore is dysentery, which was so 
 familiar to our ancestors, so happily rare among us ? Why does it thus wait upon 
 and afflict the march of armies ? • Upon what depends its frequency in hot climates ? 
 We may expect to obtain some answer to these questions by searching into the 
 causes of the disorder. 
 
 It has been ascribed to exposure to wet and cold ; to the use of unwholesome 
 food ; to the agency of malaria ; to contagion. 
 
 Weather and season have a manifest influence in tlie production of dysentery. In 
 temperate chmates, Hke our own, it is an autumnal disorder. In tropical countries 
 it is observed to be more common and more severe when rains succeed to long- 
 continued drought. In respect to this, as to other bowel affections, a high diurnal 
 temperature of the air appears to be the predisposing, and exposure to cold the ex- 
 citing cause, I stated, on a former occasion, that great vicissitudes of temperature
 
 816 DYSENTERY. 
 
 are very frequent and very pernicious, even under the torrid zone. Scorching days 
 are followed by extremely cold nights. The dysentery which arises under these 
 circumstances is apt to run on into the ensuing winter. Soldiers in the field against 
 an enemy are peculiarly obnoxious to the agencies which favour or generate the 
 complaint. Marching, or engaged in actual conflict, during the day ; bivouacking 
 at night, often in the open air, and under every variety of weather; ill-provided, too 
 often, with clothes and bedding; their food scanty, precarious, or of bad quality; 
 seizing the many opportunities which their dreadful trade supplies of license and 
 intemperance; depressed, it may be, by disaster or defeat; we need not w^onder 
 either at the prevalence of dysentery among them, or at its untractableness while 
 they remain subject to the same morbid influences. Neither can the causes be 
 warded off from the patient, nor, in general, can the patient be removed from the 
 causes. Yet occasions do arise which show distinctly enough this alleged relation 
 of cause and effect. Frxsens morbiim facit — sublata tollit. Take, on the one 
 side, the following facts from Sir John Pringle's book On the Diseases of the Army. 
 The men who had fought at Dettingen lay that night on the field of battle, w-ithoul 
 tents, exposed to a heavy rain. For the next night or tw^o they encamped on better, 
 but still wet ground ; and they w^anted straw. Nearly half of these troops were 
 soon after affected with dysentery ; while three companies which had not been engaged 
 in the battle, nor exposed to rain, nor lain wet, escaped the complaint entirely. 
 Take this converse fact, related by Desgenettes. Four hundred of the French 
 "arm}?- of Egypt," reduced to a state of extreme weakness and emaciation by dysen- 
 tery there contracted, embarked at Alexandria on their return towards France; were 
 carried away, in short, from the alleged causes of their disorder. Nineteen died at 
 the very outset of the voyage ; which, had, however, so good an effect, upon all the 
 rest, that before they reached Malta they were thoroughly convalescent. 
 
 The very frequent coincidence or alternation, in some places, of dysentery w-ith 
 intermittent poison, has given rise to the opinion that both these diseases are alike 
 attributable to the malarious poison.. But dysentery prevails where there is no other 
 evidence of the presence of malaria. You may recollect that when we were upon 
 the subject of ague, I showed you that its repeated paroxysms were attended with 
 extreme and increasing congestion of blood in the internal organs ; of which conges- 
 tion the tumid spleen, the ague-cake, was an effect and a token. Now, whatever 
 gorges the splenic vein, gorges its tributary, the inferior mesenteric, which carries 
 the blood from the rectum and the descending colon. Upon such congestion of the 
 mucous membrane, inflammation is readily engrafted ; and, in this indirect way, 
 dysentery may be said to result from the marsh effluvia. Ague is an effect of ma- 
 laria, and dysentery is sometimes a sequela of ague. In precisely the same manner, 
 dysentery is apt to supervene, in hot chmates especially, upon hepatic congestion 
 and disease. 
 
 That dysentery is, in itself, a contagious malady, we have no satisfactory evi- 
 dence. In its sporadic form, in this country, we never see it spread from person to 
 person. But it is a prominent symptom in some epidemic visitations of continued 
 fever, which undoubtedly is contagious. To this fact I am inclined to attribute the 
 notion, formerly much more common than it now is, that simple dysentery is 
 catching. 
 
 The remarkable decline of dysentery in this metropolis has been cotemporary with 
 that of other disorders, and is due to the same combination of causes. For nearly 
 two centuries we have had no plague among us. Agues, formerly very rife in Lon- 
 don, have almost disappeared. Continued fevers, wdiich used to break out annually 
 m hot weather, are comparatively unfrequent. I believe that we may trace these 
 great blessings to an event which was regarded, at the time, as a national judgment ; 
 [ mean the great fire that, in 1606, consumed everything between Temple Bar and 
 the Tower. The streets and houses thus destroyed had been filthy in the extreme, 
 close, densely crowded, and consequently most unhealthy. The impurity of the air 
 excited, perhaps, some maladies ; and it certainly predisposed those who dwelt in it 
 10 various kinds of diseases, "the seeds of which (says Dr. Heberden) like those of 
 vegetables, will only spring up and thrive when they fall upon a soil convenient fo!
 
 DYSENTERY. 817 
 
 their growth." To the better construction of the houses and of the streets in the 
 rebuilt cit)' ; to the increased means of ventilation ; to the general formation of drains 
 and sewers; to the more copious supply of water; and to the more temperate and 
 cleanly habits of the people ; we may fairly ascribe our present exemption from 
 dysentery, from ague and continued fever, which are often the parents of dysentery, 
 and from the plague itself. In too many parts of this overgrown place, there is still 
 much room for improvement. 
 
 The pyrexia that accon?panies dysentery sometimes begins before the local symp- 
 toms declare themselves ; more frequently it succeeds their manifestation. Occa- 
 sionally the fever runs high, the pulse is hard and frequent, the skin hot, the face 
 jflushed, and the tongue furred ; and the patient complains of headache and thirst. 
 But in this, as in other abdominal diseases, the pulse soon becomes small and weak, 
 the strength rapidly declines, and the temperature of the body sinks. 
 
 In acute cases, the pain is often severe ; but it is subject to remissions and exacer- 
 bations. It occupies the hypogastrium, or some part of the course of the colon, 
 where there is usually more or less tenderness on pressure. The patient is tormented 
 by a sensation as if there were some excrement ready to be dislodged, goes perpe- 
 tually to the night-chair, and is irresistibly impelled to strain violently to get rid of 
 the irritation. But the efforts are ineffectual ; he discharges but little ; and what is 
 voided is either altogether a jelly-like mucus (in which case the complaint has been 
 called the dysenteria alba, and the morbus mucosus), oi more commonly it is mucous 
 and bloody (the bloody flux of our old authors), mixed with films, and membranous 
 shreds, and morsels that resemble flesh. In many of the dejections there is no 
 genuine fecal matter at all; or the small indurated balls which I just now mentioned 
 come away occasionally. Frequently the ejected mucus is variegated in colour, 
 green, or black, or reddish, like the washings of meat, and horribly fetid. Some- 
 times pain and difficulty in making water are added ; there is dijsuria, the irritation 
 of the rectum being reflected upon the bladder through the lower portion of the 
 spinal cord. Sometimes the stomach sympathizes, and nausea and vomiting ensue. 
 With all this local suffering there is a continuance of febrile distress ; the patient 
 passes sleepless, or dreamy and disturbed nights, and is low-spirited and desponding. 
 in the fatal cases, the pulse becomes very smaU and rapid, the features sharpen, and 
 the surface grows cold. Death begins at the heart. 
 
 Inspection of the dead body discloses more or less ulceration, chiefly of the large 
 ■■sitestine. The glands that are scattered over its surface are enlarged and prominent, 
 :!Ooking somewhat like small-pox pustules, for which indeed they have been mis- 
 taken. They probably form the foci of most of the ulcers, which are sometimes 
 narrow and oblong, lying across the gut; sometimes very large and irregular, with 
 here and there islands or ridges of thickened mucous membrane. In the worst 
 cases, the whole extent and circumference of the bowel present, internally, one irre- 
 gular, confused, and tattered mass of disorganization. 
 
 [In tbe ordinary cases of dysentery, the morbid appearances detected after death are, in- 
 flammation witli thickening of the mucous membrane of the colon and rectum ; occasionally, 
 mortification and slougliing of this membrane, but more generally, in protracted cases, deep 
 and extensive ulcerations, in the course of the transverse bands of the colon, or enlargement 
 and ulceration of the follicles of the large intestines. In the more violent forms of the dis- 
 ease, especially those which occur in hot and intertropical climates, in addition to the inflam 
 mation. ulceration, mortification, or sloughing of the inner coat of the large intestines, there 
 is often morbid vascularity of the mesocolon, mesentery and omentum, with adhesions of the 
 omentum to the adjacent viscera, and of contiguous portions of the intestines to each other. 
 The latter usually happen only when ulcers have perforated nearly all the coats of the 
 bowels. The glands of the mesocolon and mesentery are often enlarged, sometimes in 
 flamed, and more rarely in a state of suppuration ; the corresponding portion of the intestine 
 being usually the seat of a deep and extensive ulcer. The omentum occasionally adheres to 
 these diseased glands, forming a band by which a portion of intestine may become strangu 
 lated and be the cause of death. 
 
 The ulcerations of the large intestines are commonly most numerous and extensive in the 
 
 caecum and upper portion of the colon. The ileo-ctpcal valve has, in some eases, been found 
 
 entirely destroyed by the ulceration ; the lower portion of the ileum forming then an intus- 
 
 su.sception into the caecum, and becoming there strangulated has caused death. In a lb'* 
 
 53 3t
 
 818 DYSENTERY. 
 
 more fortunate instances, the strangrulated portion of the ileum sloughs off, after adhesion has 
 taken place between the adjacent parts, so as to maintain the continuity of the canal, when 
 the patient may recover. The right portion of the omentum is not unfrequently found ad- 
 hering to the ctecum, and this morbid attachment gives rise to symptoms which may be mis- 
 taken for hepatic abscess. Sometimes, in the whole course of the colon, we find not more 
 than eight or ten deep ulcerations, with sloughing, thick, abrupt, raised edges, surrounded by 
 an extensive thickened base, into which sinuses arid undermining cavities are seen to pene- 
 trate. These appearances, Mr. Twining states, (opera citat.) have reminded him of the foul 
 ulceration at the centre of a small carbuncle ; he has seen several patients die with only six 
 or eight of these idcers in the colon. The patients had a flushed face, restlessness, and 
 symptoms of continued fever, which were with difficulty controlled by any course of treat- 
 ment. 
 
 The last three or four inches of .the ileum are generally studded with superficial ulcera- 
 tions, and have a rough appearance from the enlarged follicles and glandular bodies ; with 
 this exception, we rarely meet with any traces of disease in the small intestines in those 
 who die of d3'sentery — excepting in those cases in which the dysenteric symptoms occur 
 towards the tennination of protracted fevers. 
 
 In a few instances the coats of the colon are so much thickened, that, when a transverse 
 section is made, its canal stands open like a thick leathern tube, the interior of the intestine 
 being covered with numerous large ragged ulcers, in the intervals of which the mucous 
 membrane is partly destroyed, and hangs in shreds. In several of these cases, Mr. Twining 
 (o?i tJie Diseases of Bengal), has observed the caecum, and lower portion of the ascending 
 colon, to be nearly covered with a thick layer of coagulable lymph, deposited beneath the 
 peritoneal coat, and extendii^g a considerable distance along the iliacus muscle; in some in- 
 stances an unusual amount of fat is found at the same jiart mixed with the lymph. In other 
 cases, when the disease has been more protracted, the whole of the great intestines are con- 
 tracted in diameter, resembling a cord, their mucous coat being at the same time covered 
 with numerous small superficial ulcers. In such cases, also, the internal surface of the 
 caecum, and of four or five inches of the colon, will now and then be of a livid red colour 
 inclining to brown, having a fleshy appearance, as if from a growth of granulations. Mr. 
 Twining (opera citat.) has met with this condition but seldom, but when it has existed., he 
 has found it to extend also to a small part of the sigmoid flexure of the colon. The patients 
 in these cases had become much emaciated, with flat contracted abdomen, dry skin, tongue 
 of a slate colour, glossy and morbidly clean, as if skinned ; the stools consisted of an opaque 
 dirty-brown water. 
 
 When death takes place after protracted suffering from dysentery, ■we often find the cel- 
 lular structure at the root of the mesentery and mesocolon, and across the bodies of the 
 lower lumbar vertebrae, deprived of its usual elasticity and pliability, and to a certain degree 
 indurated ; and in many cases entirely devoid of fat. This change is probably the result 
 of a previous inflammation at this part — giving rise to an exudation of coagulable lymph into 
 the interstices of the cellular substance. — C] 
 
 When submitted to early treatment, and when its exciting causes can be averted, 
 or avoided, dysentery is not an intractable disorder. Sir James M'Grigor remarks 
 of the camp dysentery in the Peninsula, that it had two stages, which it was of con- 
 sequence to note, because they required different and almost opposite modes of treat- 
 ment : the inflammatory stage, and the stage of ulceration. A plan proposed by Dr. 
 Somers appeared to Sir James so judicious, and proved so successful, in the first at- 
 tacks of the pure unmixed disease, that he recommended its general adoption in the 
 army. It was this : 
 
 First, the patient was freely bled. Immediately afterwards twelve grains of Do- 
 ver's powder were administered. This dose was repeated three times, at intervals 
 of one hour. Plenty of warm barley-water was at the same time given, and profuse 
 sweating encouraged for six or eight hours. A pill, contaming three grains of calomel 
 and one of opium, was exhibited every second night; and in the intervening days 
 two drachms of Epsom salts dissolved in a quart of light broth. The venesection 
 was repeated, while the strength and the pulse permitted it, until the stools were 
 free or nearly free from blood ; and Dover's powder as a sudorific, was always given 
 after the blood-letting. When the pains were great, and attended with much tenes- 
 mus, the warm bath gave instantaneous relief. " This plan being steadily persevered 
 in for a few days, the inflammatory diathesis of the intestinal canal, which had ex- 
 cited symptomatic fever throughout the general system, was found gradually to yield, 
 and make way for returning health." 
 
 If the disease was not cut short by this method, but advanced into the second
 
 DYSENTERY. 819 
 
 stage, and became chronic, the most effectual remedies appeared to be laxatives, and 
 opiates, given alternately ; and combined vpith such medicines as promote perspira 
 tion. The abdomen should be swathed with flannel, or covered by a warm adhesive 
 plaster. Much benefit may be obtained from the employment of clysters, if there be 
 not too much tenesmus to admit of the introduction of the pipe of the injecting syringe 
 Warm starch, with laudanum in it — not exceeding in quantity a couple of ounces, 
 lest the irritable bowel should expel it again — will sometimes afford signal relief. 
 Or if the pain and tenesmus are so great that a clyster-pipe cannot be used — or the 
 enema is not retained — a grain or two of solid opium inserted into the rectum beyond 
 the sphincter ani, will often allay the distress. The food should be farinaceous and 
 simple ; and great care must be taken during the convalescence to prevent a return 
 to improper diet, and a fresh exposure to cold. 
 
 There is one important point in the treatment of dysentery, concerning which a 
 striking discrepancy of opinion exists, even amongst practitioners who have had large 
 experience of the disease : I allude to the employment of mercury as a remedy. I 
 have no data for settling the question : but the amount of evidence appears to be 
 against its indiscriminate use. It seems (as we might expect) to be powerful both 
 for good and for evil. Sir James M'Grigor has probably hit the distinction which 
 should guide us to prescribe or to withhold this drug. It was, he tells us, when the 
 dysentery was complicated with disease or disorder of the liver, that mercury proved 
 so highly useful : when along with the dysenteric symptoms there were present a 
 dull pain in the hepatic region, and in the right shoulder, a yellowish-brown colour 
 of the skin, and of the conjunctiva, and uneasiness when the patient lay in any other 
 posture than on the right side. He adds : " In the early stage of the acute and un- 
 mixed disease, and before venesection has been performed, mercury will aggravate 
 the symptoms. In the more advanced stage of the disease, particularly when there 
 is hectic fever, Avith extensive erosion or ulceration of the intestine, it is invariably 
 found to hurry it on to a fatal termination." 
 
 The sporadic dysentery which we chiefly see in this country seldom requires the 
 lancet. Leeches, however, are to be applied, in the track of the colon, wherever 
 there is much tenderness or pressure. A full dose of castor oil may then be given ; 
 and after that an opiate. It is the practice of some physicians to prescribe laxatives 
 and opium together; but in this complaint it is better to alternate them. Opiate 
 enemata are of service for relieving tenesmus. These remedies will be much as- 
 sisted by the warm bath ; by hot fomentations to the abdomen ; and by such means 
 as promote the natural secretions of the skin. If there be any reason to suspect that 
 the portal system is gorged with blood, complete relief to the dysenteric symptoms 
 may often be obtained by the practice which I recommended as proper in melaena; 
 viz., the exhibition of five grains of calomel at bed-time, and of a senna draught the 
 next morning, for two or three days in succession. Should the symptoms still drag 
 on, it may be necessary to give mercury, even to the extent of making the gums 
 tender; but it should be introduced gradually. Equal parts of hydrargyrum cxmi 
 cretd and of Dover^s powder, constitute a very good combination either in pill or 
 powder for such forms of the complaint. But in the milder cases of simple sporadic 
 dysentery there is no occasion, I had almost said there- is no excuse, for giving your 
 patient a«sore mouth by the lavish employment of mercurial remedies. 
 
 [There are few cases of dysentery in which the lancet, or the application of leeches or 
 cups to the abdomen can be dispensed with, witliout endangering ulceration, thicliening, or 
 other structural changes in the mucous membrane of the intestines — by wliich the sufferings 
 of the patient are prolonged and his life endangered. When we consider that the disease 
 consists in fact in an inflammation of the lining membrane of the great intestines, proceed- 
 ing on, more or less rapidly, to ulceration, and in the more violent cases to gangrene and 
 sloughing, but little doubt can be entertained of the propriety of blood-letting in its early 
 stage ; even in the mildest cases, the application of leeches or cups to the abdomen will very 
 generally be attended with marked relief, and will materially shorten the duration of the 
 attack. The more violent forms of the disease can be successfully managed only by the 
 prompt, free, and even repeated use of the lancet, and the application at tlie same time of 
 leeches upon that portion of the abdomen where pressure causes the most pain ; and tnis 
 Bystem of active depletion must be continued, so long as fever or tenderness of the abdomeu
 
 820 DYSENTERY. 
 
 continues, more especially if the stools continue to be bloody. The use of the warm bath, 
 in a few hours after the bleeding, and its daily repetition, will always be attended with 
 benefit; or when there is no convenience for the employment of the warm bath, the abdo- 
 men may be enveloped with cloths wrung out of warm water, and repeated as they lose 
 their heat, or covered with a light, soft and warm poultice. A large number of cases, if 
 treated at their commencement by bleeding, and the warm bath or fomentations, with per- 
 haps a dose of Dover's powder at night, to ensure repose, will be very readily and speedily 
 cured by these means alone. 
 
 There exists much discrepancy of opinion in regard to the employment of purgatives in 
 dysentery. — Some practitioners insisting that they should be early commenced with and re- 
 peated at short intervals until natural stools are procured. While we cannot perceive any 
 indication that purgatives are calculated to fulfil, which cannot be as effectually met by 
 other less exceptionable remedies, we are convinced that the operation of purgatives cannot 
 fail to increase, in most cases, the irritation of the bowels, and to augment considerably the 
 sufferings of the patient. In cases where ulceration of the intestines is suspected to exist, 
 we consider that purgatives are altogether inadmissible. 
 
 Subsequent to bleeding, the internal remedy from which we have derived the most ad- 
 vantage in nearly all the forms of dysentery that have fallen under our notice, is the ipe- 
 cacuanha; we usually administer it in doses of half a grain, combined with the blue mass 
 and extract of hyoscyamus, of each one grain, repeated every three hours — ten grains of the 
 Dover's powder being given at night. After the discharges from the bowels have lost in 
 some measure their slimy, bloody appearance, and though still small, liquid, and frequent, 
 have acquired more of a fecal character, combining the ipecacuanha with acetate of lead 
 and a small portion of opium, will be found in general to quickly diminish the tormina and 
 tenesmus, and to afford marked and often very great relief to the patient. 
 
 Blisters are not a remedy from which any advantage can be anticipated until after the more 
 acute symptoms of the disease have been reduced by bleeding — previously they will often 
 do harm, but at this period they will be often serviceable. We have repeatedly observed 
 very great relief to follow their application. 
 
 To remove the painful affection of the bladder, with suppression of urine, that so frequently 
 attends violent cases of dysentery, Mr. Twining recommends injectiors of cold water into 
 the rectum as a remedy the most prompt and certain in its effects. These injections will also 
 be found an excellent remedy for the copious discharges of blood which frequently occur ; 
 these discharges will in general, however, be promptly arrested by an injection of ten grains 
 of acetate of lead in six ounces of water. 
 
 In cases where the tenesmus is severe during the night, an injection of sixty drops of lau- 
 danum in two ounces of cold water will usually remain in the rectum until morning, and 
 promote greatly the comfort of the patient. 
 
 The intense sufferings which the patients often experience from the severe tormina and 
 almost constant and distressing tenesmus attendant upon many cases of the disease, tempt the 
 inexperienced practitioner to resort at once to opiates for their relief. But the use of opium 
 in dysentery requires the utmost caution ; until the violence of the inflammation, in the more 
 severe forms of the disease, is reduced by active depletion, they are, in general, inadmis- 
 sible ; they are apt to mask the more prominent symptoms, and by the calm they thus pro- 
 duce may lead the physician into a false security as to the condition of his patient while a 
 fatal disorganization is taking place in the intestines. After, however, bleeding, either gene- 
 ral or local, or both, according to the violence of the case, has been carried to a proper extent, 
 an opiate at night in the form of Dover's powder, or during the day time opium combined 
 with ipecacuanha and tlie blue mass, will often be demanded to quiet the tormina and 
 tenesmus, and in this manner will give great relief to the patient and contribute materially 
 in shortening the duration of the most distressing symptoms of the disease. Opiate injeo 
 tions are certainly one of the most prompt and efficacious means we possess of relieving the 
 distressing tenesmus, which often continues to torment the patient after the violence of the 
 attack has been reduced. As an injection, we prefer the solid opium rubbed up with olive 
 oil, flaxseed tea or thin starch. The tenesmus is usually dependent on ulcerations low down 
 in the rectum ; and may frequently be relieved by introducing within the anus, three times 
 a day, a portion of the size of an hazelnut of an ointment composed of thirty grains of acetate 
 of lead, mixed with an ounce and a half of fresh lard. When tenesmus remains after the 
 more prominent symptoms of the disease have been removed, an injection of one drachm of 
 acetate of lead dissolved in eight ounces of tepid water was a favourite prescription with 
 Masely, and in many cases it will afford prompt relief 
 
 The utmost caution should be observed in regard to the nature and amount of the food and 
 drinks allowed to the patient as well during the disease, as in the stage of convalescence. It 
 is all important to keep the colon as nearly as possible empty so long as any degree of in- 
 flammation exists. — The practice followed by some practitioners of exhibiting to the patient 
 large quantities, daily, of flaxseed tea and other mucilaginous fluids, under the notion that by 
 »0 doing we soothe the inflamed intestine, is productive of far more injury than good. Whilst
 
 DYSENTERY. 821 
 
 the disease continues the mildest diluents only should be allowed, and theso only in moderate 
 portions at a time. Even after convalescence has been fully established, the patient should 
 be restricted to the blandest and most unirritating food, and this in very moderate quantity. 
 Errors in diet, as Mr. Twiningr very properly remarks, are among the principal causes of a 
 tardy recovery and frequent relapses. 
 
 In describing the post-mortem appearances in fatal cases of dysentery, we noticed various 
 morbid conditions of the CEecum as of occasional occurrence ; to these Mr. Twining, in his 
 work on the Diseases of Bengal, (page 69,) directs especial attention. No particular change 
 in the general treatment of the case, however, is demanded. All that is necessary is for the 
 practitioner to bear in mind the possibility of the occurrence of more or less violent inflam- 
 mation of the caecum, and by the most undeviating perseverance in the employment of the 
 remedies demanded for its removal, especially the local application of leeches, to prevent 
 the disorganization of the intestine, and the death of the patient. " When," remarks Mr. T., 
 " a considerable enlargement of the ccecum takes place, during dysentery, it is usually first 
 noticed about ten or fourteen days after the commencement of the attack. There is not 
 usually so much pain as to make the patient complain, particularly of the part affected ; and 
 unless the practitioner habitually examines the abdomen of those he is treating for dysen- 
 tery, he will be occasionally told of the swelling at a period of the disease when the patient 
 is past recovery : or he will find. Upon dissection, such a mass of disease and inflammation, 
 with induration, in the right iliac region, that he will be surprised how it could have escaped 
 his notice during life. Excepting in fat persons, the rounded, doughy, inelastic tumefaction 
 of the CEecum is easily detected by examination with the hand ; and, in fact, is often visible 
 on inspection. 
 
 The inflammation of the ccecum is to be treated by the daily application of leeches to the 
 right iliac region ; the discharge of blood being promoted by warm fomentations or poultices. 
 When by this means the morbid sensibility is removed, and the tumefaction considerably 
 reduced, a blister should be applied and kept open by some stimulating dressing. Mr. 
 Twining recommends as a means of reducing the remaining induration, " a course of Plum- 
 mer's pill, and extract of colocynth, at night, followed by the compound powder of jalap in 
 the morning." "We must remember," he adds, "that no part of the disease can be left 
 unsubdued without hazard to the patient's life." 
 
 In chronic dysentery, there is frequent watery purging, attended often with tormina, and 
 very generally with tenesmus, by which the patients are much distressed and soon greatly 
 exhausted. The discharges are mostly of a pale gray colour, often mixed with more or Less 
 cf a mucous or white slimy substance, and not unfrequently portions of undigested food. 
 They sometimes consist of a copious paste-like brown mass, in a state of fermentation ; occa- 
 sionally, they are frothy, with a whitish or pale gray sediment like a mixture of chalk and 
 beer ; in a few very protracted cases, the discharges are very frequent and copious, quite 
 Watery, and varying in colour, from a dark-brown to a bright-orange, or from a dirty yellow 
 to a pale straw. They are in some cases inodorous, or nearly so; in others they have a 
 peculiar sickening odour, and in others again they are more or less fetid. Blood is rarely 
 present in the stools, and the patients suffer from fever only in those cases in which there is 
 extensive disease of the mesenteric gland — when they occasionally presented a well-marked 
 fever of a hectic character. The abdomen is generally flat, inelastic, and somewhat retracted; 
 occasionally, however, tympanitis is a troublesome symptom. The skin is usually dry, shri- 
 veled, and desquamating, and of a dirty brown or sallow hue. 
 
 The treatment of chronic dysentery differs but little from that proper in cases of chronic 
 diarrhoea. During the continuance of the disease, and for some period after it has been 
 removed, the patient is to be strictly confined to a mild, i^nirritating diet, taken in very 
 moderate quantity, and, for drink, to some bland mucilaginous fluid, as toast or rice water — 
 and even this only in such portions as are necessary to allay his thirst. He should be 
 shielded from the influence of cold and damp, and all sudden atmospherical changes, by 
 flannel next his skin and appropriate' clothing, and by a careful attention to the temperature 
 of the chamber he occupies. 
 
 Leeches or cups to the abdomen will frequently be found of service — but their use will 
 require judgment, and a close scrutiny of each case in order that any latent or chronic inflam- 
 mation may be at once detected. Whenever indurations within the abdomen can be felt, 
 and they are attended by morbid sensibility on pressure or the least degree of febrile excite- 
 ment, the application of leeches or cups should not be neglected. When the indurations are 
 without sensibility, or after this has been removed, blisters are generally very importatit 
 remedies. The daily use of the warm bath and warm fomentations to the abdomen assidu- 
 ously employed, are means from which, in cases of chronic dysentery, the most decided 
 advantage will invariably result. Small doses of ipecacuanha combined with extract of 
 byosciamus and the blue mass, and repeated every three hours, with a dose of Dover's pow- 
 der at night, will generally be found to aid very effectually in restoring the capillary v,ircu 
 lation to its healthy state, in quieting the morbid irritability of the mucous membrane of tho 
 intestines, in moderating the profuse morbid discharges, and in rendering the stools less frt^ 
 
 3x2
 
 822 DIARRHCEA ADIPOSA. 
 
 qiient and of a more natural character. The balsam of copaiba and turpentine will often 
 be found of equal advantage in many cases of the present affection, as in chronic diarrhcea. 
 In regard to the period proper for the employment of astringents, and the articles of this 
 kind that are best adapted to the disease, the same remarks may be repeated as were made 
 in our note on chronic diarrhcea. — C] 
 
 The fluxes of which I have hitherto spoken have all consisted in an immoderate 
 discharge of some of the usual contents or secretions of the alimentary tube, in an 
 altered and unnatural state. But matters are sometimes voided from the bowels, 
 totally unlike atiy of the healthy discharges. Adeps is not an intestinal excretion, 
 yet it is sometimes passed in great abundance by stool. Many unquestionable 
 instances of this are on record, both in ancient and in modern literature. I have not 
 seen more than one, and therefore have but little to say upon the subject ; yet I must 
 not pass it over altogether. A certain quantity, sometimes it has been a large quan- 
 tit)'^, of oil, or liquid fat, has been poured forth, in a sort of diarrhoea. Sauvages 
 was aware of the disorder, and calls it, in his Nosology, diarrhcea adiposa. In a 
 paper in the Medico-Cldrurgical Transactions upon this affection. Dr. Elliotson 
 refers to an example of it described by Tulpius, in which a woman discharged every 
 day, for fourteen months, a considerable quantity of yellow fat, that lay upon the feces 
 like melted butter. When voided into a vessel of water, it floated, like oil, upon 
 the surface ; and when cold it assumed the consistence and appearance of fat. Like 
 fat, it was very inflammable, and burned with a bright flame. With all this there 
 was no kind of distress, nor any wasting of the body ; and the patient was in excel- 
 lent health sixteen years afterwards. Dr. Elliotson had a case of this kind under 
 his own care. The man had also diabetes and phthisis. The symptoms were pre- 
 cisely the same as those described by Tulpius. Dr. Prout and Dr. Faraday ana- 
 lyzed portions of the adipose matter, and they pronounced it to be genuine fat. Mr. 
 Lloyd, of St. Bartholomew's Hospital, has given us the details of a case in which the 
 evacuation of grease was associated with jaundice. The excretion looked like melted 
 fat, but when cool had the consistence of butter. Tt swam on the surface of water, 
 melted at a moderate heat, and burned readily. In this instance the head of the pan- 
 creas, and the duodenum, were involved in a mass of scirrhous disease. And this is 
 a very curious fact : for Dr. Bright also states that in three different persons, each of 
 whom he had known to pass fat from the bowels during life, and whose bodies he 
 had the opportunity of examining after death, he found scirrhous disease of the pan- 
 creas, and fungus disorganization of the duodenum. 
 
 The remarkable coincidences, occurring so often, of these fatty discharges with 
 cancerous disease of the pancreas and duodenum, is well worthy of being borne in 
 mind ; although it may not, as yet, afford any explanation of the phenomenon. 
 
 The single case of which I have had any cognizance is that of a tradesman now 
 living in my neighbourhood, who from October 1843 to August 1844, suffered fre- 
 quent attacks of this kind. First, he had severe pain in the epigastrium and right 
 hypochondrium, with little or no fever, nor acceleration of pulse. Occasionally, 
 when the pain was extreme, it was accompanied by nausea and vomiting. After 
 the pain came jaundice and white stools ; and, lastly, a discharge from the bowels of 
 a quantity of white fragments, looking exactly like coarse chewings of walnuts. 
 Sometimes much larger lumps of the same sort were voided. These lumps and 
 fragments were found to be composed of adeps. They floated, many of them at 
 least, for a while upon the surface of the water. They fek greasy ; and burned, like 
 fat, with a flame. 
 
 After this series of symptoms, the patient would recover perfectly, save that the 
 attacks reduced his strength somewhat. They occurred about once a fortnight, so 
 that he had about a score of them in ten months. 
 
 The symptoms resembled those which declare the passage of gall-stones : and 
 upon one occasion two concretions were detected among the fragments of fat. One 
 of these was yellowish ; the other black, hke a cinder. Once also, a considerable 
 portion of what seemed membrane came away. My neighbour, Mr. Francis E. 
 Hicks, (to whose kindness I am indebted for the opportunity of seeing this patient,) 
 is of opinion that a cyst, which secreted the fat, existed in the liver, and di?-
 
 INTESTINAL CONCRETIONS. 823 
 
 charged its contents periodically ; and that the membranous fragment was a part of 
 this cyst. 
 
 Projecting a little into the epigastric notch, I could feel what appeared to be the 
 edge of the left lobe of the liver. This spot was slightly tender and dull under per- 
 cussion. 
 
 I had previously been consulted by the same patient for a chronic and obstinate 
 cough, which, after harassing him for three or four years, ceased suddenly, upon the 
 occurrence of the first of these strange seizures. On that occasion, he voided at least 
 a quart of the fat. Since August, 1844, he has experienced only two or three slight 
 threatenings of an attack ; but lo, his old cough has returned. 
 
 Mr. Hicks tells me that a female relative of his own laboured for four or five 
 years under a perpetual dry cough, which was most distressing to herself, and very 
 irksome to the hearers of it. A pint of fatty matter was then passed by stool, and 
 the cough ceased at once, entirely and permanently. This happened more than ten 
 years ago. 
 
 All that we know of the disease seems to amount to this : that it is not a common 
 complaint ; and that it is not necessarily a /a/a/ complaint. Persons who have passed 
 great quantities of fat in that way have Hved in good health for many years after- 
 wards. Yet though not necessarily fatal, it has frequently been found" associated 
 with incurable malignant disease in the duodenum and pancreas. Dr. Prout informs 
 us also that in cases in which a similar oily fluid has been passed through the wre//im, 
 the kidneys have been found in a state of organic malignant disease. 
 
 With respect to the treatment of such cases, all the hints I can give you are such 
 as are furnished by the two following facts : — 
 
 Mr. Howship, in his book on morbid anatomy, mentions the instance of a lady 
 who was affected with this diarrhoea adiposa, and parted with vast quantities of fat ; 
 and who was cured upon the principle of similia similibus curantur, for she reco- 
 vered after swallowing a pint of sweet oil. And Dr. Elliotson, acting on this hint, 
 gave his patient, who was labouring at the same time under diabetes, a. quarter of a 
 pint of olive oil ; and the voiding of fat greatly diminished from that time, and soon 
 ceased entirely. 
 
 Whether these were really cures, or whether they were coincidences, is a question 
 which we want larger experience to help us to determine. 
 
 When I was speaking of the causes of enteritis, I adverted to the presence 
 0^ foreign substances, ^s they are called, in the bowels, and to intestinal concre- 
 tions. 
 
 There are some points connected with these subjects which I had not then leisure 
 to pursue, but which you ought not to be ignorant of. 
 
 Intestinal concretions are very common in some of the lower animals — in horses 
 and oxen especially. Most of you have seen, I dare say, immense intestinal calculi 
 of this kind, and great numbers of them, in the Museum of the College of Surgeons. 
 The old remedies called bezoars were of the same nature. 
 
 They occur, also, these intestinal calculi, in the human entrails, and in various 
 parts of them ; chiefly, however, in the caecum and large intestines, but sometimes in 
 the stomach : indeed, very large ones have occasionally been met with in the latter 
 organ. Bonetus describes one which weighed nine ounces, and was as big as a hen's 
 eg^. Generally they are few in number in the same person : one only, perhaps, 
 exists ; or two, or three. Yet as many as thirty have been found together in thfi 
 stomach in one case ; and in another case nine. One of the Monros of Edinburgh 
 (Monro primus) detected twelve in the colon of a boy, during life, by the touch. 
 Monro secundis took a concretion that weighed four pounds from the colon of a 
 woman. They have been known to measure as much as eight inches in circum- 
 ference. In the twenty-fourth volume of the Edinburgh Medical and Surgical 
 Journal is an account of one long one, or, perhaps, of three that had become united 
 together, weighing twelve ounces. Mr. Turner, of Keith, has very lately published 
 the case of a man who passed fourteen large intestinal concretions. 
 
 Now, what are these substances, and how do they get there? What is the patno-
 
 824 INTESTINAL CONCRETIONS. 
 
 logy of the malady ? Why, they seem to be formed, in many instances, by the 
 deposit of saline particles, intermixed with animal matter, upon and around some, 
 accidental nucleus which has entered the alimentary canal, and there stopped. 
 Sometimes a gall-stone forms the nucleus : the centre of the calculus has several 
 times been found to consist of pure cholesterine. Those matters over which the 
 gastric juice has no power, and which pass the pylorus unchanged — such as the 
 stones of fruit, husks of grain, many unbroken seeds, portions of bone, and the like. 
 Other of these intestinal concretions are evidently composed of a mass of short fibres, 
 matted, or interwoven together, after the manner oifelt. These calculi have a some- 
 what soft and velvety feel, yet are too hard to be much compressed. Sometimes 
 they involve a nucleus, and sometimes they do not. Their composition has been 
 discovered in rather a curious manner. Mr. Clift, who, as you know, has long had 
 the main charge of the Hunterian Museum, after attentively examining some of the 
 specimens there collected, fancied that they might be formed somehow of the beard 
 of oats ; and the late Dr. Wollaston, at Mr. Chft's suggestion, I beheve, undertook to 
 analyze them somewhat more rigidly; and he found that Mr. Clift's conjecture was 
 well founded. If you have ever looked closely into the structure of an oat which 
 has been separated from its husk, you may have noticed that one end of it is formed 
 somewhat like a tiny brush ; madt up of very minute needles or beards. Dr. Wol- 
 laston found that these ends were identical in their shape and composition with the 
 fibres of the intestinal concretions. 
 
 The accuracy of the result of this analysis is singularly confirmed by the fact that 
 this particular kind of intestinal calculus is almost peculiar to the bowels of Scottish 
 people ; among whom, as you know, oats form a verj' common article of diet, in the 
 shape of oat-meal. 
 
 Concretions of the same species have also been found in the intestines of Lan- 
 cashire persons; and they also use oatmeal a good deal as food. Mr. Children 
 gives an account of some in the Philosophical Transactions for 1822. The fibres 
 were cemented together by mucus ; and the concretions contained also albumen, 
 phosphate of lime and soda, and common salt. 
 
 I mentioned formerl)^ the danger which attends the incautious or excessive use of 
 magnesia, whether for stomach complaints or for urinary disorders. When this 
 substaMce is taken habitually, and when due care is not used to ensure its habitual 
 expulsion from the intestines, it is liable to accumulate and concrete there, especially 
 in the ccecum and colon. Large masses of this kind have been met with, composed 
 almost entirely of carbonate of magnesia. 
 
 And the habitual use of any other indigestible substance may have the same ill 
 consequence. The seeds of figs ; unbruised mustard seeds, which (as I mentioned 
 before) are taken daily by some persons; the woody knots found in certain pears; 
 all these have been known to form the material of concretions, or of hard injurious 
 masses in the bowels. 
 
 Now concretions of this kind come at length to produce symptoms by the pressure 
 and distension they occasion, by the ulceration to which they sometimes give rise, 
 and, above all, bj' the obstacle they oppose to the passage of the contents of the 
 intestines. They generally cut the patient off' by exciting inflammation. 
 
 But they may exist for a long time without producing any definite symptoms. 
 And when symptoms do arise, or when we ascertain that such concretions have 
 formed, we are often at a loss for a remedy. From the colon we may hope at last to 
 dislodge them: by mechanical means when they are near the outlet; by frequent 
 mjections of warm water, or soap and water, whereby thty may be softened or broken 
 down, and washed out, when they are beyond the reach of the finger, or of instru- 
 ments passed into the rectum. 
 
 We have an illustration of the patience of the alimentary canal under the presence 
 >i these masses, in what often happens when foreign bodies of some magnitude are 
 •wallowed and remain in the tube. 
 
 In one of the earlier volumes of the Medico-Chirurgiccd Transactions you may 
 iead the history of a celebrated knife-eater. A sailor, in a drunken bravado, swal- 
 lowed a clasp-knife. This was followed by no immediate bad consequences, and
 
 WORMS. 825 
 
 he used to brag of the feat he had performed. And afterwards, either to satisfy the 
 scruples of those who did not believe his assertions, or for the sake of rewards 
 which some people were thoughtless and cruel enough to offer, or to win wagers, he 
 stupidly repeated his folly, till he had swallowed (I think) thirteen knives of various 
 kinds and sizes. They killed him at last ; and their remains were found in various 
 parts of the alimentary tract. But he had no serious symptoms for some time. 
 
 Mr. Wakefield has given us an account of a culprit, confined in the Cold Bath 
 Fields Prison, who had swallowed seven half-crowns before his incarceration. One 
 day out they all clattered into the pan of his night-chair. 
 
 I saw a prisoner myself, last autumn, in the Penitentiary, who, after some sick- 
 ness, and tenderness of the belly, voided a half-crown from the rectum. This was 
 in November, 1839. He had swallowed the piece of money two years and a half 
 before — viz., in March, 1837; and, until within a week of his passing it, he had 
 enjoyed excellent health. 
 
 Before I proceed to any of the other viscera of the abdomen, I may as well take 
 fcuch notice as the nature and hmits of these lectures admit and require, of the sub- 
 ject of tvorms ; in which subject the intestinal canal is more concerned than any 
 other part of the body. It seems a strange as it is a somewhat humiliating fact, that 
 the human body should furnish food and a habitation for many of the inferior crea- 
 tures ; not only after death, but while it is yet alive. The parasitic animals which 
 thus prey upon man have been much studied from time to time, and especially of 
 kte, in their relations to natural history : and some of the facts that have been ascer- 
 tained respecting them you ought to be acquainted with. But I shall pursue the 
 subject no further in this place than it concerns us as pathologists and physicians. 
 Its natural history will, no doubt, be fully taught you by the professor of comparative 
 anatomy. 
 
 First, then, it is a notorious fact that numerous parasites do crawl over our surface, 
 burrow beneath our skin, nestle in our entrails, .nd riot, and propagate their kind, in 
 every corner of our frame : produ iu oftentimes such molestation and disturbance 
 as require the interference of medicine. Nearly a score of animals belonging to the 
 interior of the human body have been already discovered and described : and scarcely 
 a tissue or an organ but is occasionally profaned by their inroads. Each, also, has 
 its special or its favourite domicile. One species of strongJe chooses the heart for its 
 dwelling-place, another inhabits the arteries, a third the kidney. Myriads of minute 
 worms lie coiled up in the voluntary muscles, or in the areolar tissue that connects 
 the fleshy fibres. The gxcinea-worm and the chigoe bore through the skin, and 
 reside in the subjacent reticular membrane. Hydidids infest various parts of the 
 body, but epecially the liver and the brain. A Httle fluke, in general appearance 
 much like a miniature flounder, lives, steeped in gall, in the biliary vessels. If you 
 squeeze from the skin of your nose what is vulgarly called a maggot — the contents, 
 namely, of one of the hair-follicles, — it is ten to one that you find, in that small 
 sebaceous cylinder, several animalcules, extremely minute, yet exhibiting under the 
 microscope a curious and complicated structure. Even the eye has its living in- 
 mates. But it is, I repeat, in the alimentary tube that we are most apt to be plagued 
 with these vermin. 
 
 Independently of minute scientific divisions into genera and species, there are 
 some broad lines of distinction between these creatures. Thus some kinds of worms 
 occupy, as I have said, the interior of our bodies ; these are called, accordingly, 
 entozoa: some dwell externally, and are named ectozoa; or, more properly, per- 
 haps, epizoa. 
 
 There are five sorts of intestinal worms, sufficiently common to make it likeiy 
 that you will meet with some or most of them in your future practice. I shall, on 
 that account, direct your attention first of all to them. 
 
 1. A frequent tenant of the human intestines is the round worm, so like in shape, 
 bize, and general appearance to the common earth-worm. It is from tnis species, no 
 doubt, that the whole class are called worms. This round worm is ofien denonni-
 
 826 ROUND WORMS. 
 
 nated a lumbricus ; but that is erroneous : it is a species of ascaris, and it has been 
 named by naturalists the ascaris lumbricoides — the ascaris that is hke a lumbricus. 
 
 2. The ascaris vermictdaris ; or the oxyuris vermicidaris. These animals 
 resemble slender maggots rather than worms. They are often called simply asca- 
 Hdes: or, in the vernacular, //n-e«(/-i6'orms ; and they are very much like bits of 
 white thread. 
 
 3. The tricocephalus dispar ; also a small worm, but longer than the last ; its 
 vulgar denomination is accordingly the long thread-worm. 
 
 4 and 5. Two species of tmnia ; long, flat, articulated animals, resembling pieces 
 of tape. The txnia solium, or common tape-worm of this country ; and the taenia 
 lata, or broad tape-worm. 
 
 Of all these I proceed to mention a few more particulars. 
 
 The ascarides lumbricoides, or round worm, is, I say, very hke the common earth- 
 worm, and used to be thought identical with it. It runs from five or six inches to 
 about a foot in length, and it is of a reddish-brown colour, with a tinge of yellow. 
 The female worm (for they are of both sexes) is much more common than the 
 male, which is smaller also, and may be distinguished by a curved state of its tail, 
 and by the genital organs. Sometimes young ones are met with, about an inch and 
 a half long. 
 
 I shall not go into any minute description of the anatomy of these worms. You 
 cannot mistake them, except for earth-worms ; and the points of distinction between 
 the two, when known, are easily perceived. The earth-worm, then, is redder than 
 the intestinal worm, and less pointed at its two ends. The mouths of the two differ 
 much. That of the earlh-worm is a short longitudinal fissure, or slit, placed on the 
 under surface of its small rounded head. In the ascaris lumbricoides, the mouth is 
 situated at the extremity of the worm, is of a triangular shape, and is surrounded by 
 three tubercles. 
 
 It is curious that similar differences, only reversed, exist in respect to the other 
 aperture of the alimentary canal, the anus. In the earth-worm this is terminal, at 
 the very end of the cylinder : in the ascaris it is a transverse sht near the extremity, 
 and on the other surface of the animal. 
 
 Again, the earth-worm has rows of Httle projections, like bristles, upon its under 
 surface ; feet they may be called, for they appear to serve the purposes of locomo- 
 tion. In the parasite there is nothing resembling this. 
 
 By attending to these plain marks, you may avoid being deceived by impostors, 
 who pretend that they are afflicted with worms, and to prove their case bring you an 
 earth-worm or two in a bottle. 
 
 The habitat of these worms is in the small intestines. They may, and do, pass 
 upwards into the stomach, or downwards into the large bowel : in either case they 
 are generally soon voided. Sometimes they are vomited up: but they have been 
 known to creep into the oesophagus, and thence into the nostrils. Andral states that 
 he saw a case in which a child was strangled by one of these worms, which had 
 turned back and become e-ntangled in the larynx. They have been found also ni the 
 excretory ducts of the liver. This Andral has witnessed ; as has also Dr. Baron in 
 this country. 
 
 It was formerly thought that these animals were capable of perforating the coats 
 ol the intestine: but that opinion is now generally exploded. They do not appear 
 to have the means, if they possess the inclination, to bore through. What gave rise 
 to this notion was the circumstance of their sometimes passing out of the bowel, 
 through ulcerated or other openings, into the peritoneal sac ; or into the vagina or 
 bladder; or outwards through hernial apertures. 
 
 The number of these worms existing at the same time in the same person is very 
 variable. The late Dr. Hooper mentions a girl, eight years ok', who voided upwards 
 of 200 in the course of one week. An instance is recorded of a soldier who passed 
 3G7 in six days. Another patient got rid of 400 in a fortnight. 
 
 Fifty or sixty have been found in the same dead body. They often lie in packets. 
 The corresponding portion of mucous membrane has in some cases been red, in
 
 THREAD-WORMS — TAPE WORMS. 827 
 
 Others quite natural. Sometimes two are met witii ; sometimes one only. So that 
 we cannot infer with certainty that because one such worm has been voided, more 
 remain behind ; although that is always probable. 
 
 This worm is more common in the early periods of life than afterwards. 
 
 The other species of ascaris, the ascaris vermicularis or thread-worm, resembles 
 the former in some respects, but it differs from it remarkably in size. Here also the 
 female is longer and larger than the male ; the one being perhaps half an inch in 
 length, the other not two lines, and very slender. 
 
 The thread-worms hve principally in the rectum, and sometimes exist there in 
 vast numbers ; thousands : and they pass out, or are ejected, matted together with 
 mucus in the shape of balls, or entangled in portions of excrement. Sometimes they 
 emerge of their own accord, and crawl about the neighbourhood, getting into the 
 vagina in females, and even into the urethra, and causing intolerable irritation, itch- 
 ing, and distress. 
 
 They are seen, when recently expelled, to be very lively ; moving their anterior 
 extremity about continually. To this restlessness and activity the animal owes its 
 name, which is derived from the Greek word asxapc^nv, to leap. The Germans call 
 it springwurm. 
 
 This worm also belongs chiefly to infancy and childhood. It does sometimes infest 
 adults ; but generally as the patient grows older the animals cease to trouble him, 
 whether curative means are employed or not. Bremsen, however, knew a person 
 eighty years old, who was nearly killed by them. 
 
 [We have met with these worms nearly as often in the adult as in the chikl. — According 
 to our experience, the female adult is much more liable to them than the male. — C] 
 
 The third kind of these round worms is the long thread-worm ; the tricocephalus 
 dispar! It is from an inch and a half to two inches in length. One extremity, that 
 to which the head belongs, is extremely fine and small ; and then suddenly bulges 
 out into a thicker body. The thinner portion is about twice as long as the thicker. 
 Its name is derived from this variation of size. Spi-I, a hair, and xs^axyj, the head ; 
 the portion to which the head is appended being as fine as a hair. At one time the 
 head was mistaken for the tail, and then the animal was called tricuris, from i9p(.|, 
 and ovpa, the tail. The thicker or body part is rolled up in a spiral form, especially 
 in the male, the female being straighter. This worm is of a white colour, unless 
 tinged by its food. It also affects the large intestine as its place of abode ; but the 
 opposite end of that gut, the ccecum, is its favourite spot. It is sometimes met with 
 in great numbers, attached to the mucous membrane by its head ; the body hanging 
 loose. 
 
 Although jjenerally overlooked, it is said to be extremely common, and to occur in 
 most bodies. I have seldom seen it ; but then I have never hunted for it. It infests 
 the dog, the fox, the monkey, and other mammalia. 
 
 This species of entozoon attracted a good deal of attention about seventy or eighty 
 years ago ; it being then first observed in Germany d'uring the prevalence of an epi- 
 demic fever, which was characterized by a profuse mucous diarrhoea. Rcedererand 
 Wagler have given an excellent account of this disorder, under the title of morbus 
 mucosus. It was thought to have been excited by these worms, which were found 
 in abundance in the caecum after death. This opinion must have been erroneous, for 
 the animals were known in other places, long before ; and they produce, in general, 
 no inconvenience. 
 
 The two taenicB are more formidable beasts. With a general resemblance between 
 them, there are strong particular distinctions. 
 
 The tfenia solium, or common tape-worm, has a minute hemispherical head, and a 
 long flat body of a whitish colour, composed of many pieces curiously articulated 
 together. The articulated pieces are quadrilateral, very short and small in the crea- 
 ture's neck ; they become gradually square as the distance from its head increases ; 
 and at length are longitudinally oblong. These portions, ox joints as they are called, 
 have foramina on their margins, leading to ovaries within. The foramina, which are
 
 828 TAPE- WORMS. 
 
 very conspicuous, are placed alternately on the one side of the ctnimal and on the 
 other: on the right edge of one joint, on the left of that next to it. This arrange- 
 ment is, however, subject to occasional irregularities. Each joint is let in, as it were, 
 to that immediately in front of it, and the connection between them is not very firm. 
 It is less firm in proportion as the animal is older, and as we approach its posterior 
 extremity : so that the segments are apt to come away, by stool, separately. They 
 have somewhat the appearance of the seeds of cucumbers or gourds ; and the para- 
 sites, for that reason, are sometimes called cucurbitine worms. Blumenbach and 
 others have supposed that each articulated piece was a distinct worm : but that is not 
 the case. The head of the animal, and i-ts peculiar terminal segment, forbid this belief. 
 
 The common tape-worm is very narrow and thin towards its anterior extremity ; 
 one-third or one-quarter of a hne perhaps in breadth. At its broadest part it may be 
 from three to six lines wide. 
 
 The young taeniae see?n to be merely wrinkled ; but they are really articulated. 
 The question has been started, whether the lost joints are ever reproduced. It is 
 beheved that no new joints are formed, but that the original ones are gradually more 
 and more developed. The animal is hermaphrodite. 
 
 Specimens of this worm are preserved, upwards of twenty feet in length. Much 
 exaggeration seems to have existed formerly about its size. It has been said to mea- 
 sure ISO, and even 300 feet. In all probability separate portions of several have 
 been estimated as forming parts of one and the same worm. There is one case well 
 authenticated (it is cited by Bremser from Robin) in which a tape-worm was found 
 to extend from the pylorus to within seven inches of the anus ; adhering firmly to 
 the mucous membrane all the way. The animal has the power of motion. Its 
 movements are felt by the patients, within them. When recently expelled, and 
 placed in tepid water, it may be seen to shorten itself; nay, portions protruding 
 many feet from the anus have been known to draw themselves back again. 
 
 This kind of worm is more frequent in adults than in children : yet it is some- 
 times met with even in the fcetus. It is exceedingly common in dogs. It has been 
 badly named ver solitaire, for it is not always single. It is not only found in com- 
 pany with different worms, but also with others of its own species. Its natural 
 place of abode is the small intestines : but it extends sometimes into the large, and 
 sometimes into the stomach. Vandoverer declares that after an emetic one of his 
 patients vomited forty Dutch ells of the worm, and might have got rid of more 
 "if he had not been afraid of puking out all his guts, and for that reason bit the 
 worm off." 
 
 The taenia lata, or broad tape-worm, has often been confounded with the taenia 
 solium; yet there are striking differences between them; respecting which, for all 
 practical purposes, it is enough to say that the heads (as viewed through a micro- 
 scope) are very dissimilar; that the joints of the tasnia lata are shorter and broader, 
 and adhere together in a different manner ; and that the pores leading to the oviducts 
 are situated not on the edge of each joint, but in the centre of its fiat surface. This 
 variety is not so easily broken across as the former; and therefore its segments are 
 less liable to be voided in a separate form. It is probably shorter also than the tasnia 
 sohum. Fifteen feet have been supposed its average length. Marvellous stories, 
 however, are told on this head. Boerhaave declares that he effected the expulsion 
 of one, which Avas 300 ells long, from the bowels of a Russian. 
 
 The geographical distribution of these two species of taenia forms a curious part 
 of their history, and throws some light upon the doubtful question of their origin. 
 In England, Holland, and Germany, the taenia solium is common, and the taenia lata 
 very rare. In Russia, Poland, and Switzerland, it is just the reverse ; the taenia lata 
 prevails ; the taenia solium is seldom seen ; while in France the one species is nearly 
 as fre(|uenl as the other.
 
 HYDATIDS. 829 
 
 LECTURE LXXIY. 
 
 Entozoa continued. Hydatids. Trichina Spiralis. The Guinea-Worm. Stron- 
 gidiis Gigas. Origin of Entozoa. Question of Spontaneous Generation. 
 General symptoms of the presence of Intestinal Worms. Particular symp- 
 toms, and remedies, of the common Round Worm, of Thread-worms, of Tape- 
 Worms. 
 
 At our last meeting I gave a summary description, sufficient, however, for our 
 purposes as medical practitioners, of the five kinds of vermes which are most com- 
 mon in the human intestinal canal. There are yet a few more of these entozoa 
 which are curious and interesting enough to deserve a brief notice. 
 
 Hydatids — animals like bags or bladders of water — are of very frequent occur- 
 rence in various parts of the body. They are also called acephalo cysts, headless 
 bags. These are not to be confounded with enlarged Graafian or other vesicles, nor 
 with morbid serous cysts in general. They look like, or rather they are, spherical 
 sacs having one aperture only, and containing a thin colourless liquid. They are 
 usually found congregated, sometimes in vast numbers, w^ithin a large cavity or cyst, 
 to which they are not attached. This is a consequence of the pecuHar manner in 
 which the animals are propagated. The wall of the cyst is laminated, and the youncr 
 hydatids bud forth from between its layers. In the species which most commonly 
 infests the human frame, they are born into the cavity of the parent : in some other 
 species they are detached externally. We find therefore a parent bag, full of other 
 smaller bags ; which, again, are pregnant, as it were, with their own offspring, the 
 grandchildren of the primary cyst : and so on, somewhat after the manner of a nest 
 of pill-boxes. Minute in their origin, these parasites may thus increase and multiply 
 till the original cyst attains an immense size, and at length destroys life by its bulk 
 and pressure. Of course the immediate consequences of such pressure will depend 
 greatly upon the parts occupied by the hydatids. You may readily imagine what 
 kind of symptoms are likely to ensue, when they are lodged within the abdomen, 
 within the less yielding thorax, within the unyielding skull. They are more com- 
 mon in the liver than in any other single organ. I lately mentioned the case of a 
 woman, Harriet Baldwin, who died in the Middlesex Hospital, and whose liver con- 
 tained thousands of these globular bodies. The enlarged gland had completely sealed 
 up, by its pressure, a portion of the inferior cava. 
 
 We can seldom tell that hydatids exist in the body until we see them; nor, if we 
 knew of their presence, could we propose any rational method of cure. It has been 
 fancied that a galvanic current, or an electric shock, passed through the organ con- 
 taining' these creatures, might kill them, and so at least prevent their increase ; or 
 that they might be poisoned by drugs that are not seriously prejudicial to man, such 
 as mercury or iodine. But these are mere dreams of our baffled art. They some- 
 limes open a way for themselves to the surface, and escape through an ulcerated 
 outlet : and sometimes they are let out, to the surprise perhaps of the operator, who 
 only knew that he was dealing with an abscess which required puncturing. Mr. 
 Arnott put a lancet into a fluctuating tumour in the epigastrium of one of my patients; 
 very offensive pus issued, with the shriveled skins of sundry defunct hydatids. The 
 cyst was situated, I believe, in the liver. Although the orifice was slow to heal, the 
 patient ultimately got well. 
 
 There are single cyst-like bodies, with short retractile necks, bearing the generic, 
 name of cysticercus. One species of this kind, the cysticercus cellulosus, inhabits 
 the interfascicular areolar tissue of the muscles. It is rare in the human subject, but 
 frequent in the pig ; giving rise to that condition of the muscles which is famiharly 
 known as measly pork. This is one of the internal parasites with which the organ 
 of vision is liable to be infested. A most remarkable instance occurred a few years 
 
 3u
 
 830 TRICHINA SPIRALIS. 
 
 ago, in Glasgow. In the eye of a child, who had suffered repeated attacks of ophthal- 
 mia, Mr. Logan discovered one day, to his extreme astonishment, a semi-transparent 
 body, about two lines in diameter, fk)ating unattached in the anterior chamber. It 
 seemed almost perfectly spherical, except that from its lower edge there proceeded a 
 slender process, of a white colour, with a shghtly bulbous extremity, which appeared 
 to be heavier than the globular part, for it was always turned downwards. This 
 head or neck was seen to project or elongate itself from time to time ; and occasion- 
 ally it was drawn up and completely hidden in the cystic portion. When the patient 
 sat still, in a moderate light, the animal covered the two lower thirds of the pupil. 
 " Watching it carefully (says the gentleman who has recorded the case), its cystic 
 portion was seen to become more or less spherical, and then to assume a flattened 
 form ; while its head I saw at one moment thrust suddenly down to the bottom of 
 the anterior chamber, and at the next drawn up so completely as to be scarcely 
 visible." The child's head was now turned gently back, and instantly the hydatid 
 revolved through the aqueous humour, so that its head feli to the upper edge of the 
 cornea, now the more depending part. Upon the child again leaning forwards, it 
 settled, like a little balloon, in its former position ; preventing the patient from seeing 
 objects directly before her. 
 
 The animal was carefully watched for three weeks ; and no other change was 
 noticed than a slight increase in the bulk of its cystic portion. In six weeks it had 
 evidently grown bigger, the eye became injected, and the iris less free in its move- 
 ments ; and pain ensued. Extraction of the hydatid was attempted ; but the patient 
 was unruly ; the lens was forced out, and the animal ruptured and expelled in 
 shreds : the iris became entangled in the wound of the cornea, and vision in that eye 
 was spoiled. 
 
 There is a very singular microscopic parasite, the trichina spiralis, dwelling in 
 myriads, sometimes, in the rhuscles of the living human body. It was first de- 
 scribed, I believe, by Mr. Hilton, of Guy's Hospital, and afterwards more fully 
 by Professor Owen, in 1835. Mr. Wormald, the Demonstrator of Anatomy at St. 
 Bartholomew's Hospital, sent to that gentleman a portion of human muscle, which 
 presented a singular speckled appearance, as if it were mouldy. Mr. Owen found 
 that each speck was a shuttle-shaped cyst, containing a very minute cylindrical 
 worm, coiled up in two, or two and a half, spiral turns. The worm measures, 
 when unrolled, no more than g^th of an inch in length, and T^Joth of an inch in 
 diameter ; and of course requires, for a satisfactory examination, to be seen through 
 a microscope. The longer axis of the containing cyst hes between, and parallel to, 
 the fibres of the muscle. Fourteen similar instances have since come to Mr. Owen's 
 knowledge. 
 
 This is a very strange kind of parasite. One would imagine that the presence ci 
 innumerable living beings, in or between the muscular fibres, would be likely to give 
 rise to symptoms. We might expect pain, or muscular debility, or embarrassed 
 movements ; yet no indication of the presence of these worms seems to have been 
 afforded in those instances in which the condition of the subject in whom they were 
 found was known, during life. The principal points that have hitherto been made 
 out appear to be the following : — 
 
 1. The muscles thus beset with parasites are the voluntary muscles : and those 
 which lie superficially are fuller of the worm than the deeper seated. The pecto- 
 ralis major, latissiraus dorsi, and other large flat muscles, usually present them in 
 great abundance. They have been detected in the muscles of the eye : and everi 
 in those belonging to the little bones of the ear, and of whose action we are wholly 
 unconscious. They occur also in the diaphragm, in the muscles of the tongue and 
 of the larynx, in those of the soft palate, in the constrictors of the pharynx, in the 
 levator ani, in the external sphincter ani, and in the muscles of the urethra. They 
 have not yet been seen in the muscular tunic of the stomach and intestines, in the 
 detrusor urinas, or in the heart. Mr. Ow-en makes this interesting remark — that all 
 the muscles infested by the trichina are characterized by the striated appearance of 
 '.heir ultimate fascicuU : whereas the muscles of organic life, which the animal does
 
 THE GUINEA-WORM. 831 
 
 not inhabit, have, with the exception of the heart, smooth fibres, not grouped into 
 fasciculi, but united reticularly. 
 
 2. It appears, also, from what has been hitherto observed of these entozoa, that 
 their presence in the body is unconnected with age, sex, or any particular form of 
 disease. They have been concomitant with cancer of the penis ; tubercles of the 
 lungs ; exhaustion of the vital powers by extensive ulceration of the leg; fever, com- 
 bined with pulmonary phthisis ; aneurism of the aorta ; sudden depression or col- 
 lapse after a comminuted fracture of the humerus ; diarrhoea. They have also been 
 met with in the muscles of a man who, while in the apparent enjoyment of robust 
 health, was killed by a fracture of the skull. 
 
 The Filaria Medinensis — Dracuncidus — or Guinea-worm — has its residence in 
 the subcutaneous areolar tissue. It is a long, slender, round, uniform animal, like a 
 fiddle-string, or a piece of bobbin ; as you may see in the specimens before you. 
 Its length varies from five or six inches to twice as many feet. Men's lower limbs, 
 their feet and legs, are the parts most commonly possessed by this worm ; but it 
 occurs also in the scrotum, in the parietes of the belly, in the arms, beneath the con- 
 junctiva of the eye, and in almost every superficial situation. It is sometimes soli- 
 tary ; but several may co-exist or succeed each other in the same individual ; nine 
 or Ion perhaps. A Dr. Marrudri, a friend of the celebrated Clot Bey, had suffered 
 from twenty-eight of them in succession. 
 
 This entozoon is epidemic in the hot intertropical regions ; in Asia and Africa ; 
 upon the coast of Guinea, whence its trivial name. It sometimes abounds after the 
 manner of an epidemic. Sir James M'Grigor tells us that the 86th and 88th regi- 
 ments, stationed at Bombay, were much plagued by this pest. The 86th was free 
 from it upon entering the fort, in September, 1799 ; and so continued till the setting 
 in of the monsoon in 1800. In the course of the monsoon nearly 300 of the men 
 were attacked. The 88th regiment relieved the 86th. No case of Guinea-worm 
 appeared among them for nearly a month after their coming into the barracks at 
 Bombay, in October, 1800. In the latter end of November, they embarked for the 
 Egyptian expedition ; and in the course of the voyage in one ship alone 199 men 
 out of 360 were crippled and laid up with this loathsome disease. It was thought 
 to be infectious. The artillery-men, who were kept separate, escaped. Of 181 
 instances, of which Sir James M'Grigor gives a tabular account, the feet were the 
 parts affected in 121. 
 
 These animals sometimes remain for a long while in the areolar tissue without pro- 
 ducing inconvenience, and therefore without betraying their presence. Hence they 
 are sometimes brought over to this country. The great navigator, Dampier, had no 
 symptom of a Guinea-worm which he carried about with him, until about half a 
 year after he left the place in which he contracted it. Sometimes the parasite is 
 quiet and harmless for a still longer period ; in one recorded instance it was latent 
 and dormant for three years. 
 
 The symptoms which do at length arise are the following : — itching of the part 
 affected ; a sensation as if there were something creeping under the skin ; sometimes 
 a cord-like ridge can be felt in the track of the worm ; at length a vesicle, or a pus- 
 tule, or a little boil forms, from which, when it breaks, the head of the animal pro- 
 trudes. This process is often attended with fever ; and in certain parts of the body 
 the local suffering is considerable : the areolar tissue sloughs ; and sometimes danger- 
 ous hemorrhage occurs. 
 
 The only treatment which these cases appear to admit of, is the gradual and care- 
 ful extraction of the worm. Lest that part of it which already protrudes should 
 recede, or be broken, it is gently wound, day by day, round a small stick, or a little 
 roll of adhesive plaster; pains being taken not to pull upon it so much as to risk its 
 being torn asunder. The roll is protected by a bandage. Whenever, by accident, 
 the animal is broken, very serious consequences are sai'' to ensue ; violent inflam- 
 mation of the part, abscesses and sinuses and high irritative fever. This mischief 
 is ascribed by some to the presence of dead animal matter, by others, of young fila 
 riae, in the subcutaneous tissue : for I should have mentioned that the Guinea-worn;
 
 832 STRONGULUS GIGAS. 
 
 k viviparous ; and although neither digestive organs nor generative organs have yet 
 been discovered in its structure, it is sometimes found stuffed internally with a count- 
 less offspring. The extraction is tedious work. Where, indeed, the areolar tissue 
 is very loose, as in the scrotum, the worm is occasionally drawn out at the first 
 attempt ; but the process sometimes occupies weeks ; and its average period appears 
 to be not less than ten days. When the course of the animal is quite superficial and 
 obvious, the natives are accustomed to make an incision in the skin, at about the 
 middle point, and to pull the worm through from both ends. When once it is out, 
 the parts presently heal. Ail other medication (and much has been tried) has been 
 found useless; except, perhaps, the administration of assafetida ; and that not as a 
 means of cure, but of prevention. It is said that the Brahmins in India, who are in 
 the constant habit of using this drug, are exempt from attacks of the dracunculus. 
 Cleanliness was also found, in the army, to be a considerable protection. 
 
 There is a species of filaria peculiar to the eye, and another to the bronchial 
 glands ; but these are extremely rare. 
 
 The urinary organs have their parasites also ; of which I shall specify but one, and 
 that chiefly on account of its strange lurking-place, and remarkable size. I alluded 
 to a species of strongle which sometimes occupies the human kidney, and which is 
 no uncommon tenant of the same organ in various animals ; the horse, the bull, the 
 dog, the wolf, the polecat, and the otter. In the human subject, its length varies 
 between five inches and a yard, and it is sometimes half an inch in diameter. There 
 is a specimen nearly of that size in the Hunterian museum. It may well be called 
 the giant strongle, strongiilus gigas. Fancy a creature as big as a snake coiled up 
 in one's kidney. It gives rise to no distinctive symptoms, although, as you may 
 suppose, it causes much renal distress ; hematuria, retention of urine, and great suf- 
 fering in its passage out of the body, either through the natural urinary channels, or 
 by abscess and ulceration through the back. 
 
 With respect to some, at least, of the parasitic animals that I have been describing, 
 those I mean which are found shut up in close chambers, our first feeling is that of 
 wonder how they came there. Into all parts from which a road is open to the exter- 
 nal surface, we can conceive that living creatures may enter, or their eggs be carried. 
 But how can either animals or ova find their way unperceived into the substance of 
 the liver and of the voluntary muscles, into the eye, into the brain ? The whole 
 matter is obscure, yet interesting. 
 
 With respect to the common hydatids, it has been conjectured — and the conjecture 
 does not seem improbable — that they are not parasites, nor distinct animals in any 
 sense ; but merely certain of those primitive nucleated cells — from which the micro- 
 scope asserts that all the varied tissues of the body are originally formed — rendered 
 gigantic and monstrous by some erring or morbid action of the vital forces. Except 
 in size, the cell and the hydatid are declared to be alike: alike in shape, alike in 
 the mode of their growth and muhiplication. But this view of the matter, granting 
 it to be the true one, does not relieve our difficulty ; for, within these very hydatids, 
 distinct living animals have been found : parasites of the second order, entozoa of an 
 entozoon, if the hydatid be itself a separate animal — tenants of a formation-cell, if 
 the hydatid be only an extravagant development of the primary corporeal structure. 
 
 Within several of the transparent hydatids which were taken from the liver of the 
 woman Baldwin, a number of small, opaque, white grains, were visible. These were 
 examined by Mr. Tomes and myself, under the lens of his powerful microscope. 
 They were plainly minute animals: baglike, with an orifice or mouth which, in 
 some instances, protruded a little from the bag — in others, was evidently contracted 
 and drawn inwards. Around this orifice was arranged a circlet of small, flat, spear- 
 shaped rays, somewhat like a Vandyke collar. Many of these rays, or spines as 
 they have been called, were detached, and lying loose in the surrounding hquid. 
 Being very ill-informed in this department of natural history, I paid less attention to 
 these creatures than they deserved ; fancying, indeed, that they might be common 
 and well-known, or rather that they were juvenile hydatids. I have become aware
 
 ORIGIN OF ENTOZOA. 833 
 
 of my mistake through perusing a paper, by Mr. Curling, in the twenty-third volume 
 of the Medico-Cliirur girnl Transactions, where he more minutely describes pre- 
 cisely similar phenomena. Mr. Curling shows that these included animalcules are 
 parasitic vermin which infest a peculiar species of hydatid, called the Echiaocuccus 
 Hominis. Later opinions assert that what we call the ki/datids, is nothing more 
 than a nest, or habitation, formed by or for the small indwellers. 
 
 Now, whatever hypothesis we may adopt respecting the nature of hydatids them- 
 selves, the puzzling question still remains, whence originated the living beings 
 inclosed within them ? How got they thither? 
 
 It was the opinion of Linnaeus, and of other natural philosophers of his time, that 
 the intestinal worms were really terrestrial or aquatic animals which had been acci- 
 dentally swallowed, either while young and small, or in the antecedent state of ova. 
 It was even pretended that these animals had been recognised and detected out of 
 the body, in stagnant waters. But later inquirers, especially Bremser and Rudolphi, 
 have completely disproved this notion. After dedicating twelve years of his life to 
 the observation and study of entozoa, Bremser was satisfied that no creatures iden- 
 tical in structure v^ith the intestinal worms are ever met with out of the body, 
 except such as have come from the intestines of man, or of some other animal ; and, 
 conversely, that no terrestrial or aquatic worms are ever found living within the bodies 
 of men or of animals, unless they have been directly or plainly received from without. 
 
 But, then, is it not possible that, as Boerhaave supposed, aquatic or terrestrial rep- 
 tiles, casually entering the bod}'' from without, being placed under entirely new and 
 unnatural conditions, may have attained a monstrous growth, and undergone meta- 
 morphoses such as we know that some of the lower animals, by change of circum- 
 stance, do undergo ; as the tadpole becomes a frog, the maggot a butterfly ? 
 
 To this theory there are strontr grounds of objection. First, there is no ascertained 
 relation (as in the other cases) between the structure of intestinal worms, and of ani- 
 mals having an independent existence out of the body ; and they are never caught 
 (as they would surely sometimes be) in the transition state — the intermediate condi- 
 tion. Secondly, opposed to this "accidental" hypothesis are also the facts that cer- 
 tain species of worms infest certain species of animals only : that in the same animal, 
 different species of worms occupy (as we have seen) special parts of the alimentary 
 canal ; have each their peculiar habitat : that worms and animals of external origin 
 mostly die as soon as they are received into the digestive organs, while the true 
 mtestinal worms perish whenever they are delivered therefrom. Thirdly, the cir- 
 cumstances that these worms not only live, but breed within the human bowels, and 
 that they are met with even in the intestines of the unborn foetus, are very adverse 
 to this theory of an accidental error loci. 
 
 But, to give up the notion of a metamorphosis, may not intestinal worms spring 
 from specific germs or ova introduced from without, not casually, but in accordance 
 with a natural law: germs or ova which find in the interior of living bodies the 
 only conditions that admit of their development, the only soil in which they are 
 capable of germinating, the only nest in which they can be hatched ? I confess that 
 si]ch is my own belief. We have something like this, at least, in that common affec- 
 tion of horses called the " bots." A species of oestrus, or gadfl\', deposits its egq-s 
 upon the animal's hide, where they cause, I presume, some irritation, which induces 
 the horse to lick that part with his tongue. The eggs are thus conveyed into the 
 mouth, whence they reach the stomach. There they are converted into larvas, and 
 affix themselves to the parietes of the stomach. At length, when they are ready to 
 undergo their final metamorphosis, they are detached from the interior of the sto- 
 mach, pass along with the food and feces through the intestines, and are ejected fron) 
 the rectum with the dung. 
 
 Why, it is asked, may not similar phenomena take place in the human body ' 
 
 There can be no doubt that we every day swallow, inadvertently, numerous ova, of 
 
 /arious kinds. It is supposable enough that sometimes the digestive organs may, 
 
 ud sometimes they may not, have the power of decomposing or expelling the^se ova. 
 
 It is quite certain that what are generally called spurious worms may have that 
 mode of origin in the body. Thus, Ft. Eiliotson states that he had once a patient, 
 53 ^ 3u2
 
 834 SPONTANEOUS GENERATION. 
 
 an infant, who discharo-ed from the bowels a dozen live larvge, or maggots, of the 
 common fly. The child had eaten part of a high pheasant some months before. 
 There was, in that case, this instructive circumstance. The infant had been sufTerinor 
 under a chronic cough, but as soon as those larvae were got rid of, the cough ceased. 
 Dr. Elliotson says that he saw them in the napkin moving about in the fecal matter, 
 iust as they miglit have done if they had never been in the child's body. The same 
 physician tells us that he has twice known, in two different patients of his, a living 
 caterpillar to be discharged from the intestines. One of the patients was a Avoman 
 who had been in the habit of eating cabbage stalks while she was washing them for 
 the pot. The moth lays its eggs on cabbages, and she no doubt had swallowed some 
 of them, and one had hatched within her. In the ninth volume of Dr. Duncan's 
 Medical Commentaries is a precisely similar case. A boy, after a dose or two of 
 calomel and jalap, discharged from the rectum very many caterpillars, all alive, and 
 full of activity. He had been in the habit, when in the garden, of eating young 
 cabbage leaves. Till this habit began he had enjoyed good health. While the 
 animals were within his bowels he suffered severely ; had locked-jaw ; and fell into 
 a state resembhng coma. Upon their expulsion he recovered perfectly. Centipedes 
 have in like manner been vomited, and voided from the bowels. But the most won- 
 derful instance of this kind that ever was heard of, is related by Dr. Pickells in the 
 Transactions of the King and Queen'' s College of Physicians in Ireland. A young 
 woman of melancholic disposition and chlorolic appearance, had been in the daily 
 habit, from some superstitious motive, of drinking water mixed u-ith clay taken from 
 the graves of two priests who lived and died in the odour of sanctity. In this way 
 she probably imbibed the ova of the insects which subsequently issued from her 
 body. In the course of about three years and a quarter, she discharged, partly by 
 vomiting, but chiefly per anian, upwards of 2000 beetles, and their larvae, most of 
 them alive. Dr. Pickells counted more than 1300. Larvs, and pupfe, and perfect 
 insects, all came forth simultaneously. Some of them ran off, as soon as they were 
 vomited, into holes in the floor ; and two large winged insects were so lively and 
 vigorous as immediately to fly away. These strange births were preceded and at- 
 tended by a complicated and distressing train of symptoms ; a gnawing, and sense 
 of something creeping at the pit of the stomach, vomiting of blood, amenorrhoea, 
 hysterical convulsions, headache, retention of urine, and sometimes a decree of men- 
 tal derangement. She was at length freed from this disgusting malady by large 
 doses of the oil of turpentine. 
 
 These spurious worms differ from the true intestinal parasites in this — that the 
 human alimentary canal is not their only, but their accidental and unusual nidus 
 Nevertheless, their occasional presence, alive, in that place, adds to the probability 
 that some of the entozoa may be originally ectozoa. 
 
 The main difficulty, however, respects those animals which occupy shut cavities 
 within us, or are embedded in our solid organs : and this difficulty forms one avowed 
 ground of the theory of equivocal generation : which means the spontaneous pro- 
 duction of living creatures, independently of any germ, or egg^, or parent. The vul- 
 gar suppose that dirt engenders fleas, that maggots result from the putrefaction of 
 flesh, that eels arise, of themselves, in and out of mud. In other words, they infer 
 the spontaneous origin of those creatures, of which they cannot or do not trace the 
 procreation by pre-existing parents: and philosophers and men of science have done 
 ihe same. They will not believe that which they cannot see. Now this doctrine 
 of equivocal generation shocks, I confess, my mind, and offends my reason. If well 
 founded, it strikes at the root of that great argument of Natural Theology, which 
 deduces the existence of a First Intelligent Cause, from the marks of adaptation, de- 
 sign, and contrivance, so manifest throughout the visible universe. Observe the 
 demand which this doctrine makes upon our faith. In defiance of all experience 
 and analogy m respect to creatures which our finite senses are competent to examine, 
 it calls upon us to believe that living beings, of complex and intricate, yet definite 
 and harmonious structure ; provided with a digestive apparatus, with instruments of 
 locomotion, with generative organs ; of various species ; in many instances of sepa- 
 rate yet answcrmg sexes ; that not one or two of these beings, nor a pair or two, but 
 
 I
 
 SPONTANEOUS GENERATION. 835 
 
 beings and pairs innumerable, are daily formed by the casual concourse of •' organic 
 molecules." The obscurity that hangs over the origin of the entozoa is not indeed 
 the only, nor, I think, the chief ground upon which the notion of_ spontaneous gene- 
 ration rests. You are probably aware that minute animalcules, so minute that most 
 of them cannot be seen without a microscope, soon become abundant in water wherein 
 vegetable or animal matters have been dissolved by infusion. Such animalcules are 
 therefore called Infusoria. How do they come there ? There are two suppositions 
 open to us. One is, that they are formed by the fortuitous union of organic atoms 
 contained in the infusion. The other is, that they proceed from ova or germs exist- 
 ing in the liquid, or floating always in the atmosphere, and ready to quicken when- 
 ever they hght upon their proper element. That the ova of animals which are 
 themselves visible only by the aid of a microscope, should be absolutely invisible by 
 us, is not surprising. We may conclude that the latter supposition is the most true, 
 if we can show that when these ova or germs are excluded, all the other conditions 
 of the production of infusoria being present, no animalcules appear. Now Spallan- 
 zani long ago found, by careful trials, that no animalcules were discoverable when 
 the access of air to the infusion was completely prevented. But it has been objected 
 to his experiments, that the presence of atmospheric air may be one of the essential 
 conditions upon which the requisite combination of the organic molecules depends. 
 Air, solar light and heat, and organic matters in solution being given — does animal 
 (or even vegetable) life ever result? That is the question. The experimentum 
 crucis has been made, and has answered " No," as I lately learned from one of Pro- 
 fessor Owen's admirable introductory lectures ; by whom, I am glad to find, this 
 uncomfortable doctrine of equivocal generation is strongly discountenanced. The 
 experiment to which I refer was conducted by M. Schulze, of Berlin. I will read 
 5'^ou his own account of it, as I find it recorded in the Edinburgh New Philosophical 
 Journal. 
 
 "The difficulty to overcome consisted in the necessity of being assured, first, that 
 at the beginning of the experiment there was no animal or germ capable of develop- 
 ment in the infusion ; and secondly, that the admitted air contained nothing of the 
 kind. For this purpose I filled a glass flask half fall of distilled water, in which I 
 mixed various animal and vegetable substances ; I then closed it with a good cork, 
 through which I passed two glass tubes bent at right angles, the whole being air 
 tight. It was next placed in a sand-bath, and heated until the water boiled violently 
 and thus all parts had reached a temperature of 212°. While the watery vapour was 
 escaping by the glass tubes, I fastened at each end an apparatus which chemists 
 employ for collecting carbonic acid ; that to the left was filled with concentrated sul- 
 phuric acid, and the other with a solution of potash. By means of the boiling heat, 
 everything living, and all germs in the flasks or in the tubes, were destroyed; and 
 all access was cut off by the sulphuric acid on the one side, and by the potash on 
 the other. I placed this easily moved apparatus before my window, where it was 
 exposed to the action of light, and also (as 1 performed my experiment during the 
 summer) to that of heat. At the same time I placed near it an open vessel, with the 
 same substances that had been introduced into the flask, and also after having sub- 
 jected them to a boiling temperature. In order now to renew constantly the air 
 within the flask, I sucked with my mouth, several times a day, the open end of the 
 apparatus filled with solution of potash ; by which process the air entered my mouth 
 from the flask through the caustic liquid, and the atmospheric air from without entered 
 the flask through the sulphuric acid. The air was of course not at all altered in its 
 composition by passing through the sulphuric acid in the flask, but if sufficient lime 
 was allowed for the passage, afl the portions of fiving matter, or of matter capable of 
 becoming animated, were taken up by the sulphuric acid and destroyed. From the 
 28lh of May till the beginning of August, I continued uninterruptedly the renewal 
 of the air in the flask, without being able, by the aid of the microscope, to perceire 
 any hving animal or vegetable substance, although durijBg the whole of the time 1 
 made my observations almost daily on the edge of the liquid : and when at last I 
 separated the difl<3rent parts of the apparatus, 7 could not find in the whole hquid the 
 slightest trace of infusoria, of confervas, or of mould. But aU three presented thera
 
 836 INTESTINAL WORMS. 
 
 selves in great abundance a few daj^s after I had left the flask standing open. The 
 vessel which I placed near the apparatus contained on the following day, vibriones 
 and monads, to which were soon added larger polygastric infusoria, and afterwards 
 rotatorise." 
 
 This experiment confirms the belief which various other facts had suggested — that 
 the different kinds of entozoa are not parentless animals, and that they somehow find 
 their way into the body they inhabit, from without. The lowest of the infusoria are 
 of fixed and determinate species ; and Ehrenberg states that even the minutest 
 monads possess a comphcated organization. It may be asked, concerning both them 
 and the entozoa, why, if they ever arise spontaneously, should they be furnished 
 with a generative apparatus ? Again, some of the entozoa abound in certain places, 
 and strangers coming to those places appear to contract them there. The dracun- 
 culus was thought by the soldiers in India to be communicable from person to per- 
 son, as the itch insect, and the chigoe, to both of which it has some analogy, cer- 
 tainly are. The infant filaria probably creeps in through the skin without causing 
 any noticeable pain. Even that monster among the entozoa, the tape-worm, invades 
 the bodies of those persons who visit the countries to which it belongs. I told you 
 before, that when tape-worm occurs in Germany, it is always the tasnia solium ; 
 when in Switzerland, almost always the tsenia lata. Now the celebrated Soemmer- 
 ing was afflicted by one of these beasts ; and he was by birth a German : yet the 
 worm that he voided was of the foreign species, the tasnia lata. He had resided, 
 however, for some time in Switzerland ; and there, we can scarcely doubt, he caught 
 the ovum, or the young one, of the parasitic animal. Mr. Abernethy once told me 
 the following curious story : — A shepherd had to drive a flock of healthy sheep to a 
 distant part of the country. The journey occupied two or three days. On the road 
 one of the animals broke its leg, and was carried the rest of the way on horseback. 
 All the flock, except this hurt individual, was turned for one night into a marshy pas- 
 ture. The broken limb was set, and the patient got well ; and was the only one of 
 the whole flock that did not subsequently become affected with the rot; the only one 
 that escaped having flukes in its liver. Is it not presumable that the ova of these 
 parasites were swallowed with the herbage cropped by the sheep in the damp mea- 
 doAV ? The germs of the entozoa which dwell in closed chambers, and within the 
 solid viscera of the body, are probably carried thither by the blood. 
 
 Upon the whole, we may reject the hypothesis of equivocal generation, and fall 
 back upon the Harveian axiom, taken in its most extended sense, of omne vivum ex 
 ovo. If I have digressed somewhat in order to set before you the grounds of my 
 own beHef in this matter, the interest and importance of the subject must be my 
 excuse. 
 
 What I have further to say will relate exclusively to the intestinal worms of the 
 human body : their predisposing causes ; the symptoms they occasion ; and the 
 modes of getting rid of them. 
 
 However much we may be in the dark as to the exact mode in which these para- 
 sites reach their habitations, we do know something of the circumstances that appear 
 to favour their production and muhiplication. They certainly prevail most in per- 
 sons who, from whatever cause, are weak and unhealthy ; and particularly in scro- 
 fulous children. There are, however, many exceptions to this : they are not uncom- 
 mon in individuals who are robust and vigorous. Intestinal worms, of all kinds, are 
 more abundant in some situations than in others ; especially in places that are low 
 and moist. They are accordingly very frequent in Holland, and in some parts of 
 Switzerland. Wherever there is much debility of the digestive organs — in k'uco 
 phlegmatic habits — in persons who secrete habitualh'' a large quantity of mucus — 
 worms are apt to congregate. The children of the Negroes in the West Indies are 
 wonderfully infested by them. 
 
 It more concerns us to inquire into the general symptoms, through which the 
 existence of worms in the alimentary canal may be ascertained, or suspected- 
 
 Those symptoms are very multifarious; and, for the most part, very e9ul vocal. 
 1 know of none that can be reckoned certain or pathognomonic, except the actual 
 appearance of one or more of the animals, or of portions of them, in the exc/emcnt'i
 
 INTESTINAL WORMS. 837 
 
 of the body. Yet that they do give rise to a variety of morbid phenomena — which 
 morbid phenomena are, however, Uable to be produced by other causes also — there 
 can be no question. 
 
 The most common of these are well known to all nurses and old women ; such 
 as colicky pains, and swelling of the belly; picking of the nose, in consequence of 
 itching and irritation there ; itching of the fundament ; a foul breath ; grinding of 
 the teeth during sleep ; a variable and capricious appetite, sometimes voracious and 
 insatiable, sometimes none at all; and irregular bowels. 
 
 Worms sometimes occasion strange, and even severe, nervous symptoms, explain- 
 able upon the principle of the reflex office of the spinal cord. We conclude that 
 the symptoms are owing to worms in such cases, because they cease when the crea- 
 tures are got rid of. Some examples of this I have already noticed. Thus, Dr. 
 EUiotson's infant patient lost a chronic cough upon the expulsion of the live larvae 
 of the common fly. Bremser gives a very similar case. A child of eleven, afflicted 
 with taenia, had a troublesome dry cough. It was observed that the cough was sus- 
 pended for two months, just after a very large portion of the worm had been brought 
 away by anthelmintic medicines. This kind of coincidence happened, not once 
 only, but three or four times ; and at length, when the whole of the worm had come 
 away, the cough was permanently cured. I mentioned, some time ago, the frequent 
 association of intestinal worms with epilepsy, which is then of the eccentric form: 
 and I stated that a certain nobleman voided some kind of worm (a tape-worm, I think) 
 from his bowels, and was thenceforward free from epileptic fits, under which he had 
 long laboured. A curious circumstance, illustrating the fact that irritation of the 
 mucous membrane of the alimentary tube may affect distant parts, is quoted by Dr., 
 Joy from Albinus. A soldier received a wound, which led to the formation of an 
 unnatural anus, in front of the abdomen, and in the track of the colon. Through 
 this opening the mucous membrane of the bowel sometimes protruded ; and when- 
 ever it was out, and exposed to the contact of cool air, the patient began to cough ; 
 and continued to do so till the mucous surface was warm again. Partial palsy, 
 amaurosis, aphonia, and other nervous symptoms, occasionally depend upon the pre- 
 sence of worms in the intestines. 
 
 [Dr. Schleifer, in the Austrian Weekly Journal of Medicine, relates the case of a child, 
 nine years of age, who became dumb, after suffering in early life from cutaneous eruptions, 
 engorgement of the glands, &.c. The loss of hearing was attributed chiefly to a fall, and 
 treated accordingly. The child became emaciated, pale, with a dark leaden appearance of 
 the contour of the eyes. The tongue was white and loaded, the breath offensive, and the 
 abdomen tumid and hard. The muscles of the face were in constant motion, and the patient 
 moaned incessantly. Dr. S. suspected the presence of worms, and treated the patient accord- 
 ingly. In three weeks, eighty-seven lumbi-ici were discharged, and, during five weeks, im- 
 mense quantities of ascarides. At the end of the sixth week, the child had recovered his 
 hearing and speech. 
 
 In the Journal of Medicine and Surgery of Paris, for April, 1844, a case is quoted, from 
 the Gazette Medicales of Dijon, of a young man, nineteen years of age, who was attacked 
 with all the symptoms of acute pleurisy: chill, followed by fever; severe pain in the left 
 side; difficult, jerking respiration ; paroxysms of dry cough, which occasioned the patient to 
 scream out, &c. ; all of which symptoms promptly disappeared after the discharge of seven- 
 ty-five lunibrici. — C] 
 
 But let us examine into the symptoms which are more or less proper to par- 
 ticular species of intestinal entozoa ; and into the treatment which they severally 
 require. 
 
 A variety of symptoms are ascribed to the ascaris lumbricbidcs. Dr. Bail lie 
 says that the most characteristic are a tumid belly, enmciated extremities, offensive 
 breath, and a deranged appetite. To these may be added colicky pains of the 
 abdomen. When these animals get out of the small intestines, and ascend into the 
 stomach or oesophagus, they may occasion pain, nausea, vomiting, even convulsions. 
 They have caused death, as I mentioned before, by crawling into the biliary ducts, 
 and into the chink of the glottis. Sometimes, on the other hand, they emerge unex. 
 pectedlj, from persons who had received no previous notice of their prcsejir« 
 within.
 
 838 THREAD-WORBIS — TAPE-WORMS. 
 
 This, the commonest parasitic tenant of the human bowels, is also a troublesome 
 one to eject. A great variety of anthelmintics have been cried up as successful 
 against it; but brisk purgatives, and bitter medicines in the intervals, have the best 
 evidence in their favour. These animals seem not to like steel; and my own plan 
 of assailing them is that of purging the patient from time to time by calomel and jalap, 
 and administering, three times a day, some preparation of iron ; the sulphate, or the 
 muriated tincture. I believe that most of the patent worm-medicines consist of mer- 
 cury, jalap, and scammon}^ given in strong doses. The fetid drugs, assafetida, gal- 
 banum, valerian, are often used. Cowhage, also, the dolichos pruriens, which is 
 supposed to tease the skin of the parasite no less than that of the human worm; and 
 tin-filings, which are thought to bruise or lacerate the offenders, are favourite reme- 
 dies with some persons. I have never tried them. The oil of turpentine I have not 
 found so successful in expelling this species of ascaris as I shall presently show you 
 that it is against the tape-worm. Croton oil has been much commended, either given 
 by the mouth or rubbed upon the abdomen. Common salt, coloured by cochineal, 
 and exhibited every morning in half-drachm doses, was found by Dr. Rush to be 
 very successful. 
 
 The symptoms produced by the ascaris vernncvhms are itching and irritation 
 about the anus, especially in the evening, and aggravated by the warmth of the bed, 
 and by whatever overheats the body. I would refer j'ou to a paper by Dr. Heber- 
 den on this subject, in the first volume of the Medical Transactions. The case he 
 describes is the more valuable, as it was related to him by a physician who \\-as all 
 his life plagued by these thread-worms. Generally, however, tney infest children; 
 and become fewer, and at length disappear, as childhood passes into youth. When 
 they do accompany life through its several stages, although they are a source of 
 serious annoyance and suffering, they do not appear to shorten the duration of the 
 patient's existence. 
 
 To introduce at one end of a tube, several yards long, substances which are in- 
 tended to act upon animals that live quite at its other end, would be a very round- 
 about course. Whether a purgative efiiect, or a specified destructive effect, be the 
 object, enemata are preferable to medicines given by the mouth. Bitters offend 
 and destroy these little worms. I have relieved many patients from their tormentors 
 by prescribing simply the infusion of quassia as an injection. Tobacco clysters are 
 praised ; but the remedy is a hazardous one. Dr. Darwall says of an enema com- 
 posed of half an ounce of the muriated tincture of iron mixed with half a pint of 
 water, " there are few cases so obstinate that this will not suffice to overcome." Lime- 
 water, injected into the rectum, forms another effectual remedy for ascarides, and (as 
 pharmacologists love to speak) a rather elegant one. 
 
 Thread-worms may be scooped out of the rectum with the finger. Old women 
 fish for them with a piece of fat meat, or a candle, wherewith the entangled worms 
 are drawn out of the bowel. Perhaps, in troublesome cases, the plan laid down by 
 Martinet is as good as any. He recommends three successive injections: the first 
 meiely purgative ; the second specific (common salt in solution, cold vinegar and 
 water, lime-water, some bitter infusion) ; the third, oleaginous and soothing. Oil 
 often alla3's the itching. This teazing symptom may sometimes be quieted by ap- 
 plying a towel, wetted with cold water, to the fundament, while in bed. 
 
 With some means of this kind for expelling the worms, appropriate measures 
 should be combined for improving the general health. 
 
 I know of no signs by which the presence of the tricocephalus dispar is revealed; 
 and I am equally ignorant of any remedies for it. 
 
 That a tapr-icorm is within, we know when the joints of it are voided. Number- 
 less symptoms have been ascribed to this huge internal parasite. The following are 
 probably the most distinctive. Uneasy feelings in the epigastrium, which often abate 
 or arc removed by eating ; the appetite generally craving, but sometimes baa . itching
 
 TAPE-WORMS. 839 
 
 of the nose and of the anus ; nausea; colic ; giddiness ; a sour breath. Less fre- 
 quently loud borborigmi occur; and sometimes convulsions. 
 
 Louis has watched and recorded, with his accustomed minuteness, the symptoms 
 of ten cases in the wards of La Charite. Seven of the patients were males, and three 
 females. The youngest was a boy of twelve, the son of another of the patients ; the 
 oldest was seventy-four. Most of them were in comfortable circumstances, and had 
 been habitually well fed. The greater number of them had for some time been 
 passing fragments of tape-worm, with their stools, in their clothes, and in their beds. 
 In one of the cases the articulations had been twice only detected in the stools, and 
 each time upon the operation of a purgative. 
 
 In all the patients but two, the other symptoms commenced when the evacuation 
 of the fragments commenced. This renders it probable that the worms begin to give 
 annoyance when they get into the large intestine. The temporary relief that results 
 from the expulsion of portions of the animal strengthens that supposition. The case 
 is mentioned in the Aledico-Chinirgical Journal of a man w^ho was in the habit of 
 freeing himself from large fragments of tape-worm by introducing a slick into his 
 rectum, and twisting the worm round till it broke. 
 
 The chief symptoms observed in Louis's cases were colicky pains of the abdo- 
 men ; itching of the anus, and of the end of the nose ; uneasiness in the epigastrium ; 
 and deranged dicestion and appefite. 
 
 Pain in the abdomen occurred in all the instances : but it differed, in different 
 cases, both in degree and in kind. It was intermittent ; and mostly felt towards the 
 flanks. 
 
 There was itching at the margin of the anus in seven of the ten cases ; itching of 
 the nose in four. With one exception, only, itching was present in one or the other, 
 or in both of these situations. 
 
 The appetite was craving in one patient; unaffected in four; variable or bad in all 
 the rest. In all, slight emaciation was observed. In all, the pupil of the ej^e was 
 of its natural dimensions. This is noticed, because dilatation of the pupil has been 
 set down as one of the symptoms of tsenia. 
 
 Louis thinks that the following combination of symptoms indicates with tolerable 
 certainty the presence of some kind of worm in the intestines. Pain in the belly; 
 colic of various degrees of intensity, unaccompanied by diarrhoea; itching about the 
 anus, and at the end of the nose. If pains in the limbs, lassitude, and. nervous symp- 
 toms exist also, the diagnosis is strengthened. 
 
 We have a very effectual remedy for tsenia — at any rate for the tape-worm of this 
 country — in oil of turpentine, given in large doses. The anthelmintic virtues of 
 this substance were not generally known till a paper on the subject, by Dr. Fenwick, 
 of Durham, was published, in 1811, in the Medico-Chirurgical Transactions. A 
 sailor, plagued by this parasite, had noticed that large fragments of the worm were 
 passed whenever he had swallowed an unusual quantity of raw gin. Thinking that 
 a stronger spirit might have a stronger effect upon his internal enemy, he tried a 
 glass of turpentine, which completely cured him. This practice was then taken up 
 by some unprofessional persons, who gave turpentine, with similar success, in several 
 cases. At last Dr. Fenwick, in conjunction I believe with my friend Dr. Southey, 
 investigated the subject; and when they had satisfied themselves of the value of the 
 remedy, the result of their inquiries was communicated by Dr. Fenwick to the late 
 Dr. Baillie, in a letter which was read before the Medical and Chirurgical Society. 
 But there is nothing new under the sun. Fifty years ago, Mr. Maiden, in the 
 Memoirs of the London Medical Society, recommended the same remedy, in the 
 same doses, for the same purpose. But his recommendation had been neglected, or 
 forgotten. 
 
 The dose of turpentine is from half an ounce to two ounces. It may be given i'l 
 combination with castor oil ; or castor oil may be administered afterwards to assist 
 its })urgative effect. It should be taken in the morning, fasting : and no drink should 
 be admitted into the stomach until the medicine begins to operafe, lest sickness and 
 vomiting should be provoked. The worm generally is voided, dead, within an how 
 or two.
 
 840 TAPE-WORMS. 
 
 The inconveniences of turpentine as a remedy are its nasty taste, the sort of intojci- 
 cation it is apt to produce, the distressing sickness it excites in some persons, and the 
 strangury it sometimes occasions. This effect of it, however, is less common from 
 large than from small doses of the oil. The bowels should be kept open with castor 
 oil, so long as the urine retains the violet smell, which indicates the presence of the 
 turpentine in the circulation. 
 
 Upon the continent a celebrated empyreumatic oil, called Chabert's, is in great 
 repute. It contains turpentine ; but is still more nauseous than it. One part of the 
 empyreumatic oil of hartshorn is mixed with three parts of oil of turpentine. Aflir 
 the mixture has stood for three days, three-fourths of it are to be distilled over, in 
 glass vessels, by means of a sand bath. Chabert was a veterinarj'^ surgeon, and had 
 used this remedy with remarkable success upon domestic animals, cow's, dogs, and 
 sheep. Bremser, after testing its safety by taking it himself, administered it, he tells 
 us, to no less than 5(X) individuals troubled with taenia. Among these were two 
 children, a year and a half old. He found it both a powerful and a permanent cure. 
 Of the whole number treated there were but four who required a second course of 
 the remedy. It seems to kill both the worms and their ova. The dose is two tea- 
 spoonfuls, night and morning, until four or six ounces have been taken ; a purgative 
 being from time to time interposed. If that dose produces any confusion of head, it 
 must be diminished. 
 
 Bremser admits that this curative process is tedious, but affirms that, on the other 
 hand, it is safe, and but little inconvenient. When the patient has continued free 
 from any symptoms of tape-worm for three months, he concludes that the cure is 
 absolute. Other practitioners agree with him in attesting the efficacy of this oil; but 
 are not so confident about its perfect safety and convenience. 
 
 Another great remedy is the bark of the pomegranate-root. This is at least as old 
 as the time of Celsus. It has long been employed in India. Its value has only 
 been recently appreciated in France; and in this country it is not much used, I 
 believe, even yet. You may read a very instructive account of its effects in a paper 
 communicated to the Medical and Chirurgical Society by Mr. Breton. He boiled 
 two ounces of the fresh bark of the root in a pint and a half of water, till the decoc- 
 lion was reduced to three quarters of a pint. Two ounces of this, cold, he gave to 
 a patient who had tape-worm, and repeated the dose every half hour until lour doses 
 had been swallowed. About an hour after the last dose, an entire taenia was voided 
 alive. 
 
 The bark dried in the sun he found still more active. A stout man forty years 
 old, took a decoction prepared in the same way as the former, only with the dried 
 instead of the fresh bark. Three hours after the first dose, a live tape-worm came 
 away, nineteen feet two inches long. The medicine thus prepared seemed to be too 
 strong ; the patient was sick, giddy, and trembling for several hours. He, also, had 
 taken four doses. 
 
 To two boys, of seven and ten years of age, he began early in the morning to 
 iidminister one ounce of a decoction made of half the previous strength, every half 
 hour, for six times ; and then stopped. In the middle of the day he resumed the 
 medicine in half-ounce doses. Giddiness and faintness soon came on ; and, about 
 five o'clock, each of the patients passed a ta?nia of the solium kind. 
 
 A scruple of the powder was given, mixed with water, every hour for five succes- 
 sive hours, to a boy of nine. Forty minutes after the last dose a living tasnia was 
 expelled. 
 
 The same quantity was given to a girl, ten years of age ; beginning at eight, and 
 repealing the dose hourly till twelve o'clock. At twenty-four minutes past one she 
 voided a living taenia lata; and the next morning, at nine o'clock, a dead taenia 
 sohum. This curious case shows that the two species may exist in the same person 
 at the same time. 
 
 Mr. Breton relates other examples, but those which I have cited are quite suffi- 
 cient to demonstrate the power of this substance. The bark appears to act upon the 
 worm as a poison. In tepid water tjeniae will live for several hours. When they 
 are plunged into the aforesaid decoction, they writhe and manifest great uneasiness^
 
 INFLAMMATION OF THE LIVER. 841 
 
 Between the first dose of the medicine and the expulsion of the worm, the shortest 
 period appears to liave been three hours, the longest twenty-five. 
 
 Louis's ten cases, before referred to, were all treated by a nostrum called the potion 
 of M. Darbon. It proved successful in all. Eight or ten ounces of it were taken 
 in the morning, before breakfast ; and the cure was accomplished by that single dose. 
 It is said to be quite safe, to have no very decided taste, and to cause no further in- 
 convenience than a slight colicky feeling, and uneasiness in the epigastrium, less 
 than is produced by many a purgative : and even these sensations were probably 
 owing to the movements of the worm ; for when, after the lapse of four months, 
 the dose was repeated, it was followed by no inconvenience at all. The medicine 
 is not strongly cathartic, and sometimes requires the aid of a lavement. In each, 
 of these cases the expelled taenire were apparently dead. Their Aeaf/s were detected 
 in the evacuations : in one instance seven heads were seen. Louis says that within 
 a few days at furthest after the discharge of the worms, all the previous symptoms 
 of their presence ceased ; and the patients improved in respect to appetite, digestion, 
 complexion, flesh, and strength. They all remained well four months afterwards, 
 and then the potion was again administered; but it brought away no more worms. 
 Some of the patients, who had previously tried other modes of cure, had never 
 enjoyed so long an interval of freedom. 
 
 Various other remedies have been employed, and employed with more or less 
 success. One of them, the root of the male fern, formed the basis of a nostrum, 
 called Madame Nouffer's, which was so highly thought of, that in 1776 the King 
 of France gave that lady some hundred pounds sterhng for the secret of its com- 
 position. I think, however, you will find the oil of turpentine equal to the cure of 
 tape-worm in most instances. Should it fail, or should circumstances forbid its use, 
 I would advise you to resort to the bark of the pomegranate root. It seems pro- 
 bable that M. Darbon's remedy, if its nature were divulged, would supersede all 
 others. 
 
 LECTURE LXXV. 
 
 Diseases of the Liver. Acute Inflammation. Abscess of the Liver. Causes and 
 Treatment of Acute Hepatitis. Clironic Hepatitis. Jaundice. Its Symptoms, 
 Causes, and Species. 
 
 From the alimentary canal I go to the other organs directly or indirectly con- 
 cerned in the digestion and assimilation of our food. And, first, let us look at that 
 large gland, the liver, of which the main office, so far as we can perceive, is the se- 
 cretion of bile. 
 
 The liver is liable to various forms of disease : but it is not so frequently in 
 fault as many would have us believe. It is often blamed most gratuitously and 
 unjustly. 
 
 The researches of Mr. Kiernan, recently published in the Philosophical Trans- 
 actions, have paved the way for a better understanding in future of its pathology. If 
 I did not feel myself too much circumscribed by the remaining limits of this course 
 of lectures, I should be glad to attempt to assist you in construing Mr. Kiernan's 
 somewhat difficult and very valuable paper. But doubtless you are made familiar 
 with the anatomy of the organ, as described by him, in other lectures : and I must 
 content myself with noticing, as we go along, one or two points, in respect to its mor- 
 bid appearances, concerning which, before Mr. Kiernan took the subject up, great 
 mistakes prevailed, even among the most celebrated pathologists. 
 
 I shall follow the usual order, and consider first, injiammation of the liver, which 
 may be either acute or chronic. 
 
 Tht se are, both of them, diseases that are much more common in warm climates 
 than here. 
 
 Of well-marked acute hepatitis the symptoms are fever, with pain and a sense or 
 
 3v
 
 842 INFLAMMATION OF THE LIVER. 
 
 tension in the ri-^hl hj-pochondrium, inability to lie on the left side, difficulty of breath 
 ing, a dry coujb, vomiting, hiccup. 
 
 You will not find all these symptoms present in every case : yet they are all worth 
 attending to. 
 
 The pain is sometimes sharp and pricking, like a pleuritic stitch: sometimes dull 
 and tensive. In the former case the peritoneal covering of the gland is supposed to 
 be affected ; in the latter its parenchyma. The pain sometimes extends to the right 
 clavicle and to the top of the right shoulder. This circumstance was noticed by 
 Hippocrates ; and I have referred to it bel'ore as a good example of what are called 
 sympathetic sensations. The existence of this pain makes it probable that the 
 inflammation affects the convex surface of the hver. Occasionahy the left shoulder 
 is painful : the left lobe of the hver being involved in the disease. The pain in the 
 right side is aggravated, often, by the movements of the diaphragm in respiration ; 
 and this explains the embarrassment of the breathing, and the short dry cough. Why 
 the patient cannot well he on the left side is obvious enough : all the connections of 
 the inflamed organ are then put upon the stretch by its weight. There are, how- 
 ever, some exceptions to this rule. On the under or concave part of the hver lies the 
 pyloric extremity of the stomach ; and that viscus often s^-mpalhizes with the hepatic 
 inflammation : nausea and vomiting occur ; and hiccup. The thoracic symptoms 
 on the one hand, or the stomach symptoms on the other, may be expected to predo- 
 minate, according as the convex or the concave surface of the organ is chiefly the 
 seat of the inflammation. 
 
 The situation of the pain, the cough, the short and shallow breathing, used to 
 puzzle the older observers : and they confess their occasional inability to determine 
 whether the inflammation was situated in the lower lobe of the right lung, or in the 
 liver. But now-a-days we need have no difficulty in making the diagnosis. The 
 ear wilHell us, if we employ auscultation and percussion, whether the contents of- 
 the chest or of the belly are suffering: and my own experience has taught me that 
 sharp pain, with feverishness, occurring in the debateable ground of the right side, 
 denotes pleuritic inflammation far more often than it denotes hepatic. 
 
 Jaundice is an occasional, but by no means a necesaanj effect or accompaniment 
 of hepatitis, whether acute or chronic : and, therefore, what I have to say of that 
 symptom I shall give under a separate head. 
 
 Acute hepatitis may terminate in resolution ; or it may terminate in diffused sup- 
 puration ; or, what is more usual, in the formation of a circumscribed abscess, or of 
 abscesses, in the liver. In this climate we do not often meet with hepatic abscesses ; 
 but they are very common in hot countries : and some of the most interesting events 
 of the disease have relation to the progress of these collections of matter. When 
 they approach the surface of the liver, adhesions generally take place (in virtue of 
 that conservative principle of which we so constantly discern the working) between 
 the diseased organ and the neighbouring parts. If no such adhesion occurred, ihe 
 matter would at length burst into the cavity of the peritoneum ; and this does some- 
 times happen. The peritonitis, which is thus suddenly set up, is almost fatal. I 
 referred, however, in a former lecture, to one instance in which it was recovered from. 
 Sometimes the adhesion is effected between the liver and the parietes of the abdo- 
 men, and the abscess points externally, and may be opened by the surgeon. Such 
 a case occurred in my neighbourhood last year. Sometimes the liver glues itself to 
 the stomach, or to the intestines ; and then the abscess breaks into the alimen'.ary 
 tube, the matter is evacuated by vomiting, or by stool : and all goes on tolerably 
 well again. In other instances the agglutination is to the diaphragm, which is per- 
 forated, and the pus makes its way into the sac of the pleura, or through the lung 
 to the bronchi, and so out by the mouth. I have seen three examples of this my- 
 self. In one the abscesses originated in the formation and degeneration of hydatids 
 in the liver ; and the patient ^(a woman, she was under Dr. Macmichael's cure in 
 the Middlesex Hospital) spat up quantities of yellow fluid, consisting partly I sup- 
 pose of pus, but chif^fly of pure bile. The examination of the dead body ultimately 
 demonstrated the nature of that case. The second of the three patients got well: 
 yet 1 cannot doubt that, bating the hydatids, the disease ivas essentially of the same
 
 INFLAMMATION OF THE LIVER. 843 
 
 kind. It also occurred in a woman, whom I admitted into th(5 hospital. She was a 
 kitchen-maid at the Thatched House Tavern in St, James's Street ; and she had 
 received a violent blow at the back part of the right hypochondriuin. This was fol- 
 lowed by pain there and by fever ; and at length she began to have cough, dyspncea, 
 and expectoration. She brought up an abundance of frothy mucus of a bright yel- 
 low colour: not at all resembling the rusty sputa of pneumonia, but exacily of the 
 tint which bile would give to it. At the same time large crepitation could be traced 
 from the bottom to the top of the right lang, I fully expected that this woman would 
 die : but by degrees the j^ellow expectoration ceased, all the auscultatory signs gra- 
 dually disappeared, and she recovered perfectly. 
 
 It is plain that in such instances as this, there must be adhesion of the Inng to the 
 diaphragm also: but cases have occurred in which the matter burst into the cavaly 
 of the pleura, and presently destroyed the patient by suffocation. 
 
 The event of the third case is still s^^h judice. A gardener, of forty-five years 
 old, was attacked, four weeks before he came under my care in the hospital, with 
 severe pain in the right loin. Just at the edge of the short ribs, and not far from the 
 vertebral column, on the right side, I found a large elastic swelling, very tender, and 
 of a bluish red colour. As the patient's urine was most remarkably loaded with 
 amorphous deposits, my iirst suspicions turned towards the kidney. It soon, how- 
 ever, became evident that, although the tumour was below the diaphragm, the parts 
 above that muscle were involved in the disease. The righl, half of the thorax was 
 dull to percussion ; no vesicular breathing was audible there, but some scattered cre- 
 pitation and bronchophony. Four days subsequently to his admission the patient 
 began, during an effort of coughing, to discharge almost in a stream, from his mouth, 
 a considerable quantity of gray, pultaceous fluid, of the consistence of gruel, and hor- 
 ribly foslid. Altogether the amount of matter thus expectorated was estimated at 
 two quarts. The pain then ceased ; and the swelling was observed to be less. After 
 three days more, it was deemed proper to puncture the tumour, and matter was let 
 out having precisely the qualities of that which he had ejected through the mouth. 
 The patient remained eleven weeks in the hospital, the expectoration becoming less 
 unnatural, and the discharge from the abscess gradually diminishing. He then 
 chose to depart. Some months afterwards he applied for re-admission, and again 
 stayed with us a week or two. His health had much improved during the interval: 
 but the wound in his back was still open, and he still continued to expectorate some- 
 what : and yellow bile was frequently to be seen, both on the dressings which 
 covered the puncture, and in the vessel into which he spat. I think it probable that 
 this man may eventually recover, at the expense, however, of a permanently da- 
 maged lung. 
 
 Rigors occurring during the progress of hepatitis should make us suspect that 
 suppuration is taking place : if the pain is thenceforward mitigated, or exchanged 
 for a sense of \veight, and hectic fever sets in, we may be tolerably certain that pus 
 has formed. 
 
 Of the several courses taken by an hepatic abscess, that towards the surface of the 
 body is the most common ; and it is the only one with which w'e are able to interfere. 
 And the chief thing we have to look to, is not to interfere too soon. The adhesion 
 of the inflamed organ to the wall of the abdomen is the indispensable condition, not 
 of success only, but of safety, where the question arises of puncturing the tumour. 
 Without such adhesion the pus will be transferred from the cyst to the cavity of the 
 peritoneum ; or if the abscess be not reached by the scalpel, that cavity will be laid 
 open. Now it is not easy to ascertain whether there be adhesion or not. Certainly 
 the operation ought not to be attempted until the parts above the abscess are very 
 thin, and are verging to a point; and even then, unless there were some distinc 
 purpose, besides that of saving a little time, some urgent distress or danger to relieve, 
 I think such abscesses might be more prudently left to themselves. Dr. Gregory, 
 of Edinburgh, used to mention a case in which, as fluctuation was palpable, and the 
 tumour pointed, it was proposed to open it ; but the patient died, somewhat suddenly, 
 before the operation could be performed; and inspection of the dead body showed 
 that no adhesion existed. Mr. Malcolmson has lately published, in the 3Iedico-Chi-
 
 844 ACUTE HEPATITIS. 
 
 riirgircd Tranaactions, two or three instances of a like kind. These are circum- 
 stances which teach us to be cautious about recommending the operation. 
 
 A case is recorded of the bursting of an hepatic abscess into the pericardium; 
 another into the vena cava. Facts of this kind constitute mere medical curiosities, 
 and have no practical bearing. 
 
 It is clear, both from the size of the organ, and from its situation in the body, that 
 an abscess in the liver can never be otherwise than gravely hazardous. Yet many 
 recover from them. Much evidently depends upon the manner and direction in 
 which the pus seeks a vent. The most desirable road for its exit is one which it 
 sometimes takes, but which I have not yet mentioned. It occasionally flows out into 
 the duodenum through the excretory ducts of the liver, when these happen to have 
 been laid open by the suppurating process. Next to this we may hope for its dis- 
 charge through the adhering parietes of the abdomen ; next by a breaking of the 
 abscess into the ahmentary canal. The escape of the matter through the air-pas- 
 sages is fearfully perilous ; and its entrance into the shut serous sacs, or into the 
 great blood-vessels, almost necessarily fatal. 
 
 I have spoken of an abscess in the liver, as an event of acute inflammation of that 
 organ. Such inflammation is apt to arise, in tropical countries, after exposure to cold. 
 In any climate it may be excited by a blow, or other mechanical injury. But abscess 
 in the liver seems to be far more frequently the result of other remote causes. You 
 will call to mind those collections of matter which form in the liver, as well as else- 
 where, in consequence of suppurative phlebitis. There is, moreover, acknowledged 
 connection between hepatic suppuration and dysentery. In hot chmates the two are 
 often found coincident. It has commonly been thought that, in these cases, the affec- 
 tion of the liver happens first, in the order of time ; that the hepatic disease, inter- 
 fering with the freedom of the portal circulation, occasions congestion of the submu- 
 cous capillary blood-vessels, and so disposes the membrane to take on inflammation 
 under the influence of any slight exciting cause. In some recent lectures, however, 
 dehvered before the College of Physicians, Dr. Budd has proved, by a careful colla- 
 tion of a large number of authentic instances, that the relation of these two morbid 
 conditions to each other, is exactly the reverse : that the dysentery is the primary 
 disorder, and the hepatic abscess the secondary ; the link of connection between 
 them being the same as between suppurative inflammation of a vein, and the forma- 
 tion of pus in parts more or less remote. The blood, in its return through the 
 veins which are tributaries of the vena porta, carries with it, if not pus, yet some 
 vitiating ingredient from the inflamed membrane : and this vitiating ingredient pro- 
 vokes inflammation in the capillary vessels of the liver. 
 
 This, to the best of my knowledge, is a new, and certainly it is an important view 
 of the pathology of hepatic abscess. I trust that, ere long. Dr. Budd will lay before 
 the public the evidence upon which it is founded. 
 
 Acute hepatitis, when it occurs, requires vigorous treatment in the outset. Our 
 object is, if possible, to prevent suppuration. Blood should therefore be freely taken 
 from the system by venesection, and from the neighbourhood of the inflamed part 
 by leeches. I will not weary you by going over the old ground that we have so 
 often trodden already, nor repeat observations which have been many times made 
 respecting the methods, and the requisite amount, of this great antiphlogistic remedy. 
 Depletion of the portal vessels may also be indirectly obtained by purgatives; espe- 
 cially by such purgatives as produce copious and watery stools. The neutral salts 
 are therefore proper in this disorder. It may be, as some suppose, that they operate 
 beneficially, as counter-irritants, upon the duodenum; but their eWecl in draining 
 the veins that feed the vena porta, and thereby relieving the hepatic congestion, is 
 more obvious and more intelligible. These saline medicines should be much dilutea; 
 and their action may be quickened, if that be necessary, by adding the infusion of 
 senna. 
 
 After blood-letting has been duly performed, and the force of the inflammatory 
 action has been broken, blisters may be applied to the right hypochondriuni : and I 
 lielieve that repeated blistering is more serviceable than a single bUster kept open by 
 sjivme ointment. 
 
 I
 
 CHRONIC HEPATITIS. 845 
 
 Some diff^^rence of opinion prevails among medical men in regard to the employ- 
 ment of mercury in the outset of acute hepatitis. I cannot pretend to offer you the 
 results of my own observation on this point, but I find that the best authorities, 
 among those who have had to treat the disease in hot climates, are against its use at 
 the very first, as being stimulating to the liver. I suspect that this is a piece of 
 theory : but at all events, after the first violence of the inflammation has abated, that 
 remedy is not to be omitted, either in the acute, or in the chronic form of the disorder, 
 to be mentioned presently : only in the one case it should be so administered as to 
 affect the system as speedily as possible; in the other it is to be introduced. with a 
 slowness which bears a proportion to the pace of the disease. 
 
 When suppuration has taken place, or is unavoidable, when the patient ceases to 
 complain of pain, but has in its stead a feeling of weight in the hypochondrium, 
 and becomes distinctly hectic, a corresponding change must be made in the treatment. 
 Active depletion is no longer admissible ; you must sustain the strength by a more 
 nourishing diet, and prescribe some tonic remedies ; the sulphate of quina, with 
 sulphuric acid ; or the nitro-muriatic acid, which enjoys a considerable repute, greater 
 perhaps than it merits, for the relief of liver complaints. 
 
 Acute inflammation of the liver is apt to degenerate into chronic. Chronic in- 
 flammation may also arise under the circumstances that give birth to the acute form. 
 Chronic hepatitis, again, is not unfrequently produced by the presence of specific 
 disease in the liver ; of carcinoma ; of scrofulous tubercles. JVIelanosis and hydatids 
 are both of them of common occurrence in the same part ; and they may give rise 
 to symptoms, or they may not : and when these morbid conditions do declare them- 
 selves by external signs, those external signs are very much the same as belong to 
 chronic hepatitis. The precise diagnosis is exceedingl)'' obscure ; the symptoms 
 point distinctly to the fiver as the seat of the disorder ; but as to its exact nature, we 
 must often be content with probabilities alone. 
 
 The symptoms of chronic hepatitis— or of the chronic forms of disease to which I 
 have alluded, when they show themselves by symptoms — are (I give you them in 
 Cullen's words) "some fullness and some sense of weight in the right hypochon- 
 drium; some shooting pains felt at times in that region; some uneasiness or pain 
 felt on pressure in that part ; some discomfort from lying upon the left side; perhaps 
 some degree of jaundice ; and sometimes a certain amount of fever coinbining itself 
 with more or fewer of these symptoms." In short, they are just the symptoms of 
 acute hepatitis occurring in a minor degree. 
 
 Chronic affections of the liver are sometimes attended with an increase, and some- 
 times with a diminution, of its size. When it is augmented in bulk, its place and. 
 enlargement may be ascertained by palpation and percussion ; nay, the magnified 
 gland may sometimes be seen, extending beyond its proper situation in the hypo- 
 chondrium, and passing far down into the abdomen. I have known the liver reach 
 to the right groin : and when its left lobe is affected, it will sometimes stretch across 
 towards the lower part of the left side of the belly. On the other hand, the liver 
 may shrink into a much smaller space than it naturally occupies. These small livers 
 are usually hard. Interfering more with the portal circulation than many enlarged 
 livers do, they are more frequently attended with dropsj'' of the peritoneum. 
 
 The "hobnail" liver, the cirrhose of modern French writers, is nodulated as well 
 as hard. The irregularity of its surface may be so great as to be perceptible to the 
 touch. I fully described this condition of the liver when I was upon the subject of 
 passive ascites, of which it is the most common cause. 
 
 I mentioned, also, some time ago, the " fatty" liver, so frequently found associated 
 with pulmonary consumption. The liver in this state is soft, enlarged, smooth on its 
 surface, and of a buff or tawny colour throughout. Mr. Bowman has lately shown 
 that these changes are owing simply to the unwonted abundance of certain small 
 granules of fat, of which, in the healthy organ, each lobule contains a few only. If 
 in a phthisical patient we find the liver palpably enlarged, we may guess that it is 
 encumbered with this interstitial fat : but there are no symptoms peculiar to the fatty 
 liver. As to its cure, we are quite helpless : and the same may be said of the hobnail 
 
 3v2
 
 846 CHRONIC HEPATITIS. 
 
 liver, as well as of all those forms of disease in which the organ is loaded with specific 
 deposits. 
 
 Dark masses of extravasated blood are sometimes found interspersed through this 
 gland, and then, by an absurd perversion of language, the patient is said to have had 
 "apoplexy" of the liver. 
 
 The same causes which produce acute hepatitis, acting in a less intense degree, 
 will excite chronic inflammation of the same textures. Intemperance, also, and par- 
 ticularly the habitual and excessive use of alcoholic liquors, certainly tends to generate 
 hepatic inflammation, especially in its more chronic form. We see this even here, 
 and it is still more strikingly perceptible in v^^arm climates, as you may learn by 
 reading the works of those persons who have had experience of the diseases of India. 
 Dr. William Ferguson, for example, who was for some time chief of the medical 
 staff of the windward and leeward islands in the West Indies, observed that there was 
 a regular increase and aggravation of these chronic affections of the hver among the 
 troops after they received their monthly pay, when they drank great quantities of 
 ardent spirits ; arrack in the East Indies, and rum in the West. 
 
 There has long been supposed to be what is called a gin-drinker' s liver, in which 
 a section of that gland presents an appearance very closely resembling the section 
 of a nutmeg; and a good deal of useless speculation has been employed as to the 
 nature of the change which has taken place in such cases. Mr. Kiernan has clearly 
 shown that the nutmeg aspect of the liver is produced by mere congestion of blood. 
 Congestion of the liver is, indeed, very likely to arise under the daily stimulus of 
 distilled spirits, but it arises under various other circumstances besides ; and there- 
 fore it is no safe test of the intemperate habits of the party. And of this we had 
 sufficient evidence before Mr. Kiernan's observations were published. Again and 
 again have I met with the nutmeggy liver, strongly marked, when there was reason 
 to believe that the possessor of it had never transgressed the strictest rules of tem- 
 perance in drinking: in young persons, for example, of both sexes, who certainly 
 never had been dram-drinkers. Disease of the heart is a very obvious, and a very 
 common cause of hepatic congestion. 
 
 You are aware that the congestion occurs under two forms, according as the 
 branches of the hepatic vein, or of the vena portge, are gorged. If both these sets 
 of vessels are full, the liver is universally red. If the hepatic vein alone be the seat 
 of the congestion, then in the centre of each lobule we see a red speck, surrounded 
 by yellowish matter; the specks are isolated, the yellow colour is arranged in a sort 
 of net-work. Whereas, if the portal system be greatly engorged, the red streaks 
 will be continuous, and the yellow portions hemmed in by them, and isolated. I 
 show you these distinctions in some specimens prepared by Mr. Kiernan himself. 
 
 I should have stated, when speaking of the signs of chronic hepatitis, what is sin- 
 gularly true of chronic hver affections in general, that they are apt to be attended 
 with much languor and lassitude, and a remarkable depression of spirits ; and with 
 that sort of dread, and apprehension of impending evil, which I mentioned as being 
 a striking feature of hypochondriasis: the very derivation of which term marks its 
 frequent connection with hepatic disorder. There is sallowness of the complexion 
 also ; and sometimes emaciation. 
 
 The same rem.edies are adapted to the chronic as are proper for the acute inflam- 
 mation of the liver: the comparative mode of their exhibition, however, differs 
 somewhat. 
 
 Blood-letting is not often necessary or advisable, except when more violent aggra- 
 vations than usual of the inflammatory symptoms supervene. Topical bleeding, and 
 blistering, are more expedient. 
 
 But the two main remedies to be tried in this complaint are mercury, and the 
 sahne puriratives, given in small doses, and repeated for a long time together. Five 
 grains of biue-pill every night, or every night and morning ; and as much of the 
 sulphate of magnesia as will produce one or two watery stools every day, for weeks, 
 perhaps, in succession. Patients are not so well content to bear this discipline when 
 it is administered in boxes and phials, as physic; but they have more faith in the 
 natural mineral waters : so that a residence at Cheltenham, or some such place, is
 
 JAUNDICE. 847 
 
 exceedingly proper to be recommended in these cases ; where the daily use of tho 
 waters may keep up a continual drain on the system of the vena portse ; and where 
 relaxation from business, the amusements that are constantly going on, with change 
 of scene and of society, may contribute to dissipate the hypochondriacal feelings 
 which are so apt to render the subjects of chronic hepatic disease supremely 
 wretched. 
 
 Moderate exercise, in the open air, on horseback and on foot, should be encouragea 
 There is no doubt that hepatic as well as gastric derangements are fostered by 
 sedentary habits. Tepid bathing is another expedient from which benefit may be 
 hoped. In many instances it will be proper to make trial of Scott's nitro-muriatic 
 bath. 
 
 Iodine has been thought of much use in certain kinds of hepatic disease ; in those 
 kinds especially which are connected with enlargement of the viscus. The iodide 
 of potassium, or a mixture of the iodide and of iodine, or some of the combinations 
 of iodine and mercury, may be given in such cases; or the iingiienfum iodinii 
 composifum, or the unguentum hydrargyri iodidi of the Pharmacopoeia, may be 
 rubbed night and morning upon the hypochondrium. I have not seen much benefit 
 from these forms of medicine myself, in such cases ; but they are said, by persons 
 of experience and credit, to have been successful in their hands. 
 
 Tantxacnm is also a drug which has been much employed in liver complaints, 
 since Dr. Pemberton's book on the diseases of the abdomen was published ; but it 
 is very doubtful, in my mind, whether it ever does much good. The Germans are 
 very fond of giving the rauriate of tnnmonia in small and frequent doses. They 
 have the same belief in the virtues of this salt, in various disorders, as the English 
 practitioners have in those of mercury ; and, what is curious, they attribute to it 
 some specific agency upon the functions of the liver. 
 
 In the account which I have now given of the principal diseased conditions of the 
 liver, I have not included nor dwelt upon all the changes of structure and appear- 
 ance to which that organ is liable. There are various conditions which disclose 
 themselves by no intelligible symptoms during life, of which the nature has not yet 
 been determined, and of which the cure still remains to be discovered. At this 
 advanced period of the course, and with no time to spare, I do not think it necessary 
 or right to trouble you with the unprofitable discussion of matters that are not strictly 
 practical. 
 
 I have mentioned jaundice as an occasional symptom both of acute and of chronic 
 inflammation of the liver. But jaundice is spoken of, in general, as constituting, 
 itself, a distinct form of disease. If we consider it in that light, its diagnosis is most 
 easy. We have only to look upon our patient to know what is the matter with him. 
 But jaundice depends upon various and very different morbid conditions ; and, look- 
 ing to those conditions as the true objects of diagnosis, we find that the real nature 
 of a given case of jaundice is often involved in very great obscurity. 
 
 Let us first consider the constituent features of jaundice, whether it be regarded 
 as a disease, or as a sign of disease. They are, yellowness of the skin and of the 
 eyes; whitish feces; urine having the colour of saffron, and communicating a bright 
 yellow tinge to white linen. 
 
 The characteristic yellow hue is owing, no doubt, to the presence of bile, or at any 
 rate of the colouring matter of the bile, in the circulating blood. And the deep tint 
 of the urine is evidently derived from the same source. On the other hand, the 
 paleness of the feces is to be ascribed to the want of bile, which always exists in 
 healthy and natural excrement. This last symptom is not, however, a constant one ; 
 there may be jaundice while bile appears in the stools. I shall explain how this is 
 supposed to happen, presently. 
 
 It has been made a question how the bile, or its colouring matter, comes to be 
 visibly present in the blood, or rather in many of the tissues supplied by the blood, 
 and in several of the other fluids of the body. The general opinion, and probably 
 the true one, is, that the bile, after being secreted in the liver, is reabsorbed, and car- 
 ried into the circulation, and so conveyed to the surface, and to the parts in which
 
 848 JAUNDICE. 
 
 the change of colour is observed. This explanation is consistent with the pheno- 
 mena wnicl) we notice in the disorder. 
 
 But another theory has been broached on this subject; first, I believe, in this 
 country, by Darwin. It has been more recently revived by M. Chevreul, who is 
 followed by Mr. Maj'^o. These pathologists are of opinion that the bile is formed, 
 not b}"^ the hver, but in the blood : that the office of the liver is to strain ofiT or with- 
 draw the bile from the circulation, constantly, as fast as it is formed; just as the per- 
 petual elimination of urea from the blood appears to be one great purpose of the 
 kidneys. They hold, therefore, that jaundice manifests itself whenever the due 
 separation of the bile from the blood is suspended or imperfect. Failing of its natu- 
 ral vent, this peculiar substance accumulates in the blood, seeks other outlets, is 
 deposited in various places, and, in fact, partly escapes through unaccustomed chan- 
 nels. They speak of jaundice as a symptom of suppression of bile, while others 
 consider it as a sign of retention; using these words, suppression and retention, in 
 the sense in which they are applied to the secretion of urine. They maintain that 
 the proper function of the liver, the abstraction of bile from the blood, may be 
 arrested by alterations of the substance and structure of that gland ; or by the oblite- 
 ration or obstruction of the gall-bladder or ducts, impeding or forbidding the removal 
 of the bile already formed ; or by some obscure influence of the nervous system 
 upon these organs. They introduce the last kind of cause with the view of explain- 
 ing those cases, which certainly occur, in which jaundice is the result of severe 
 bodily pain, or strong mental emotion. Nay, on their supposition, we might even 
 suppose that the yellowness is sometimes due to a spontaneous and unwonted abun- 
 dance of the elements of bile in the blood ; in which case, we need not wonder that 
 jaundice should go along with perfect integrity of the biliary apparatus. 
 
 The advocates of the first-mentioned supposition are aware of the difficulties 
 opposed to its reception, by the occasional absence, even in cases of well-marked 
 jaundice, of all organic disease or apparent obstruction to the excretion of the bile. 
 They show that in verj^ many cases there is some obvious mechanical obstacle to the 
 efflux of the secreted fluid ; and in those instances in which none can be discovered 
 after death, they conceive either that the ducts of the hver had been temporarily 
 plugged up by inspissated bile, or a sort of biliary sand — or that they were closed 
 for a time by spasm — or by some morbid condition of the duodenum. 
 
 Now, of these two hypotheses, that which ascribes the yellowness to the reabsorp- 
 tion of secreted bile is, to my mind, the most probable and the simplest; and I can- 
 not see that it is attended with more difficulty than the other. But you may choose 
 for yourselves between them ; and I pass from this digression to a somewhat closer 
 examination of the principal circumstances noticeable in the complaint. Its technical 
 appellation, I should observe, is icterus., which is the Greek name for a bird with a 
 yellow plumage, the galbula, or golden thrush ; the sight whereof, by a jaundiced 
 person, was death (Pliny tells us) to the bird, and recovery to the patient. Various 
 other terms have been applied to the disorder, most of them having reference, like 
 jaundice itself (from the French Jo?/?2e), to the unnatural colour. Morbus arqiiatics, 
 from its exhibiting some of the bright hues of the rainbow ; aurigo, from its resem- 
 bling gold ; and we hear the common people say, now-a-days, such a one is as yel- 
 low as a guinea. The Latins spoke of it, also, under the title of morbus regius. 
 Why they so called it, we learn from the following curious passage in Celsus, giving 
 an account of the pleasant regimen, fit for royalty itself, to be adopted by those who 
 labour under the malady: "Per omne vero tempus utendum est exercitatione, fric- 
 lione : si hiems est, balneo; si asstas, frigidis natationibus ; lecto etiam et concla/i 
 cultiore, lusu, joco, ludis lascivia, per quae mens exhilaretur: ob quce regius morbus 
 dictus videtur." 
 
 The whiteness of the stools I have mentioned as being a very common, but not a 
 ..onstant appearance. It clearly depends upon the absence of bile. But sometimes 
 •.here IS bile in the discharged feces, and, at the same time, the yellow colour of the 
 ^km and eyes. This probably depends upon the circumstance that some branches 
 of the hepatic ducts are obstructed, while the others are free ; and thus the bile that 
 is secreted is, in part, reabsorbed into the blood, and in part carried off into the intes-
 
 JAUNDICE. 840 
 
 tines. In a former lecture, I stated that one of the uses of the bile appeared to be 
 that of stimulating the bowels to action ; it is the natural purgative. Accordingly, 
 in most cases of jaundice, the bowels are costive. But neither is lids uniform. In 
 some of the worst cases, wherein the jaundice depends upon hepatic disease, which 
 is connected with disease also of the mucous coat of the intestmes, there is constant 
 iiarrhcea. 
 
 In some instances the yellowness of the skin is at first attended with itching, which 
 is occasionally so intolerable as to require the employment of opiates to allay it. In 
 most cases there is no itching at all. The bile never fails to appear in a deep vessel, 
 even black ; and which tinges any white substance that is dipped into it of a bright 
 yellow. The urine which thus sometimes seems black, may be proved to derive 
 that appearance merely from concentration of the yellowness, by pouring a little of 
 it into a shallow white dish, or by diluting it with water ; when the brilliant yellow 
 tint will become manifest. Bilious sweat sometimes occurs, staining the patient's 
 linen yellow. The saliva, in some jaundiced persons, has the same yellow tinge, 
 and a distinctly bitter taste. It has been said that the milk of women who are nursing 
 is made yellow in this disorder. Dr. Heberden, however, states that he never wit- 
 nessed this ; and he had known a woman with a very deep jaundice upon her, 
 suckle her infant for six weeks together with no apparent bad effects upon its health. 
 One man assured him that his tears were yellow. You are aware of the vulgar 
 notion, that to a jaundiced eye all things appear yellow. It is an old notion, for we 
 find it expressed by Lucretius : — "Lurida prteterea fiunt qusecunque tuentur Ar- 
 quati." Heberden was disposed to regard this as a mere poetical fiction. But cer- 
 tainly it is sometimes, though very rarely, indeed, a fact. Two women, whom he 
 considered, however, to be of little credit, told Heberden that objects appeared yellow 
 to them. I have been assured of the same thing by a medical man who experienced 
 it in his own person. If I do not mistake. Dr. Mason Good saw all things yellow 
 when he was jaundiced. Dr. EUiotson has had some very interesting cases of this 
 phenomenon. One of his icteric patients declared that objects seemed yellow when 
 looked at with one eye, but not with the other ; and in the eye that perceived the 
 yellow tint he observed two large red vessels running towards the cornea. And in 
 one or two instances, which he met with afterwards of yellow vision with both eyes 
 in jaundiced patients, he found inflammation, or distended blood-vessels in both eyes. 
 This very morning I saw in the hospital a patient of Dr. Wilson's, a middle-aged 
 woman, affected with jaundice. She affirms that all objects seem yellow to her 
 vision. In both eyes there are several varicose and singularly tortuous vessels, pro- 
 ceeding across the sclerotica towards the cornea, and some of them reaching its 
 margin. It seems probable therefore that ttie ophthalmic vessels, in their natural 
 state, do not permit the colouring matter of the bile to pass through them ; but that 
 when they become enlarged by disease, so as to admit the colouring particles of the 
 blood, they may also give a passage to the yellow colouring matter, which tinges 
 the humours of the eye : and in that case the objects seen through the yellow fluids 
 would appear like those viewed through a piece of yellow stained glass. This is a 
 point which is worth your attention in future. 
 
 The shades of yellowness are different in different patients. Those who are pale 
 and fair present a bright lemon colour. But in those who are florid, or whose cheeks 
 and skin are flushed with fever, the tint will more resemble that of the Seville orange 
 Again, if the patient be naturally swarthy, or if his visage is livid or dusky through 
 imperfect arterialization of his blood, the superaddition of jaundice will give him a 
 greenish hue. These differences resuU from natural or acquired difl!erences of com 
 plexion antecedent to the' icterus. But sometimes the bile that is reabsorbed is 
 vitiated and dark ; and we may have, for that reason, as Dr. Bail lie has pointed oui, 
 cases of green or black jaundice. You will remark that from whichever cause the 
 green or dark colour proceeds, whether from a mingling of the yellowness of the 
 bile with the blueness of lividity, or from the circulation of green-coloured bile, such 
 cases are especially unpromising cases. 
 
 Icterus depends, as 1 have said, upon various and different internal causes : and 
 frequently we cannot determine at all, until death affords us the means of inspecting 
 54
 
 8r»0 JAUNDICE. 
 
 tht! parts concerned in its production, what the precise exciting cause may be ; even 
 when it is simply mechanical. Any kind of pressure made upon the excretory ducts 
 of the hver will produce it ; and such pressure may be exercised b}'' tumours seated 
 in the liver itself; or by a scirrhous pylorus; or by specific disease situated in the 
 head of the pancreas, of which I have seen several examples ; or by a diseased con- 
 dition of the duodenum : and these possible causes of a detention of the bile in its 
 receptacle should always be borne in mind when we, are investigating an obscure 
 case of jaundice. 
 
 The impediment, in the cases just supposed, is external to the ducts ; but they 
 may be obstructed within, plugged up by inspissated bile, or by a biliary calculus. 
 This forms one of CuUen's species of icterus — the icterus culculosus. The concre- 
 tion is most commonly situated, I believe, in the ductus choledochus ; sometimes, 
 however, in the cystic, and sometimes in the hepatic duct. The pain that attends 
 the passage of a gall-stone through these ducts is often dreadful. Perhaps there is 
 no pain to which the body is subject that is more severe. You will not wonder at 
 this, when you consider that through a tube, of which the natural size scarcely ex- 
 ceeds that of a goose-quill, there sometimes passes a stone as big as a walnut. The 
 common duct has been found so dilated as readily to admit one's finger. CuUen's 
 definition of this species is "Icterus, cum dolore in regione epigastricil, acute, post 
 pastum aucio, et cum dejeclione concretionum biliosarum." INow the last of these 
 circumstances, the voiding of biliary calculi by stool, may happen over and over 
 again, without its being noticed, and it does not help us at all to judge of the nature 
 of the complaint at its commL-ncement, while the gall-stone is still in the ducts. With 
 the pain, which is not constant, but comes and goes, there are much nausea and 
 vomiting ; and sometimes hiccup ; and the matters vomited are usually very sour. 
 The patient is flatulent and dyspeptic; languid and gloomy. At length the concre- 
 tion passes into the intestines ; the pain suddenly ceases, and all is soon well again. 
 Attacks of this kind, having happened once, are very apt to be repeated. 
 
 Now this pain you might readily mistake for the pain of inflammation, were it not 
 marked by these two circumstances — the absence of tenderness and the absence of 
 fever. Pressure, instead of augmenting, usually mitigates it. The patient keeps 
 his hand firmly applied to his epigastrium ; or rests, perhaps, the weight of his body 
 upon some hard substance placed beneath his stomach. 1 speak now of the begin- 
 ning of the attack, before there has been much retching ; for a degree of tenderness 
 of the abdominal muscles is often produced by repealed straining and vomiting. The 
 pulse is unaffected, or I should rather say it is not accelerated, during the pain : 
 occasionally it is even slower than natural, and the skin cold. Though there be no 
 inflammation, rigors may occur ; just as they sometimes happen when a solid sub- 
 stance — a bougie to wit — is passing through, and distending the urethra. 
 
 Nevertheless, inflammation does sometimes arise, and then the pulse becomes 
 frequent, and the skin hot, and thirst and headache are complained of, and the epi- 
 gastrium IS tender; and if blood be drawn it exhibits the buffy coat. Sometimes the 
 gall-stone makes its way, by ulceration, through the contiguous structures, and so is 
 discharged outwardly, or into the bowels. In such cases there must have been 
 inflammation. 
 
 As jaundice often occurs without any pain, so a gall-stone may enter and pass 
 through the ducts, and produce pain, when there is no jaundice. The cystic duct 
 alone may be blocked up, and that portion only of the bile be prevented from escaping 
 which is accumulated in the gall-bladder. It is probable that re-absorption of the 
 contents of that cistern is not very active. Or a calculus of an angular shape may 
 stick in the common duct, and thus impede, without entirely stopping, the egress of 
 the bile. Dr. Heberden thought that gastrodynia was not unfrequently owing to 
 biliary concretions : founding his opinion upon the fact that many persons sufler, for 
 months or years, under occasional attacks of epigastric pain, which is at last asso- 
 ciated with jaundice. But after all, this might happen from progressive disease in 
 the stomach itself; and it is a pity that Dr. Heberden's views were not fortified by 
 diaseclioQ. 
 
 Wiief ')nce a large calculus has forced its way through the natural channels of
 
 JAUNDICE. 85 
 
 the bile, they remain permanently dilated ; and smaller stones may be afterwards 
 voided without pain or other notice of their passage. There are persons who get 
 rid of scores of them in this way, during the course of their lives. 
 
 Sometimes a large concretion, after its extrication from the biliary passages, lodges 
 in the more capacious intestines, and gives rise to serious obstruction there. I men- 
 tioned, recently, one case of this kind which had fallen under my own notice. But 
 in general the concretions are presently voided with the stools : and they should 
 always be looked for. The patient is much gratified by seeing that his enemy has 
 been expelled; and also by the proof he thus obtains of the sagacity and judgment 
 of his physician. The feces should be mixed with water, upon the surface of which 
 any gall-stones, since they are specifically hghter than that fluid, will float. I never 
 but once succeeded in thus catching a concretion in the evacuations of a patient, 
 whose symptoms had led me to search for it. 
 
 We often find gall-stones, even in vast numbers, in the gall-bladders of persons 
 who, during their lifetime, had never been known to suffer pain about the fiver, or 
 to have jaundice, or to exhibit any token of the presence of such concretions. We 
 infer from this that, while they remain in the reservoir of the bile, they are harm- 
 less ; and that the suffering and the hazard they occasion are mechanical conse- 
 quences of their transit through the gall-ducts. I have heard of an instance in which 
 upwards of 1,300 gall-stones were taken from a human gall-bladder after death. 
 
 These gall-stones are not, as you might suppose, mere lumps of inspissated bile. 
 There are, I believe, concretions of that kind, but they are very rarely met with in 
 the human subject. The ordinary calculi consist, in a great measure, of a peculiar 
 substance, cholesterine, which exists in a state of solution in healthy bile, but which, 
 in some morbid conditions of that fluid, being released from its solvent, assumes its 
 proper crystalline form. Very fittle is knovvn respecting the circumstances under 
 which the change lakes place. Cholesterine, Dr. Prout tells us, is the product of 
 some modification of the oleaginous principle. Biliary concretions seldom form in 
 children. They are much more common in women than in men. They occur 
 most frequently in persons who are corpulent, lead sedentary lives, use generous 
 fare, sleep much, and neglect their bowels: all which things foster or denote a torpid 
 and congested state of the hepatic system. Cattle are said to be subject to bihary 
 calculi when shut up in stalls during the winter, and to lose the complaint when 
 they are again turned out into the pastures in the spring. Hence the absurd notion, 
 countenanced even by Van Swieten, that grass is a good remedy for jaundice. 
 
 Another variety of jaundice, also noticed by Cullen, is supposed to depend upon 
 mere spasm of the gall-ducts. ^^ Icterus spasmodicus, sine dolore, post morbos 
 spasmodicos, et pathemata mentis." 
 
 Now the existence of this cause is hypothetical. The gall-ducts, though not dis- 
 tinctly muscular, possess a vital power of contraction. I am not aware that the 
 disease has ever been clearly traced to a connection with "morbi spasmodici." It is 
 an alleged cause which we can neither prove nor disprove. Certainly the " pathe- 
 mata mentis" play their assigned part: fits of anger, and of fear, and of alarm, have 
 been presently followed by jaundice ; and it has also been produced by great bodily 
 suffering, by a severe surgical operation, or, perhaps, by the dread which attended 
 it. Mr. North witnessed a case in which an unmarried female, on its being acci- 
 dently disclosed that she had borne children, became in a very short time yefiow. A 
 young medical friend of mine had a severe attack of intense jaundice, which could 
 be traced to nothing else than his great and needless anxiety about an approachino- 
 examination before the Censor's Board at the College of Physicians. There are 
 scores of instances on record to the same effect: and tJiis is observable of such cases, 
 that they are often fatal, with head symptoms : convulsions, delirium, or coma, super- 
 vening upon the jaundice. But with respect to the immediate cause of the icteric 
 symptoms, they may, I say, depend 'upon a spasmodic constriction of the gall-ducts. 
 Mr. Mayo has suggested another cause, viz., the sudden formation of bile in unusually 
 large quantity in the blood, by some influence propagated through the nerves. 
 
 Jaundice sometimes supervenes upon violent and long-continued vomiting; in
 
 852 JAUNDICE. 
 
 which case the extremity of the gall-ducts is supposed to have been compressed by 
 the coats of the duodenum. 
 
 Jaundice may also occur, as I stated before, as a symptom of acute or chronic 
 inflammation of the liver ; and then its treatment will merge in that of the primitive 
 disease which occasioned it. 
 
 Icterus occasionally comes on during pregnancy ; and disappears after childbirth 
 The pressure of the gravid uterus may thrust other organs, a loaded colon for ex- 
 ample, against the liver, and so impede the passage of the bile. The little exercise 
 that pregnant women are apt to take, and the costiveness that frequently attends 
 their condition, may have some influence in causing the icterus gravidarum. 
 
 All systematic writers follow Cullen in making jaundice a common disorder among 
 newly-born children. The icterus neonatoruin occurs, they say, a few days after 
 birth ; is not attended with any suffering, or obvious disturbance of the bodily func- 
 tions ; and soon disappears. Now there seems reason to beheve that this is not 
 icterus at all ; and has no relation to the biliary organs. The surface of the infant, 
 at its birth, is frequently of a deep red, from hyperemia or congestion of blood ; pre- 
 senting a condition which falls little short of a mild but universal bruise. By degrees 
 the redness fades, as bruises fade, through shades of yellow into the genuine flesh- 
 colour. Such, 1 am assured by those who are more conversant with these matters 
 than myself, is the pathology of the icterus infantum. Of course true jaundice may, 
 as well as most other complaints, befall the earliest period of life ; but I conceive 
 that it seldom does. 
 
 The prognosis in jaundice is generally favourable ; except when it depends upon 
 structural disease of the liver, or supervenes suddenly upon some great mental or 
 bodily shock. In both these cases the prognosis is bad, or doubtful. It is better, in 
 that variety connected with hepatic disease, if the disease proceeds from some known 
 cause, by which a low degree of inflammation has been produced ; and the cause is 
 such as can be avoided for the future. Just, indeed, as in chronic hepatitis, of which 
 the icterus is simply an occasional symptom. The prognosis is worst of all in old 
 persons, when the constitution is impaired, and there is no obvious cause for the 
 disease ; and particularly when the colour of the skin is greenish, or approaching to 
 black. 
 
 [Mr. Twining, in his work on the Diseases of Bengal, has presented some very interesting 
 and important views in relation to the patliology of jaundice. 
 
 Mr. T. has found that jaundice, not only during its early stage, but for a long period subse- 
 quently, while the discoloration of the skin remains, is very generally attended with some 
 morbid sensibility when pressure is made over the situation of the gall-bladder and capsule 
 of Glisson, though the uneasiness, during the absence of pressure, is most generally referred 
 to the epigastrium. 
 
 When the disease occurs in plethoric subjects, and the stools are of a pale clay colour, Mr. 
 T. has found it almost always attended with fever, and in some cases he has known robust 
 patients to die, with symptoms of oppressed brain, within thirty-six hours after the sudden 
 appearance of intense jaundice, for the accession of which no cause could be assigned. 
 
 In consequence of the acknowledged obscurity which exists in regard to the true pathology 
 of the disease, he was anxious to ascertain the exact condition of the liver and biliary ducts 
 in persons labouring under jaundice. The almost invariable existence of pain, increased 
 upon pressure, confined to a circumscribed spot on the right side, just below the centre of a 
 line drawn from the right nipple to the umbilicus, led him early to suspect circumscribed 
 inflammation of some part of the liver as the most frequent cause of the disease. This 
 opinion he believed to be confirmed by the good effects which, in the majority of cases, are 
 produced by a systematic course of depletion: nevertheless, if circumscribed inflammation 
 be the efficient cause of jaundice, he found it difficult to explain why the disease was so 
 freqtiently absent during the progress of the most unequivocal and intense inflammations of 
 large portions of that organ. The examination of individuals who had recovered from jaun 
 dice only a short time before death occurred from other diseases, exhibited no appearances 
 in the liver indicative of any circumscribed portion of it having been the seat of recent 
 inflammation. In the course of his dissections, however, Mr. T. found that albuininous infil- 
 tration into the cellular structure of the capsule of Glisson was sometimes present. Within 
 this capsule are situated two small bodies, which, from their structure, appearance, and uni- 
 formitv of situation, he is inclined to believe are absorbent glands : one of them is situated
 
 JAUNDICE. ^ 853 
 
 '^ear the termination of the gall-bladder in the cystic duct, the other, at the upper part of tha 
 ductus communis; the superior gland is sometimes very small, and occasionally, it is more 
 closely attached to the side of the gall-bladder than to the cystic duct; the lower one 
 is more uniform in bulk, being usually half the size of a small bean; it is always placed 
 just at the common biliary duct. Irritations affecting the absorbent vessels passing through 
 this gland may, Mr. T. conceives, cause in it such a degree of swelling as would produce 
 transient compression and closure of the common duct, and thus prevent the passage of the 
 bile into the intestines, and give rise to the phenomena of jaundice. So long as the obstruc- 
 tion is complete, the stools will be nearly white, or of a very pale gray colour; when, how- 
 ever, the jaundice is attended with severe fever and symptoms of intense gastro-enteritis, the 
 stools will very often be coloured by the blood which is poured out by the capillary vessels 
 of the intestinal mucous membrane, as well as by other morbid secretions. 
 
 When previous inflammatory disease of the capsule of Glisson has caused an infiltration 
 of coagulable lymph into the cellular structure of that part, at a remote period, and its sub- 
 sequent absorption has left a degree of induration and constriction, Mr. T. believes that a 
 very slight enlargement of the lower gland will effectually compress the common biliary 
 duct ; he has seen its canal obliterated, from this cause, exactly at the point of contact with 
 the swollen and indurated gland. He has, also, seen the cystic duct obliterated where it 
 was in contact with the upper gland, in consequence of the enlarged and diseased condition 
 of the latter ; but he does not believe that this could have any influence in the production 
 of jaundice. 
 
 Mr. T. does not deny the agency which biliary calculi — tumours of the pancreas, liver or 
 spleen, or scirrhous pylorus may occasionally have in the production of the phenomena of 
 jaundice, nor that, in some rare cases, the disease may have been excited simply by mental 
 emotion ; nor is he willing to place undue importance on the observations upon which his 
 views of the most frequent cause of the disease are based. Should these, upon more ample 
 investigation, be found to be correct, they will have an important influence upon the treat- 
 ment of the disease. 
 
 According to Mr. T., the most sticcessful plan of treatment in those cases of jaundice ac- 
 companied with pain, augmented upon pressure, of the right side of the abdomen, is by 
 depletion by the lancet and leeches — active purgation — the daily use of the warm bath — and 
 sudorifics, aided by low diet and perfect rest, in the commencement of the disease; followed 
 by milder purgatives, and a small blister over the region of the gall-bladder, kept open for 
 a long time. Subsequently, a course of Cheltenham salts, or small doses of rhubarb and sal, 
 polychrest, with gentle exercise, and frictions with camphorated liniment over the right hypo- 
 chondrium are advisable : at the same time, it may be proper to allow a mild unirritating 
 diet, in such quantities as shall improve the patient's strength. The disease may sometimes 
 occur under circumstances that forbid depletion. This Mr. T. considers an unfortunate cir- 
 cumstance, as he has but little confidence in other modes of treatment. 
 
 In those cases in which the stools indicate the entire absence of bile from the intestmes, 
 Mr. T. considers the use of mercurials to be of doubtful propriety; but, when bile does pass 
 into the dtiodenum, he admits that calomel may be useful, in conjunction with the remedies 
 already detailed. Excepting in cases where there is pretty positive evidence of the exist- 
 ence of biliary calculi, which he believes to be less frequently a cause of jaundice than is 
 generally imagined, he doubts the propriety of having recourse to opiates. 
 
 Whether the views of Mr. Twining in regard to the pathology of jaundice be or be not 
 correct, must be determined by the result of future and more extended observations ; they 
 are sufficiently plausible and important, however, to demand the attention of the physician 
 and to influence him in his treatment of the disease. In respect to the plan of treatment re- 
 commended by Mr. T., we believe it will be found, with one exception only, to be, in a large 
 number of cases, the only proper and successful one. The exception to which we allude, ia 
 the indiscriminate admimslTaXion of active purgatives : jaundice is, not unfrequently, connected 
 with more or less extensive inflammation of the stomach and small intestines, and in these 
 casRS, the employment of active purgatives to the extent racommended by Mr. T. would un- 
 questionably be decidedly injurious. — C] 
 
 3w
 
 854 JAUNDICE. 
 
 LECTURE LXXVI. 
 
 Treatment of the variotts Species of Jaundice. Diseases of the Gall-bladder ; of 
 the Spleen ; of the Pancreas. Diseases of the Kidneys. Nephritis and Neph- 
 ralgia. Phenomena constituting a ''fit of the Gravel.''^ Different kinds oj 
 Gravel. Diseased states of the Urine. Description and remedies of the Lithic, 
 Phosphatic and Oxalic Diatheses. 
 
 In the last lecture, after describing the symptoms, causes and treatment of acute 
 and chronic inflammation of the liver, and after pointing- out various other forms of 
 chronic disease to which that organ is obnoxious, I spoke of jaundice. I offered 
 )''ou some comments upon its phenomena; and I indicated several different internal 
 conditions upon which it may, in different cases, depend : and the lecture was closed 
 with some brief hints respecting the prognosis of icterus. I have yet to consider the 
 plans of treatment best adapted to the several varieties of the complaint. 
 
 Some kinds of jaundice are obviously and absolutely irremediable. From others 
 the patients recover, whatever treatment may be adopted, or without any treatment 
 at all. Hence, as is customary in such circumstances, remedies the most worthless 
 and absurd are extolled for their efficacy against jaundice. The patient gets well, 
 and the drug last tried is held to have cured him. Post hoc, ergo propter hoc, is an 
 argument more often applied I believe to the variations of disease, than to any other 
 class of events. 
 
 In that species of icterus which occurs, sometimes, in connection with acute or 
 chronic inflammation of the liver, the treatment must be such as I yesterday recom- 
 mended for acute and chronic hepatitis. Mercury forms an essential part of that 
 treatment; and, unless the disease yielded sooner, I should urge the remedy until 
 its effect upon the gums, and, therefore, its presence in the circulating blood, was 
 apparent. 
 
 But to the icterus calculosus, mercury is not so well adapted. What we want is, 
 not a more plentiful or a more healthful secretion of bile, but to get rid of the me- 
 chanical impediment to its excretion : or, at any rate, if that cannot be accomplished, 
 to ease the acute sufferings of the patient. Should fever attend the passage of a 
 gall-stone, or, should the epigastric pain become epigastric tenderness, leeches may 
 be applied, or a vein may be opened. The abstraction of blood may prevent any 
 thickening of the distended gall-ducts ; or it may perhaps relax their spasmodic 
 closure around the calculus. But, in general, blood-letting is not of service nor 
 requisite in this variety of jaundice. Our great resource, for relieving the pain, and 
 for loosening the presumed spasms, is opium, given in full doses: and I can add 
 but little, with any advantage, to the directions laid down, on this head, by Dr. He- 
 berden. "This pain (says he) can only be assuaged by giving and repeating opium 
 and its preparations, as often as the continuance of the pain requires them ; and be- 
 cause this pain is very apt to return, the patient should always be advised to keep 
 by him, as long as the distemper lasts, pills of pure opium, each weighing one grain 
 — or what is equivalent to them — that no time may be lost in quieting a sensation 
 which is so difficult to endure. One of these pills may be taken as soon as the pain 
 comes on, and it may be repeated once or twice in the course of two hours, if the 
 pain require it ; and I have often found it both safe and necessary to give much 
 more." 
 
 This plan, of giving opium in the form of pills, is the more judicious, because, 
 from their small bulk, they are more hkely to be retained than draughts Avould be. 
 Sometimes the stomach is so irritable as to reject even a pill. I would add, there- 
 fore, to Dr. Heberden's recommendations, that of throwing an opiate injection into 
 the rectum ; half a drachm or a drachm of laudanum, mixed with a small quantity 
 of warm gruel. Another very useful expedient is the warm bath. If this cannot
 
 THE GALL-BLADDER. 855 
 
 be readily procured, hot fomentations to the epigastrium, the mustard-poultice, the 
 turpentine stupe, are valuable substitutes for it. Dr. Prout states that he has seen 
 more alleviation afforded by large draughts of hot water, containing the carbonate 
 of soda in solution (one or two drachms to a pint), than by any other means. " The 
 alkali counteracts the distressing symptoms produced by the acidity of the stomach ; 
 while the hot w^ater acts like a fomentation to the seat of the pain. The first por- 
 tions of w'ater are commonly rejected almost immediately ; but others may be 
 repeatedly taken ; and after some time it will usually be found that the pain becomes 
 less, and the water is retained. Another advantage of this plan of treatment is, that 
 the water abates the severity of the retching, which is usually most severe and 
 dangerous where there is nothing present upon which the stomach can react. This 
 plan does not supersede the use of opium, which may be given in any way deemed 
 most desirable ; and in some instances a few drops of laudanum may be advan- 
 tageously conjoined with the alkaline solution, after it has been once or twice 
 rejected." The pain having been quelled, the bowels should be swept out by a 
 brisk purgative. 
 
 When the jaundice appears to have been suddenly engendered, by moral causes, 
 the rationale of its production is obscure; and the treatment has a corresponding 
 uncerlaint)'-. The bile, retained or readmitted into the blood, is supposed to operate 
 as a poison upon the nervous system. But the mental state which precedes and 
 seems to occasion the jaundice, may possibly be itself the cause of the nervous symp- 
 toms that follow. In other forms of the malady patients remain intensely yellow, 
 often for a long time together, without becoming comatose, delirious, or convulsed. 
 Not that this is conclusive. We know that a given poison may influence different 
 persons very differently. The same dose of opium that will put one man to sleep, 
 will stimulate a second to madness, and will have no sensible effect upon a third. In. 
 the very complaint before us, one patient is tormented with a universal itching, which 
 we attribute to bile in his blood ; and ten others remain free from that disagreeable 
 feeling. If we were sure that the bile was the material cause of all the cerebra' 
 symptoms, we might hope to draw some of the poison off by blood-letting : but we 
 are not sure of this ; and reasoning upon the matter helps us not much towards the 
 cure. The lesson which experience has furnished amounts to no more thaa this : 
 that active purging is sometimes followed by evident amendment, and ultimate 
 recovery. I would bleed also, if the ^jwZse warranted venesection, but not otherwise. 
 In all the varieties of what, from its intensity and rapid accession, I may call acute 
 jaundice, purging is strongly indicated : and we sometimes succeed in rectifying the 
 whole morbid condition by thus applying a sudden lurench (so to speak) to the 
 biliary organs; by giving, for instance, half a scruple or a scruple of calomel, and, 
 a few hours afterwards, half an ounce of castor oil, with half an ounce of spirit of 
 turpentine. 
 
 When green jaundice arises from hepatic disease, we can only palhate. Mild 
 laxatives and anodynes comprise all that such a state admits of. For the icterus 
 gravidarum, delivery is the natural cure: it may sometimes be removed by the 
 careful employment of aperients. 
 
 The gall-bladder has its own diseases, which I do not stop to investigate, foi they 
 seldom become the objects of specific treatment. Sometimes it is found shrivelled 
 up, and nearly empty : sometimes enormously distended ; sometimes ruptured. 
 Of these conditions, the distension of the gall-bladder is the only one that we can 
 ever expect to recognize in the living body. The bag then projects beyond the 
 edge of the liver, and is palpable externally, forming an elastic tumour in the right 
 side. Authors lay down marks for distinguishing a distended gall-bladder from 
 abscesses of the liver, and from an hydatid cyst ; but they are not much to be trusted 
 to ; nor is the precise diagnosis of any great moment. The practical rule seems to 
 be that, when the swelhng is adherent to the parietes of the abdomen we may punc- 
 ture It, whatever is its nature : but under no other circumstances. 
 
 I have already, incidentally, described most of the morbid states of the sphen
 
 856 THE SPLEEN — NEPHRITIS AND NEPHRALGIA. 
 
 which are susceptible of relief from medicine : especially the enlargement of that 
 body constituting the ague-cake of the fens, and occuring in connection with inter- 
 mittent fever ; and that other kind of enlargement which sometimes goes along with 
 hsematemesis and melsena. The spleen is liable to tubercles also ; to deposits of 
 other specific tumoui-s, and of bone ; and to softening of its substance. 
 
 The best remedy for the ague-cake is the remedy for intermittent fever, qidna. 
 Purgatives also have the effect of reducing hypertrophy of that curious organ. One 
 caution enforced by Dr. Abercrombie, is, that in splenic disease, mercury should be 
 sedulously avoided, or rather such an employment of mercury as would risk tender- 
 ness of the gums. Dr. Williams, of St. Thomas's Hospital, states in a recent pub- 
 lication, that he has made many trials of the bromide of potassium as a remedy in 
 various disorders : but that he has satisfied himself of its utility only in cases of dis- 
 eased spleen. Of this I know nothing. 
 
 Again, it may seem a slight to the pancreas to pass it over without noticing the 
 diseases to which it is subject. But really those diseases appear to be but few ; and 
 they do not signify their existence by any plain or intelligible signs. I have, nine 
 or ten times perhaps in my life, met with carcinomatous deposits in the pancreas. 
 In every instance the head of the gland, that extremity which lies next to the bowel, 
 has been the exclusive or the principal seat of the disease. I have known this 
 change in the pancreas to cause jaundice, by obstructing the bile-ducts : I have 
 known it in the same way to occasion very great enlargement of the liver itself; and 
 I have known it to produce enormous and slowly fatal distension of the stomach by 
 compressing the duodenum, and so preventing the free passage of the aliment 
 through that gut. As to remedies for pancreatic diseases or disorders, I do not know 
 of any. 
 
 Diseases of the kidneys — and disorders of their function — and alterations in the 
 fluid they secrete — require more consideration. And I proceed at once to the sub- 
 ject of their inflammation; to nejihritis : and it will be practically convenient to 
 lake nephralgia, or pain of the kidney, into the account at the same time. Nephral- 
 gia is commonly, but not always, produced by the transit of a urinary calculus from 
 the pelvis of the kidney, through the ureter, towards the bladder. This constitutes 
 what is called, in common parlance, a fit of the gravel. The symptoms are these: — 
 pain, sometnnes dull, but more frequently very severe, in the loins, usually on one 
 side, and descending often along the track of the ureter of the same side ; numbness 
 of the corresponding thigh ; in the male, retraction, and perhaps pain, of the testicle; 
 a frequent desire to make water, which is generally high coloured ; nausea and 
 vomiting. 
 
 If to these symptoms there be added pyrexia, we learn the important fact that in- 
 flammation is present : we have the symptoms of acute nephritis. The passage of 
 gravel from the kidney sometimes does, and sometimes does not, provoke inflamma- 
 tion of the gland. Nephritis is very seldom idiopathic. It may sometimes arise 
 under the influence of cold : more frequently it is excited by calculous matter lodged 
 in the kidney ; by a blow or fall upon the loins; by the internal administration of 
 cantharides, or of turpentine. It is to the presence of fever that we look, to establish 
 the inflammatory character of the renal affection 
 
 Nephralgic pains require to be distinguished on the one hand from rheumatic, and 
 on the other from colic pains. In lumbago there is pain in the back, and it may or 
 may not be attended with fever ; but the pain usually aflects both sides, and is ag- 
 gravated by such movements of the body as call the muscles of the loins into action, 
 particularly by stooping. It originates, frequently, in some strain or efTort, of which 
 the patient is made painfully conscious at the time. It is seldom accompanied by 
 any notable trouble of the urinary functions. When rheumatic pain extends from 
 the back into the thigh, it mostly follows the course of the great sciatic nerve, and is 
 felt down the outer part of the limb ; whereas the pain that accompanies nephritis or 
 nephralgia shoots rather along the track of the anterior crural nerve. Lastly, lumbar 
 (tain, depending upon rheumatism, is not attended with nausea and vomiting. 
 
 Thf pain of colic is often associated with sickness and retching ; and it may occupy
 
 NEPHRITIS AND NEPHRALGIA. 857 
 
 (hose parts of the abdomen which correspond to the place of the ureters. I'he uri- 
 nary functions are undisturbed ; and this is a capital point of distinction. The 
 numbness of the thigh, and drawing up of the testicle, are sufficiently characteristic 
 when they happen ; but they are frequently altogether absent. 
 
 Some years ago I was sent for by an exceedingly intelligent surgeon, who had 
 been one of the house-surgeons at the Middlesex Hospital. I found him in bed. He 
 told me he had pain in the abdomen. It had begun in the morning in the situation 
 of the right kidney, and soon extended round to the right side of the abdomen and 
 the groin. Two days before, he had experienced a similar attack of pain in the 
 renal region, stretching round into the hypogastrium. When I saw him, he de- 
 scribed the pain as lying more round the umbilicus than elsewhere ; and he expressed 
 a strong persuasion, from the feelings which attended it, that it would be removed by 
 free action of the bowels. But he felt nausea, and had vomited some medicine 
 which he had taken. He had no fever, no retraction of the testicle or numbness of 
 the thigh, and the pain was not increased by pressure. Neither had there been any 
 marked irritation of the bladder. He said, indeed, when I questioned him on that 
 point, that he thought he had made water rather more frequently than usual the 
 day before. I mention this case to show you the occasional obscurity of the symp- 
 toms. Here a well-instructed medical man believed that nephralgia, existing in his 
 own person, was colic. To my judgment, however, it seemed most probable that a 
 small calculus had been, passing from his kidneys, towards and perhaps into his 
 bladder. I may as well tell you the event of the case, which interested me a good 
 deal-; for it exhibits the train of symptoms that are apt to ensue after nephritic 
 attacks, although in this instance they were but slightly pronounced. His bowels 
 were well acted on by a purgative, and the next day he was free from pain, and 
 apparently well. 
 
 Two days after this, he had more frequent calls to pass urine than were usual with 
 him, and having done so on one occasion, he presently felt the want again, and then 
 passed a little blood. The urine had been of a clear amber colour throughout. At 
 the expiration of two or three days more he called upon me to say that, after making 
 water, he had perceived in the vessel a small crystallized mass, which he took out, 
 supposing it to be (what it very much resembled) a fragment of sugar candy. In 
 fact, he had been eating sugar candy, and thought some portions of it had fallen 
 down between his waistcoat and shirt, and afterwards into the chamber-pot. He had 
 the curiosity, he said (some misgiving he must have had, too, for I had told him my 
 own opinion of the nature of his attack), to put a small crystal from this fragment 
 into his mouth; and as.it neither tasted sweet nor dissolved, he suspected it might 
 be a urinary concretion, and brought it to me. And sure enough it was so ; a piece 
 of very pure oxalate of lime, which he had been fortunate enough thus to get rid of. 
 It was a quarter of an inch in length, and less than one-eighth of an inch broad, 
 consisting of an aggregation of small crystals. It was exactly similar in appearance 
 and colour to a piece of brown sugar-candy of the same size. It would pass, long- 
 ways, into a large crow-quill. 
 
 That it was oxalate of lime, was proved in this manner. A little separate crystal 
 was heated to redness on a piece of platinum foil, by means of a spirit-lamp and 
 blowpipe. By these means the oxalic acid was destroyed, and quick-lime left. This 
 residue, moistened, and pressed into a powder on a piece of turmeric paper, gave 
 the characteristic brown colour. 
 
 You see, then, that a nephritic affection may be mistaken for an attack of colic. 
 In reference to practice, it would indeed be a mistake of no great importance, smce 
 the remedies that are proper in the one case are generally proper, or not improper 
 in the other. If the pain be attended with fever, antiphlogistic measures are alike 
 indicated in each of the two diseases. 
 
 The numbness of the thigh, and the drawing up of the testicle, are analogous 
 phenomena to the pain which affects the shoulders in hepatic disorders. Irritation 
 of one extremity of a nerve, situated internally, and belonging to an organ which 
 is not endowed with a high degree of sensibility, causes sympathetic sensations in 
 
 3 w2
 
 858 NEPHRITIS AND NEPHRALGIA. 
 
 the sentient extremities of other branches of the same nerve, or of communicating 
 nerves. 
 
 And this sympathetic afTection of distant parts is sometimes attended (as I formerly 
 observed) not merely with pain, but with some degree of inflammation also. The 
 testicle occasionally swells, and becomes tender during a nephritic attack. On the 
 other hand, as the nerves which communicate with those of the testicle or thigh, may 
 or may not be implicated in the renal disorder, so we see how it happens that these 
 curious symptoms, so instructive when they do occur, may frequently be wanting, 
 as they were in the example I just now detailed to you. 
 
 When the symptoms I specified in the outset are attended with fever, we conclude 
 that we have to deal with nephritis ; and when inflammation of the kidney, how- 
 ever produced, lasts for a certain period, without abatement, suppuration is to be 
 dreaded. Such suppuration is marked, sometimes, by the supervention of rigors, 
 by throbbing, perhaps, and it may be by a remission of the pain : but I beheve it 
 may take place without throwing out any such signals. Nay, I think it probable 
 that inflammation, confined to the parenchymatous substance of the kidney, may 
 arise, and run through all its stages, without denoting its presence or progress by 
 any noticeable local signs ; and that the sharp and peculiar symptoms ascribed by 
 authors to acute nephritis manifest themselves only when the investing membrane 
 of the gland, or its pelvis and excretory tubes, are involved in the inflammator}^ pro- 
 cess. However this may be, suppuration leads to ulceration, to the formation of 
 renal fistulse, to the establishment of a purulent discharge, and hectic fever; and 
 finally, in most cases, to a fatal event ; whether the inflammation was at first idiopa- 
 thic, or dependent on a calculus. 
 
 I may illustrate these remarks, by stating the heads of a case which has occurred 
 to me since this course of lectures began. I admitted Caroline Barnard, a married 
 woman, forty years old, into the hospital, on the 18th of October. Among other 
 things she complained of pain in the situation of the right kidney. She had been ill 
 SIX weeks, and at the commencement of her illness her urine had been very turbid, 
 as indeed it still was : and she had experienced much pain and difficulty in passing 
 it, and after it had passed. From that time she had frequent nausea and retching, 
 and occasional numbness of the right thigh. She had been losing flesh fast ; and 
 her pulse was frequent. There was some tenderness discoverable in the right renal 
 region ; and after a time a manifest fulness there, and hardness ; and at length oedema 
 of the integuments and extreme tenderness. She suffered also well marked hectic 
 fever, and had severe and repeated rigors. On the 4th of November, after a careful 
 examination of the right loin, we satisfied ourselves of the presence of matter. I got 
 Mr. Arnott, therefore, to see her, and put a lancet into the abscess ; and a large 
 quantity of faint-smelling pus came out. She was greatly relieved by the operation ; 
 and a purulent discharge, mixed \\\\\\ shreds of cellular membrane, came away in 
 abundance for some days : but in time the discharge ceased, the swelling subsided, 
 and the opening healed. We began to hope that it had been merely an abscess in 
 the neighbourhood of the kidney, irritating it and affecting its functions. But in 
 three weeks after the abscess was punctured, the swelling was found to have re- 
 curred ; and she again began to suffer much. The tumour was again opened, and 
 pus of a more offensive character than before evacuated. In the early part of De- 
 cember she sank. 
 
 We found the right kidney small, collapsed and hollow ; in some parts a mere 
 flabby bag. On its posterior surface there w^as an opening, which formed a commu- 
 nication between the interior of the kidney, and the abscess in the areolar tissue, 
 which had pointed externally. The pelvis of the kidney was much dilated ; and 
 the substance of the gland destroyed to a considerable extent, by suppuration and 
 ulceration. The ureter, where it left the pelvis of the kidney, was found to be im- 
 pervious. 
 
 The other kidney was much enlarged, but of quite healthy and sound structure. 
 That kind of compensation had occurred which I formerly mentioned as not unusual 
 when, of double organs, one has been rendered incapable of its natural functions, and 
 ine other takes up its duty and performs a twofold amount of work. The organ of
 
 NEPHRITIS AND NEPHRALGIA. 859 
 
 which the function is thus increased, becomes hypertrophied. This woman did not 
 die because there was not urine enough secreted ; but she sank under the wasting 
 punlent drain, the irritation and pain she suffered, and the protracted hectic fever. 
 in this instance the inflammation and suppuration occurred independently of the for- 
 mation of calculous matter. 
 
 Sometimes the pus finds its way out of the body through the natural passages, and 
 appears in the urine. This woman's urine was thought, by some of the pupils, to 
 contain pus. Tt was quite thick, and of a yellowish colour. But heat rendered it 
 transparent. You must not judge by a cursory look at the water. The effect of 
 heat proved that the yellow material was not pus : the impervious condition of the 
 ureter showed afterwards that it could not have been. 
 
 When calculi exist in the kidney, they often betray their presence there, by 
 causing bloody urine. But bloody urine may proceed from various causes ; and in 
 conformity with my usual custom, I shall by and by offer you some general remarks 
 on hsematuria, as one of the hemorrhages. 
 
 I showed you, at our last meeting, that gall-stones might inhabit the gall-bladder 
 in considerable numbers, and be quite harmless, unless they atteinpted to escape from 
 their prison, through the very narrow channel of egress from it; and I intimated that 
 the same observation was often applicable to urinary concretions. Renal calculi do, 
 indeed, in many cases, produce abiding uneasiness, or frequently recurring pain, in 
 the situation of the affected kidney, bloody urine, and gastric disturbance; especially 
 when the concretions are shaken or displaced by sudden jolts, or jarring movements 
 of the body ; or when the system is deranged by intemperate habits. But in many 
 other instances these calculi cause no pain or annoyance, so long as they remain in 
 the kidney ; although they inflict horrible suffering, in general, while, for the first 
 time, they are forcing their way along the narrow ureter. A concretion cannot be 
 formed in a moment ; 3'et the attack of pain often comes on in a moment, without 
 any previous warning. After a while it remits, perhaps, as suddenly'- ; the calculus 
 having passed (it may be presumed) from the ureter into the bladder; and then in- 
 dications, more or less palpable, usually begin to declare themselves of its presence 
 in that reservoir. Moreover, it is not uncommon to find calculi in the kidney 
 alter death, of the existence of which there had been no symptom manifested during 
 hfe. 
 
 The /reo/menf of nephritis — or of the nephralgia calculosa, when accompanied by 
 fever, or occurring in young, strong, and plethoric persons — is just such as would be 
 proper in cases of severe colic, or enteritis : and therefore it is that any mistake between 
 these disorders at the outset is not of so much practical consequence. The objects of 
 treatment are, to arrest the inflammatory process ; to quiet existing irritation ; and to 
 obviate any fresh causes of irritation. Venesection, therefore, in proportion to the 
 strength of the patient and the violence of the symptoms, will sometimes be proper: 
 and it will always be advisable to take away blood freely from the neighbourhood of 
 the suffering part by cupping. Warm fomentations ; the warm bath ; the injection 
 of warm water into the bowel ; these are all expedients of which practical men ac- 
 knowledge the value. The warm enemata not only clear out from the large intes- 
 tines any irritating matters they might contain, but, from the proximity of the colon to 
 the kidney, they perhaps have the effect of an internal fomentation. It is desirable 
 also to get the bowels well acted upon by purgative medicines as soon as possible: 
 the relief that follows free alvine discharges is often very marked. There is some- 
 times a difficulty, from the irritability of the stomach, in administering purgatives by 
 the mouth. Calomel, however, will often be retained, when other substances are 
 rejected. It is generally considered of importance to give those purgatives only 
 which are not likely, after being absorbed into the blood, to irritate the urinary pas- 
 sages. On this account the saline purgatives are to be avoided. Nothing is so 
 good as castor oil, if the stomach will bear it ; or infusion of senna, with manna, may 
 be used ; or, if the stomach be very quesisy, pills, composed of cathartic extract, and 
 calomel. 
 
 When there is no fever, i. e., when the case is one of nephralgia, and a calculus 
 IS passing, after the intestinal canal has been cleared by a purgative, 't will be
 
 860 GRAVEL. 
 
 necessary to give opium in full doses to allay the pain : and it may either bo 
 adiTi mistered in the form of pill through the stomach ; or introduced into the rectum. 
 
 When a person suffers what is called a fit of the gravel, the pain, I saj?^, is at length 
 very suddenly relieved, in general, in consequence of the calculus having emerged 
 from the ureter and entered the bladder. We judge that this has taken place, first, 
 by the cessation of the pain ; and secondly, by the supervention, sooner or later, of 
 symptoms indicative of stone in the bladder ; viz., a more than usually frequent in- 
 clination to make water; pain, referred to the extremity of the urethra, especially 
 just after passing urine : and stoppages and renewals of the stream of water while the 
 patient is endeavouring to void it. 
 
 The time which a calculus takes in travelling from the kidney to the bladder 
 varies a good deal. The painful journey may be over in a few hours; or it may 
 last two or three days. More rarely the symptoms continue, with irregular intervals 
 of comparative quiet, for weeks. And sometimes, notwithstanding the peculiar pain, 
 which amounts to torment, all morbid symptoms cease, and yet no calculus has 
 passed, apparently, into the bladder : none, i. e., of the symptoms of stone, ensue ; no 
 calculus is voided by the urethra ; and none found in the bladder when the patient 
 at length dies. 
 
 What is the explanation of these circumstances ? Why, as calculi have been 
 discovered in such cases in the kidney, it has been supposed that a concretion may 
 get into the very beginning of the ureter, where it is a little larger than elsewhere, 
 and give rise to the peculiar symptoms, yet never pass fairly into that narrow 
 tube ; but at length fall back again into the pelvis of the kidney ; when the symptoms 
 cease. 
 
 But the same symptoms undoubtedly occur, occasionally, when there is no cal- 
 culus at all. Sir B. Brodie has referred to this form of complaint. In people who 
 live intemperate and luxurious lives, pain is apt to seize upon one renal region, and 
 to extend round and'downwards into the groin : and these symptoms will be followed 
 by frequent, difficult, and painful micturition, the urine being unusually acid, high- 
 coloured, and sometimes turbid. The whole irritation appears to be produced 
 by this unhealthy urine : at least the complaint vanishes after cupping the loins, 
 purging, the warm bath, and two or three full doses of colchicum given at short in- 
 tervals. 
 
 Sometimes the little stone becomes immovably wedged in the canal of the ureter. 
 If it completeljr shuts the tube, the urine accumulates behind it, and that portion of 
 the ureter dilates. The obstruction usually proves fatal, by its influence upon the 
 functions of the kidney, and thereby upon the whole economy. But if the urine 
 finds a passage by the side of the impacted concretion, this danger is averted, or post- 
 poned. 
 
 When we have reason to believe, from the nature and course of the symptoms, 
 that a calculus has come down from the kidney, and lodged in the bladder, then it 
 becomes an object of deep interest to the practitioner, and of fearful importance to 
 the patient, to try all means to bring about its expulsion before it grows too large to 
 be voided. For grow it almost surely will, by the continual accretion of earthy 
 matter upon its surface, if it remains long in the bladder. We know that it may, af 
 first, be voided, provided the urethra be in a healthy and natural state ; that what- 
 ever has passed through the ureter, may pass through the urethra also. 
 
 The objects to be kept in view are these : first, to procure a plentiful secretion of 
 bland urine, wherewith the bladder may become filled ; secondly, by lulling the sen- 
 sibility of the parts concerned, to prevent or lessen that spasmodic effort of the 
 sphincter of the bladder, which the presence of the calculus is apt to provoke ; and, 
 thirdly, to ascertain that the channel of the urethra is open and unimpeded. 
 
 To effect the first of these purposes, the patient should be instructed to drink freely 
 of diluent liquors; such as barley-water, or linseed-tea, in which may be mixed a 
 small quantity of the sweet spirits of nitre. To fulfil the second, he should take a 
 full dose of opium at bed-time. By these means the pain and irritation which may 
 have been produced by the calculus, will be soothed ; and the bladder will gradually 
 fill He should then make water, having first placed himself in such a position
 
 GRAVEL. 861 
 
 that the outlet of the bladder shall be at the lowest part of that receptacle. He may 
 etand up, and lean forwards ; or it may be well to make wator while kneeling, in a 
 warm bath. If these expedients are not presently successful, the urethra may be 
 cautiously expanded, and habituated to the contact of a solid body, by the daily in- 
 troduction of a full-sized bougie. Sometimes the calculus will follow the bougie, 
 as it is withdrawn, through the urethra. In this way the patient will have a fair 
 chance of getting rid of the stone. In this way a very near friend of my own, a 
 physician now practising in this town, did expel a formidable, though not very large, 
 piece of rough oxalate of lime several weeks after its entrance into the bladder. 
 Out it came, at last, with a smart clink, which was music to his ear, against the 
 chamber-pot. A gentleman was not long since sent up to me from Kent, by a former 
 pupil of this College, with the following history. About a month before he had been 
 suddenly attacked with acute pain in the loins, extending forwards into the left flank 
 and pelvis, with nausea and vomiting. For nearly ten days these symptoms con- 
 tinued to occur at intervals ; then they ceased : and then he began to be troubled by 
 a frequent and very urgent inclination to make water, and by pain after voiding it, 
 just above the arch of the pubes. I gave him directions, in accordance with the 
 plan just now mentioned ; and wished him to allow some surgeon to explore the 
 contents of his bladder. To this he would not, as yet, he said, consent. I saw him 
 on the 2d of August. He returned into Kent the next day. On the 5th, while 
 taking a walk, he was seized with a most imperative desire to make water, but found 
 that he could part with none. Concluding that a calculus had entered, and stopped 
 up the urethra, he was proceeding homewards, but was soon constrained again to 
 try to empty his bladder : and then he had the satisfaction of feeling, and seeing, a 
 stone fly out with great force : but, as he had turned towards a hedge, he could not 
 find it. From that moment he was quite easy. 
 
 When a calculus of a certain size has once traversed the tubes that lead respect- 
 ively to and from the bladder, others sometimes follow it with more ease. I show 
 you here a large concretion which was passed, or pissed if you will, by a patient of 
 mine without his knowing it. He is subject to epilepsy, which is probably eccen- 
 tric, and excited by renal disease. He is closely and anxiously watched by his wife. 
 One day last year she noticed that the urine he had just voided was shghtly tinged . 
 with blood : and she then found this oblong stone, which is composed of hthic acid, 
 in the vessel. 
 
 If the renal calculus, after it has reached the bladder, cannot be got rid of by the 
 expedients I have been recommending, the question arises, whether medicine can do 
 any further good, or whether the patient is to be delivered over to the surgeon. 
 
 Most of these small concretions admit of being mechanically crushed into smaller 
 fragments, which are then readily washed out by the stream of urine. Larger stones 
 are extracted entire, through incisions of the bladder. Yet there are many cases in 
 which, for various reasons, surgery declines to attempt the removal of vesical calcuh. 
 Medicine still offers to these unfortunate patients the means of mitigating, at least, 
 their sufferings. But it often can do more than this. It is very important for you 
 to know that judicious medical treatment may retard or prevent, and that injudicious 
 medical treatment may promote and hasten the enlargement of such calcuh. Let ns 
 briefly consider the principles by which our judgment and our practice, in this serious 
 matter, must be guided. 
 
 I have described a fit of the gravel. We say that a patient has the gravel when 
 he passes concrete matter with his urine, whether in the form of powder, of grit or 
 sand, or of more massive calculi. We do not apply that term to the cases in which 
 the urine is clear when recently voided, and warm ; but throws down an earthy sedi 
 ment as it cools : which sediment redissolves if the urine be again artificially heated 
 Now, besides the different forms which the gravel assumes, of powder, sand, and 
 little stones, there are (as you may have guessed from certain terms that I have been 
 obliged to employ) several kinds of gravel ; differing, I mean, in their chemical com 
 position. The main signs — the pain, the sickness, the affection of the testicle, the 
 subsequent bladder symptoms — are much the same, whatever be the nature of the 
 solid matter that descends from the kidney, and fingers in the bladder. But other
 
 862 LITHIC DIATHESIS. 
 
 circumstances difTer widely. The qualities of the water previously to the formation, 
 and to the discharge, of the sabulous matter ; the state of the system at large. And 
 it is quite impossible to treat cases of calculus in the kidney, or of stone in the bladder, 
 v.'ith propriety, or safety, without constant reference to the condition of the urine. 
 The morbid states of that secretion are of the greatest interest. I cannot undertake 
 to enter upon the subject in much detail. Yet some outline of it I must attempt, 
 especially where it touches upon points of practice. 
 
 You know, probably, that the urine voided by a person in health alwaj's exhibits 
 acid properties, always turns Htmus paper red. Not that healthy urine contains a 
 free acid ; but only (according to Dr. Prout, who is the great authority in these things), 
 that certain of the alkaline and earthy bases are not exactly neutralized, but exist 
 in the state of supersalts. The pure lithic acid is nearly insoluble ; but the lithate 
 of ammonia is very readily soluble : and it is this which reddens the vegetable blues. 
 Now, whether out of the body, or within it, the lithate of ammonia will, of course, 
 be decomposed, if any acid be present in the urine, for which ammonia has a stronger 
 affinity that it has for the lithic acid : and the latter will be thrown down, in the form 
 of a red sand : little crystals, in point of fact, they are very much like, in shape, size, 
 and colour, to the particles of Cayenne pepper. I show you some collected by one 
 of my out-patients at the hospital. He must have passed a peck of it while under 
 my observation : and I am sorry (having lately lost sight of him) that I did not 
 procure a large quantity for the museum. 
 
 Now this lithic acid, or red sand, or gravel, is liable to form in the kidney, if not 
 in the bladder, and to concrete into calculi ; and the calculi once formed, or, indeed, 
 any solid substance, will constitute a nucleus, upon and around which a further and 
 repeated incrustration of a similar nature is almost sure to take place. You will at 
 once perceive the importance of doing nothing to aggravate this disposition to deposit 
 lithic acid ; but of trying to prevent, or stop it. If there be symptoms of stone in 
 the kidney, or in the bladder, and we have reason to believe that it consists of lithic 
 acid, there are medicines which would tend to render matters worse, and there are 
 others of which the effect would be to correct the lithic acid diathesis, as it is called. 
 But how are we to know whether the presumed calculus be of that kind or not ? 
 or, rather, how are we to know that the lithic diathesis exists ? Why, we learn that 
 it exists by noticing the habitual qualities of the urine, and the habitual state of the 
 patient's general health. 
 
 In the urine of persons who have the lithic diathesis, you will find that there are 
 frequent deposits, after it has become cool, of reddish sediments, looking like brick- 
 dust, and, therefore, called lateritious. These sediments consist chiefly of the 
 lithate of ammonia, tinged with certain colouring matters in the urine. Sometimes 
 pure lithic acid appears, in the shape of fine sand, or in larger crystals. The urine 
 itself is bright, of a dark coppery colour, hke brown sherry. It is more acid than 
 the urine of health, and gives to litmus paper a deeper shade of red. It is apt, too, 
 to fall below the average quantity. 
 
 The presence of this diathesis is likewise accompanied, and so far denoted, by a 
 tendency to feverish and inflammatory complaints. The patients are troubled with 
 acidity of stomach and heartburn ; many of them are subject to gout or rheumatism. 
 They are mostly also indolent and luxurious, or intemperate in their mode of fife. 
 Adults are peculiarly obnoxious to this condition of the system after the age of 
 forty. But children, up to the period of puberty, are very liable to have lithic acid 
 gravel. 
 
 Whenever a paroxysm of nephritic pain befalls a person whose time of life, whose 
 habits, the characters of whose health, and the habitual qualities of whose urine, are 
 such as I have been describing, you may conclude that the concretion which has 
 occasioned the symptoms is of the Hthic acid kind : and you may expect that such 
 attacks will recur; for it is observed of these lithic acid renal calcuii", that they are 
 generally numerous in the same individual. I speak of the habitual — or of the 
 fiequently recurring — qualities of the urine : for a deposit of lithic acid gravel, or 
 of superabundant lithates, may occur to the healthiest individual, under accidental 
 and transient disturbing causes. Many persons will tell you that their water becomej 
 
 Iffi
 
 LITHIC DIATHESIS. 863 
 
 turbid with red sand whenever they have a cold. Febrile and inflammator} aihnents 
 will produce the sediment : even too full a meal: or exercise taken immediately- 
 after a full meal. In all such cases it seems probable that the customary evolution 
 of lactic acid through the skin is somehow prevented : in consequence either of a 
 check given to the perspiration, or of imperfect assimilation of the food. The lactic 
 acid, thus diverted from its natural emunclory — or some other acid generated within 
 the system — is determined to the urine, and precipitates the lithic. 
 
 Now the formation of lithic acid, and of the lithates, may be controlled by the 
 exhibition of alkaline remedies. You will find that free livers use alkalies to neutralize 
 the excess of acid which results from their intemperate habits ; the carbonates of soda, 
 or of potass. They do this, without any reference to the appearance of their urine, 
 to prevent or appease the uneasy feelings produced by a debauch. But it is of im- 
 portance to be aware that one of these alkalies is preferable, for the purpose of 
 obviating the lithic acid diathesis, to the other. Soda will sometimes combine with 
 the Hthic acid, and form an insoluble salt, as hard, and as pernicious, when deposited 
 around a nucleus, as the lithic acid itself. With potass there is no such danger. If 
 it should combine with the lithic acid, the resulting sak is perfectly soluble, and will 
 pass away dissolved, in the urine. Magnesia is also a good medicine in such cases ; 
 but it has this disadvantage, as I showed you indeed before, that it is apt, when taken 
 habitually, to cause intestinal concretions : and these may be as dangerous as the 
 urinary ones. One of the best modes of giving the bicarbonate of potass is in the 
 common saline draught. The stomach has the power apparently of destroying the 
 vegetable acids; and the remedial properties of the bicarbonate become thus equally 
 certain with those of the pure alkali, while it is much less likely to derange or dis- 
 agree with the stomach. Of course the mode of living ought to be changed when 
 the lithic diathesis prevails ; the patients should dine moderately and plainly, eating 
 of one dish, and avoiding acids, and all articles of diet likely to generate acid in the 
 stomach; saccharine substances, therefore, and fermented liquors. But, as I men- 
 tioned in a former lecture, they will not, if they can help it, give up their accus- 
 tomed indulgences : and they attempt, and we attempt, but the attempt is often 
 made in vain, to remedy disorders, which might with ease and certainty have oeen 
 prevented. 
 
 You must take care not to give these alkaline remedies too long ; nor in too great 
 quantity. You must not push them to such an extent as entirely to destroy the 
 acidity of the urine : for if you do, your patient is exposed to the same danger as 
 before, but from an opposite cause. A white sand or gravel will be apt to form in 
 the alkaline or neutral urine : and this will collect itself, by the force of aggregation, 
 around any existing calculus, or foreign substance. The white deposits consist 
 mainly of the triple phosphate of ammonia and magnesia; and if you examine 
 collections of urinary calculi, you will find that they are sometimes made up of 
 concentric layers ; and one layer may be composed of lithic acid, and the next of 
 the triple phosphates ; and so on, as the condition of the urine has alternated. You 
 must test the urine, therefore, and see that it still reddens litmus, though perhaps 
 famtly. Indeed it may do so, without containing any free acid : so that urine which 
 only slightly reddens litmus paper may nevertheless be capable of depositing the 
 triple phosphate. The saline draught has always a tendency to make the urine 
 alkaline ; and thus it is, probably, that it proves of use in febrile disorders : but it is 
 an absolute poison to those whose urine is already alkaline. Colchicum has a similar 
 tendency to diminish the acid reaction of the urine. So has mercury. And I may 
 tell you — speaking generally of morbid states of the urine — that it is much more 
 easy to correct too great acidity than to rectify the opposite condition. We can almost 
 always make acid urine neutral or alkaline : but to render alkahne urine acid is often 
 beyond our power. 
 
 It is scarcely less important to attend to the functions of the skin, in persons having 
 the Hthic acid diathesis, than to the functions of the stomach. The warm bath is 
 often an excellent adjuvant, in their treatment. In cold weather, warm clothing must 
 be enjoined ; and the avoidance, in all weathers, of such exposure to cold as mighl 
 suppress or materially lessen the amount of healthy perspiration.
 
 864 PHOSPHATIC DIATHESIS. 
 
 You will have gathered, from what I have already said, that there is a morbid 
 condition of the system, the opposite of that in which the lithic diathesis prevails. 
 The phosphatic diathesis, namely ; in which there is a readiness to deposit ivliite 
 gravel ; composed of minute shining crystals of a triple salt, the phosphate of ammo- 
 nia and magnesia. The way in which this is formed, according to Dr. Prout, is as 
 follows. Healthy urine contains the phosphate of magnesia, which is very soluble ; 
 and, therefore, is dissolved in that fluid. But, under certain circumstances, the urea 
 of the urine becomes decomposed in the kidneys, and ammonia is extricated, which 
 combines with the phosphate of magnesia, and forms an insoluble triple salt. Some- 
 times with the triple phosphate just mentioned, there is also an admixture of phos- 
 phate of lime. 
 
 It is a fact of great practical importance, that the tendency to the formation of the 
 phosphates goes along with a debilitated condition of the system. Persons who have 
 been rendered weak and feeble by overmuch toil, by mental anxiety, by insufficient 
 nourishment, are very apt to pass water that is alkalescent or but faintly acid, and 
 to exhibit the tokens, in their urine, of the phosphatic diathesis. They are, for the 
 most part, cachectic, sallow, languid, spiritless, exhausted. The urine itself is pale, 
 copious, slightly turbid or opaline, of a low specific gravity, and it does not smell 
 like healthy urine : sometimes it has somewhat the faint odour of weak broth. It 
 IS occasionally alkalescent when voided ; never more than slightly acid. As the 
 urine cools, the white sand is thrown down ; and in many cases a sort of film is 
 formed upon the surface of the water, exhibiting, as you see it in different hghts, all 
 the colours of the rainbow : an iridescent pellicle. This has been found to consist 
 of the triple phosphate. If you skim the pellicle off, by placing a bit of paper under 
 it, and then suffer the paper to dry, you may distinctly see the little crystals. Urine 
 of this kind speedily grows putrid and highly offensive. Sometimes it has a strong 
 ammoniacal smell. You may estimate the intensity of the phosphatic disposition by 
 the rapidity with which the urine becomes alkalescent. Occasionally the salt is so 
 abundant that it is thrown down while the urine is still in the bladder ; and the last 
 portions of the issuing stream look milky. 
 
 Anything which tends further to depress the powers of the system will aggravate 
 the phosphatic diathesis. When you find that your patient passes urine such as 1 
 have been last describing, which does not redden litmus paper, but on the contrary 
 turns litmus paper that has been reddened by a weak acid, blue again, or even in 
 some cases is alkaline enough to make turmeric paper brown — in such cases you 
 must cautiously abstain from all remedies that are calculated to lower the vital 
 powers ; from saline draughts, and alkalies of every kind ; from mercury and col- 
 chicum ; from bleeding ; and even from active purgation : or j^ou will add to the 
 patient's dangerous weakness ; and promote the more abundant deposit of the alka- 
 line phosphates. But you may do more than abstain from what is hurtful : you 
 may counteract the phosphatic tendency by a generous diet and by the exhibition 
 of tonic medicines ; bark, wine, and acids ; the muriatic acid, or the nitric, or both 
 too-ether, may be given in such cases with vast advantage sometimes. Opium is 
 also a remedy to be employed in this form of disease. No single drug probably 
 has so much power in rendering alkahne urine acid, as opium. And it is indicated 
 for other reasons ; it composes the nervous anxiety to which these patients are mostly 
 a prey. Mental relaxation — freedom from care — the relinquishment of all exhaust- 
 ing habits and pursuits — these, too, are points of vast importance, whenever they are 
 attainable. 
 
 I should state that the tendency to deposit the mixed phosphates, though sometimes 
 idiopathic, is much more often consequent upon local disease in some part of the uri- 
 nary organs, especially in the bladder and prostate gland. It is also a frequent result 
 of certain injuries of the back. 
 
 There is yet another diathesis sufficiently common and important to claim your 
 best attention. I mean the oxalic ; in which there is a tendency to the formation, 
 in the kidney, of the oxalate of lime, or mulberry calculus ; an epithet derived from 
 the occasional resemblance of the concretion to that fruit, in respect to colour and
 
 OXALIC DIATHESIS. 865 
 
 inequality of surface. This diathesis is not so obvious as the other two, but it is no 
 less real. 
 
 The urine differs much in its sensible qualities from that of both the precedino- 
 varieties. Unlike the urine of the phosphatic diathesis, it is bright and clear; un- 
 like that of hthic, it is remarkably free from sediment. The mulberry calculus is 
 soUtary also ; or recurs at long intervals ; and the diathesis prevails chiefly durincr 
 the prime of hfe. In both these particulars the contrast with the lithic diathesis is 
 striking. 
 
 The persons who manifest this disposition are usually dyspeptic ; sometimes 
 very much so; sometimes very slightly. They are uneasy during the assimilation 
 of their meals ; suffer flatulence when the stomach is empty ; prefer vegetable diet 
 to animal ; are fond of sweets, especially of sugar. They are liable to boils and 
 carbuncles, and to scaly cutaneous eruptions. According to their original tempera- 
 ment, they are nervous and irritable, or dejected and desponding in rnind. A neph- 
 ritic attack relieves them from all this discomfort for years perhaps. When the 
 oxalic diathesis is strongly marked, the skin. Dr. Prout says, "is apt to assume an 
 unnatural appearance, difficult to describe, but the colour of which may be said to 
 vary from dull greenish yellow in the sanguine, to dark olive or livid in the melan- 
 cholic temperament." 
 
 The formation of the oxalate of lime within the body depends, according to Dr. 
 Prout, either upon the non-assimilation of oxalic acid taken with the food, or upon 
 the mal-assimilation of saccharine aliments. Hence, as a general rule, both curative 
 and prophylactic, sugar and other saccharine substances should be rigidly excluded 
 from the diet of these patients. They should avoid, also, all kinds of fermented 
 liquor. The young stalks of the jV«<6ar6-plant, which of late years have come into 
 such general use in this country for tarts in the spring; and sorrel, of which our 
 neighbours, the French, consume a good deal in salads, and in other ways ; both con- 
 tain oxalic acid ; and hard water contains lime. Dyspeptic persons who drink such 
 water, and eat such articles of food, and are thus daily introducing, without suspect- 
 ing it, the consthuent ingredients of the mulberry calculus, are vexy hkely indeed to 
 incur the pain and the exceeding peril of a renal concretion of that kind. You must 
 see, therefore, the great importance of detecting the oxalic diathesis ; and of forbid- 
 ding, to those who have it, all such viands as contain the oxalic acid, and of recom- 
 mending them to use pure water, even distilled water, for drinking. Animal food, 
 and the stronger farinaceous matters, are best for them. 
 
 Dr. Golding Bird refers the oxalate of lime to a different source : maintaining that 
 it results from a re-arrangement of the elements of urea, whereby oxalate of ammo- 
 nia is formed in the first instance ; and afterwards oxalate of hme, by the decompo- 
 sition of the calcareous salts natural to the urine. 
 
 Agreeing with Dr. Prout that the mulberry calculus is not of very frequent occur- 
 rence — Dr. Bird nevertheless finds that small crystals of the oxalate of lime are 
 extremely common : although from their transparency, and from their having nearly 
 the same specific gravity with the urine in which they exist, they do not "disclose 
 themselves to the naked eye, nor sink down in manifest deposit. They are made 
 plainly visible by the microscope. 
 
 The same writer slates that the persons whose urine is thus charged with crystals 
 of oxalate of lime are, for the most part, highly sensitive and irritable, hypochon- 
 drically apprehensive of impending evil, full of gloomy fears concerning their bodily 
 and mental powers, dyspeptic, weak, and usually emaciated. 
 
 With respect to direct remedies for this diathesis, Dr, Prout tells us that he has 
 •«een more benefit derived from the mineral acids, alone or combined with tonics, than 
 from any other. But the effects of these acids must be watched : and when' iney 
 begm to produce a deposit of the hthate of ammonia, or of lithic acid, their use must 
 be suspended. He recommends to patients who happen to be at a distance, the 
 muriatic, or nitro-muriatic acid, till the hthate of ammonia, or hthic acid, begins to 
 appear in the urine ; or for a month. " By adopting," he says, " such a course of 
 acids tiinse or four times in the year, and by carefully regulated diet, I have seen 
 55 3x
 
 866 SUPPRESSION OF URINE. 
 
 the diathesis gradually subdued, and at length removed altogether." Dr. Bird also 
 testifies to the efficacy of similar measures. 
 
 These observations will serve, I hope, in some degree, as landmarks, to guide 
 your treatment of patients labouring under renal or vesical calculi, or presenting 
 symptoms such as warrant the apprehension that disorders so fearful may occur. It 
 is impossible for me to do full justice to this interesting subject in these lectures; and 
 I must refer you, for more minute information respecting it, to Dr. Prout's invaluable 
 volume ; to Sir Benjamin Brodie's most instructive book on the Diseases of the Uri- 
 nary Organs ; and to an excellent work recently published by Dr. Golding Bird, on 
 Urinary Deposits. 
 
 LECTURE LXXVII, 
 
 Suppression of Urine. Diabetes : Qualities of the Urine ; Symptoms , Anato- 
 mical Appearances ; General Pathology of the Disease ; Treatment. Diuresis. 
 
 Systematic writers have adopted the term Ischuria to express that condition in 
 which no urine is voided. It includes, therefore, those cases in which no urine is 
 secreted ; and those in which, although secreted, it is not discharged from the body. 
 Now these two conditions are exceedingly different from each other in most respects ; 
 and I shall prefer making use of the two plain English names, suppression of urine, 
 and retention of urine. Even these terms are sometimes confounded with each 
 other. In suppression, the secretion is suspended : in retention it may be as active 
 as ever. Retention of urine is a surgical case ; involving points of great practical 
 interest. Suppression belongs to the physician : and the technical term for it is 
 Ischuria renalis. It is sometimes spoken of as paralysis of the kidney ; a phrase 
 to which I object, because I think palsy is a word which ought to be restricted to a 
 loss of power over the muscular fibre. 
 
 This affection usually occurs in persons who are advanced in hfe, and inclined to 
 corpulency. Why it should be so I cannot tell you, but such is the fact as stated 
 by most observers. Sir Henry Halford has related one of five instances of this dis- 
 ease that he had met with in the course of seven-and-twenty years. He says it was 
 an exact copy of all the others that had fallen under his notice : and as his account 
 of the general course of the symptoms coincides with the statements of other writers, 
 I may give you his narrative, in lieu of a formal description. 
 
 "A very corpulent robust farmer, of about 55 years of age, was seized with a 
 rigor, which induced him to send for his apothecary. He had not made water, it 
 appeared, for 24 hours. But there was no pain, no sense of weight in the loins, no 
 distension in any part of the abdomen : — and therefore no alarm was taken till the 
 following morning, when it was thought proper to ascertain whether there was any 
 water in the bladder, by the introduction of the catheter : and none was found. I 
 was then called (says Sir Henry), and another inquiry was made, some few hours 
 afterwards, by one of the most experienced surgeons in London, whether the bladder 
 contained any urine or not: when it appeared clearly that there was none. The 
 patient sat up in bed, and conversed as usual, complaining of some nausea; but of 
 nothing material in his own view : and I remember that his friends expressed their 
 surprise that so much importance should be attached to so little apparent illness. 
 The patient's pulse was somewhat slower than usual; and sometimes he was heavy 
 and oppressed. 
 
 " I ventured to state (continues the author) that if we should not succeed in making 
 the kidneys act, the patient would soon becor.ie comatose, and would probably die the 
 following night : for this was the course of the malady in every other instance that 
 1 naa seen. It happened so ; he died in thirty hours after this, in a state of stupe- 
 faction " 
 
 This is the curious and important point in the history of such cases. If no urine 
 l>e separated from the blood, coma soon supervenes, and death. It is beheved that
 
 SUPPRESSION OF URINE. 867 
 
 *hese consequences result from the detention of urea in the system. Urea is a mere 
 excrement, which, in health, is removed from the blood by the kidneys, as fast as u 
 enters that fluid. When it is not so carried off', it accumulates in the blood, circu- 
 lates with it to every part of the body, and acts as a poison, especially upon the 
 brain. This is one of several cases, showing that the carrying fluid of the body may 
 become the vehicle of disease and death, if it be not duly purged of deleterious mat- 
 ters which pertain to the unceasing processes of organic life. If carbonic acid be 
 not extricated by the lungs, the animal functions are as certainly and almost as 
 speedily extinguished by that gas, as the flame of a taper might be. And we have 
 recently seen that when the outlet from the liver is shut up, when the blood is not 
 purified from the excrementitious bile, the powers of animal life are weakened, and 
 sometimes utterly and rapidly destroyed. 
 
 Suppression of urine, for a considerable time, is not, however, necessarily and 
 universally fatal. Patients labouring under the epidemic cholera would secrete not 
 a drop of water for some days ; and yet recover. It was remarkable how entirely 
 free such patients were from any approach towards coma. Was the urea here 
 drained off' from the blood in the enormous and unnatural flux from the stomach and 
 bowels ? I think it probably was : but I do not know that any chemical search was 
 ever made for that substance in the fluids so effused. There are, however, sonrie 
 very singular instances on record of persons who have passed days and even weeks 
 without secreting urine ; and without showing any other indication of impaired 
 health. What degree of credit such narratives deserve I do not know ; but assuming 
 that there was neither fraud nor mistake, it may be suspected that either the natural 
 secretion was compensated by some vicarious or supplemental discharge ; or that a 
 small quantity of urine was actually separated by the kidneys. " If any water, 
 however small the quantity (remarks Sir Henry Halford), had been made in these 
 cases, I should have thought it possible that the patient might have recovered : for it 
 has often surprised me to observe how small has been the measure of that excre- 
 mentitious fluid which the frame has sometimes thrown off', and yet preserved itself 
 harmless. But the cessation of the excretion altogether is universally a fatal symp- 
 tom in my experience, being followed by oppression on the brain." The same emi- 
 nent physician states that in three of his five cases there was observed a remarkably 
 strong urinous smell, in the perspiration, for twenty-four hours before death. This 
 I believe is of common occurrence in such cases. Other patients have vomited, or 
 passed by the bowels, watery matters possessing some of the sensible qualities of 
 urine : and a urinous fluid is said to have been found in the ventricles of the brain 
 in some of the fatal examples. 
 
 I have spoken of suppression of urine as a malady, though it probably is never 
 anything more than a symptom. Yet it is one of those symptoms which, from our 
 uncertainty respecting their origin and determining cause, we are obliged to treat, 
 and to study, as if they were substantive diseases. In the only well-marked instance 
 that I have seen of suppression of urine coming on in an apparently healthy person, 
 some blood had appeared in the urine for a day or two before the secretion was 
 totally suspended ; and the kidneys were found gorged with blood. Extreme con- 
 gestion, or inflammation, of the substance of the gland, is probably at the bottom of 
 many of these cases. The same train of symptoms supervene not unfrequently upon 
 organic renal disease. They happen, too, when the ureters become impervious 
 from disease, or from impacted gravel. In this condition urine continues to be 
 secreted, for a time at least, and distends the ureter behind the seat of the obstruc- 
 tion. The apoplectic state which ensues may arise from a re-absorption of the 
 fecreted fluid ; or, in consequence of the obstacle, the secretion itself, after going on 
 to a certain point, may stop, and then the case becomes a case of suppression. 
 
 Respecting the treatment of this formidable condition I can say but little. Cup 
 ping upon the loins, venesection, if warranted by the state of the pulse, the hot bath, 
 sudorific medicines, purgatives, and large warm enemata, seem to me the kind of 
 remedies indicated. To endeavour to force the secretion of urine by strong stimu' 
 lating diuretics, would strike one, a priori, as being hazardous. Yet this practice 
 has its advocates ; and should experience declare in its favour, theoretic objections
 
 868 DIABETES. 
 
 ought to be disregarded. If benefit is so to be obtained, probably the best drug for 
 our purpose would be cantharides. Dr. EUiotson refers to some examples of its 
 success in the hands of Sir Astley Cooper ; and afterwards of another practitioner 
 who took the hint from Sir Astley. He suggests that as the tincture of cantharides 
 is a very uncertain preparation, the remedy should be given in the solid form, a grain 
 at a time, and that a large bhster should be laid upon the loins. Beyond these hints 
 I am unable to give you any assistance towards the management of this obscure but 
 serious complaint. 
 
 The opposite condition of the kidney, in respect to its peculiar function — that, I 
 mean, in which its secretion is largely and morbidly augmented — is scarcely less 
 fatal than the total suppression we have just been considering; but it is not so rapidly 
 fatal. When the amount of urine secreted and passed is permanently too great, 
 when it is constantly running off, as it were, from the system, the patient is com- 
 monly said to have diabetes: from 5taf3aww, to pass through. 
 
 But it is not every case of an excessive flow of urine that deserves to be called 
 diabetes. Great quantities of aqueous urine are passed by hysterical and nervous 
 patients. We all make more water in cold weather than in warm ; the functions of 
 the skin and of the kidney compensating each the occasional defect of the other. 
 Certain drugs and articles of diet are also well known to cause a temporary excess 
 in the amount of urine secreted. 
 
 In fact, although the quantity of urine voided is the most obvious and striking 
 symptom of diabetes, its definite and characteristic symptom is a most remarkable 
 change in the quality of that liquid: in its becoming loaded with sugar. You will 
 find, indeed, two species of diabetes mentioned by many authors — the diabetes in- 
 sipidus, and the diabetes mellitus. The former term ought in my opinion to be 
 abolished. If it refers merely to an unnatural abundance of urine, not otherwise 
 differing in its composition from healthy urine than in containing a large proportion 
 of water — by calling such a state diabetes, we hnk together in the same genus two 
 essentially different conditions. In true diabetes the urine is never without sugar. 
 The quantity may indeed be small ; and it may not be sensible to that coarse test, 
 the taste : but modern observers almost all agree in rejecting any species of diabetes, 
 in which the urine is not at all saccharine. 
 
 The sensible qualities of diabetic urine differ strikingly, in many particulars, from 
 those of the urine of health. Its chemical quahty differs strikingly too, as I have 
 already told you ; but it is in one particular only. Fortunately, no extraordinary skill 
 is required to recognize the morbid secretion. 
 
 Diabetic urine is light-coloured, and transparent ; of a pale straw, or greenish tint. 
 Its odour is peculiar. According to Dr. Prout the scent somewhat resembles that 
 of sweet hay, or that of milk ; but to my nose it is more like the faint smell of certain 
 apples, or rather of an apple chamber. Its taste is, more or less decidedl)^ sweet. 
 Notwithstanding its limpM and aqueous appearance, diabetic urine is remarkably 
 heavy. 
 
 It was long believed that the quantity of urea in diabetic urine was reduced much 
 below the natural standard ; and that the sugar was somehow formed at the expense 
 of the urea. Dr. Prout, in his earlier researches, always detected a little, and but a 
 little, of this peculiar principle. Later observations have shown, however, that the 
 urea is not so scanty ; nay, that it is generally as abundant as in the urine of health, 
 and sometimes even more so. The presence of the sugar conceals the urea ; inter- 
 feres with the action of the ordinary tests of that substance. By certain modes of 
 procedure, which I need not stop to descrine, the urea may readily be discovered : 
 and it is often found, I say, to be rather excessive than deficient. The usual saline 
 matters belonging to healthy urine are present also in that of diabetic persons ; and 
 m the same relative proportions; but, as might be expected, their absolute amount, 
 m a givon quantity of the liquid, is very much diminished. In short, the only essen- 
 tial deviation from the standard chemical constitution of the urine is, that it holds in 
 solution a quantity of sugar. This explains its peculiar odour, its sweetness, and 
 perhaps its excessive quantity. It accounts also for another very characteristic pro-
 
 DIABETES. 869 
 
 perly of diabetic urine ; I mean its high specific gravity. In general, you know, the 
 specific gravity of the urine is inversely proportional to the quantity secreted in a 
 given time ; the more copious and dilute it is, the lighter it is. But in diabetes, so 
 strong is the saccharine impregnation that the specific gravity more than keeps pace 
 with the increased quantity of the liquid secreted. The specific gravity of diabetic 
 urine is always much higher than that of healthy urine. 
 
 The quantity of urine secreted and voided is sometimes enormous : far more than 
 could be supphed by the quantity of fluid taken as a drink, although that, as I shall 
 presently explain, is excessive too. A healthy person passes from one to three or 
 four pints of urine in the twenty-four hours. The quantity, as you well know, is 
 liable to considerable variation : perhaps the average may safely be laid at about forty 
 ounces. But patients in diabetes will void 40 pints in the same time. I have 
 myself seen 26 ; 13 or 14 are not uncommon ; and cases are recorded by writers of 
 credit and veracity, in which 70 pints were passed daily. Nay, one Italian author 
 declares that 200 pints have been discharged in that time. 
 
 The saccharine matter thus held in solution may be obtained in its solid form, by 
 evaporating the urine. I have seen large flat cakes of beautifully crystallized diabetic 
 sugar. It differs somewhat from common sugar, the produce of the sugar cane ; and 
 approaches more nearly to the sugar of grapes. By rapid evaporation of the water a 
 thick syrup is procured resembling treacle ; but Dr. Maclntyre, who has presented 
 to our hospital-museum some very perfect specimens of this sugar, prepared by Mr. 
 Blandford, informs me that to get it well crystallized, the evaporation in a steam bath 
 should be stopped while the urine is still of thin consistence. It may be quickly re- 
 duced to one-half, perhaps, of its original quantity. Then it should be set aside, in 
 shallow plates ; and in the course of ten days or a fortnight the sugar will be depo- 
 sited in a regularly crystalline form. 
 
 The sugar is sometimes so abundant, that it undergoes a rude crystallization as the 
 urine dries, wherever it happens to fall. A girl who was in St. Bartholomew's 
 Hospital, while I was a student there, observed th^t if her water was accidentally 
 sprinkled upon her black stuff shoes, every drop left a white powdery spot behind it. 
 So also an aged patient under Dr. Maclntyre's care expressed to him her alarm at 
 finding that her black worsted stockings were covered with a white dust, from the 
 same cause. A man recently under my charge in the Hospital, complained that 
 two pair of his black cloth trowsers had been spoiled in a similar manner. I re- 
 niember hearing from a diabetic patient in the Edinburgh Infirmary, that his atten- 
 tion was first drawn to his urine by the number of flies and wasps which its sweet- 
 ness attracted to the chamber-pot. 
 
 This daily produce of sugar from the laboratory of the human body, is surel}' a 
 very singular and surprising phenomenon. Sugar is not a constituent of healthy 
 urine. i3r. Prout (who is more consulted on this subject than any one else, and 
 whose experience in respect to it is commensurably great) says that he has never 
 known saccharine matter to occur in the urine of any other animal than man. I 
 once had a coach-horse which I supposed might have diabetes. He was a greedy 
 feeder, and drank eagerly, yet he grew thinner and thinner ; and wherever I had 
 occasion to stop, there he invariably began to stale : so that I became thoroughly 
 ashamed of his leaking. Dr. Prout was good enough to examine his urine for me. 
 It contained no sugar, but its healthy properties were much changed : it had less than 
 the natural quantity of hippuric acid, and more of earthy matters. The disease, he 
 tells me, is known at the Veterinary College ; whence specimens of such urine havu 
 been sent to him for inspection : but it is not true diabetes. 
 
 The unnaturally high specific gravity of diabetic urine is a constant quality; and 
 you must attend to this, for it is almost always a faithful index, not only of the pre 
 sence, but of the severity of the disorder. Dr. Prout places the specific gravity of 
 healthy urine between 1015 and 1025, that of distilled water being represented by 
 1000. Different authors vary somewhat in their estimate of the natural standard ; 
 but we may be content to follow Dr. Prout. He says that the specific gravity of 
 diabetic urine has been stated to vary from 1020 to 1050: that he has many limes 
 
 8x2
 
 870 DIABETES. 
 
 seen it higher than this, but very seldom so low. In fact it ranges generally between 
 1030 and 1060 ; and the average may be taken at 1040. 
 
 So much with reference to the quantity and qualities of the urine discharged in 
 this complaint. It is attended, however, as you may suppose, with other and im- 
 portant symptoms. 
 
 As so much fluid is evacuated from the body through this channel, it might be ex- 
 pected that the other channels for the excretion of liquid matters would be compara- 
 tively dry: and so they are. The skin is arid, harsh and unperspirable. The 
 patients tell you that they never sweat : that they cannot get into a perspiration. 
 This is a very general symptom ; yet in some few patients, especially as the fatal 
 period of the complaint draws near, the surface readily becomes humid. Again, the 
 bowels are mostly costive, and the feces remarkably solid and free from moisture. 
 The tongue is dry, parched and sticky ; sometimes unnaturally red and clean : and 
 the waste of watery particles from the system seems to be felt and expressed by the 
 inordinate thirst which the patients suffer. Their drought is often insatiable. I re- 
 member one girl telling me that when she was debarred from an excess of water to 
 drink, she would get up if she heard it raining in the night, and catch some of the 
 descending drops to satisfy the tormenting sensation of thirst. And another patient, 
 a very sensible fellow, informed me that, believing it could not be good for him to 
 drink so much, and feeling no confidence in his own resolution to refrain, he was in 
 the habit of betaking himself in the summer time to fields and dry pastures, where 
 no water was at hand to quench his strong desire for it. The appetite for food is 
 often, but not always, equally keen ; and the patients, especially those in the lower 
 ranks of society, are apt to think, while they wonder at their weakness, that there 
 cannot be much the matter with them, since they continue to eat and drink so fa- 
 mously. 
 
 Again, the enormous daily drain upon the system may be expected to cause 
 various symptoms and sensations which may all be referred to debility "and defective 
 nutrition. Dr. Henry published a table, showing the quantity of solid extract in 
 everj' wine pint of urine of different specific gravities from 1020 to 1050. Taking 
 1040 as the average specific gravity, and ten pints as the average quantity of the 
 urine discharged daily, the patient would in this manner lose, every twenty-four 
 hours, 15 ounces 7 drachms — or more than a pound and a quarter — of solid ma- 
 terials. 
 
 We need not be surprised, therefore, at the hunger, the wasting, the hectic fever, 
 the feehng of emptiness and sinking at the stomach, the debility, the chilly state of 
 the bod}', and especially of the extremities, the aching and sense of weariness in the 
 loins and legs, the aversion to exercise, the loss of virility; all of which symptoms 
 are generally present. I may add, to complete the picture, some others, enumerated 
 by Dr. Watt, and confirmed by Dr. Prout, and consistent with my own experience 
 of the disease. They are, uneasiness in the stomach after meals, flatulence and acid 
 eructations, dimness of vision, redness of the whole interior of the mouth, spongi- 
 ness of the gums, looseness of the teeth, and some degree of irritation and inflam- 
 matory redness about the external orifice of the urethra: these last are symptoms 
 noticed in persons dying of inanition. Again, listlessness and depression of 
 spirits, weakness and peevishness of temper : " the once vigorous mind becomes 
 feeble, oblivious, and vacillating — the once amiable temper, fretful, suspicious, and 
 intolerant." With all this there is a peculiar faint and unpleasant odour of the breath 
 and person ; an odour which Dr. Prout says is hay-like, which some call melleous, 
 but which reminds me, as I said before respecting the urine, of the smell of a room 
 in which apples have been kept. I have recognized the complaint, upon first enter- 
 ing the sick-chamber, by this pecuhar scent. 
 
 Diabetes is generally a chronic disorder, creeping on at first insidiously, and 
 spreading itself, under judicious management, over many years. Yet it is some- 
 times fairly entitled to be called an acute disease ; for it occasionally breaks out sud- 
 denly, is attended with much febrile disturbance, and runs a short course, uncon- 
 trolled by any treatment. One such instance I have seen. Much more frequently 
 Tl proves fatal through the supervention of some organic mischief, such as debility is
 
 DIABETES. 871 
 
 calculated to foster and develop. It often becomes associated in its progress with 
 pulmonary disease, especially with tubercular phthisis. So common is this, that 
 some persons have thought it universal. But it is not so. I have myself witnessed 
 more than one or two dissections of persons dead of diabetes, whose lungs did not 
 contain a single tubercle. Sometimes the disease terminates in incurable dropsy : 
 and sometimes the patient is cut off suddenly, either by apoplexy, or by some pecu- 
 liar affection of the stomach. 
 
 There is some kind of connection between diabetes and certain affections of the 
 skin, and of the subjacent reticular membrane. Dr. Prout remarks that it usually 
 follows cutaneous complaints, but accompanies or precedes those which involve the 
 areolar tissue. Persons have been known to lose chronic eruptions upon the super- 
 vention of diabetes. On the other hand, carbuncles and malignant boils are frequently 
 the companions of that disorder. The examination of the dead body throws little or 
 no light upon the pathology of diabetes. We naturally look with interest to the 
 kidneys. But we find nothing there to explain the symptoms noticed during life. 
 What I have usually remarked has been a deep purplish red colour of the kidneys, 
 which were veined and vascular, but not otherwise altered in texture. Andral and 
 others tell us that the kidneys are found hypertrophied in diabetes. But hypertrophy, 
 and unnatural vascularity, are circumstances which we are not surprised at when we 
 reflect upon the vastly increased quantity of vi-ork which the glands have been per- 
 forming. W^e must regard both these unnatural conditions rather as being the con- 
 sequence, than as being the cause, of the morbid flow of urine. In one instance, 
 after sudden symptoms of gastritis, which followed the incautious potation of strong 
 ale, I found the mucous membrane of the stomach distinctly inflamed, in its cardiac 
 portion. I have found also the mesenteric glands diseased, converted almost entirely 
 into bone. But neither of these changes is constant. They were purely accidental 
 in those particular cases. 
 
 What, then, is the origin and source of this strange complaint ? whereabouts in 
 the body is the sugar formed ? is it made, by the kidneys, from the blood 1 or is it 
 made, from the food, by the stomach ; and carried into the blood to be simply cast 
 out through the urinary channels ? or is it elaborated in some intermediate stage of 
 what Dr. Prout has called the secondary assimilation ; which includes the formative 
 and the destructive processes that take place in the body subsequently to the act of 
 sanguification ? These questions, which are full of interest, have been much de- 
 bated ; and until very lately pathology was unequal to their solution. It was natu- 
 rally thought that, if the sugar pre-existed in the blood, and was only withdrawn 
 from it by the kidneys, it would be discoverable in the blood. Yet able chemists 
 sought for it there in vain. Hence it was inferred, that by some new combination 
 of its elements, saccharine matter was actually formed in the kidneys. The chemistrv 
 and the reasoning were both faulty. Sugar has, now, been detected in diabetic 
 blood. It is detected with some difficulty, partly perhaps because its presence is 
 masked by the albumen of the serum, but partly because its quantity is small ; and 
 its quantity is small because it is continually decanted out of the blood, as fast as it 
 enters, and with it a profusion of water also, through the kidneys. In this respect 
 the sugar and the urea are alike. They are both excretions which the blood is in 
 haste to cast forth. It would seem also as if the sugar necessarily carried with it a 
 large quantity of aqueous fluid from the blood, and was simply diuretic. When the 
 amount of sugar eliminated is diminished, as by certain remedies it may be, the 
 quantity of urine diminishes too. 
 
 Traces of sugar had, I believe, been found in the blood by some previous in- 
 quirers : but it is to Mr. M'Gregor, of Glasgow, that we are indebted for the full 
 exposition of this interesting fact. His researches, published last year (1837) in 
 the Medical Gazette, have thrown a new and strong light upon the patholog}'- of 
 diabetes. 
 
 By a peculiar process, he did, I say, that which many preceding chemists had 
 failed to accomplish ; he detected sugar in the serum of the blood of diabetic patients.. 
 The serum had a milky appearance, he says; and I have seen that myself: il^ 
 specific gravity was above the healthy standard. Having coagulated the serum by
 
 872 DIABETES. 
 
 heat, he carefully dried it ; then cut the dried mass into very small pieces, and boiled 
 then^ in distilled water; and lastly, he evaporated the decoction to a certain point. 
 To the liquid thus concentrated he added a portion of yeast, and the presence of 
 sugar was manifested by the fermentation which ensued, and which lasted for several 
 hours. Yeast, I should tell you, is a most delicate test of sugar, and will readily 
 detect half a grain in two ounces of liquid. 
 
 Mr. M'Gregor went a step further back. He obtained, by means of an emetic, 
 ihe digested food from the stomachs of two men who had dined two or three hours 
 before. One man was in health ; the other had diabetes. In each case the food had 
 been of the ordinary kind. Applying, after due preparation, the test of yeast, he 
 found that the vomited matters fermented strongly ; especially those from the diabetic 
 patient. 
 
 Then he varied the experiment. Thinking that the sugar, in these cases, might 
 have been introduced in the vegetable portion of the food, he adopted precautions to 
 exclude that possible source of fallacy. He administered to a healthy man, and to 
 a diabetic man, a vomit and a purge, to clear out the alimentary canal. Next he fed 
 them upon roast beef and water, and nothing else for three days. Then, three or 
 four hours after a meal, the contents of their stomachs were procured by the operation 
 of the sulphate of zinc, as an emetic ; and treated as in the former case. What 
 the healthy man vomited did not ferment at all. What came from the diabetic pa- 
 tient fermented " pretty briskly." 
 
 The fault, then, we may safely conclude, lies in the digestive organs. Instead of 
 healthy and nutritive chyle, saccharine matter is prepared by the stomach, and enters 
 the circulation. That which should be converted into muscle, and fat, and bone, 
 and nerve, and membrane, is hurried ou^ of the system, as sugar, with the urine. 
 Thus far we see our way with tolerable clearness. But ivhy the stomach should 
 cease to perform its accustomed chemistry upon the food, and even upon sugar itself 
 as an article of food, Ave have not yet learned. That single important step is still 
 wanting to the complete solution of the pathological problem. 
 
 I may mention that Mr. M'Gregor carried his inquiries further still, and met with 
 some curious results. He examined the saliva ; the feces ; and the sweat. He 
 found sugar in the saliva. He could find none in the sweat. The feces of one pa- 
 tient, allowed to dry spontaneously, became covered, after the lapse of some time, by 
 distinct crystals of sugar. And yeast having been administered to two patients, in 
 ounce doses, after each meal, had soon to be discontinued, because the patients, to use 
 their own expressions, felt as if they "were on the eve of being blown up." 
 
 We know but little about the causes of diabetes. It is not a very common dis- 
 order; and in those who become afflicted with it, there probably has existed a pie- 
 disposition to it. Dr. Prout remarks that the complaint runs sometimes in families, 
 and is inherited. I had under mj own observation, for some time, three children, 
 two brothers and their sister, all affected with diabetes. The mother, a maternal 
 uncle, and a sister of a friend of mine, all died of this malady. The same author 
 mentions among the predisposing causes, long-continued intemperance, and especially 
 the immoderate use of spirits, severe evacuations, excessive labour joined with a poor 
 acescent diet. Distress and anxiety of mind are held also, and justly I think, to be 
 among the predisposing causes. It occasionally seems to be produced, at once, by 
 the operation of some exciting cause, such as exposure of the body to cold ; or the 
 drinking of large draughts of cold fluid while the person w^as hot and perspiring. 
 Dr. Bardsley states that, in twelve instances of the disease which had fallen under 
 his own notice, the patients attributed their ailment to one or the other of these two 
 causes. Now these are common causes of disease ; and that a predisposition does 
 exist is probable from the fact, that where the exciting cause has acted on several 
 individuals at the same time, one alone has become affected with diabetes. There is 
 u narrative illustrating this, by Sir Henry Marsh, in the third volume of the Dublin 
 HospiUd Reports. A patient of his traced the apparent origin of his diabetes to ex- 
 posure to wet, cold, and privation, at sea, while in imminent danger of shipwreck. 
 Another of the crew fell ill of ague. Others escaped entirely, or had only common 
 colde
 
 DIABETES. 8^3 
 
 If the account which I have been obliged to give you concerning the intimate 
 nature, and the causes, of this curious malady, should appear unsatisfactory, so also 
 I fear, will what I have still to say respecting its cure. I dare not affirm that diabetes, 
 although it seems a merely functional disorder, has ever been cured. Dr. Prout has 
 known some kw patients, two perhaps, or one, recover. Apparent recoveries — nay, 
 apparent cures — are not very uncommon. And this it is of great importance to 
 know. Remedies are not useless because they fall short of their full scope. It is 
 better to keep a man on the edge of a precipice, if you cannot pluck him away from 
 it, than to let him fall over. And many diabetic patients are kept in this predica- 
 ment of dangerous safety. There are certain remedies that exercise a strong con- 
 trolling influence over some of the most prominent and troublesome of the symptoms; 
 and that sometimes even restore the patient to a state which he mistakes for health ; 
 and which a medical man, unwarned of its fallacious character, might also mistake. 
 The urine may recede within the natural limits. There may remain one morbid 
 circumstance only, and that of a nature easily overlooked : indeed it is sure to escape 
 observation if it be not especially searched after. I allude to the unnaturally high 
 specific gravity of the urine. So long as the density of the urine continues perma- 
 nently and decidedly above the heakhy standard, there is no real security. The 
 smallest disturbing cause — exposure to cold, an intemperate meal, unusual exertion 
 and fatigue, sudden or strong mental emotion — may bring back all the symptoms in 
 their former severity. If these and similar hurtful agencies can be averted, life may 
 sometimes be prolonged, in much comfort, for many years. 
 
 There are three objects to be kept in view, in the treatment of every case of 
 diabetes. 
 
 First, to restore the defective power of the digestive apparatus : 
 
 Secondly, to cut off, or restrict as much as possible, the supply of saccharine mat- 
 ter from without : 
 
 Thirdly, to mitigate or remove the most distressing symptoms. 
 
 If we could achieve the first of these objects, the other two would fall out of sight ; 
 for the disease, which is really a variety of dyspepsia, would be cured. But hitherto 
 all the resources of our art have, in this respect, been baffled. Our main hope of 
 uUimate success must lie in the regulation of the ingesta; whereby, also, the second 
 indication is to be fulfilled. Some of the food is, in every case, carried to the proper 
 account, or the patient would speedily die. If we can succeed in directing a sufficient 
 amount of healthy nutriment to the organic tissues of the body, the draining away 
 of any superfluous sugar will be borne well enough. 
 
 About the beginning of the present century, Dr. Rollo discovered and taught that 
 a diet composed exclusively of animal matters had a signal effect in reducing the 
 quantity and in diminishing the sweetness of diabetic urine. Mr. M'Gregor's experi- 
 ments tell us why this is. Animal food furnishes but scantily the materials for the 
 formation of sugar. "The saccharine alimentary principles are chiefly derived 
 (says Dr. Prout) from the vegetable kingdom, and indeed constitute what may be 
 called, by way of distinction, vegetable aliments.''^ If, then, we can exclude aliments 
 of this kind, and confine the patient to animal food alone, we thus cut off" the supply 
 of the materies morbi ; and without indeed curing the disorder, suspend its worst 
 effects. But unluckily very few persons can long endure this mode of living. So 
 far as ihey can endure it, they are comparatively safe. We are obliged to relax, in 
 some degree, the rigour of our rule; and it is curious to observe how suddenly and 
 decidedly the saccharine properties and the quantity of the urine are augmented, 
 when, by stealth, or by permission, the patient adds to his meal the smallest portion 
 of vegetable food — even a biscuit or two. 
 
 We must therefore contrive to vary the animal diet as well as we can ; encourag- 
 ing the patient by a free license to choose among the diffi?rent kinds of meat, game, 
 poultry, and eggs, in their diversified modes of preparation, and admitting into his 
 oill of fare as small an admixture as possible of vegetable substances. Green gar- 
 den-stuff, the oleracea, spinach, cabbage, celery, and the like, maybe taken with less 
 risk of increasing the saccharine matters in the system, than potatoes, and those other 
 articles of vegetable diet which contain a notable proportion of sugar, gum, or starch
 
 S74 DIABETES. 
 
 All kinds of fruit must be forbidden. You vill seldom be able to debar )'our patients 
 entirely from bread : none should be allowed but such as is well fermented, and 
 somewhat stale, or thoroughly toasted ; and even that as sparingly as may be. 
 
 It is also of much importance to admonish the patient, whose appetite is generally 
 ravenous, against eating too large a quantity, even of animal food, at any one tune. 
 Not only is the digestion still further weakened and oppressed by an intemperate 
 meal, but the patient's life may be put in peril by every such act of unwise indul- 
 gence. Of this I have witnessed one example, and have heard of several more. 
 
 The quantity of drink should likewise be limited. It may properly enough con- 
 sist of animal broths : and these should be taken tepid,, for they are then more likely 
 to be taken in moderation. The patients must, however, and will, have something 
 else, to slake their urgent thirst. I have found (acting upon a suggestion of the 
 elder Dr. Latham) that distilled water, acidulated with phosphoric acid, appeases, 
 more than most things, that painful sensation. The water of the Bristol Hot Well, 
 which contains carbonate of lime in solution, is praised by Dr. Prout for the same 
 purpose. 
 
 Dr. Christison gives an important caution in respect to drinks ; viz., that, when 
 the thirst has already been much indulged, the quantity of liquid taken must not be 
 greatly reduced all at once. Sudden failure of the vital powers has not unfrequently 
 ensued upon abrupt changes of that kind. 
 
 Very numerous are the remedies which have been tried, and which have been 
 recommended, for this disorder. I shall notice those only of which I have had per- 
 sonal, and in some degree favourable experience. 
 
 The first of these is blood-letting, which has been strongly advocated by Dr. Watt, 
 of Glasgow, and by Dr. Satterley, formerly one of the physicians to the Middlesex 
 Hospital. It is not a remedy which would naturally occur to one's mini as being 
 likely to prove of service in such cases ; but both the authors I have mentioned 
 speak of it in terms of high commendation. They affirm that, under small and 
 frequent bleedings, the strength increases ; the clamminess of the mouth, and dry- 
 ness of the skin, diminish ; and the blood by degrees assumes the buffy coat. I have 
 once seen the method of frequent blood-letting fairly put to the test. At first, the 
 patient did seem to be benefited by it ; but she ultimately died : and I am satisfied 
 that her death was accelerated by one bleeding too many, or by too large an abstrac- 
 tion of blood at one time. 
 
 This measure has the best chance of being useful, when the malady is recent, and 
 attended with febrile disturbance. In chronic cases, in old persons, and whenever 
 the debility is already great, venesection can seldom be requisite or proper ; although 
 even then, as Dr. Prout remarks, it may be borne better than one might expect. 
 Local bleeding is, however, of much service in relieving local uneasiness. Leeches 
 may be applied to the epigastrium, if the patient has tenderness there, or complams 
 of a sense of fullness or of burning in the stomach. Cupping to the loins, if they 
 greatly ache. 
 
 Opium is a treasure to us in this disorder. It quiets the nervous irritabihty of the 
 patient, allays many of his most distressing sensations, and restrains in a remarkable 
 manner the morbid profluvium from the kidneys. But you must not suppose, from 
 observing these favourable changes, that you are curing the disease by it. It appears 
 to control the diuretic influence of the sugar in the blood ; but it does not banish the 
 sugar itself. And, as far as my experience goes. Dr. Prout is in the right when he 
 stales that moderate doses of opium generally suffice to check the excessive dis- 
 charge. Five grains of Dover's powder, for example, three times a day, will do as 
 much good, and on the other hand be productive of far less inconvenience than larger 
 quantities of that narcotic substance. The sudorific properties of this compound 
 are thought to render it ehgible ; although it has seldom any apparent efTect, in that 
 way, in diabetes. If the ipecacuanha which it contains should disagree with the 
 stomach, an equivalent quantity of any other preparation of opium may be substituted 
 for it. 
 
 There is another remedial measure which has also, in some cases at least, a loosi 
 beneficial influence on the condition of the patient ; I mean forced perspiration^
 
 DIABETES. 875 
 
 perspiration induced by the hot-air bath. Of this I have seen some striking- exam- 
 ples. A very well-marked case of diabetes came under my care in the JMiddlesex 
 Hospital several years ago. A vapour, or hot-air bath, had just then been constructed 
 in the hospital, and I thought it a good opportunity for trying whether the suo 
 pended functions of the skin might not be restored, and the extravagant action of the 
 kidneys perhaps corrected, by that powerful mode of exciting perspiration. I should 
 tell you that other plans of treatment had already been put in force, with but partial 
 advantage. It would occupy more time than I can now spare to enter upon the 
 details of this case ; but I will read to you the man's own statement, which he wrote 
 down before he left the hospital, in evidence of the benefit he derived from the 
 sudatorium. 
 
 "The urine" (these are his words) "is reduced more than one-half, and does rot 
 contain much sweetness, but sometimes tastes salt, with a mixture of bitter. iViy 
 stools, which were dry, and like balls packed together, are now quite natural. The 
 pains in my limbs are entirely removed. My spirits, which were very much de- 
 P'essed, are now revived, and cheerful. The unpleasant aching of my kidneys, of 
 Afhich I spoke little lest 1 should be cupped in the loins, is now removed ; only I feel 
 weak there. I am cured of the pain m my stomach, and the circuitous working of 
 the wind in my bowels, which formed lumps in my belly as it passed, resembling 
 those formed by the cramp. I have likewise got rid of the palpitation at my breast, 
 which was accompanied with a sort of dread. My breathing is much improved ; 
 perspiration, in a great measure, restored ; and my skin, which was dry, is now be- 
 come moist. I sleep well at night, whereas I could not sleep more than two or three 
 hours out of the twenty-four. My thirst, which was excessive, has ceased to be 
 troublesome." 
 
 This man, who, m the statement I haVe just read, has so graphically described 
 his own morbid sensations, and the relief from them which he had obtained, left the 
 hospital thinking himself well : but, the specific gravity of his urine remained above 
 1030. 
 
 In about half a year afterwards, he went one evening to Hyde Park to see some 
 fire works, got wet feet, and began to cough. The diabetic symptoms returned 
 more severely than ever ; and he soon died. I found his lungs stuffed with tubercles. 
 
 In furtherance of the principle upon which the use of the hot bath is recom- 
 mended, the other well-known methods of promoting the natural functions of the 
 skin should be followed; friction, and more especially warm clothing. 
 
 Steel is sometimes singularly beneficial in repairing the strength, and enlivening 
 the spirits ; as indeed it is well known to be in other forms of disease attended with 
 a copious and permanent drain upon the system, and with a diminution of red blood. 
 Of course it may be combined with opium, or with any other medicine which the 
 circumstances of the patient may render needful. 
 
 I scarcely need say that the bowels require attention. Not that active purgation is 
 advisable, but simply their regulation. Castor oil, rhubarb, aloes, lenitive electuary, 
 are more appropriate in these cases than the purgative salts, w4iich are apt to be 
 diuretic also. 
 
 There is one other drug from which I think I have seen the happiest effects. 
 i mean the creasoie. I first became acquainted with its virtue, from prescribing it, 
 almost accidentally, until a consultation could be arranged with Dr. Prout, for a 
 child, eight years old, in whom the disease was well-marked, and who had been 
 brought to London f^om the country for advice. She had been rapidly wasting away 
 for ten weeks, was extremely feeble, soon tired, very thirsty, especially at night, and 
 had (what was also new to her) an enormous appetite. She was passing from three 
 pints to two quarts daily of pale urine, having a specific gravity greater than 1040. 
 I desired that her diet should be as exclusively animal as she could bear, and that 
 she should take one minim of creasote, suspended by means of mucilage in an ounce 
 and a half of water, three times a day. Curiously enough, the child liked the tarry 
 flavour of the medicine. Upon this plan, with gentle aperients occasionally to regu- 
 late her bowels, she remained for upwards of a twelvemonth. Her urine soon fell in 
 Quantity within the limits of health, and in density to about 1030. She regained her
 
 876 CHRONIC DIlrKii.dx'3. 
 
 lost flesh, strength, complexion, and spirits, aad p^rew '"^ns'deraOly. At length she 
 suddenly sank under an obscure affection 0/ the chest. a brotner of this iittle girl 
 has lately manifested unequivocal signs ol the same complaint ; and in him it appears 
 to have been equally checked by the saiae method of treatment. I have detected 
 sugar in the urine of another boy belonging to the same family. 
 
 There were two points in this young lady's case which deserve a passing remark. 
 As her urine diminished in quantity it began to deposit the lithates. This Dr. Prout 
 considered a very promising earnest of a return to a better diathesis : and I find that 
 in cases which have crept on insidiously from the first, he is accustomed to date the 
 malady from the time when lateriiious sediments, previously common, disappeared 
 from the water. 
 
 The other point was, that calomel always sickened this child, and aggravated all 
 the diabetic symptoms. This is consistent with Dr. Front's experience, who tells us 
 that he has never seen mercury do good in diabetic disease ; but on the contrary 
 almost invariably do mischief. I would advise you to read his judicious observations 
 upon the too common abuse of that mineral. 
 
 I am quite aware of a possible fallacy in the case I have been mentioning, with 
 respect to the efficacy of the creasote. With the use of that drug was associated a 
 stricter adherence to a purely animal diet ; and it is impossible to estimate with pre- 
 cision the separate effects of these two remedial measures. I am, however, disposed 
 to believe that the creasote, by its well-known preservative property, checks the con- 
 version of the food into sugar. And I think it is a mistake to go on increasing the 
 dose. To most stomachs it proves irritating and hurtful when pushed beyond a cer- 
 tain small amount. Dr. Maclntyre tells me that he has found the creasote very 
 useful in diabetes. I must, however, acknowledge that, in common with others, I 
 have sometimes been totally disappointed by it. 
 
 For many years of my professional life I had not met with an instance of what 
 has been called diabetes insipidus : from which I infer the rarity of that disorder. I 
 shall use the term chronic diuresis to express this affection. 
 
 Very recently a marked instance of such chronic diuresis has presented itself in 
 the hospital. A boy, eleven years old, not unhealthy looking, but lean, was 
 admitted there under my care. He was much troubled by thirst ; and by frequent 
 micturition, which, even in the night, disturbed him many times. His bowels were 
 costive, he had a capricious appetite, and his skin was dry. He voided during the 
 twentj'-four hours several pints, seldom less than nine or ten, of simply dilute urine, 
 of a faintly yellowish hue, and having the specific gravity of 1002. Sometimes, 
 indeed, it was found to be scarcely heavier than distilled water. In other respects 
 he appeared tolerably well. It was supposed that he had been affected in this 
 way for about twelve months ; his desire for drink having been the first symptom 
 noticed. 
 
 During his residence, of many weeks, in the hospital, under my observation, I 
 made trial of every plan and drug that I could think of, for repressing the unnatural 
 flux of urine. Nothing did him any good : some things, I fear, by disturbing his 
 stomach and bowels, did him some temporary harm. He went out much as he 
 camt m. 
 
 Although I can tell you neither upon what this disorder depends, nor how it may 
 be remedied, I mention the case because it afforded me a proof that liquid may be 
 absorbed into the body from the atmosphere ; either by the external skin, or by the 
 pulmonarj' mucous membrane, or by both these surfaces. Dr. Prout, to whom I 
 showed both the urine and the patient, advised that, for a time, his supply of drink 
 should be limited. Accordingly, very much to the poor boy's sorrow, he was put 
 upon a daily allowance of a pint and a half. 1 have no doubt that my injunctions 
 were strictly observed, both by himself and by the nurses. Nevertheless, without 
 losing flesh or weight, he passed, during the corresponding twenty-four hours, ten 
 pints and a half of urine. 
 
 T got evidence of the same fact in another way also ; namely, by weighmg the
 
 ALBUMINOUS URINE. 877 
 
 boy at short intervals : although the experiment was not repeated so often as I wished 
 it had been. I give you the results of one of these trials. 
 
 Immediately after he had emptied his bladder he was found to weigh 3 st. 8 lb. 
 oz. 3 dr. Three hours subsequently, having taken nothing in the interim, he 
 weighed 3 st. 9 lb. oz. 2 dr. Then he voided 16 oz. of urine : after which his 
 weight was again 3 st. 8 lb. oz. 3 dr. So that he must have imbibed about a 
 pound of liquid in that brief space of time.* 
 
 In this instance there was merely an excess in the aqueous ingredient of the urine ; 
 the solid matters were apparently there, in their due proportion to each other, but in 
 a very small ratio to the water. 
 
 But the aqueous ingredient may be in excess, while the absolute quantity of urea 
 is deficient. On the other hand, with an excess of the watery material, there may 
 be an excess also in the quantity of urea it contains. 
 
 Dr. Willis has distinguished these three varieties of chronic diuresis by the terms 
 hydruria, anazoturia, and azoturia, respectively. Although I am no friend to the 
 multiplication of technical names, I must tell you that the distinctions expressed by 
 these terms are real, and of some importance. Anazoturia we shall find to be often 
 symptomatic of a peculiar organic disease of the kidney, which I hope to describe 
 in the next lecture. 
 
 Azoturia, which is accompanied by an unnaturally high specific gravity of the 
 urine, is apt, on that account chiefly, to be mistaken for diabetes. As recoveries 
 from it are not uncommon, it may be suspected that some of the boasted cures of 
 diabetes were cures of this less serious disorder. In the one case, the yeast test 
 detects the presence of sugar in the superabundant urine ; in the other case it finds 
 none. 
 
 LECTURE LXXVIII. 
 
 Albuminous Urine. Means of detecting the Albumen. What it imports. Anato- 
 mical characters of Bright s Kidney. Symptoms to which this renal disease 
 gives rise. Nature of the affection. 
 
 Another morbid condition of the urine, imperatively demanding your attention, 
 is that in which it is habitually impregnated with albumen. This albuminous con- 
 dition is much more common, and in general not less serious, than the saccharine 
 condition which I described yesterday. 
 
 There is no albumen in healthy urine. Neither can we recognize its presence, 
 in any urine, by mere inspection. We detect it by certain tests : and I will tell you, 
 in the first place, what these are ; and how to use them. 
 
 Albumen — of which we have so familiar an example in the "white" of eggs- 
 begins to pass from the fluid to the solid state at the temperature of 160° Fahrenheit. 
 When diluted it may require for its complete coagulation the heat of 212°. Hence 
 one simple and easy test of its presence. We discover that albumen is contained 
 in the urine, by heating that fluid to the boiling point. This is most conveniently 
 done in a small glass tube, by the flame of a spirit lamp. It is seldom that any pre- 
 paration of the suspected urine is requisite. It may, perhaps, be hazy in conse- 
 quence of its containing mucus ; and if its transparency be much troubled, it will be 
 well to filter the fluid before testing it. When, as sometimes happens, albuminous 
 urine is already turbid from the presence of the lithates, these dissolve as the heat 
 
 * This boy lived more than two years afterwards, and continued to yield an excessive 
 quantity of pale, neutral urine, scarcely heavier than distilled water. After death, scrofu- 
 lous tubercles were found in his brain and in his lungs. His kidneys were gorged with 
 venous blood, but of healthy structure. There was nothing wrong, apparently, in his organ» 
 of digestion. 
 
 3y
 
 878 bright's kidney. 
 
 IS applied, and the urine first beconties clear ; and then, as the temperature rises, the 
 albuminous opacity begins to be visible. 
 
 The phenomena observable in the heated urine vary in different cases, chiefly by 
 reason of the variable amount of albumen. The whole is sometimes converted into 
 one gelatinous mass: but this is uncommon. Usually the albumen first appears in 
 the form of a whitish cloud, of which the constituent particles muhiply, and collect, 
 in proportion as the quantity is considerable, into small curdy fragments or flakes. 
 These soon subside to the lower part of the tube, leaving the supernatant liquid 
 clear. The amount of albumen is of course to be estimated by the portion of the 
 tube that it occupies. 
 
 Now this test, by heat, is not conclusive, nor sufficient. There are circumstances 
 that may impede or prevent its effect in coagulating albumen, which, nevertheless, 
 is present. On the other hand it may, under other circumstances, produce a falla- 
 cious appearance of albumen where none exists. 
 
 Albuminous urine has often a less acid reaction with litmus paper than healthy 
 urine. The reason of this I will explain presently. When recently discharged from 
 the bladder, the urine may be neutral or even alkaline ; or it may become neutral or 
 alkaline, by spontaneous decomposition after it has left the bladder. In any case, 
 the urine, thus alkaline or neutral, will not coagulate when heated, even thougn it 
 may be full of albumen. Again, although there may be no albumen, heat may 
 cause a flaky precipitate, consisting of the earthy phosphates. 
 
 We avoid, or remedy, these sources of fallacy, by testing the suspected urine 
 with nitric acid also, which has the property of precipitating the albumen in a flaky 
 or pulpy form. It will thus detect albumen when the tested urine is alkahne ; and 
 by restoring its acidity, it Avould make the albumen discoverable by the test of heat. 
 It has likewise the effect of redissolving the spurious precipitates which may be 
 thrown down by the application of heat, and consequently of showing that they are 
 spurious. 
 
 Nitric acid alone, however, is not, any more than heat alone, an unequivocal 
 touchstone of the presence or absence of albumen ; for it may occasion a flaky 
 precipitate of lilhic acid, when there is no albumen. But this defect is compen- 
 sated by the complementary criterion of heat ; the precipitate being redissolved 
 by raising the temperature of the urine, while any coagulated albumen remains 
 insoluble. 
 
 Dr. Christison states that, in his experience, "sometimes nitric acid added in 
 excess did not separate albumen which had been present in large quantity" — a fact 
 which he thinks " is probably to be ascribed to the albumen itself having undergone 
 more or less decay, along with the other principles of the urine." Hence the urine 
 should, if possible, be examined before it has become decomposed by lapst of time. 
 If, however, you employ both these tests with different portions of the same urine 
 at the same time, and with the same portion in succession, you will avoid all risk of 
 mistake. 
 
 Other tests there are, frequently spoken of, and sometimes recommended ; particu- 
 larly the ferrocyanate of potass, corrosive sublimate, creasote, and oxalic acid. They 
 are unnecessary, in addition to heat and nitric acid ; and they are liable to fallacies 
 from which these last, when combined, are free. Unless you are expert chemists, 
 you had better avoid them. 
 
 Now it is quite certain that the presence of albumen in the urine does often accom- 
 pany and bespeak a very serious organic disease of the kidney. For this disease 
 we have no appropriate name. I wish we had. Some call it granular degeneration 
 of the kidney, but the epithet granular is not always applicable. It is most fami- 
 liarly known, both here and abroad, as Bright'' s kidney or Bright'' s disease ; after 
 the eminent physician who, in 1837, first described it, and showed its great patholo- 
 gical importance. These are odd-sounding and awkward terms ; but in the lark of 
 better I must employ them. 
 
 It is very difficult to describe, in words, the anatomical characters proper to this 
 renaJ disease ; for they are neither very definite nor very constant. The description
 
 bright's kidney. 879 
 
 that I am about to attempt will be made more intelligible by Dr. Bright's plates and 
 those of M. Rayer, which are both before you. 
 
 The morbid appearances presented by the substance of the kidney are such as 
 denote some change in its intimate structure. Its cortical (or secreting) portion is the 
 primary and chief seat of this degeneration ; yet what is called its medullary (^'. e., 
 its excreting) part, is also sometimes implicated, but in a less degree. 
 
 These morbid appearances relate to the size, figure, and consistence of the kidney ; 
 to the colour and condition of its surface, and of its interior. With respect to some 
 of these points there is much variety in different cases ; and studying this variety 
 under the light which is thrown upon it by the clinical history of the disease, we 
 have reason to believe that it is connected with different stages of the disorganizing 
 process. Thus if we look to the size of the diseased organs, they are sometimes 
 much larger than natural, sometimes of the ordinary magnitude, sometimes consider- 
 ably smaller. The average weight of the adult human kidney is four ounces. M. 
 Rayer has met with some, in this disease, weighing twelve ounces. Both the incre- 
 ment and the decrement of the natural bulk belong principally, if not altogether, to 
 the outer secreting portion of the gland. If a longitudinal section of the exaggerated 
 kidney be made, its cortical part is seen to be unduly broad ; and the same part is 
 disproportion ally narrow when the whole organ is smaller than common. For this 
 reason, in the latter case, the radiating medullary portions approach nearer to the 
 surface than they are observed to do in a healthy kidney. And it furthermore 
 appears that the enlargement is most commonly coincident with the earher, and the 
 contraction or shrinking with the later stages of the renal disease. 
 
 The consistence of the diseased gland is variable also. Sometimes, and for the 
 most part in the earlier periods, it is soft and flabby : sometimes, and especially m 
 the later periods, it is remarkably compact and hard. The size and the consistence 
 of the kidney are, in most cases, inversely proportional to each other. 
 
 Again, lhefor7n of the kidney, in the disease in question, often undergoes some 
 modification. As the special change proceeds, the exterior of the gland shows a 
 tendency to become indented by linear depressions, and to present a lobular shape. 
 This, however, is by no means a constant phenomenon, even in the most advanced 
 stage of the malady. 
 
 When its proper investing tunic is stripped off — and less distinctly through the 
 same tunic, before its separation — the surface of the kidney appears mottled, mar- 
 bled, or stained ; of a yellowish-gray colour in one place, and of a dark or purple 
 tint in another. Occasionally it is pale throughout its whole extent ; more commonly 
 of divers hues, and variegated with httle streaks, which are portions of vessels con- 
 taining red blood. Sometimes the surface is curiously speckled ; often uneven as 
 if strewed with prominent grains ; in some instances quite rough and scabrous. These 
 several unnatural appearances are usually the more conspicuous, in proportion as the 
 complaint is the more advanced. 
 
 The most uniform, however, and the most characteristic of the morbid appear- 
 ances, are those presented by the cut surface of the kidney, when it has been divided 
 into two symmetrical portions by a longitudinal incision. We then perceive that the 
 cortical substance is the main seat of the morbid alteration. It has lost in a greater 
 or less degree, its proper red colour and uniform aspect. Sometimes it puts on a 
 speckled or granular appearance ; but this, in my experience, is less common than a 
 pale, nearly homogeneous surface, somewhat like the section of a parsnip. Its na- 
 tural strife are confused or obliterated. The incised surface gives one the notion of 
 some deposit, whereby the original texture of the part is obscured. The blood- 
 vessels seem, many or most of them, to have been emptied by compression, or to be 
 blocked up by yellowish solid matters ; while the healthier pyramidal masses belong- 
 ing to the medullary portion of the kidney are displaced, and pushed aside, or 
 encroached upon by the same yellowish matter, which sometimes interposes itself 
 between, and opens out, their radiating tubuli. Together with these changes ol 
 appearance and structure, I have several times found the veins that emerge from the 
 kidney firmly plugged up by coagula of blood. 
 
 In some rare cases the kidney is studded, both on its surface and throughout iu
 
 880 SYMPTOMS. 
 
 interior, with numerous small cysts or cells, contaming a thin transparent liquid. 
 These cysts have been inaccurately termed hydatids. It is not at all uncommon to 
 meet with one or two such cysts in this diseased state of the organ. 
 
 It has been made a question whether the various appearances which I have been 
 attempting to describe, and which sensibly differ in degree and combination in dif- 
 ferent cases, are characteristic of different morbid conditions, or merely of different 
 stages and varieties of the same essential change. Our knowledge of the subject is 
 scarcely sufficient to supply a positive solution of this question. Excepting perhaps 
 the cyst, my own opinio?! is, that they are all accidental forms and effects of one and 
 the same morbid process. At the same time I ought to tell you, that both Dr. Bright 
 and Dr. Christison appear to incline to the opposite conclusion. 
 
 There is still another state of the kidney, very different to the eye from any that 
 I have yet mentioned, but which has been thought, and which I think, to be, in 
 some cases at least, the first stage of all in the disorganizing process. This state, 
 which I referred to when speaking of suppression of urine, may be briefly described 
 in two words — sanguine congestion. The whole organ is gorged with blood, which 
 sometimes drips freely from it when it is cut open. The kidney is in general large, 
 somewhat flabby, of a deep dark red, even of a chocolate or purplish colour, nearly 
 uniformly diffused, except that the cut surface is usually diversified by still darker 
 tuft-like spots, which have been ascertained to be the Malpighian bodies filled with 
 blood. This change from the natural appearance of the kidney is evidently of a 
 recent kind ; and the symptoms that have been observed to belong to it are these :^ 
 Fever preceded often by rigors ; uneasiness or dull pain in the loins; nausea and 
 vomiting ; a very scanty secretion of urine, which is sometimes tinged with blood, 
 and always albuminous ; occasionally complete suppression of urine. To these 
 symptoms there is presently added, in most cases, sudden and general anasarca — 
 what is commonly called inflammatory, active, or febrile dropsy. If the secretion 
 of urine be entirely suspended, death soon ensues by coma, as I explained to you 
 yesterday ; but if not, the disorder is frequently fatal by the supervention of some 
 acute internal inflammation ; pleurisy, or pericarditis, or pneumonia, or peritonitis. 
 Many persons recover completely from the condition expressed by this combination 
 of pneumonia. Many seem to recover, but bear about with them the germs or 
 beginnings of those more chronic and latent changes which constitute " Bright's 
 kidney." 
 
 And what are the signs which indicate, to an instructed eye, the presence of those 
 changes ? Some of them are precisely the same, in kind, as those which denote 
 the acuter disorder ; only mitigated in degree, and of slower march and succession. 
 The patients are subject to obscure lumbar pains : to sickness from time to time, 
 and retching; and their urine is apt to be red, brown, or dingy, as well as albumin- 
 ous, from the intermixture of some of the colouring matter of the blood. They are 
 obnoxious to inflammations of the serous membranes also; and more particularly 
 to head affections, of which they often die ; drowsiness, convulsions, apoplexy. 
 And, to finish the resemblance, many of them, ay, most of them, become at length 
 anasarcous. Besides these symptoms there are others which are not seen in the 
 acute malady ; because it is acute. Gradually increasing pallor is almost constant ; 
 disease of the heart is common ; and the skin, in general, even in the absence of 
 fever, is remarkably dry and unperspiring. The patients are troubled by a frequent 
 want to make water ; by flatulence of the stomach and intestines ; and by caprice 
 of the bowels, which are sometimes obstinately costive, sometimes prone to diar- 
 rhoea. 
 
 Now it is worth your while to remark, with respect to this category of symptoms, 
 that (the state of the urine excepted) they have no special prima facie reference to 
 renal disease. They are all common enough in various other complaints. In truth 
 they are mere secondary consequences of Bright's disease ; and in so far as they are 
 symptoms of it, they are indirect symptoms. Before Dr. Bright, no one perceived, 
 in such symptoms, any indication of disease of the kidney. The primary and fun- 
 damental organic malady reveals itself by no direct symptoms, excepting those which 
 are furnished by the urine.
 
 STAGES OF THE DISEASE. 881 
 
 Seeing, then, that this pecuhar disease ot the kidney is coupled with effects so 
 grave and perilous, and seeing that one of its most positive and distinctive marks is 
 in albuminous state of the urine, two questions of great interest at once present 
 themselves. 
 
 1. Does albuminous urine always imply the presence of Bright's disease ? 
 
 a,. Is Bright's disease, when present, always accompanied by albuminous urine! 
 
 To both these questions the answer is — no. 
 
 It is certain that some articles of food have the effect, in some persons, of render- 
 ing tne urine for a time albuminous : perhaps it would be more correct to say that 
 certain forms of indigestion cause this change. Albumen has also been detected in 
 the urine under that general state of irritation produced occasionally by mercury, or 
 by a bUster to the skin. In the crisis of some febrile disorders, and in some cases 
 of pregnancy, the same phenomenon has been observed. Whenever blood, pro- 
 ceeding from any part of the long tract of mucous membrane which lines the urinary 
 organs, mingles with the urine, that fluid of necessity contains albumen, and coagu- 
 lates if tested by heat or by nitric acid. 
 
 On the other hand, when the kidney is really affected in the way already described, 
 the admixture of albumen with the urine is apt to disappear, for a while, even sud- 
 denly. I have known it vanish for several hours, immediately after the effectual 
 application of a hot-air bath ; and after profuse purging by a full dose of elaterium. 
 Sometimes it is absent for a longer period. 
 
 Another important question, therefore, now arises. Finding albumen in the urine, 
 how are we to know whether it does, or does not, indicate the presence of Bright's 
 kidney 1 
 
 We may judge, in part, by frequently testing the urine, and noticing whether the 
 albuminous impregnation be transitory or persistent. In part also we judge by the 
 absolute amount of the albumen in a given measure of urine. If the water be deeply 
 charged with that unnatural ingredient, the presumption is strong that the kidney 
 disease is in progress ; and when that disease is confirmed, another remarkable 
 change is found to have taken place in the urine. Its specific gravity is very low ; 
 and strikingly in contrast with that of diabetic urine. This is therefore a very strong 
 additional diagnostic circumstance. 
 
 On Dr. Prout's authority we have assumed the specific gravity of healthy urine to 
 range between 1015 and 1025. Other writers make it higher. But the urine voided 
 in Bright's disease is sometimes as low as 1004 ; and its mean specific gravity does 
 not exceed 1013. 
 
 I need scarcely again remind you, that the question of specific gravity must always 
 be viewed in relation to the absolute quantity of urine secreted. The specific gravity 
 depends, of course, upon the proportion of the solid constituents of the urine contained 
 in a given quantity. If the aqueous portion be augmented, the effect upon the abso- 
 lute density will be the same as if the solid contents were proportionally diminished. 
 But when, as frequently happens in certain stages of this renal disease, the specific 
 gravity decreases while the quantity of the urine decreases also, that conjunction of 
 phenomena becomes especially significant. 
 
 The density of the urine being thus unnaturally low, notwithstanding the addition 
 of the new substance albumen, it follows, as a matter of inference, that the solid con- 
 stituents proper to healthy urine must be sensibly diminished : and they are found, 
 in fact, to be so. These solid ingredients consist mainly of urea, and of certain salts. 
 The aggregate solid contents amount, in health, to sixty-seven or sixty-eight parts in 
 every 1000. In Bright's disease the amount has been ascertained to be diminished 
 to twelve or fourteen parts, and even, in an extreme case, to less than this — to about 
 six parts. 
 
 The urine contains, then, albumen : and it is deficient in urea. These two facts 
 suggested-, naturally enough, to M. Solon, and to others, the notion that ^he albumen 
 might be formed, by a sort of conversion, at the expense of the urea; since these 
 substances, by a slight alteration in the ratio of their elements, pass respectively each 
 into the other. But it is not so. Dr. Christison had observed many years ago, thai 
 when the urine was deprived of the greater part of its urea, the quantity of al^'uraen 
 '>( 3 V 3
 
 S82 bright's kidney. 
 
 contained in it was small ; and, on the other hand, in cases where the urea was con- 
 siderable in quantit}', the albumen was plentiful also. In a recent work on this 
 subject, the same physician states that the whole of his subsequent experience has 
 been in conformity with this observation. 
 
 It being certain, therefore, that the albumen is not vicarious of the urea, what 
 (you may ask) becomes of the urea ? It is detained in the blood ; and may readily 
 1)6 recognized there in considerable quantity : and herein lies, as I conceive, the secret 
 of the secondary affections which belong to this disorder, and of its great fatality. 
 The body is poisoned in detail by the retention of its own excrements. The blood 
 not being dul}"^ purified through that great emunctory, the kidneys, is spoiled for its 
 purpose of nutrition. Besides containing urea, it undergoes other and more mani- 
 fest changes. Its proportion of fibrin varies; and it gradually becomes poor in 
 colouring matter ; the serum is less albuminous also, and of a lower specific gravity, 
 than in health. The quantity of albumen in heahhy blood averages from sixty-five 
 to sixty-nine parts in 1000. In this malady Dr. Babington has found it reduced to 
 sixteen parts. The average specific gravity of healthy serum is 1030 ; but in 
 Bright's disease it descends to 1024, 1020, and even to 1013. Now Dr. Christison 
 has made out the very interesting fact, that there is a definite inverse ratio between 
 the coagulabihty of the urine, and the density of the serum. The more albumen 
 there is in the former of these fluids, the less is there in the latter, and the lower 
 is its specific gravity. So that the deficiencies of the one fluid balance the super- 
 fluities of the other. All this is ver}^ diflt'rent from what takes place in diabetes, in 
 which sugar is excreted with urine that is otherwise health}^ : whereas, in Bright's 
 disease, urea, which ought to be discharged, remains in the blood ; and albumen, 
 which ought not to be separated, is taken from the blood and carried out with the 
 urine. 
 
 I have now described the changes presented by the kidneys in this disorder, the 
 symptoms which attend it, and the morbid conditions both of the urine and of the 
 blood. But these all vary and fluctuate at different periods of the complaint. I 
 must next, therefore, endeavour to state what has been ascertained of its course and 
 progress. 
 
 When the chronic disorder is not a legacy left by the more severe and acute form 
 of disease which I have termed febrile dropsy, it is apt to creep on very insidiously, 
 and to escape our notice : and its history is not yet fully known. It will be enough 
 if I distinguish two stages of the malady — the earl}^ and the advanced. 
 
 In the early stage the urine is generally scanty. Instead of about 40 ounces in 
 the twenty-four hours, the patient voids 16, 12, 8, or even so little as 2 or 3 ounces. 
 Sometimes the secretion is nearly or quite suppressed : and then the head seldom 
 fails to become affected in the way already described. The urine has also an un- 
 natural appearance. It is red, or dark, obscurely turbid, like muddy beer. It froths 
 more than usual: and if you blow into it through a tube, }^ou raise bubbles similar 
 to those which may be formed in soapy water. Its specific gravity is somewhat, 
 yet not greatly, reduced ; about 1021, perhaps ; it is seldom at this period so low as 
 1016. It contains an abundance of albumen. 
 
 At the same early period, blood drawn from the arm exhibits the bufl'y coat. The 
 serunr. is much diminished in density, and contains a considerable quantity of urea. 
 There is no decrease in the fibrin ; perhaps it is a little augmented : and there is no 
 great change in the amount of colouring matter. 
 
 In the more advanced stages of the disease, the quantity of urine is frequently not 
 below the standard of health ; and it sometimes considerably exceeds that standard, 
 so as to constitute one variety of chronic diuresis (anazotitria)., which some call 
 diabetes insipidus. It is usually pale, slightly opaque, and of a very low specific 
 gravity; 1014, 1010, 1007. Once, when the quantity of the urine was 7iot in 
 excess. Dr. Christison found the specific gravity to be no more than 1004. There 
 is a corresponding reduction in the natural solid ingredients of the urine. Albumen, 
 too, is present, but more uncertainly than in the earlier periods : fluctuations in this 
 respect are more common than before. It is a mistake to suppose that the amount 
 of album2n increases as the disorder advances. The contrary rule would be more
 
 SECONDARY AFFECTIONS. 8^ 
 
 near the truth. Tn general the albumen is plentiful and almost constant in the outset 
 of the malady ; less surely present as it proceeds ; and sometimes entirely absent 
 in its latter periods ; and it is of importance to remark that the alteration in tlie 
 specific gravity follows the opposite law. The declension of density, so far from 
 being corrected, augments with the progress of the disorder. Hence the one of 
 these morbid phenomena is a valuable check upon the other, considered as an index 
 of what is going on in the kidney. 
 
 And another fact, which it is essential for you to know and to remember, is, that, 
 in any stage of the disease, the supervention of febrile disturbance, from local inflam- 
 nnation or whatever other cause, tends to renew, for the time, those qualities of the 
 urine which belong, to the early period. 
 
 Meanwhile, the disease advancing, the serum of the blood recovers more or less 
 Its lost specific gravity, in proportion to the decrease of albumen in the urine. The 
 quantity of fibrin seems, in some cases, to diminish. But the striking and most cha- 
 racteristic change is the rapid disappearance of 'the colouring matter, the hematosin, 
 as it is called. This may at length be so much reduced, as to form less than a third 
 of the healthy average. If venesection be occasionally employed, this process of 
 depravation is accelerated; but it takes place whether blood be artificially withdrawn 
 from the system or not. " I am acquainted," says Dr. Christison, " with no natural 
 disease, at least of a chronic nature, which so closely approaches hemorrhage in its 
 power of impoverishing the red particles of the blood. Hence the peculiar pallid 
 or dingy hue of the patient's skin ; the leucophlegmatic and even waxy aspect which 
 invariably stamps the victims of this complaint. 
 
 These characters, then, of the urine and of the blood, when rightly compared and 
 interpreted, reveal not only the existence of the renal disease, but also, with much 
 probability, the stage or degree that it has reached. 
 
 Let us next review, a little more in detail, those secondary affections which I have 
 already pointed out as being incidental to the subjects of this renal malady. They 
 are of much consequence : for in the course of the disease, more or fewer of them 
 are almost sure to occur ; most of them are productive of very serious distress ; and 
 some of them place the patient's life in immediate jeopardy, and often bring it to a 
 premature end. Moreover, it is by these secondary affections that our suspicion of 
 the primary disease upon which they depend is, in general, first awakened : and it 
 is to the prevention or the removal of these same secondary affections that our cura- 
 tive endeavours must chiefly be directed. 
 
 The most common, and practically the most important, of them all, is &>nasarca ; 
 but of this, although I mention it first, I shall postpone, for a while, the further consi- 
 deration. 
 
 Another very common, and very important secondary complication, is the occur- 
 rence of what we compendiously call head-symptoms : various manifestations of 
 derangement in the cerebral functions; headache, drowsiness, delirium, epileptic 
 seizures, apoplexy. So frequently indeed is the death of the patient preceded by 
 coma, with or without convulsions, that Dr. Christison considers this to be the "natu- 
 ral termination " of the disease, or " the mode in which it proves fatal when life is 
 not cut short by some other incidental or secondary affection." Of seventy fatal 
 cases observed by Dr. Bright, death was ushered in by well-marked cerebral symp- 
 toms in thirty. 
 
 I have already told you the circumstances under which these affections of the brain 
 usually arise. They almost always follow any great diminution, or the entire sus- 
 pension, of the secretion of urine. But this rule is not so strict is to admit of no 
 exception. Occasionally, but I believe very seldom, the urine, in this disorder, is 
 reduced to a very small amount, while the head remains undisturbed. Of this Dr 
 Christison has recorded a remarkable instance. One of his patients voided no more 
 than two ounces of light urine daily, for nine days before his death ; yet he continued 
 sensible to the very last minute of his existence, and died simply of inanition. Some- 
 times apoplectic symptoms occur, and carry the patient off, although there has been 
 no extreme or material reduction in the quantity of urine. 
 
 Now when death has thus taken place in the way of coma, and the case had been
 
 884 bright's kidney. 
 
 complicated with anasarca, and serous liquid is found accumulated in unnatural 
 measure in the cerebral ventricles, and in the tissue of the pia mater, it seems rea- 
 sonable to ascribe the coma to the presence and the pressure of that liquid. The 
 dropsy has extended to the brain. And this view of the matter is strengthened by 
 the connection which may sometimes be noticed between the accession of coma and 
 the visible increase of the dropsy in other parts of the bod3\ My own experience 
 accords entirely with that of Dr. Christison as expressed in the following statement. 
 "If the dropsical fluid be allowed greatly to accumulate, drowsiness, the first symp- 
 tom of the affection of the head, very soon makes its appearance in the generahty of 
 cases, and it will speedily pass to fatal coma if not controlled, but the removal of the 
 dropsy will usually remove the drowsiness." 
 
 To many cases, however, this explanation will not apply, there being no morbid 
 collection of water within the skull, nor any other appreciable change there ; nor, 
 perhaps, any dropsy elsewhere. In such cases we refer the ultimate symptoms, the 
 stupor and the death, to the poisonous influence of the urea in the unpurified blood 
 upon the organs of animal life. Yet this explanation also has its difficulties. Urea 
 must often circulate with the blood without affecting the brain. Dr. Christison 
 states tliat he has repeatedly known the daily discharge of the solids of the urine to 
 be reduced, for weeks together, to one-fourth of the natural amount, while, moreover, 
 analysis of the blood showed that it was loaded with urea, without the appearance 
 of any head-symptom. Dr. Bright also relates a case to the same purpose. A per- 
 son labouring under this disease of the kidney lived for four or five years under his 
 occasional observation. The blooil was analyzed in the earlier stage, and found to 
 contain a large quantity of urea ; as much as the urine itself contained. Yet this 
 patient had no Jits till towards the close of his life. 
 
 I have sometimes fancied that the pale and watery condition to which the blood is 
 at last reduced, may have something to do with the stupor and coma. I showed you, 
 some time ago, when speaking of spurious hydrocephalus, that similar symptoms are 
 apt to ensue, in conjunction with a similar defect of hematosin. It would seem that, 
 under such circumstances, the functions of the brain are exercised irregularly, lan- 
 guidly, and at length, not at all, in consequence of the failing supply of its appro- 
 priate stimulus through the arteries. 
 
 Another striking circumstance observable in this disease, is a readiness of various 
 organs of the body to inflame, and particularly of the serous membranes. According 
 to x\l. Solon, who has lately published a thick volume on Albumimme, this disposi- 
 tion has not been so manifest in France ; but of its frequent appearance in this 
 country I can add my own testimony to that of Dr. Bright, of Dr. Christison, and of 
 Dr. Gregory. Such intercurrent acute inflammation is not an uncommon cause of 
 the patient's death. The pleura appears to be much more often affected in this 
 manner than either the peritoneum or the pericardium. 
 
 It follows from this tendency that when we come to inspect the dead body, we 
 seldom find the kidney to be the only part in which structural changes are plainly 
 visible. Most commonly evident traces of disease are met with in various organs. 
 
 Disorder of the stomach and bowels is, certainly, a frequent companion of the 
 renal malady: nausea, vomiting, flatulent distension, diarrhoea. 
 
 It would appear, however, that these incidental and secondary complications pre 
 vail with irregular frequency in different places. The}- are probably determined, in 
 some measure, by local and peculiar agencies. Thus vomiting and diarrhoea have 
 been more familiar to the Edinburgh observers than in London to Dr. Bright, or in 
 Paris to M. Solon : while the headaches and coma, so often witnessed by the British 
 physicians, have been comparatively uncommon in France. 
 
 Disease of the heart, if not a secondary consequence, is a verj'^ frequent accompa 
 niment of Bright's kidney. It is probable that the cardiac disease, and the renal 
 disease, have sometimes no connection in respect to cause and effect, but are both 
 results of some common cause ; of habitual intemperance, for example. 
 
 I am, however, of opinion that the renal malady has a direct tendency, by its effect 
 upon the blood, to generate disease of the heart. It induces anaemia ; and anaemia, 
 RS I shoAV?^ you on a former occasion, implies debility of the muscular texture of the
 
 NATURE OF THE DISEASE. 885 
 
 heart, and leads to dilatation of its cavities ; and the weak muscle, becoming irritable 
 also, grows thicker as it labours more. In fact, this is the kind of cardiac disease 
 which, more than any other, has been found coincident with the peculiar change in 
 the kidney. Among 100 cases, recorded in a tabular form by Dr, Bright, there are 
 27 in which no affection of the heart could be detected. In 52 instances the heart 
 presented the characters of hypertrophy, and of these no fewer than 34 were free 
 from, any trace of valvular disease. Among the 34 there were 11 cases of disease 
 affecting the aorta : in the remaining 23 no cause for the existing hypertrophy and 
 dilatation could be found in the heart itself, or in the great blood-vessels. The true 
 cause may therefore be reasonably supposed to have been the renal disease, ope- 
 rating upon the involuntary muscle through the quality of the blood. 
 
 Whether the renal disease be ever produced by the cardiac, is more questionable. 
 In the acute renal affection, when it proves early fatal, the kidney is always found 
 to be gorged with blood. And the customary intermixture of blood with the urine 
 warrants the belief that the same condition was present in the patients who have 
 recovered. From this state of engorgement springs, apparently, the subsequent 
 series of changes. It is therefore a plausible conjecture that whatever tends to pro- 
 duce congestion of the kidney, tends also to aggravate, and may even cause, the 
 peculiar changes in question. I need not now tell you that disease of the heart does 
 frequently occasion congestion of the venous system, and gorge the viscera with 
 blood. Under this influence the liver often enlarges. On the other hand, disease 
 of the heart, even such as gives rise to venous congestion and to dropsy, often lasts 
 long, and proves ultimately fatal, without the occurrence of albuminous urine, and 
 without any appreciable change of structure in the kidney. 
 
 Pain or tenderness of the loins, is sometimes, and sometimes only, an accompani- 
 ment of the renal disease. This symptom is more often present in the early than in 
 the later stages of the malady. It occurred in one-third of twenty-eight cases 
 narrated by M. Solon. Dr. Gregory noticed it in the half of his patients. 
 
 The causes of the disease of which I have been endeavouring to sketch the out- 
 line, are often obscure. Its more obvious symptoms, in the chronic form of the 
 malady, have been observed, in very many instances, to begin soon after the ex- 
 posure of the body to wet and cold under unfavourable circumstances. But it is by 
 no means certain — indeed the probabilities preponderate on the other side — that, in 
 these instances, the renal disorder had not previously existed in a latent state. 
 
 It is certain, however, that the acute kidney affection, which may be considered 
 identical with febrile dropsy, does often ar.se under similar circumstances of ex- 
 posure, and is attended with a marked disturbance of the functions of the kidneys. 
 And Bright's disease, in its chronic form, has been noticed as occurring in persons 
 who had previously suffered, and had apparently recovered from, an attack of febrile 
 dropsy. Are we not warranted in believing that the recovery was imperfect in such 
 cases ? that the kidney had sustained irretrievable injury ? and that the disease, 
 although from the treatment employed, or by lapse of time, it had become tranquil « 
 or latent, was ready again to give indications of its existence upon any repetition of 
 its exciting cause ? 
 
 Again, it is matter of common observation that intemperate habits have often pre- 
 ceded the development of this disease. Yet we may conclude that intemperance in 
 drinking is rather a predisposing than an essential cause, from the fact that the 
 malady is not unknown among children, and other persons whose manner of life has 
 been strictly sober. I had lately an example of this in a young girl, fifteen years 
 old, who had never menstruated. And this leads me to remark that the renal disor- 
 der has been known, in many instances, to follow a sudden check or suppression of 
 the cataraenia. It has sometimes seemed to owe its origin to blows received upon 
 the loins. 
 
 The complaint happens at all' ages: less often, however, in extreme youth than 
 afterwards. Sabbatier records that he saw, while in the service of M, Baudelocque, 
 a young infant affected with anasarca and albuminous urine. The first case described 
 by M. Solon is that of an infant, seventeen months old, in whom similar symp- 
 toms appeared shortly after exposfe to cold and wet. In 1838 a boy between
 
 886 bright's kidney. 
 
 five and six years old, anasarcous and passing bloody and albuniinous urine, was in 
 the Middlesex Hospital, under the charge of my colleague, Dr. Wilson. M. Con- 
 stant, in the Gazette Medkah for 1835, citps the case of a child of five years of age ; 
 and M. Rayer gives two plates, representing the kidneys of two children, the one 
 five and the other six years old, who both died of dropsy with albuminous urine, the 
 sequel of scarlet fever. In each of these the changes described bj'^ Dr. Bright were 
 well marked, and the bulk of the kidney was considerably increased. 
 
 The malady is, however, much more common in adults : not, in all probabihty, 
 because the kidney is more readily susceptible of it at one period of life than another, 
 but because, as life advances, the circumstances which tend to produce or to foster it, 
 become of more frequent operation ; intemperance, exposure to great vicissitudes of 
 temperature, and (perhaps) disease of the heart. 
 
 It occurs, I presume for the same reasons, oftener in men than in women. 
 
 Dr. Christison suspects that Bright's kidney happens chiefly in persons of scrofu- 
 lous habit ; and he found it, in several instances, coincident with phthisis pulmonalis. 
 My own experience would not have led me to that opinion. I partake of M. Solon's 
 doubts, whether the co-existence of pulmonary consumption and of this renal malady 
 is more than casual. Dr. Bright tells us that " the instances in which phthisis, or 
 any form of scrofulous or tubercular disease, has been connected with the renal affec- 
 tion, have been decidedly rare." 
 
 What, after all, is the true character and essence of the organic metamorphosis 
 which constitutes this formidable disorder, Bright's kidney ? All that has been as- 
 certained of its early stages, of its course, and of its causes, furnishes to my mind a 
 strong presumption that the structural change, in all its varieties of aspect, may be 
 ultimately traceable to an undue accumulation and stagnation of blood in the blood- 
 vessels of the kidney. Those curious arterial bunches, the Malpighian bodies, ap- 
 pear especially to be over-filled and obstructed. Raj'-er calls the complaint albwni- 
 noifs nephrifis; and perhaps the congestion (which unquestionably is present in 
 what I consider the acute form of the malady) may sometimes pass into chronic in- 
 flammation. We do not, however, find that it ever terminates in suppuration : yet 
 suppuration is no uncommon event of true inflammation of that part, excited by vio- 
 lent injuries, or by the lodgment of calculi within it. It seems to me more probable 
 that the mischief done to the kidney is owing to extreme congestion, and its usual 
 consequences — the oozing forth of the blood in substance, or of some of its constitu- 
 ents, into the interstitial textures, as well as into the excretory tubes of the kidney. 
 The appearance of these ingredients of the blood, and even sometimes of blood itself, 
 in the urine ; the increased size of the gland in the earlier stages ; the various shades 
 of colour which its surface and parts of its interior present, as the colouring matters 
 of the effused fluids are more or less absorbed ; the impermeability of those altered 
 parts by artificial injections ; the ultimate shrinking and hardness of the organ, as the 
 disorder becomes chronic, and absorption proceeds ; these are all consistent with this 
 theory. It is plain that the morbid conditions of the urine depend, in part at least, 
 upon the mechanical transudation of certain portions of the blood, which pass through 
 the kidney unchanged, as through an inert filter. Mixed with the urine we find 
 serum, with its albumen, and its salts, which diminish the acidity of the mixture, or 
 even render it neutral ; and in many cases we find more or less of the colouring mat- 
 ter also of the blood. Those portions of the extravasated fluid which have no outlet 
 of escape, solidify, and thus obliterate the natural texture of the part they have in- 
 vaded. The obstruction of the emergent veins of the kidney by firm clots of blood 
 is in harmony with the same supposition. 
 
 When the kidney is thus spoiled, its natural function is imperfectly or but partially 
 performed. The change which it should effect upon the blood by purifying it from 
 urea, fails to be accomplished. The albuminous impregnation, and the other altered 
 qualities of urine when voided, maybe explained either by supposing that the secret- 
 ing power of the whole gland is interfered v/ith, but not absolutely suspended ; so 
 that the urine is incomplet'ely elaborated : or, by supposing that portions of the gland 
 are spoiled, and portions remain sound and effective ; that true urine is formed by 
 the healthier portions, and mixes with the constituents of the blood wKich pass, as
 
 ANASARCA. 887 
 
 such, througli the diseased portions. The latter of these hypotheses :ys most in ac- 
 cordance with the fact, that in the advanced stage of the disorder (when we may- 
 conceive the spoiled parts to have become mere solid unchanging masses) the albu- 
 men is apt to disappear from the urine : and also with the fact, that complete recovery 
 does, sometimes, appear to take place ; in which cases we may imagine that, although 
 a small portion of the substance of the gland has undergone irremediable change, 
 enough of it remains healthy to serve the wants and purposes of the economy. 
 
 I have yet something to say respecting the dropsy, which is so common an ac- 
 companiment of these renal changes ; but I must d ^fer it till to-morrow. 
 
 LECTURE LXXIX. 
 
 Anasarca; its consideration, resumed. Distinction of chronic General Dropsy 
 into cardiac and renal. Characters and signs of each of these varieties. Treat- 
 ment. 
 
 We were yesterday occupied with the circumstances of that remarkable disease, 
 which has never received a good distinctive name, but which is sometimes called 
 Bright'' s disease, after the distinguished living physician who first recognized and 
 described it, sometimes yellow degeneration of the kidney, sometimes granular dege- 
 neration. I endeavoured to represent to you by words and by drawings, thj morbid 
 appearances that are most commonly noticed in the several stages of the complaint : 
 which morbid appearances may, one and all of them, be traced (as I think) to con- 
 gestion of the kidney ; to the detention of blood in that organ, and to the physical 
 consequences of such detention. I spoke of the symptoms which appear essential 
 to the malady, and which consist in certain striking changes in the urine and in the 
 blood of the patient. I mentioned also the symptoms which are incidental to the 
 renal disease. But of one of those incidental symptoms, or secondary consequences, 
 I postponed the full consideration till to-day ; I mean the anasarca, with which, most 
 commonly, yet by no means always or necessarily, it is complicated. 
 
 This is, for several reasons, a very important symptom. It is usually the first 
 thing that prompts us to suspect, and to inquire after, the renal malady. It was 
 through his researches into the relation subsisting between chronic dropsy and the 
 conditions of the urine, that Dr. Bright was led to the discovery of the associated 
 affection of the kidney. The dropsical accumulation adds greatly to the patient's 
 distress, and sometimes constitutes nearly the whole of it. It adds proportionally to 
 his danger. Moreover, it is that consequence of the renal disorder over which our 
 curative measures have the most control. Indeed, under this complication we have, 
 practically, to consider the remedies of the dropsy, distinct from the remedies of the 
 renal change. 
 
 In most cases, at the outset at least of the dropsy, the skin is dry, and the urine 
 is scanty : and the anasarca is observed to increase, or to decrease, as the quantity of 
 urine diminishes or augments. The aqueous fluid, Avhich should escape from the 
 surface and through the kidneys, collects in the subcutaneous areolar tissue. As the 
 disorder advances, the tendency to effusion of serum through the sides of the blood- 
 vessels is probably increased, not only by the sluggish movement of the blood in the 
 veins, from progressive debility of the heart, but also by the cause of that debility 
 the thin and watery condition of the blood itself; a condition which I yesterday 
 pointed out to you as one of the most uniform and striking effects of the primrry 
 disease. 
 
 And here I again take up the subject of anasarca and gene 'al dropsy. You will 
 remember that, in the earlier part of the course, I entered somewhat fully into ihf 
 general pathology of dropsies. At the same time I promised you that I would after- 
 wards, and when you were better prepared to understand them, endeavour more fully
 
 888 ANASARCA. 
 
 to explain some grand distinctions which have been found to exist between different 
 forms of general dropsy. Having now, at last, brought before you all the ojganic 
 changes which are apt to give rise to anasarca, I am in a condition to redeem that 
 promise. In doing so, I shall probably have to remind you of some things which 
 you have already heard from me. 
 
 ^^nasnrca, you will please to recollect, signifies the filling up of a considerable 
 part, or of the whole, of the subcutaneous areolar tissue, with serous or watery fluid ; 
 and when to this is added a collection of liquid in the large serous cavities also, we 
 call the complaint general dropsy. 
 
 It is obvious that this condition may exist, and in nature it does exist, in various 
 degrees : from slight infiltration of the areolar tissue, scarcely noticeable until, after 
 some hours passed in the upright posture, it accumulates in visible oedema about the 
 ankles — to the other extreme, in which the integuments are everj'^where stretched to 
 the utmost, even to bursting; the insteps bulging upwards; the legs and thighs 
 enormously enlarged, cylindrical, unshapely, and exhibiting partial vesications ; the 
 surface of the trunk of the body capable of being kneaded and moulded hke dough ; 
 the skin of the penis distended, and, in consequence of its confinement by the fras- 
 num, twisted and circumvolved so as materially to impede the outward passage of 
 the urine ; the scrotum, as big as a child's head, preventing the miserable patient 
 from approximating his thighs, and from lying upon either side ; the hands swollen ; 
 the face and neck bloated. With all this, the peritoneum is generally full of hquid, 
 and at length the pleurae ; and as the scene is about to close, there is water in the 
 ventricles of the tirain, and an anasarcous pia mater. 
 
 Now, from whatever cause this watery condition of the whole body may arise, the 
 effects resulting yj-om the presence of the water are the same. And of what do 
 patients in this state usually complain ? Why, of shortness of breath, and palpitation 
 of the heart ; of a sense of impending suffocation if they intend to lie down, or 
 actively to bestir themselves ; of tightness and distress across the epigastrium, re- 
 lieved somewhat by eructation, augmented by food and drink ; of weight and stiff- 
 ness of their limbs ; and, sometimes, '^f drowsiness. 
 
 The explanation of all this is easy and obvious. The shortness of breath may be 
 accounted for on various grounds : by oedema of the lungs themselves, a state that is 
 revealed to us through auscultation ; by water in the pleura ; by the pressure up- 
 wards of the diaphragm, which embarrasses still more the labouring heart and lungs ; 
 and i\\\\ upward pressure is increased by any kind of distension or repletion of the 
 stomach — diminished when the stomach is collapsed, and the upright position is 
 maintained. The heaviness and want of pliability of the unwieldy Umbs are, hke 
 the rest of these phenomena, purely mechanical. All parts are oppressed by the 
 unnatural load of water. 
 
 But we must look beyond the dropsy, and inquire whether the complaint has set 
 in suddenly, and simultaneously with febrile disturbance, invading all the districts 
 of the body at once, and quickly reaching its present degree ; or whether it has crept 
 upon the patient slowly and by stealthy steps : whether it has had any obvious or 
 probable exciting cause ; or whether it has approached insidiously, we know not 
 whence or a hy : whether (in a word) the case be one of active and febrile dropsy, 
 or of chronic and passive. 
 
 No'vV, setting aside, for the present, an)'- more particular consideration of the acute 
 or febrile form of general dropsy, and contemplating those forms only which are 
 chronic, we find that all, or nearly all of them, may be arranged in two great classes ; 
 those Avhich depend upon disease or debility of the heart forming one class, those 
 which depend upon disease of the kidney constituting the other. To these classes 
 we accordingly apply the terms cardiac dropsy and renal dropsy. They are often 
 combined in the same individual ; but, taking the pure cases of each form, we may 
 proceed to inquire into their peculiar features, how they may be distinguished, and 
 rthat differences of treatment they may require. 
 
 And first of cardiac dropsj^ 
 
 The mode in which disease of the heart may occasion general dropsy has been 
 sufficiently explained already. We infer that the dropsy, in a given case, has this
 
 CARDIAC DROPSY. 889 
 
 origin, if we find that thoracic symptoms, such as cough and dyspnoea, preceded the, 
 dropsy : or if we perceive direct signs of cardiac disease, such as distended jugular 
 veins, irregular movements of the heart, unnatural impulse, altered sounds; or, if 
 we trace the history of some previous acute disease, affecting especially the left side 
 of the thorax: or if we learn that the patient has formerly suffered acute rheuma- 
 tism : or if the patient's age is so much advanced as to make it probable that some 
 of those organic changes in the heart and large blood-vessels are in progress, which 
 are almost natural in the dechne of hfe. And our inference is confirmed if there be 
 no discoverable indication of renal disease. 
 
 But we see many persons who labour unequivocally under organic disease of the 
 heart, yet who survive, even for many years, without becoming dropsical. The 
 interesting question therefore arises, of what kind of heart-disease is dropsy a conse- 
 quence and symptom ? You already know the answer. It is such disease as offers 
 a certain amount of permanent obstruction to the passage of the venous blood. 
 Hence, dropsy is especially associated with dilatation of the right chambers of the 
 heart. It would not be correct to say that the anasarca is dependent on such dilata- 
 tion, for the dilatation itself is at once an effect and a sign of impeded transmission 
 of blood from the right side of the organ. Nor is such dilatation a necessary attend- 
 ant on the general accumulation of water. The impediment may be sufficient to 
 gorge the right cavities, while it is yet too slight in amount, or too recent in dura- 
 tion, to have dilated them. 
 
 What, then, are the physical conditions which oppose to the blood in the veins 
 such an impediment as we are now considering? The two great vital organs con- 
 tained within the thorax, the heart, namely, and the lungs, form different parts of 
 one common mechanism, the object of which is to supply every tissue of the body 
 with blood that has recently been purified by exposure to the air ; and these organs, 
 thus closely related in their functions, are moreover so reciprocally dependent, that 
 structural disease occurring in the one, tends to produce disease, sooner or later, in 
 the other also. 
 
 And I wish you again to observe the order and direction in which disease is, 
 almost always, propagated from one part of this apparatus to another. It is a back- 
 ward direction — opposite, I mean, to the course of the blood. There are, strictly 
 speaking, two hearts, which he side by side in respect to their anatomical position, 
 but which, reference being made to their vascular inter-communication, are really 
 separated from each other by the lungs. The great veins precede, and the great 
 arteries follow, this chain of connected organs. Disease occurring in any one part 
 of the chain becomes a cause of consecutive disease in the part immediately behind 
 it. And this law obtains, as I have shown you before, in regard to the several 
 chambers of the heart, considered as a single organ. 
 
 Thus, structural disease situated at the aortic outlet of the heart, and of such a 
 kind as to hinder the exit of the blood from the left ventricle, gives rise to permanent 
 changes in that ventricle ; to hypertrophy with, or less commonly without, dilatation. 
 The hypertrophy is strictly a compensating and conservative change ; and when it 
 is exactly proportioned to, and keeps pace with, the impediment which has given it 
 birth, so as precisely to balance and countervail it, no delay takes place in the 
 stream of arterial blood, and the injury is, as yet, confined to the left ventricle. That 
 chamber is remodeled, and adapted to its purpose by the vis medicatrix naturae; 
 and no other evil manifests itself than, perhaps, some shght encroachment and 
 pressure upon the neighbouring parts, in consequence of the augmented volume of 
 the heart. 
 
 So long as the mitral valve remains healthy and effective, it offers a barrier of pro- 
 tection against the extension of the disease in the direction which is retrograde to the 
 course of the blood. But at length, in most instances, the stress becomes sensible 
 further back. The left auricle and the pulmonary veins become choked and dis- 
 tended ; the blood is detained in the lungs. Then commences dyspnoea : at first 
 occasional only, whenever the heart is tasked with the conveyance of a greater quan- 
 tity of blood in a given time than usual, as in brisk movements of the body, or sud- 
 den emotions of the mind ; or when it is oppressed by circumstances that diminisQ 
 
 3z
 
 890 ANASARCA. 
 
 :he capacity of the chest ; by a full meal, therefore, by flatulent disten^'ou of the 
 Biomach and intestines, by the recumbent posture. Afterwards the shortness of 
 breath becomes more or less constant and distressing. 
 
 Now this loaded and embarrassed state of the lungs, even when it is permanent 
 and has reached a considerable degree, may exist without materially interfering with 
 the functions of the right or venous heart : for the pulmonary plethora may be 
 reheved by increased secretion from the bronchial mucous membrane. Dyspncsa, 
 even when it has become habitual, may piecede for some time any appearance of 
 dropsy. 
 
 At last, however, the effects of the original evil augmenting and extending, the 
 right ventricle also becomes unable duly to propel its contents into the pulmonary 
 vessels; it continues morbidly full, is first distended occasionally, then permanently, 
 and dt length really dilated ; and with that dilatation we have a turgid venous sys- 
 tem, of which we see a part in the prominent veins of the neck. 
 
 In this way then may be explained a series of symptoms which you will often 
 witness, and be consulted about, in persons who are growing old. You will find 
 irregularity of the pulse; preternatural impulse perhaps of the heart; occasional 
 snortness of breath ; large crepitation, habitually audible in the lower portions of the 
 lungs ; more or less expectoration, sometimes tinged, sometimes even loaded, with 
 biood. Eventually the ankles begin to swell ; and the patient (if his life is not cut 
 short earlier in some other way) becomes by degrees decidedly and universally 
 dropsical. 
 
 Many of the direct signs of diseased heart may exist, therefore, w^hile there is no 
 anasarca : intermissions and irregularity in its movements, palpitation, the impulse 
 proper to hypertrophj'. But when dropsy has supervened, we may expect also the 
 signs which denote dilatation of the right chambers. The heart is heard and felt to 
 beat beyond the prcecordial limits ; the pulsations become feeble and unequal, if they 
 were not so before ; the patient is liable to fluttering palpitations, to extreme and 
 panting dyspnoea on the shghtest exertion, even on taking food into the stomach, or 
 adopting the recumbent posture ; his skin assumes a dusky hue, and his lips and 
 extremities are apt to be livid. 
 
 In these cases the anasarca first becomes manifest about the ankles. During the 
 earlier stages the oedema disappears in the night, and returns towards the next even- 
 'iig. It is sometimes confined, for a long while, to the legs ; but ultimately it creeps 
 up towards the trunk of the body ; the loins and flanks become doughy, the scrotum 
 fills, and water collects in the serous bags of the abdomen and thorax. In extreme 
 cases the dropsy is universal, pervading the areolar tissue of the head and face and 
 upper limbs. 
 
 As the accumulation of serous liquid is commonly gradual, the reticular tissue, 
 partly perhaps through maceration, but chiefly from continued pressure and stretch- 
 ing, loses its elasticity ; and the cedema is soft, and pits readily. 
 
 Sometimes, the fluid continuing to increase, the cuticle is raised by it, and large 
 vesications take place on the limbs ; or some part of the areolar tissue sloughs, and 
 a breach of surface is made, and the fluid drains off by this vent in great abundance, 
 to the signal relief of the patient. This beneficial accident furnishes us with a 
 valuable practical hint. 
 
 Such, then, is the consummation of disease commencing in the left heart, and 
 working its gradual way, through the lungs to the right heart. But the obstacle may 
 originate at a less distant link in the chain. The circulation may be checked, first of 
 all, in the intermediate lungs : and it may be worth our while to consider, for a moment, 
 the relations which subsist between general dropsy and certain pulmonary diseases. 
 
 Whenever, in pneumonia, a large portion of one or of both lungs becomes impei- 
 vious to air and to blood — or when pleurisy fills one side of the thorax with liquid, 
 which, by its pressure, shuts out both air and blood at once from one-half of the respi- 
 ratory apparatus — the egress of the blood from the right heart, and, therefore, from 
 the venous system, must be checked. We might expect that dropsical effusion would 
 be the result of these changes ; and in truth it does sometimes occur. That it does 
 not happen more frequently is to be attributed, I believe, to the free evacuations, and
 
 RENAL DROPSY. 891 
 
 the strict abstinence, which are early put in force in those complaints, and which 
 rel'eve the venous plethora before it produces eflusion. 
 
 So, again, luncrs that are hollowed out in large cavities or rendered solid over a 
 wide space by numerous tubercles, are manifestly incapable of admittingr inio their 
 vessels from the right ventricle the ordinary quantity of venous blood. In these 
 cases, however, the whole mass of blood is diminished, and kept within the limit 
 which does not imply distension of the veins, by the constant agency of various 
 causes ; by the imperfect nutrition consequent upon abdominal disease ; by the some- 
 times copious expectoration ; by the wasting diarrhosa ; by the profuse nocturnal 
 sweats. Accordingly anasarca is an unusual symptom in pulmonary phthisis, or 
 shows itself in the latter periods only of the disease, in the form of oedema of the 
 legs : and its occurrence then is mainly owing to the debihty which affects, in com- 
 mon with the other muscular parts of the body, the moving organ of the blood. 
 
 The pulmonary disease which more commonly and certainly than any other, 
 though often very slowly, leads to dropsy, is emphysema of the lungs. I showed 
 you, some time ago, that in this morbid condition many of the smaller blood-vessels 
 of the lung become gradually obliterated ; and when the disease is extensive and 
 advanced, large portions of the organ are visibly white and bloodless. Meanwhile, 
 the nutrition of the body is not impaired ; the same quantity of blood continues to be 
 returned towards the heart, but it finds not a ready entrance into the pulmonary 
 blood-vessels, when delivered from the right ventricle. A certain amount of accu- 
 mulation becomes habitual in that chamber, and in the great veins ; and at length 
 the capillary vessels feel the mechanical congestion, and more or less anasarca ensues. 
 
 So much for dropsy that is purely cardiac. Let us next consider the circumstances 
 from which, during the lifetime of the patient, we draw the conclusion that the 
 dropsy he exhibits is of renal origin. 
 
 There is nothinsf, that I know of, very peculiar or distinctive in the characters of 
 the anasarca itself. When the renal complaint sets in suddenly, and with acute 
 symptoms, dropsy usually supervenes soon. So also, during its more chronic pro- 
 gress, anasarca is apt to show itself, or to increase, whenever local inflammation, or 
 febrile disturbance, happens to arise. The more rapid and copious the effusion, the 
 less do the dropsical parts pit upon being pressed. It may be said also of this renal 
 form of dropsy, that accumulation in the larger serous cavities is not, in general, a 
 prominent feature. 
 
 If we find, upon due scrutiny, no material or adequate embarrassment of the 
 respiratory functions, no deviations from the natural sounds of the heart, no derange- 
 ment of its regular movements, no alteration in the force of its pulsations, or in the 
 space over which they can be felt and heard, no distension of the large veins of the 
 neck — then we have reason for suspecting that the anasarca is connected with some 
 vice of the kidney. 
 
 But we cannot infer from the presence of heart-symptoms, that the kidney is free 
 from disease. 
 
 Our judgment is guided, or assisted, in some degree, by the complexion of the 
 patient. When general dropsy depends upon disease of the heart, the cheeks and 
 lips are occasionally florid, often purplish or hvid, frequently dusky and loaded. 
 Sometimes (as in chlorotic women, where the heart may be temporarily distended 
 without any positive organic disease, and the blood is thin and poor) the face and 
 mucous membranes are pale : but in the renal variety of dropsy there is a very cha- 
 racteristic hue ; an evident lack of red blood, indeed, in the capillaries, but withal an 
 unhealthy dingy sallowness, significant, to a practised eye, of some deep-seated al- 
 teration of structure. 
 
 Our suspicion that the kidney is the organ primarily in fault is strengthened, if 
 we trace certain accidents in the history of our patient. An attack, for example, of 
 illness, attended perhaps, with temporary swelUng of the body and disturbance of 
 the urinary functions (acute dropsy, in short), soon after some exposure, under un 
 favourable circumstances, to the influence of cold ; either applied to the external 
 surface, or to the stomach by a draught of cold drink. For, as I told you yesterday, 
 there is reason to believe that in acute dropsy is often laid the foundation of thos«
 
 892 ANASARCA. 
 
 peculiar changes in the kidney which, since they xere first pointed out by Dr. Bright, 
 Lave been chiefly studied in their connection with chronic dropsy. That as rheu- 
 matic carditis may occur, and become latent as to its effects for some time, and j'et 
 implant the germs of future cardiac dropsy, so the stress or strain which befalls the 
 kidney in cases of febrile anasarca, may set on foot a morbid process that long works 
 silently and unobserved, but at last declares its operation by symptoms ; the repro- 
 duction of the dropsy in a more chronic form being the most significant symptom of 
 all. The acute attack may have been forgotten ; there may have been no obvious 
 (though there may have been ill-understood) indications of the renal affection ; and 
 its existence has been, therefore, unsuspected. 
 
 The discovery of intemperate habits would also be of importance in aid of our di- 
 agnosis, if these same habits had not a like influence in causing disease of other organs 
 as well as of the kidney, and especially of the heart. There may, however, be no 
 such episodes as these in the patient's history. The dropsy may have come on im- 
 mediately after some exposure, or obviously injurious influence, yet not with acute 
 symptoms, and in a temperate subject : in which case it is probable that the renal 
 disease had pre-existed in a latent state. Or the anasarca may have stolen on by 
 degrees, without any apparent cause. 
 
 But the most conclusive evidence of the renal disease is to be found in the condi- 
 tions of the urine : which were fully explained to you in yesterday's lecture. I shall 
 therefore only add four rules upon the subject, which have been laid down by Dr. 
 Christison, and generally acquiesced in by Dr. Prout. These rules assert that or- 
 ganic disease, or granular degeneration, or granular disorganization of the kidney — 
 all which phrases we may condense into the compendious expression "Bright's kid- 
 ney" — is present : 
 
 1. In most cases of febrile dropsy, including those which are consequent upon 
 scarlet fever. To this proposition I have already given my full assent. 
 
 2. In all cases of anasarca, wherein the cedematous parts are elastic, and do not 
 pit upon pressure. I am not so sure of this rule. I believe that the firmness of the 
 cedematous parts has relation rather to the rapidity with which the effusion has taken 
 place, than to the local origin of the dropsy. In proportion as the accumulation in 
 the areolar tissue has been chronic and gradual, does the swelling receive and retain 
 indentation from external pressure. 
 
 3. In most, or all cases of dropsy attended with diuresis, provided the urine be 
 not saccharine. Such cases. Dr. Christison truly remarks, are far from being un- 
 common. Of course the diuresis here spoken of is such as occurs independently of 
 diuretic remedies. 
 
 4. In all dropsies associated with urine of a very low specific gravity (say below 
 1010), and not exceeding the natural standard of quantity, whether it be albuminous 
 or not. To the last two rules there are probably very few exceptions. 
 
 The dropsy which is dependent upon " Bright's disease" yields, not unfrequently, 
 to treatment ; but it is prone to recur. Of the renal disease itself the prognosis is, 
 no doubt, very unpromising. Yet I do not think so despairingly of these cases as I 
 once thought ; and as many think. I have known a few instances of what seemed 
 complete recovery after well-marked symptoms of the disorder. Certainly success 
 enough has followed careful treatment to encourage us to use all diligence in prose- 
 cuting such remedial measures as are already known, and in devising new ones. 
 
 I have been speaking of dropsies that are purely cardiac, and of dropsies that are 
 purely renal. But I have already told you that disease of the heart and disease of 
 the kidney, frequently go together; and I have endeavoured to estimate their relation, 
 in such cases, to each other. When both organs are structurally affected, the dis- 
 position to dropsical accumulation must evidently be augmented. What share they 
 have, respectively, in producing the dropsy, it would be very difficult, and practically 
 ;t is not very important, to determine. 
 
 In chronic general dropsy of a purely cardiac origin, the kidneys, being sound, 
 offer the most convenient and eligible channel for carrying off the superfluous water. 
 Diuretic medicines, therefore, rank among the most important of our curative expe- 
 dients. AVhen they fail to act, or prove insufficient for the purpose sought, we next
 
 RENAL DROPSY. 893 
 
 have recourse, the state of the bowels permitting, to drastic or hydragogue purga- 
 tives. 
 
 Diuretics are notoriously of most uncertain operations; sometimes completely 
 answering our wishes, oftener perhaps disappointing them altogether. When the 
 urine is strongly acid, and deposits, on coohng, a sediment like brick-dust, it may be 
 well to try, at first, the alkaline diuretics, and particularly the salts of potass. Nitre 
 added to the common saline draught ; or a combination of the acetate and bicarbon- 
 ate of potass ; or the bitartrate in small doses ; or the iodide of potassium : or the 
 liquor potassse. In my own experience the tincture of squills also has seemed to 
 correct this superacid and turbid condition of the urine, while it increased its quantity. 
 
 The benzoate of ammonia is another salt which I have found to operate very 
 powerfully, in several instances, as a diuretic. 
 
 Digitalis sometimes promotes, in a remarkable degree, the flow of urine ; and this, 
 in my judgment, is its most useful and manageable property. Small quantities of 
 the tincture, or of the infusion, may be added to other formulae. Or the powdered 
 leaves may be combined in pills. But one of the best modes of exhibitino- dio-itahs 
 for this purpose is to give larger doses of the infusion, half an ounce, for example, in 
 some cordial water, at intervals of four or six hours, till three doses have been taken 
 in succession ; and then to pause and note its effects ; and to repeat the three doses, 
 or not, accordingly. 
 
 The spirit of nitrous aether, and the compound spirit of juniper, have both of them 
 well-marked diuretic properties, and may, with propriety, be added to most of the 
 liquid formulae for augmenting the discharge of urine. And, as vehicles for more 
 active, or more concentrated ingredients, those vegetable infusions or decoctions should 
 be chosen which are reputed to possess similar virtues ; such as the decoction of 
 broom-tops, or of juniper-berries, or of winter green, or the infusion of buchu. 
 
 Squills, turpentine, the tincture of cantharides, are drugs of a more stimulant nature, 
 more peculiarly adapted to cases in which there is no febrile disturbance, and the 
 kidneys are obstinately inactive. 
 
 Sometimes a combination or farrago of diuretic substances proves more efficacious 
 than larger doses of any of the ingredients administered singly : and the operation 
 of some of these combinations is undoubtedly quickened and exalted, in many in- 
 stances, by the addition of mercury. A fluid drachm of the officinal solution of the 
 bichloride in each dose of a mixture ; or small quantities of calomel or of blue pill 
 when the medicines are given in a solid form. A very useful pill of this kind, much 
 recommended by the late Dr. Baillie, consists of three or four grains of the pilula 
 hydrargyri, mixed up with one grain of the dried powder of squills, and half a grain 
 of the dried leaves of digitalis; to be given twice or thrice a day. Dr. Baillie states 
 that squills and digitalis are much less effectual by themselves, than when combined 
 with mercury. 
 
 Tn choosing purgative drugs to aid the effect of diuretics in carrying off the drop- 
 sical fluid, or to take their place when these fail to act, we select those which produce 
 copious and watery discharges from the bowels. A combination of jalap and cream 
 of tartar has been long and deservedly esteemed for its excellent operation in this 
 way. Gamboge is also a good cathartic. It may be given two or three times daily, 
 in grain or two-grain doses, with a drachm of cream of tartar, suspended in two 
 ounces of peppermint water. Or half an ounce of cream of tartar, mixed in six 
 ounces of peppermint water, may be administered in one dose every morning. 
 Croton oil, and elaterium, are still more powerful evacuants of serous liquid from 
 the intestines. One or two drops of the former, or from a quarter of a grain to a 
 grain of the latter, will be about a proper dose. It is astonishing how much relief 
 to the feelings of the patient, and how great a diminution of the dropsical symptoms, 
 are sometimes obtained by these active cathartics. Patients will earnestly beg for a 
 repetition of them, even when their operation is attended, for the time, with consi- 
 deraOie pain or sickness, and much general distress. 
 
 In addition to these measures for the removal of the collected water, auention must 
 be paid to the actual condition of the heart. If the dropsy has been the result of 
 anaemia, or of cachexy of the system, you must endeavour to strengthen your patient, 
 
 3z2
 
 804 ANASARCA. 
 
 nnd to repair his impoverished blood, by nutritious food and tonic medicine, and 
 especially by the administration of steel. I told you formerly that preparations of 
 iron have an exceedingly good effect, oftentimes, even in cases of organic disease 
 of the heart, consisting in dilatation and tenuity, and consequently weakness of its 
 muscular parietes. 
 
 On the other hand, if there be violent palpitations of the heart, with a strong 
 heaving impulse, you may appease the excessive action, and afford sensible comfort 
 to the patient, by applying leeches, from time to time, to the prsecordia. 
 
 Of the renal variety of chronic general dropsy, whether pure or mixed, the treat- 
 ment is less accurately ascertained. The uncertainty which has perplexed men's 
 minds respecting the nature of the renal disorder, has extended, in some measure, to 
 their choice of remedies for it. 
 
 Whenever (in renal dropsy) acute symptoms and febrile disturbance occur, much 
 relief may be expected from the abstraction of blood. When drawn from a vein, it 
 usually shows the huffy coat. The existence at the same time of pain in the loins, 
 would" indicate the propriety of applying cupping glasses to that part. Nevertheless, 
 the impoverishing effect of the disease itself upon the blood, and the probable de- 
 pendence of some of the more distressful and alarming symptoms upon the thin 
 serous condition of the circulating fluid, as well as the increased facility with which 
 the dilute blood may transude outwards — these are circumstances which should in- 
 duce every cautious practitioner to have recourse to this heroic remedy only when 
 it is clearly demanded. 
 
 One definite object, in the renal as well as in the cardiac variety, is to remove the 
 dropsical fluid, from which the danger and the suffering often chiefly proceed. But 
 it is a more nice question, when the kidney is involved in the disease, how this is to 
 be accomplished. Can we, with the same safety as in cardiac cases, employ diuretics ? 
 It has been thought that we cannot. As the primary morbid state of the kidney is 
 certainly often, and probably always, a state of congestion, it has been feared that 
 direct diuretics, such as are calculated to cause, keep up, or augment congestion of 
 the kidney, or to stimulate and irritate that organ, would be likely to accelerate the 
 disorganizing process of which it is already the seat. 
 
 Now, although these views are theoretical, and their justness has not yet been 
 established by positive proof, you had better, when yoM can, observe the caution 
 which they suggest. You had better endeavour to empty the distended cavities, 
 and to relieve the loaded areolar tissue, through the bowels, or through the skin. 
 Sometimes, however, — more often indeed than in cardiac dropsy — we have the 
 untoward complication of irritable bowels, or habitual diarrhcea ; and then drastic 
 cathartics are inadmissible. But when this complication is not present, they are 
 eminently useful. 
 
 Much benefit is sometimes derived from measures that act powerfully or steadily 
 upon the cutaneous transpiration ; and especially from warm, or hot-air, baths. The 
 hot-air bath is, in many rpspects, preferable to the common warm-water bath, and 
 even to the vapour bath. Upon the principle of heterogeneous attraction, the escape 
 of the liquid from the surface of the body is more promoted by a dry heat than by 
 water artificially raised to a high temperature, and even than by an atmosphere made 
 moist, as well as hot, by vapour. The risk, moreover, of exposure to cold, and the 
 inconvenience and hazard of fatigues, are much less : for the hot air can be brought, 
 with but little trouble or expense, to the patient as he lies in bed. I have often 
 applied the sudatorium to patients labouring under renal dropsy, and they have ob- 
 tained much relief from it : but the relief is seldom of itself sufficient, or of more 
 than temporary duration. Still it is an expedient that should never be neglected; 
 and in pursuance of the same indication, diaphoretic medicines should at the same 
 lime be diligently exhibited. Dr. Osborne states that when the renal disease has 
 been uncomplicated with other organic mischief, he has always found the dropsy to 
 disappear upon the re-estabhshment of the functions of the skin. 
 
 These measures failing — as fail they often will ; and diarrhoea forbidding the use 
 of drastic purgatives ; or drastic purgatives and diaphoretics together proving insuf-
 
 TREATMENT 895 
 
 ficient ; we miisf, even in renal dropsy, choose the least of two evils ; or rather we 
 must incur the risk of one possible and contingent evil, for the chance of obtaining 
 what, if obtained, is a certain and positive benefit ; we must endeavour to remove 
 the dropsical accumulation by means oi diuretics, whether these accelerate the pro- 
 gress of the disease in the kidney or not. 
 
 Such diuretics, therefore, are, in the first instance, to be selected, as seem the least 
 likely to stimulate the kidneys injuriously. The bitartrate of potass has been found 
 one of the most certain and useful. Digitalis also is esteemed safer, and therefore 
 more proper for this purpose, than many others : and the simultaneous exhibition 
 of these two has, perhaps, the surest effect of all. 
 
 When diuretic medicines act as we intend them to do, and increase the quantity 
 of urine, they are commonly of great service by reducing the dropsical swelhng. 
 But they are apt to be very capricious and disappointing. In some unhappy caseL 
 of renal dropsy I have tried every known form and combination of diuretics without 
 augmenting the secretion from the kidneys. And sometimes, although a plentiful 
 discharge of urine takes place, no impression is made upon the anasarca. 
 
 It is yet an unsettled question whether mercury be advisable, or even admissible, 
 in these cases. The current of medical opinion sets against it ; perhaps too strongly. 
 It has been observed that salivation is apt to be produced by a small quantity of this 
 drug; and to be unusually troublesome and severe, without bringing any commen- 
 surate advantage. I mentioned to you formerly Dr. Farre's opinion, that mercury 
 has the property of rapidly destroying red blood : if so, it must be regarded rather 
 as an ally, than as an antagonist, of this malady. On the other hand, some patients 
 have appeared to recover altogether, after passing through a furious salivation. One 
 of the reputed virtues of the mineral is that it promotes interstitial absorption — a pro- 
 perty which the changes apparent in the kidney in renal dropsy would seem to render 
 valuable. 
 
 When internal remedies prove inefTectual, and outward applications to procure 
 sweating miss their aim, we turn to those mechanical expedients which (in either 
 variety of general dropsy) often afford ease, and prolong life, and may even some- 
 times, perhaps, achieve a cure. 
 
 I have told you that the tense and stretched integuments occasionally give way ; 
 the areolar tissue sloughs, and from the breach thus made water wells copiously 
 forth, and great relief ensues. Sometimes, though very rarely, the whole of the 
 accumulated liquid has so escaped, and the dropsy has not reappeared. The sore 
 has healed, and the natural cure has been complete. 
 
 This spontaneous mode of draining away the liquid has been imitated by art. For 
 the unwieldy legs become painful as well as cumbrous; the integuments threaten 
 to inflame, or to mortify ; and if we can diminish the tension by removing a portion 
 of the included fluid, we avert or lessen this danger. The penis and scrotum also 
 in the male, and the labia pudendi in the female, become, in many cases, enormously 
 swollen, and hinder the exit of the urine, which is therefore spilled upon the tumid 
 parts, rendering them erythematous and raw, to the grievous aggravation of the 
 patient's sufferings. 
 
 Now, seeing that vesications sometimes form upon the dropsical limbs, and give 
 vent, in some degree, to the fluid, practitioners have been induced to follow that indi- 
 cation by exciting artificial blisters. But they are highly dangerous ; leading often 
 to gangrene of the surface thus inflamed. Within my recollection it was the custom 
 to make incisions, with a lancet, in the oedematous legs. These gashes seldom 
 healed again ; but degenerated into sloughing sores ; and not unfrequently they 
 hastened the dissolution of the patient. 
 
 A vast improvement upon these expedients is the modern practice of acupunc- 
 ture, which consists in perforating the integuments here and there with a fine 
 needle. 
 
 It is surprising how much fluid may be let out in this way ; and how much relief 
 may be bestowed by this trilling operation. The liquid trickles rapidly forth ; and 
 I have known it soak through the patient's bed, and form a pool on the floor of the 
 room. In one instance, a physician being the patient, the limpid fluid which ihu*
 
 896 ANASARCA. 
 
 oozed from a puncture in the thigh was caught, and collected in a glass, by means 
 of a little gutter of oiled silk. It was found that ninety minims, or a fluid drachm 
 and a half, escaped in a minute ; which is at the rate of eleven ounces and a quarter 
 in an hour: and this drain went on for upwards of four hours. 
 
 The surface on which punctures of this kind have been made, sometimes becomes 
 red ; erysipelas supervenes, which it is difficult to arrest, and the patient sinks. In 
 some of these cases the same event would probably have occurred, even although 
 no punctures had been ,made, from mere tension of the integuments, and the pro- 
 gress of the disease. When such appearances present themselves, the affected hmb 
 should be kept in the horizontal position ; and strips of hnen, wetted with a solution 
 of goulard, should be applied to the inflamed surface. 
 
 Under the old system of incisions it was found (and reason would teach us to 
 expect this) that there was more hazard of sloughing when they were made on the 
 legs, than on the thighs. The risk is much less when needles are used. But even 
 these punctures are not to be made without attending to certain precautions. They 
 should not be too near each other : an inch and a half, at least, should intervene be- 
 tween them. Neither should they be too numerous, nor too deep. The depth must 
 depend upon the circumstances of the case ; and especially upon the place where 
 the puncture is to be made. The needle must not be pushed so deep as to penetrate 
 or wound any fascia ; for the danger of subsequent inflammation would thereby be 
 increased. 
 
 The peritoneum may, at the same time, require to be emptied in the same 
 mechanical way, by help of a trocar. I am always loth to recommend tapping, until 
 the symptoms actually call for it, and until all other means of dispersing the water 
 have been tried in vain. But the circumstances that warrant or demand the per- 
 formance of the operation, the dangers that attend it, and the means of obviating 
 these dangers, were fully pointed out Avhen we were on the subject of ascites. 
 
 By whatever means we may succeed in getting rid of the dropsy, there will still 
 remain (except in the comparatively few cases that are unconnected with organic 
 disease, and depend simply upon debility and aniemia) the necessity for guarding 
 against the re-accumulation of the water, by remedial measures addressed to the 
 fauky organs. You may sometimes keep the disease of these organs in check, even 
 when you cannot cure it. 
 
 In cardiac dropsies, besides the medicines already specified, andeviating tem- 
 perance and regularity of life must be enjoined ; and the patient should carefully, 
 and always, avoid all active motion or exertion of the body, and all strong emotion 
 of the mind ; whatever, in short, might tend to hurry the circulation. You will 
 scarcely be able to enforce this prudence, without plainly showing the patient the 
 risk he will incur by its neglect. 
 
 In the renal variety of the disorder, in addition to the appropriate remedies alreadj'' 
 enumerated, particular attention must be paid to the avoidance of all exposure to cold 
 and vicissitudes of the weather, and to keeping the surface of the body warm. Such 
 patients should be constantly clothed in flannel from head to foot. To those who are 
 able to choose their place of abode, I should strongly recommend resort to a warm 
 climate. Some benefit may also be hoped for from counter-irritation — blisters or 
 issues to the loins. 
 
 The diet in the chronic forms of the disease should be nutritiv^e but unstimulating. 
 M. Solon suggests that if, in the renal cases, urea be detected in the blood, the 
 patient should be restrained from too animalized a diet. Dr. Budd has had the 
 Bame thought, and has put to the test, I believe in the Hospital-ship Dreadnought, 
 tlie utility of withholding all articles of food that contain azote. I have found this 
 restriction entirely useless in one painful case, in which it was fairly enforced. la 
 fact, tne principle of such restriction appears to be wrong : the urea is furnished to 
 the blood, not in the primary assimilative process, but in that which is secondary 
 and destructive. 
 
 One more point, and I have done. Much unnecessary penance used to be imposed 
 upon dropsical persons, by stinting their allowance of drink. It was natural to sup-
 
 CHYLOUS URINE. 
 
 pose that the accumulation would increase in proportion to the quantity of liquid 
 swallowed. But experience has shown this opinion to be erroneous, and 
 
 " Crescit indulgens sibi dirus hydrops" 
 
 has ceased to be more than a poetical doctrine. The patient may safely be allowed 
 to exercise his own discretion in this respect. When the peritoneum is full, distress 
 is apt to ensue upon the distension of the stomach by drinks ; but this source of suf- 
 fering is soon discovered and avoided. The sick man is better able than his physi- 
 cian to judge which evil is the greatest ; the torment of unslaked thirst, or the dis 
 comfort that may be produced by its immoderate indulgence. 
 
 LECTURE LXXX. 
 
 Chylous Urine. Hsematvria ; its diagnosis, general and particular ; Local dis- 
 orders of the Urinary Organs on which it depends ; Treatment. Abdominal 
 Tumours. 
 
 I HOPE I have convinced you that the morbid conditions of the urine are worth 
 studying. You have heard, probably, of the quacks who call themselves "water- 
 doctors," and who pretend that, by mere inspection of the urine of a patient living 
 at a distance, they can tell what is the matter with him, and how he may be cured. 
 This skill, which looks like conjuration, the scientific physician of the present day 
 does really possess. Of some very important forms of constitutional disorder, and 
 of some specific local maladies, he reads the sure evidence in the sensible and 
 chemical qualities of the secretion from the kidneys. And I do not hesitate to say, 
 that a rightly instructed person might form a more accurate opinion respecting a sick 
 man fifty miles ofT, and prescribe for him more judiciously, upon being furnished 
 with a vial of his urine, than some practitioners whom I have known could do, if 
 they had the patient bodily before them. You may learn much (and so, no doubt, 
 you ought) by prying into the arcana of the night-chair : but you may learn more,- 
 I am persuaded, by the habitual perusal of the chamber-pot. 
 
 1 have not yet quite done with the subject. 
 
 Sometimes urine is voided whi/^h appears to contain chyle. It looks white and 
 milky, and stiffens as it cools into a tremulous jelly, like blanc mange, and takes the 
 shape of the vessel into which it was passed. The coagulum gradually separates 
 again into two portions : one of which is liquid and whitish, and when left at rest for 
 a few hours, throws up to the surface a sort of creamy matter, containing (as cream 
 does) a butyraceous or oily principle : the other is a delicate fibrinous mass, of flesh- 
 like appearance, having a red tinge from the presence of some of the colouring 
 matter of the blood. This is the character of the urine passed a few hours after a 
 full meal. When the patient has long been fasting, the urine is simply opalescent, 
 and the coagulum, small and partial. 
 
 Dr. Prout attributes this curious deviation from the natural qualities of the urine 
 to a double fault ; first, in the organs of assimilation ; secondly, in the functions of 
 the kidney. The chyle, from some derangement of the assimilative process, is not 
 raised to the blood standard ; and being unfit for its purpose, is ejected through the 
 kidneys ; and these organs, instead of converting it, as usual, into the lithate of am 
 monia, suffer it to pass through them unchanged. 
 
 Of this rare disorder I have not met with an instance. Dr. Prout has seen more 
 or less of thirteen cases. Five of the patients were males, eight females. Two of 
 the males, and one of the females, were below the age of puberty. Seven of the 
 cases occurred in natives of the East or West Indies, or in persons who had lived 
 for many years in hot climates. Mr. Thomas informs me, that during a residence 
 of ten v^ars in Barbadoes, he saw at least a dozen well-marked exaiaples of chyloiu 
 ".57
 
 898 HiEMATURIA. 
 
 urine in negroes. It would seem, therefore, that a tropical climate predisposes cer- 
 tain individuals to this affection. In one case, drinking cold water while the body 
 was warm seemed to have been the exciting cause ; and exposure to cold was thought 
 to have had something to do with the attacks in other cases. 
 
 The general health suffers less than you might suppose. Two of the females, 
 while labouring under the complaint, became pregnant, and brought forth healthy 
 children ; and one of the two lived nearly twenty years, with the disorder upon hei 
 all the time. 
 
 In the slighter cases there is usually some degree of feverishness, some uneasi- 
 ness in the back and loins, some thirst, a dry skin, and torpid bowels. When the 
 malady is more severe, the symptoms approach to those of diabetes ; the thirst is 
 more urgent, the appetite unnaturally craving ; and there is some degree of emacia- 
 tion and debility. In this severer variety the urine is apt to coagulate before it leaves 
 the bladder; and the patient experiences difficulty in passing it, the urethra being 
 blocked up by the clots. Dr. Prout states that he has known this to constitute the 
 most troublesome symptom of the disease. In one of the fatal cases the body 
 was examined, and the kidneys found perfectly healthy. Occasionally the com- 
 plaint ceases of its own accord, even for years, and then recurs, without any 
 apparent cause. We may conclude from these circumstances that it is n purely func- 
 tional disorder. 
 
 With respect to treatment, little can be said. Dr. Prout has found several things 
 of temporary service, in the chronic state of the affection. The mineral acids ; astrin- 
 gents, such as alum, and the acetate of lead ; opium ; counter-irritation. But the 
 suspended symptoms have always soon returned. 
 
 Lastly, the urine may contain blood: and I proceed to consider some of the phe- 
 nomena that occur in connection with hxmaiurla ^ under which term 1 would com 
 prebend every kind of bleeding from the urinary organs. 
 
 Blood alters, of course, the colour of the urine with which it is mixed ; giving it, 
 in some instances, a bright red tinge, and causing it, in others, to assume a dark hue ; 
 to become brown, like coffee, or even to approach to blackness. Hence we are some- 
 times too ready to conclude that urine of a distinctly red colour, or so very dark as 
 to appear almost black, derives its peculiar tint from blood that has somehow mingled 
 with it. 
 
 But. in truth, urine may be perfectly red, or nearly black, and yet be quite free 
 from blood. There are certain substances which, when taken as food, invariably 
 impart a red colour to the urine. One of these is the prick Ijr pear, or Indian fig as 
 it is sometimes called, the cactus opimtla of botanists. When the Spaniards first 
 took possession of America, many of them were alarmed by observing that they 
 passed what they supposed to be bloody urine : bat it was soon discovered that the 
 red colour of the secretion was owing to the liberal use they made of that fruit. Dr. 
 Hennen, in his book on MilUary Surgery, quotes a precisely similar example from 
 Elliot's Journal of his Travels for determining the boundary of the United States. 
 He says that "his people ate very plentifully of this substance at an island of the 
 iMississippi (Kayo-ani), and were not a little surprised the next morning at finding 
 their urine appear as if it had been highly tinged with cochineal. No inconve- 
 nience resulted from it. It would seem (he continues) that the juice of this plant 
 rnay be analyzed into a crimson dye by other processes besides that of the cochineal 
 insect." 
 
 Another vegetable substance with which, in this country, we are more familiar, 
 and which will produce the same effect, is beet-root. Desault relates the case of a 
 person who noticed that he every morning voided urine of a deep red colour; exactly- 
 such as would result from adding fresh blood to that hquid, except that no deposit 
 rook place The man became frightened at this, and consulted M. Roux, who, after 
 i>ome examination, began to suspect that the water owed its red appearance to some 
 other cause than the admixture of blood. It turned out that his patient was in the 
 habit of supping every night upon the red beet-root ; and as soon as, by M. Roux's 
 advice, he relinquished this article of diet, he was freed at once from his supposed 
 bloody urine, and froru his fears. 
 
 I
 
 HEMATURIA. W9 
 
 A similar tinge is said to be given to the urine by the use of madder as food, by 
 some species of strawberries, and by drinks made of sorrel. Logwood, which we 
 sometimes use in medicine, has the same effect. 
 
 It is right that you should know these facts : for by swallowing large quantities of 
 such substances, and by complaining of sensations which they do not really feel, 
 impostors may endeavour, without any difficulty, or pain, or danger to themselves, to 
 deceive others into a belief that they are suffering under some serious and disquali- 
 fying disease, and are proper objects of charity. Moreover, a knowledge of the 
 effects of these vegetable matters may sometimes enable you, as in the case men- 
 tioned by Desault, to remove unfounded anxiety and alarm from the minds of per- 
 sons who are innocently and unconsciously giving themselves red urine. 
 
 The natural tint of the urme inclines towards redness, independently of any 
 admixture of blood, in many instances of fever, and of acute inflammation. Occa- 
 sionally urine of a pink colour is passed by persons who are subject to obstinate 
 dyspepsia connected with organic disease. This pink tint is most apparent when 
 the water is contained in an opaque, shallow, white vessel. 
 
 Again, urine of so deep a colour as to be called, in common parlance, black, may 
 or may not owe that hue to the presence of blood. When blood is the cause of the 
 unnatural colour, the blackness must be ascribed to the chemical action of some free 
 acid upon the blood : as I showed you formerly to be the case with blood that is 
 vomited in hcematemesis. 
 
 1 also pointed out to you some little while since, that the urine, in jaundice, some- 
 times, seems to be black, when it is collected in large quantity, and in a deep vessel. 
 This colour is merely a concentration of yellowness, as appears at once by diluting 
 the urine with water. It then assumes a bright yellow colour. The aspect of the 
 skin in icterus will always secure you against mistaking or overlooking this cause 
 of black urine. 
 
 There has been observed, also, though very rarely, a form of black urine, de- 
 pending upon the presence in that £2cretion of a peculiar principle to which Dr. 
 Marcet gave the name of melanic acid. The only specimen of really black urine 
 that I ever saw, was shown to me by Dr. Prout ; who knew nothing, however, of 
 the circumstances under which it was voided. It appeared to me to be full of coal- 
 dust. 
 
 With these two exceptions, almost all urine that is of a very dark or blackish colour 
 owes that quality to the circumstance of its containing blood, which has been more or 
 less altered, by various causes, from its original appearance. 
 
 When blood is present in any considerable quantity, a portion of it subsides to the 
 bottom of the vessel, and may be recognized without any difficulty. And even 
 wh6n there is not enough blood to give a marked and characteristic deposit, a very 
 small admixture of it will be found to disturb the natural transparency of the urine, 
 rendering it of a smoke-brown or dull cherry colour; whereas the reddish or pink 
 urrne which contains no blood is clear and untroubled ; and if, on cooling, it throws 
 down a sediment, that sediment may be redissolved by heating the urine — a result 
 which does not take place when a portion of blood has been deposited. Another 
 rough test is, that a mixture of urine and blood tinges a piece of white linen dipped 
 into it, of a red colour. A better criterion is afforded by gradually raising the sus- 
 pected urine to the boiling temperature. If it contains blood, a grayish-brown floe- 
 culent precipitate, consisting of coagulated albumen tinged with the colouring matter 
 of the blood, will form, and gradually subside, and leave the supernatant liquid clear, 
 and with its natural tint. But if you use the microscope, that will furnish you with 
 the best evidence upon this point. If there be blood in the urine, there will be blood- 
 corpuscles, turgid or collapsed, diffused through the urine, or collected at the bottom 
 of the vessel : and whatever modifications they may present, they may always, Dr 
 Bird says, be identified by "their non-granular surface, uniform size, and yellow 
 colour under the microscope." 
 
 We have by no means accomplished the diagnosis when we have merely ascer- 
 tained that there is blood in the urine ; and that the case is a case of haematuna. 
 The question remains, of what is such haematuria a sign. The blood emerges from
 
 900 HiEMATURIA. 
 
 the urethra, but it may have been poured out at any point of a long and somewhat 
 complex tract of mucous membrane. It may have proceeded from one or both of 
 the kidneys ; from each or either ureter ; from the bladder ; from the prostate gland, 
 or from the urethra. 
 
 Hsematuria strictly idiopathic must be very rare. Cullen remarks that neither he 
 nor any of his friends had ever met with an instance of it. I shall mention presently 
 the only example of hemorrhage from the urinary organs, apparently idiopathic, that 
 has fallen under my own notice. 
 
 Blood is excreted with the urine in that acute affection of the kidney which I have 
 already spoken of as lying at the root of most, if not all cases of febrile dropsy. The 
 albuminous urine proper to the chronic form of Bright's disease sometimes contains 
 the colouring matter as well as the serum of the blood. Hsematuria is occasionally, 
 I beheve, vicarious of some other hemorrhage, and especially of bleeding from the 
 hemorrhoidal vessels : so that it is always right, in obscure cases, to inquire w^hether 
 the patient has been habitually subject to hemorrhage from the rectum ; and if so, 
 whether that hemorrhage is suspended. These cases have even been called hsemor- 
 rhoides vesicx. 
 
 Hcematuria occurs also, independently of any strictly local complaint, in the course 
 of certain disorders which affect the system at large ; especially in scurvy and pur- 
 pura hemorrhagica. Bloody urine is sometimes a symptom, and one of the most 
 fatal augury, in typhus fever, small-pox, measles, and the plague. 
 
 But setting aside these more general forms of hsematuria, let us inquire what local 
 affections of the urinary organs themselves may give rise to hemorrhage ; and how, 
 under different circumstances, we are to interpret this symptom. 
 
 One very common source of hemorrhage from the urinary passages, is the presence 
 within them of calculous matter. The pressure occasioned by the aggregation of 
 the earthy mass, when it is formed in the kidney, or by its accidental change of posi- 
 ion, lacerates, or lays open by ulceration, some of the smaller vessels with which 
 .t is in contact. And in those cases in which a calculus descends into the bladder, 
 and is ultimately voided, it may, in succession, give rise to hemorrhage, first from 
 the kidney from which it is separated ; secondly, from the narrow tube of the ureter 
 through which it is forced ; thirdly, from the bladder, which it enters, and wounds, 
 or irritates ; and fourthly, from the urethra in the last stage of its progress out of the 
 body. 
 
 There will be the same liability to hsematuria, if the concretion, instead of coming 
 down from the kidney, is formed originally in the bladder. The appearance of blood 
 in the urine suggests, therefore, in many cases, the fearful suspicion, that there is, or 
 is likely to be, a stone in the bladder. Dr. Heberden, in his Commentaries, says, 
 " urine made of a deep coffee colour, or manifestly mixed with a large quantity of 
 blood, has within my experience been very rarely the effect of any thing but a stone 
 in the urinary passages. I therefore suppose a strong probability of this cause, when- 
 ever I see this appearance." 
 
 Again, blood may proceed from the kidne}', or from the bladder, in consequence 
 of malignant fungous growths, to which those parts are liable : a disease which, 
 though more surely fatal than the stone, is scarcely, to the unhappy subject of it, so 
 appaUing. 
 
 Hemorrhage may take place from the surface of the bladder from chronic disease, 
 not cancerous, of that membrane. Mr. Howship has recorded an instance of this 
 kind which occurred in Mr. Heaviside's practice. An old East Indian, who had 
 long been subject to nephritic complaints, was suddenly seized with what was 
 ihought to be retention of urine. A catheter was passed, but as no water flowed, it 
 was supposed that it had not entered the bladder, in the situation of which there 
 was a manifest tumour. The patient died the next day ; and the bladder was found 
 distended by a very large coagulum of blood which had come from the diseased mu- 
 cous membrane. There was no trace of hemorrhage in the kidneys, nor in the 
 ureters. 
 
 I hold in my hand a preparation showing disease of the prostate gland, which had 
 been accompanied by hsematuria.
 
 HEMATURIA. 901 
 
 Now we judge of the exact seat of the hemorrhage, and of its cause, partly by the 
 nature and appearance of the effused blood, and partly by the symptoms that precede 
 or accompany the bleeding. 
 
 Dr. Prout states that " when blood is derived from the kidney, it is in general 
 equally diffused throughout the whole urine : on the contrary, when derived from 
 the bladder, the blood for the most part comes away in greater or less quantity at the 
 termination of the discharge, the urine having previously flowed off nearly pure." 
 
 There are also certain modifications of the sensible qualities of the excreted blood, 
 by means of which the same distinguished physician thinks he can pronounce, with 
 considerable confidence, that the hemorrhage is owing to malignant disease. "The 
 red particles of the blood (he says) discharged in the earlier stages of fungoid dis- 
 ease, have often a remarkable appearance, and appear to the eye larger than natural; 
 so that after they have subsided to the bottom of the urine, they at first sight some- 
 what resemble grains of lithic acid gravel, and, like that substance, when the vessel 
 is inchned, may be distinctly seen to roll along the bottom. From this peculiar ap- 
 pearance of the red particles of the blood, the presence of malignant disease may be 
 often suspected before the symptoms assume a decided character." .In a more ad- 
 vanced stage of the disease, there is often a dark-coloured offensive bloody sanies in 
 the urine, and more or less of mechanical impediment in passing it. I should con- 
 ceive that the microscope might aid the diagnosis of such cases. 
 
 There is one phenomenon which, whenever it occurs, is very characteristic of 
 hemorrhage from the kidney, or the commencement of the ureter. I mean the ex- 
 pulsion, with the urine, of slender cylindrical pieces of fibrin, which have evidently 
 been moulded in the ureter, and subsequently washed down into the bladder by the 
 descending urine. These little coagula are commonly of a whitish colour, the red 
 particles of the blood having been removed ; and they look like slim maggots, or 
 small worms. They denote, with much certainty, that the hemorrhage which they 
 accompany is renal. 
 
 Such, then, are some of the points of diagnosis furnished by the qualities of the 
 excreted fluid itself. 
 
 The bleeding may be presumed to come from the kidney, or from the upper part 
 of the ureter, when it is accompanied or preceded by a sensation of heat, or of 
 weight, or by some degree of pain, in the situation of the kidney ; especially if these 
 uneasy feelings are confined to one side of the body. This presumption will of 
 course be strengthened if calcuh have been known to descend from the kidney ; and 
 converted into certainty if the patient suffers, together with the hasmaturia, a fit of 
 the gravel ; and if there be no symptom of stone, or of disease, in the bladder. 
 
 On the other hand, when no symptoms referable to the kil^ney or the ureter are 
 present, while there are signs of stone, or of disease of the bladder, or of a diseased 
 prostate- — a mixture of mucus with the blood ; occasional retention, or a sudden stop 
 in the stream of urine ; pain referred to the glans penis immediately after the 
 bladder is emptied — then we conclude that the blood proceeds originally from thai 
 receptacle. 
 
 When pure blood comes away, either guttatim, or in a stream, unmixed with urine, 
 and neither preceded nor accompanied by any desire to make water, it is probable 
 that the itrefhra is the locus of the hemorrhage. 
 
 Bleeding from the surface of the urethra doubtless niay, and commonly does, pro- 
 ceed from some mechanical injury done to that channel: as in the passage outwards 
 of a fragment of stone, or inwards of a surgical instrument. But it is probable that 
 blood is sometimes exhaled from the same membrane in considerable quantity, under 
 circumstances which favour or produce a strong determination of blood to the genual 
 organs. A young man came to the Middlesex Hospital with hemorrhage from 
 the urethra, and said that he had lost a considerable quantity of blood in this way, 
 within a few hours. The hemorrhage appeared to have been the consequence of 
 excessive indulgence in sexual intercourse. His own account of the matter was 
 that he had passed the night with a female, in whom the monthly period had jusi 
 returned ; and he ignorantly fancied that the hemorrhage from his own person wti3 
 the result of a sort of contagion. However, the bleeding was permanently arrestee! 
 
 4a
 
 902 HEMATURIA. 
 
 by the introduction of a bougie, which was allowed to remain for a short time in 
 the urethra. This was the solitarj^ instance to which I alhided just now, of (perhaps) 
 idiopathic hemorrhage, occurring within my own knowledge. When the hemor 
 rhage comes originally from the urethra, the blood may regurgitate into the bladder, 
 and coagulate there ; and mislead an observer into the belief that the hemorrhage 
 was vesical. 
 
 It appears, then, that, in many instances, certain local symptoms are associated with 
 hcematuria, and point distinctlj^ to the part of the urinary apparatus whence the blood 
 proceeds. 
 
 But many cases are very obscure. Blood sometimes appears, mixed in greater or 
 less quantity with the urine, when there is no pain, nor any other sign which would 
 lead us to fix upon one part rather than another as the source of the hemorrhage. 
 Now I believe that hasmaturia, bearing this indeterminate character, will generally 
 turn out to be rcnuJ, and to depend upon earthy concretions in the kidney. It is 
 true that the hemorrhage which results from cancerous disorganization, whether of 
 the kidneys or of the bladder, may also be painless. But cancerous disease of 
 these organs (unless it extends from parts in the neighbourhood, as from the rectum, 
 or from the uterus, to the bladder) is very rare ; and when it does occur, the nature 
 of the case ma]' usually be ascertained from those peculiar qualities of the effused 
 blood which I have mentioned as being characteristic of malignant growths. 
 
 A calculus can seldom remain long in tjie bladder, at any rate will seldom cause 
 bloody urine, without giving some other notice of its presence there : but concretions 
 form in the kidney, sometimes in great numbers, and reach a considerable size, and 
 remain there long, without furnishing any signal from which we might suspect their 
 existence ; except (perhaps) the occurrence of hcematuria. We know this, because 
 calculi are frequently met with in the kidneys of persons Avho had never suffered 
 anA' pain or obvious derangement of the urinary organs during life ; and because, in 
 other persons, in whom such calculi pass down from the kidney towards the bladder, 
 the first notice of their existence is often given by the acute suffering they inflict 
 during their transit through the narrow ureter. 
 
 Yet though calculi may lodge in the infundibula, or in the pelvis of the kidney, 
 without manifesting their presence by exciting pain, it is very conceivable that, by 
 progressive enlargement, they may lay open, or by accidental change of position 
 they may wound, some of the smaller blood-vessels of the part, and so give rise to 
 painless hfematuria. It will strengthen the presumption that such is the source of 
 the bleeding, if it has succeeded (as hemorrhage from the urinary passages often 
 does succeed) to a fall ; a shock, or jar of the body ; or jolting on horseback or in a 
 carriage. Similar movements may occasion bloody urine when there is stone in the 
 bladder; but then the irritation will he felt in that sensible part; the hfematuria will 
 not be painless ; the bleeding will not be the only symptom. 
 
 It is, then, I say, my belief that very many of the obscure cases of hfematuria may 
 be referred to renal calcuU : and if this view of the subject be correct, it will render 
 it probable that the alleged instances of. idiopathic hemorrhage from the kidneys 
 oucfht thereby to be reduced in number. 
 
 The expulsion of the blood in hcematuria, whether it be painful or not, is sometimes 
 attended with severe rigors. I mentioned before, that, in some persons, almost any 
 irritation of the urethra, the passing a bougie, for example, will bring on a shivering 
 fit. I had some time ago a patient under my care in the hospital, who had hsema- 
 turia of an obscure kind, and the discharge of blood was always marked by a smart 
 rigor. Dr. Prout speaks of an instance of obstinate hsematuria in which a shaking 
 fit constantly preceded hemorrhage. Dr. EUiotson, too, in one of his lectures, gives 
 •^n account of a case of intermittent hasmaturia. The patient was under his care 
 m St. Thomas's Hospital, and had formerly had the Walcheren fever. He was 
 admitted for ague, and every time that the cold stage of his attack came on, he voided 
 a quantity of pure blood from the urethra. He was cured, by quina, both of his ague 
 and of his hemorrhage. 
 
 If we may trust to the records of physic, instances of periodic hsematuria are not 
 oncommor.
 
 HEMATURIA. 003 
 
 One circumstance yet remains, worth noticing, in respect to htematuria ; and it 
 depends upon tlie hemorrhage itself rather than upon the disease of which the bleed- 
 ing is a sign. I allude to the coagulation of the effused blood in the bladder, how- 
 ever it may have got there. This circumstance is sometimes the source of much 
 inconvenience, and suffering, and even of danger, to the patient. It may cause reten- 
 tion of the urine and all its evil consequences ; and a still worse event is, that the 
 coagulum sometimes supplies a nucleus, around which calculous matter is deposited, 
 and thus lays the foundation of that horrible malady, " the stone." 
 
 You will perceive, from what I have said, that the /rca/??te/i/ of hcematuria resolves 
 itself, in most cases, into the treatment of the disorder, or bodily condition with which 
 the hemorrhage is associated, and of which it is merely a symptom. 
 
 Sometimes, however, the bleeding itself is so profuse, or so long-continued, as to 
 require direct efforts on our part towards its restraint. 
 
 " When (says Dr. Prout) the bladder becomes distended with blood, and complete 
 retention of urine in consequence takes place, recourse must be had to a large-eyed 
 catheter, and an exhausting syringe, by the aid of which, and the occasional injection 
 of cold water, the coagula may be broken down and removed. If the hemorrhage 
 be so profuse that the bladder becomes again distended with blood in a very short 
 time, the injection of cold water into the rectum or bladder is sometimes of great use; 
 and should these means fail, from twenty to forty grains of alum may be dissolved in 
 each pint of water injected into the bladder; a remedy that seldom fails to check the 
 bleeding, even when the cause is malignant disease. I have never known any 
 unpleasant consequences follow the use of this expedient, and have seen it imme- 
 diately arrest the most formidable hemorrhage, when all other means had failed ; 
 and when the bladder had repeatedly become distended with blood, almost imme- 
 diately after its removal." 
 
 Among remedies given by the mouth, the same physician thinks highly of the 
 acetate of lead. I have mentioned before, in these lectures, a nostrum called, after 
 the name of its inventor, Rnspini's styptic. This has often been known to put a 
 stop to hemorrhage which had resisted other remedies. I will read you one example 
 of this from Sir Benjamin Brodie's published lectures. Speaking of hfematuria, 
 dependent upon disease of the prostate gland, he says : " Those medicines which 
 operate as styptics when taken internally, and which are useful in cases of hemor- 
 rhage from the lungs, are also useful in hemorrhage from the prostate. I had a 
 patient with very diseased prostate. A frightful hemorrhage took place. The usual 
 methods of treatment were adopted, but were of no avail. The skin became pale, 
 the pulse became weak, and the patient was exhausted ; yet the bleeding continued. 
 Large quantities of blood were drawn off with the catheter : nevertheless the bladder 
 continued to become more and more distended with blood, and was felt prominent in 
 the belly as high as the navel. All other remedies having failed, I gave the patient 
 a dose of the nostrum known by the name of Ruspini's styptic, and repeated the dose 
 two or three times in the course of the next twelve hours. In about half-an-hour 
 after the iirst dose was taken the hemorrhage ceased ; and it never returned. The 
 patient lived a year and a half afterwards, and there was no reason to beheve that 
 any ultimate harm arose from the bleeding." 
 
 For a long while this nostrum seems to have baffled analysis. The late Dr. 
 Maton told me that Dr. Wollaston had examined it, and had arrived at the negative 
 conclusion, that it contained no metallic substance. Dr. A. T. Thomson has since 
 announced that it mainly consists of a solution of gallic acid in alcohol diluted with 
 rose-water. 
 
 There is no substance more highly spoken of as a remedy for internal hemorrhage^ 
 by foreigners, and especially by the French, than the extract of Rhatany root, the 
 Krameria of our Pharmacopffiia. A female was sent to me by my colleague, Mr. 
 Arnolt, complaining that for some weeks she had been passing bloody urine. She 
 had gone through the ordinary routine of treatment without benefit. There were no 
 symptoms present which threw any light on the precise source or cause of the 
 hemorrhage. I recommended a trial of the rhatany, and she began to take a scrupi*:' 
 of the extract, mixed with water, three times a day. As in Sir Benjamin Brodie's
 
 904 ABDOMINAL TUMOURS. 
 
 case, the hfematuria ceased after the first dose, and it did not return for many months. 
 I mention this instance the rather, because the gallic acid enters into the composition 
 of this vegetable extract also. 
 
 Now the gallic acid is one of those substances which, when introduced from the 
 digestive organs into the blood, passes through the round of the circulation unchanged, 
 and reappears in the urine. We may conceive, therefore, that it stays internal hemor- 
 rhage by exciting its astringent property upon the ultimate capillary blood-vessels in 
 its passage through them. It certainly is applied, in solution, after its elimination 
 from the blood, to the urinary passages : and thus, in hsematuria, it may be presumed 
 to produce its styptic effect upon the bleeding surface. 
 
 To the same principle are owing, I believe, the astringent and styptic virtues of 
 the uva ursi, bistort, tormentil, the pomegranate, kino, catechu, and the several pre- 
 parations of gall nuts. I am sorry that I have not had much opportunity of trying 
 ihe gallic acid itself, in its separate state ; for I have neard of several instances of its 
 successful employment in cases of internal hemorrhage. If, as I beheve, it really 
 has this power, it is very desirable that it should be prescribed in a more definite and 
 precise manner than is afforded by its natural combinations with so many different 
 vegetable matters. 
 
 I am unwilling to take leave of the cavity of the abdomen, without saying a few 
 words (very iew they must be) respecting the various kinds of tumour to which it 
 is obnoxious. It may seem strange that the diagnosis of abdominal tumours, which 
 manifest themselves to the touch, and to the sight, should be so difficult and puzzling 
 as it often is. I mentioned some reasons for this before : the loose and shifting man- 
 ner in which some of the viscera of the belly are packed and fastened ; their fiabilitj'- 
 to enlarge beyond their natural limits ; their accidental dislocations under disease. It 
 would be vain to attempt even a sketch of the infinite variety of these deviations 
 from the healthy state. Every case of abdominal tumour forms a separate object of 
 study, and must be judged of by its proper circumstances. All that I can profess to 
 do, is to offer you some rough hints on this interesting subject. 
 
 Some kinds of tumour result from morbid growths; such are all the varieties of 
 cancer: some from the presence and multiphcation of parasites ; of which we have 
 examples in collections of hydatids : some are produced by the distension of hollow 
 organs ; as when concretions, or fecal matters, or gases, lodge in the intestines ; or 
 when urine accumulates and is pent up in the bladder: some consist in the mere 
 enlargement of parts. 
 
 Let us enumerate the principal of these ; that you may know what chiefly to 
 expect. 
 
 1. There are, I say, tumours from lodgments in the bowels _: and these are more 
 hopeful than most kinds of abdominal tumours. Sometimes the stomach, or some 
 part of the intestinal canal, is distended in consequence of a mechanical impediment 
 to the course of its contents : and this impediment may be invincible. 
 
 2. Ovarian tumours are very common. Of these I spoke at some length in a 
 former lecture. 
 
 3. The liver is very liable to enlargement : either from simple congestion of 
 blood; or from the interstitial deposit of adipose matter; or from the intrusion of 
 malignant growths ; or from colonies of hydatids. 
 
 4. So also the spleen swells, from fullness of blood, or from specific deposits in us 
 substance. 
 
 5. The kidneys sometimes attain a <zait size ; being occupied by malignant disease, 
 ')r swollen by pus that finds no vent. 
 
 (5. Enlargements of the mesenteric glands ; cancerous degeneration of the peri- 
 toneum, especially where it forms the omentvm ; tumours connected with the uterus ; 
 nneurisms of the aorta; vast distension of the gall-bladder; constitute other species 
 of abdominal swelling, which I simply mention without further comment. 
 
 Now oui judgment of the character of a given tumour is naturally influenced by 
 'ts place. In the right hypochondrium, we suspect the fiver; in the left, the spleen ; 
 n ihti epigastric region, the stomach ; in the hypogastric, the womb, or the bladder",
 
 ABDOMINAL TUMOURS. 905 
 
 ;n either flank, an ovary, or perhaps a kidney ; in the track of the colon, we guess 
 at fecal collections. 
 
 But sometimes the situation of the tumour fits more than one, or than two, sup- 
 positions. Between the ribs and the ilium on the right side we may have an 
 enlarged ovary, a tumid kidney, a distended ceecum. A prominence in the epigas- 
 trium may be due to cancer of the stomach, to an infarcted transverse colon, to a 
 ventral aneurism. Above the pubes, the distended bladder, or the enlarged uterus, 
 may equally project. The sigmoid flexure of the colon loaded with feces, the left 
 kidney exaggerated by disease, a bulky ovary, may either of them occupy the same 
 sinistral space. 
 
 Moreover, the colon deviates strangely, and not seldom, from its natural course and 
 position : and the magnified viscera may invade, by their displacement, or by their 
 h'regular expansion, the regions that are proper to other organs. 
 
 Our conjectures are assisted by the associated symptoms, and by observation of 
 the regular performance, or of the disturbance, of particular functions. Yet here, 
 also, we meet with continual sources of fallacy. Pressure from a tumour without 
 may, as well as infarction wilhin, impede the passage of alimentary matters through 
 the bowels, of urine through the ureters ; and cause, in the one case, flatulence and 
 tormina, in the other, retention or suppression of urine. Growths foreign to the liver 
 may, nevertheless, press upon its excretory ducts, and occasion jaundice. And so of 
 other parts and functions. I mean, that the functions prominently deranged are not 
 always the functions of the part occupied by the tumour, but of organs which are 
 secondarily and accidentally subjected to its disturbing influence. Your sagacity 
 will be abundantly tried in balancing the evidence of different symptoms in these 
 obscure, yet palpable, forms of disease : and after all you will often doubt ; and often, 
 when you do not doubt, you will mistake. 
 
 Enlargement of the fiver may usually be distinguished from other tumours of the 
 right hypochondrium, by y9ercws.sio?i. Try from the clavicle downwards. At first, 
 you get a hollow sound. Then, a little below the nipple perhaps, (for the spot varies 
 much in different subjects,) the sound begins to grow dull. If this dullness be trace- 
 able, without change or interruption, to the tumour, the inference is strong that the 
 tumour is hepatic. Any other tumour there situate leaves, most commonly, when 
 the patient is recumbent, a palpable sulcus above it : or a space in which the sound, 
 upon percussion, is different from that which is yielded by the fiver. 
 
 Percussion helps us to discriminate an ovarian from a renal tumour. When the 
 swelling is large, the intestines lie behind the one, in front of the other : and the 
 sound is affected accordingly. 
 
 Tumours that are readily movable, are generally intestinal, omental, or ovarian. 
 
 A pulsating tumour is not necessarily an aneurism. The healthy artery will fift 
 almost any sort of hard swelling that happens to lie directly over it. 
 
 The occurrence of hsematemesis or melgena would corroborate your belief that a 
 tumour in the right hypochondrium was hepatic — in the left, was splenic. 
 
 Even when you are satisfied as to the organ affected, there comes another ques- 
 tion, scarcely, in some cases, less difficult than the first — What is the nature of the 
 tumour? 
 
 Suppose, for the sake of illustration, that your inquiry relates to the liver. If the 
 tumour be large, smooth, roundish, of slow growth, and the general health be not 
 materially deranged, it is most likely an hydatid tumour. If, along the edge and 
 upon the surface of the augmented liver, you can feel large inequalities and projec- 
 tions, and if the complexion and general state of the patient are expressive of failing 
 health, the enlargement is, in all probability, cancerous : and if there be other traces 
 of carcinoma in the system, this conclusion becomes almost certain. Small hard 
 irregularities betoken the hobnail liver; which is, sooner or later, accompanied by 
 ascites. When, without pain or jaundice, the liver of a phthisical patient trans- 
 gresses its natural boundaries, it is, presumably, a fatty liver. 
 
 By applying a similar method of investigation to other ventral enlargements, you 
 may frequently hit the right scent, and trace the mischief to its true source. T* 
 treat the subject in detail would require a volume. I may refer you to a series o*" 
 
 4a3
 
 906 ACUTE RHEUMATISM. 
 
 papers by Dr. Bright, in the Giiy^s Hospilal Reports ; where you will find a host 
 of examples, and much valuable informalion, concerning the most common and the 
 most important kinds of "abdominal tumours and intumescence." 
 
 LECTURE LXXXI. 
 
 Acute Rheumatism; Symptoms; Varieties; Treatment. Chronic Rheumatism ; 
 
 Phenomena : Plan qjf Cure. 
 Gout: Description of a Paroxysm; Progress of the Disease ; General state of 
 
 the Health in Gouty Persons ; Causes of the Disease; Diagnosis between Gout 
 
 and Rheum,atism. 
 
 I PROCEED, this afternoon, to the consideration of that very common, very painful, 
 attd sometimes very perilous disease, rheumatism. There are two species of it, the 
 acute and the chronic. They graduate, however, insensibly into each other; and 
 the chronic is often a sequel of the acute form. Yet this is not necessarily so. 
 Chronic rheumatism occurs in persons who have had no preceding attack of the 
 disorder in its acute stage or degree. 
 
 Rheumatism implies inflammation: but as I mentioned in an early part of the 
 course, it is inflammation of a peculiar or specific kind. In the first place, it is in- 
 flammation of a particular tissue — \he fibrous tissue: and it may, therefore, manifest 
 itself wherever that tissue is employed in the fabric of the body. No doubt the in- 
 flammation does involve other tissues also : but it is ahvaj^s, probably, by extending 
 to them through what has been called contiguous sympathy. Thus we have the 
 synovial membrane of a joint inflamed in many cases, the inflammatory action having 
 spread from the fibrous textures around the joint : or, as 1 formerly pointed out to 
 you more in detail, the serous surface of the pericardium, and the serous surface (or 
 what is analagous to a serous surface) of the inside of the heart, and especially that 
 part of it which is carried over the valves — each and all of these serous membranes 
 are extremely liable to be affected with inflammation in the acute form of rheumatism: 
 but in all of them it is probable that the fibrous tissue was the first to suffer. The 
 pericardium is, as you know, a fibro-serous membrane ; and fibrous tissue is inter- 
 posed between the folds of the serous membrane, in the cardiac valves. 
 
 Rheumatism, therefore, is essentially inflammation of the fibrous tissue : and it 
 most commonly seizes upon the fibrous parts that lie round the /a?'0"e/' Join/s ; the 
 ligaments and the tendons : and in this respect you may almost consider the perpe- 
 tually moving heart as one of the large joints. Yet this inflammation, when confined 
 to the fibrous tissues, is not common inflammation. At any rate, it does not reckon 
 among its events (as common inflammation does) either suppuration or gangrene. If 
 suppuration sometimes occurs (and it certainly occurs very rarely) it is because the 
 rheumatismal inflammation has extended to contiguous textures, and then has run 
 the ordinary course of inflammation. Inflammation of the areolar tissues around a 
 joint may thus inflame and suppurate. The inflammation of the synovial membrane 
 nuty be of sufficient intensity to give rise to the formation of pus. When, however, 
 the inflammation extends to the serous tissues within and around the heart, the pro- 
 ducts of the inflammaliorv are jus the same as when inflammation of the same tex- 
 ture, of the common kind, is any how produced. 
 
 Acute rheumatism, then, consists in redness, heat, pain, and swelling (that is to 
 say, in inflammation) of the parts lying around, or entering into the composition of, 
 one or more of the larger joirus of the bodj'- : general!}" of several at the same time, 
 or in succession ; with a disposition to shift from one joint to another, or to certain 
 internal organs, and especially to the membranes of the heart; and with fever. 
 
 This tendency to shift its place — to what is usually called metastasis — is a very 
 remarkable feature of the disease. The inflammation will appear in one joint sud-
 
 ACUTE RHEUMATISM. 907 
 
 denly, and as suddenly subside in another which it previously occupied ; and then, 
 perhaps, it will jump back again to its old quarters. In many instances, however, 
 it invades fresh joints without wholly 'ceasing, and sometimes even without diminish 
 ing at all, in those formerly affected. It may visit in this way every large joint in 
 the bod}', and even seize upon some of the smaller ones ; or it may possess nearly 
 all of them at once. It is most commonly seen to affect the ankles and knees, the 
 knuckles, wrists and elbows. It is often seated in the shoulders, also, and in the 
 hips. The joints of the fingers frequently suffer ; and I have seen one instance in 
 which the joints of the jaws were manifestly implicated in the rheumatic inflamma- 
 tion. But by far the most serious and dangerous leap which the diseased action is 
 apt to take, is to the membranes of the heart. 
 
 But I pointed out to you, in a former lecture, the symptoms of rheumatic car- 
 ditis, its consequences, the various ways in which it connects itself with the joint 
 affection, and the treatment by which we are to attempt to moderate it. I dismiss, 
 therefore, this, the most momentous complication of acute rheumatism, from the pre- 
 sent discussion, and shall confine myself solely to the disease as it manifests itself 
 externally. 
 
 The shifting and migratory inflammation of the textures lying round or composing 
 the larger joints, is attended with high inflammatory fever; with a remarkably full, 
 bounding pulse ; with flushed cheeks; headache; profuse, drenching, sour-smelling 
 perspirations, which distress and weaken the patient, but bring no relief to his pain; 
 with a white-coloured, dirtyish, thick fur on the tongue, which is red, however, at its 
 tip and edges ; with turbid and acid urine. But this severe and inflammatory fever 
 (si/nocha, CuWen calls it) has no tendency to degenerate into a typhoid form ; and 
 that is a striking feature in the complaint. Neither is the intellect affected, except 
 when carditis takes place ; and then, as I stated formerly, violent delirium is apt to 
 ensue, misleading the practitioner, drawing his attention away from the chest, where 
 fatal changes are in progress, and fixing it upon the head, where no inflammation at 
 all exists, but which is disturbed through sympathy with the cardiac disorder. 
 With this exception, we do not find patients in acute rheumatism delirious. Through- 
 out all this febrile disturbance, there is no coma, no marked trouble of the stomach 
 or of the bowels, no vomiting, no diarrhoea, no petechise, no aphtha;, no sordes about 
 the mouth, all which are of ordinary occurrence in the course of common continued 
 fevers. 
 
 The joints are exquisitely tender, as well as painful. The fibrous tissues, which 
 are endowed with but little sensibility in their sound and healthy state, become 
 acutely painful when occupied by inflammation. The pain is increased by pressure, 
 and therefore by whatever implies pressure ; by movements of the joints, conse- 
 quently. The patients are reduced to perfect helplessness by the pain. Their com- 
 mon phrase is, that they have entirely lost the use of their limbs ; and this is true 
 enough in fact, but not true in the medical sense of those words. They have not 
 lost. \\\e power oi moving them; there is wo palsy ; but iYiey dare not inovQ them, 
 because the effort gives them so much torment. 
 
 Pain in the affected joints is more constant than swelling, and swelling more con- 
 stant than redness. The swelling diflers also, in different cases, in rather a remark- 
 able manner. In fact, two varieties have been made of acute rheumatism. The 
 distinction was first drawn by Dr. Chambers, at St. George's Hospital, and after- 
 (\'ards made public by Dr. Francis Hawkins, in his Gulstonian lectures. The vari- 
 eties are spoken of under the names oi fibrous or diffused rheumatism, and synovial 
 rheumatism. I will briefly state their distinctive characters. 
 
 In the one, then, the inflammation commences in the immediate neighbourhood 
 of one of the larger joints : not in the joint, but near it. It attacks the tendons, 
 fasciae, ligaments, and possibly also the muscles. There is not at first much redness, 
 or swelling ; but after the pain has been of some duration, there is a puffiness around 
 the parts affected, caused apparently by turgescence of the blood-vessels, and at 
 length ?light pitting, or oedema, may supervene, from effusion into the surroimding 
 areolar tissue; and what redness is present is disposed in streaks, foUow'ng the 
 course of the tendons.
 
 908 ACUTE RHEUMATISM. 
 
 On the other hand, in the synovial variety, which shows itself more frequently 
 and more plainly in the knee than anywhere else, the pain which marks the onset 
 of the complaint does not last long before some degree of swelling is perceptible, 
 together, in most instances, with slight redness of the skin; and this swelling is not 
 due so much to turgescence of the blood-vessels, or to oedema of the areolar tissue, 
 as to fluid poured into the cavity of the joint. And the form and character of the 
 swelling indicate that it is the result of the fullness and distension of the synovial 
 membrane. It is tight and elastic, and protrudes, as it were, through the spaces that 
 intervene between the tendons and ligaments by which it is in other parts bound 
 down and restrained ; and JItccf nation is often distinctly perceptible in the superficial 
 joints, when both hands are apphed to them. 
 
 These are the local differences between the two forms of the disease. And there 
 are differences equally well-marked between the constitutional symptoms that attend 
 them. 
 
 It is in that form which xar ihx^iv is called fibrous rheumatism, that the inflam- 
 matory fever runs so high ; that the tongue is so thickly furred ; that the round, full, 
 bounding pulse occurs ; that the profuse, spontaneous, acid perspirations break out. 
 which exhaust the patient's strength without alleviating his sufferings ; that the urine 
 is high-coloured, and deposits a copious sediment like brick-dust. 
 
 In the synovial form, the fever is either less intense from the beginning, or soon 
 moderates after the joints begin to swell; the tongue is less foul; the patient sweats 
 much less. It is to this form that the term rheumatic gout is often applied. And 
 growing experience has led me to beheve, that in this popular appellation the real 
 nature of the complaint is most truly expressed. Gout and rheumatism are very 
 similar in kind ; and what has been called synovial rheumatism, while it forms a 
 connecting link between the two, and partakes of the characters of both, is more 
 nearly allied to gout than it is to rheumatism. 
 
 Conformably with this belief, it has been noticed that the tendency of the inflam- 
 mation to settle upon the cardiac membranes is much greater in the fibrous than, in 
 the synovial disease. This is a most important difllerence. 
 
 I know of no other exciting cause of acute rheumatism than exposure to cold, and 
 especially cold combined with, moisture. And this is the reason why the disease i' 
 very common among the poorer classes of society, who are more in the way of thai 
 cause, and cannot guard against it so effectually as their wealthier brethren ; among 
 whom it is comparatively rare. 
 
 Acute rheumatism is principally a disease of youth, prevailing most, I believe, 
 from the age of puberty to that of thirty-five or forty. I have repeatedly, however, 
 seen it in children ; sometimes as early as the third or fourth year ; and I slated to 
 you some time ago, that the chance of the joint affection being complicated with 
 rheumatic carditis is the greater in proportion as the patient is the younger. With, 
 perhaps, one exception, I never knew the disease occur in an unequivocal form before 
 puberty, without its being attended with inflammation of the fining or investing 
 membranes of the heart. 
 
 I have already told you what I believe to be the proper plan of treatment to pursue 
 when rheumatic carditis is present: in that case, the affection of the limbs is of 
 secondary consequence. But what are we to do when there is no complication of 
 the joint disease ; no invasion of any of the viscera ? 
 
 Why, if you seek for instruction upon this matter in books, or even among prac- 
 tic^l men, you will meet with a very perplexing diversity of opinion. Apart from 
 the cardiac afl^eclion, acute rheumatism has no danger about it ; and the articular 
 inflammation usually terminates, sooner or later, in recovery, whether the heart be 
 implicated or not. And most persons who have been for any considerable time in 
 practice have their own favourite method of conducting the disorder to its termina- 
 tion. While many employ free blood-letUng, and other active antiphlogisiic reme- 
 dies, some, on the contrary, even in the present day, put their trust in bark. Some 
 give large doses of calomel in the outset of the disease, such as half a scruple or a 
 scruple, with or without a grain or two of opium ; and they repeat the dose daily 
 or oftener, till the urgent symptoms give way ; and in this manner I have seen the
 
 ACUTE RHEUMATISM. 909 
 
 disease apparently cut short. But I have also known many instances in which the 
 disease was painful, and protracted, and obstinate, although this practice was adopted 
 early, and fairly prosecuted. Some physicians, again, give smaller and more fre- 
 quent doses of calomel and opium ; and some think opium alone to be as useful as 
 this combination. Others depend mainly upon colchicum ; others, upon large and 
 repeated doses of conium ; and some attempt the cure of acute rheumatism by 
 sweating the patient by means of guaiacum, and similar stimulant medicines, and a 
 profusion of bed-clothes. 
 
 Now you may be sure — when men's opinions, concerning the treatment of a dis- 
 ease which is of common occurrence and easy recognition, are thus unsettled and 
 diverse — you may be sure, first, that no specific for that disease has yet been disco- 
 vered ; and secondly, that the disease is not very obedient, or not steadily obedient to 
 any remedial plan. When I first began to practise, I pleased myself, now and then, 
 with the belief that I had ascertained the best cure for acute rheumatism : so rapidly 
 and decidedly did the disorder recede and cease upon the administration of such or 
 such a remedy. But, on the next trial of it perhaps, my expectations have been 
 miserably disappointed. This marked improvement has happened under the use of 
 colchicum, of conium, of calomel with opium, of alkahes. I did not, in the prosperous 
 cases, mistake spontaneous recovery for cure. The change was too great and imme- 
 diate, and the instances of success were too numerous, to admit of that explanation. 
 Whether it be (as I suspect) that shghter diagnostic marks have been overlooked, 
 and that sometimes goiit has in reality been cured under the semblance of rheuma- 
 tism — whether bodily idiosyncrasies have withstood the influence of remedies — or 
 whether atmospheric agencies have kept up the disorder in spite of proper treatment 
 — I cannot tell : certain it is that we are occasionally baffled, and the patient con- 
 tinues to suffer, notwithstanding the diligent enforcement of all the approved reme- 
 dies and plans of treatment, one after the other. I am far, however, from thinking 
 that remedies are useless : and I do by no means assent to the dictum of the first Dr. 
 Warren, who, when asked what was good for acute rheumatism, answered " six 
 weeks." 
 
 In the fibrous or genuine form, with the bounding pulse, the flushed face, the high 
 inflammatory fever, you may bleed your patients from the arm ; especially if they 
 are young and robust. They will bear to lose a large quantity of blood without, 
 fainting; and you will always find the blood drawn to be remarkably buffed and 
 cupped. The pain and inflammation are 'ocal ; but the case is not adapted to local 
 remedies. W^e may, by leeches, or cupping, or cold applications, be able perhaps 
 to subdue the inflammation in a knee or an elbow : but from the migratory character 
 of the disorder, we incur the risk, by such topical measures, of giving the inflamma- 
 tion a new and a more serious location. 
 
 Venesection will, almost always, afford a marked degree of relief to the sufferings 
 of the patient : but the relief will seldom be complete or permanent : and we may 
 sometimes with propriety repeat the bleeding. In very few instances, however, can 
 we hope to extinguish the disease by blood-letting. And this is one of the cases in 
 which you must not take the state of the blood already drawn as a criterion of the 
 propriety of abstracting more. The blood will remain ready to show the buffy coat 
 long after the use of the lancet has ceased to be available or safe. 
 
 The advantages of blood-letting in this complaint are, first, the partial relief which 
 it bestows. It is seldom that the pain is not sensibly mitigated, and the fever calmed, 
 provided the bleeding has been carried to a proper extent, sufficiently soon. Secondly, 
 free and early venesection may sometimes perchance (but not often) cut short the 
 attack. This, however, is a favourable effect which you must not reckon upon, and 
 which I would not advise you to aim at. But, in the third place, blood-letting may 
 be serviceable, by preparing the body for other remedies : for calomel, opium, pur- 
 gatives, colchicum. 
 
 Yet, looking to my own practice in acute rheumatism, I find that although I am. 
 in the almost daily habit of treating it — for it is a disorder from which our wards are 
 never perhaps entirely free — I rarely prescribe phlebotomy. Many of the patients 
 come under our care at an advanced period of the disease ; when the time for bleed •
 
 910 ACUTE RHEUMAVISM. 
 
 \ng with an)' prospect of benefit has gone by. Some have been bled before their 
 admission. Others, in whom the rheumatic diathesis has become inveterate, are 
 sufiering recurrences of the malady: and neither does the recurrent disease require, 
 nor would the system bear, active and repeated depletion. In many instances, again, 
 the constitution has been battered and broken by a London life : while in others there 
 is no great intensity of febrile disturbance from the first. So that the cases in which 
 I am tempted to employ the lancet are really few and far between. At the same 
 time I can well believe — what I have often heard — that in the country, in young 
 persons of unimpaired vigour, in the first attacks of the disorder, and when the iti- 
 flammatory symptoms run high, venesection may be of much service in mitigating^ 
 the sufferings of the patient, and in facilitating his cure. 
 
 I believe few persons now adopt the plan of forced perspiration for the cure of 
 acute rheumatism. Formerly it was the fashion to give powerful sudorifics : Dover's 
 powder, or antimony, in large doses ; and the patient was " accinctus ad sudorem ;" 
 covered up in bed between thick blankets, with a hot bottle or brick at his feet. But 
 in the severe, unequivocal fibrous form of rheumatism the perspiration is profuse 
 without any artificial means being used to excite it, and it is not accompanied by the 
 smallest alleviation of the pain: nay sometimes the patients will teU you that they 
 are worse, in that respect, while the sweating continues. 
 
 The preparations of colchicum have sometimes, whether venesection has been pre- 
 mised or not, an almost magical effect in quelhng the disease. Frequently, when 
 most successful, (though that is by no means a necessary condition of their success.) 
 they exercise some marked influence upon the stomach and bow^els. Colchicum is 
 very apt to occasion deadly nausea and vomiting, griping, and diarrhoea, and when 
 these consequences ensue from its use, the inflammation of the joints often subsides 
 entirely. At any rate, if the rheumatism does not give way when the stomach and 
 bowels become thus affected, you may be certain that to push the colchicam further 
 would be useless. 
 
 Our wishes, however, and our expectations, from colchicum, are often doomed to 
 be defeated. I believe that in proportion as the synovial symptoms predominate, or 
 mix themselves distinctly with the fibrous — in proportion as the disease approaches 
 in its characters to gout — you may expect to be successful with colchicum. Large 
 doses are not requisite. Twenty minims of the wine or of the tincture may be given 
 every six hours, until some result is obtained. Or a grain of the inspissated juice, or 
 of the acetous extract of colchicum, every four hours. Under this treatment the dis- 
 ease sometimes vanishes within three or four days ; the medicine producing sickness 
 and purging, and the rheumatism, or the rheumatic gout, rapidly declining. Occa- 
 sionally the same favourable event takes place, although there has been no disturb- 
 ance in the stomach or bowels. 
 
 There are some cases which yield readily to calomel and opium : and in the fibrous 
 disease I think that calomel and opium are the remedies to which, after sufficient 
 bleeding, you will do well to trust. For it is under this character that the extension 
 of the disease to the membranes of the heart is so liable to happen : and if anything 
 can protect the patient against this fearful complication of a malady w'hich, previously 
 attended by no danger, becomes by this addition almost necessarily fatal — or if any- 
 thing can arrest the carditis before it leaves indelible mischief imprinted on the heari 
 — it is (in my opinion) mercury. 
 
 Dr. Hope has lately (1837) published an account of a particular mode of using 
 calomel and opium in this disease, which mode he learned from Dr. Chambers, and 
 which is followed, more or less closely, I fancy, by many other physicians. It is 
 said to be so successful that even the details of it ought to be known. The plan is 
 described as foUow^s : — After a full venesection, or even two, in the robust, but with- 
 out any bleeding in the feeble and delicate, eight or ten grains of calomel, with a 
 grain and a half of opium, according to the age of the patient and the severity of the 
 case, are administered every night ; and followed every morning by a strong black 
 dose, sufficient to ensure four or five stools at least. With this treatment is combined 
 ihrice a day, a saline draught containing from fifteen to twenty minims of the 
 vinum colchici, and five gmins of Dover's powder. When the pain and swelling
 
 ACUTE RHEUMATISM. 911 
 
 are greatly abated, if not almost gone (which Dr. Hope affirms to happen often 
 within two da_y3, and almost always within four), the calomel is omitted ; or it is 
 omitted sooner if the gums become at all tender. The opium, however, is con- 
 tinued to the amount of a grain or a grain and a half at bed-time ; and in severe 
 cases a grain also at noon is added ; and the colchicum, and the black dose, are 
 still given as at first. Dr. Hope considers it a case of exception if the patient be 
 not well in a week. 
 
 The following are stated by Dr. Hope as being the great advantages of this plan 
 of procedure: — 1. That the patient is generally sound, well and fit for work, in a 
 week or ten days after the pains have ceased. 2. That the gums are rarely affected, 
 especially if you previously ascertain that the patient has not a morbid susceptibility 
 of mercury. 3. That it is rare to see inflammation of the heart if the treatment is 
 early begun ; not oftener, he thinks, than in one of a dozen cases. 4. If the slightest 
 symptom of endo- or peri-cardilis does supervene, a few extra doses of calomel and 
 opium, given every four or six hours, will generally affect the constitution in twenty 
 or thirty hours, which, with two or three cuppings or leechings on the region of the 
 heart, almost always place the patient in a state of safety. 
 
 Now, believing that some such plan as this, made up of blood-letting in some cases, 
 purging, calomel and opium, and colchicum, is as good as can be pursued ; and in- 
 deed that, with individual modifications, it is very much pursued, especially in Lon- 
 don at present; still I cannot help feeling great doubt — doubt which I would will- 
 ingly not entertain — about all the advantages just enumerated. Too often we do 
 not see the patient till there is such disease of the heart present as is manifest to the 
 ear ; and then, as T stated in a former lecture, perfect recovery and repair seem 
 scarcely within the scope of possibility. Too often, when the patient is seen early, 
 the sj'stem refuses to admit of the specific protection of the full mercurial action. 
 There is a practical objection also to the exaction of four or five motions from the 
 bowels of these rheumatic patients every day ; I mean the inconvenience, the increase 
 of pain, and the fresh exposure to cold, occasioned by frequently going to stool ; and 
 this is a disadvantage likely to be particularly felt in hospitals. 
 
 Bark used to be highly thought of for the cure of acute rheumatism ; but it is only 
 Deneficial, or safe, during the convalescence. Where the system has been much 
 reduced or broken by the complaint, or by the disciphne the patient has undergone, 
 1 think that the decoction of cinchona is of service in fortifying the body against the 
 renewed agency of those causes on which the original attack depended. 
 
 Cases frequently occur which are neither absolutely acute, nor absolutely chronic. 
 The inflammation, without being intense in any one joint, lingers in many; and the 
 fever, though not entirely absent, is moderate. The joints are hot and painful, and 
 the skin is dry, and there is some thirst. To this intermediate character the term 
 subacute is sometimes applied ; and it will serve our purpose of distinction. 
 
 In this form of the disease, as well as in the more active form, the urine is almost 
 always loaded with lateritious matters, and strongly acid. Looking upon this as an 
 indication of treatment, I have prescribed alkalies, and with much success : the 
 liquor potassfe, for instance, to the amount of a drachm daily, for several days to- 
 gether ; keeping the bowels free by laxative medicine. Under this plan, more surely 
 in my experience than under any other, the urine clears, the pain abates, and the 
 joints are liberated. Nitre has been praised of late as being eminently successful 
 against rheumatism: I have not had much opportunity of trying it, but I should 
 think it likely to do good in these subacute cases. 
 
 There are two kinds of chronic rheumatism : one attended with local heat and 
 swelling, although the constitution at large sympathizes very little or not at all wuh 
 the topical inflammation ; the other characterized rather by coldness and stiffiiess ot 
 the painful joints. In the former of these the pains are increased by pressure, anr' 
 by movements of the limbs, and by external warmth ; the warmth of a bed, for ex 
 ample ; and there may be even some slight degree of pyrexia at night. In truth 
 this form of chronic rheumatism claims a near relationship with the acute, rn^o which 
 ii sometimes passes, and o/" which it is frequently the sequel. It accordingly requirei*
 
 912 CHRONIC RHEUMATISM. 
 
 antiphlogistic remedies, only less vigorously applied. It is important for you to know 
 that, in these cases, you may, with less hesitation, less fear I mean of driving the in- 
 flammation to some more vital part, apply leeches, and cold washes, to the painful 
 joints. Otherwise, the principle of treatment remains unchanged. The complaint 
 is, however, often obstinate, and lingering, and prone to recur. It frequently involves 
 and cripples the smaller joints, especially those of the knuckles and fingers ; render- 
 ing them knobby, and distorting their form and position. The fingers take a per- 
 manently oblique direction, slanting outwards towards the ulna : and Dr. William 
 Budd has drawn attention to the curious fact that the corresponding joints of the two 
 sides of the body are always affected exactly in the same manner. To use a para- 
 doxical expression, the deformity is symmetrical. One crooked joint is just the copy 
 of its fellow. Surely this indicates the constitutional origin of the disorder. 
 
 In the other form of chronic rheumatism, what some call passive, the remedies 
 that answer best are of a different kind. The pain is alleviated by friction of the 
 joint, and the patients are most comfortable when they are warm in bed, and espe- 
 cially when moderate perspiration is present. They are singularly benefited also 
 by summer weather. Persons who are much troubled by this wearing complaint, 
 and who can afford to live where they please, would do well to take up their resi- 
 aence in a warm climate. Wherever they may be, such patients should be protected 
 ao-ainst atmospheric vicissitudes by warm clothing : they should be cased in flannel 
 from the neck downwards. Warm bathing is of great service ; and especially baths 
 of salt water, of a temperature not less than 100°, that they may act as a stimulus to 
 the cutaneous circulation ; warm douches ; the vapour bath ; or the hot-air bath, of 
 which, as I said before, the patient may receive the benefit lying in bed. And to 
 warm clothing, and warm bathing, may be added friction, with some stimulating lini 
 ment, and what is called shampooing. It is in these cases that stimulating internal 
 medicines are often of use. Turpentine ; some of the animal oils, the cod-liver oil, 
 for instance ; guaiacum. Opiates, too, are frequently remedial of the pain : and 
 there can be no better form for their administration than that presented to us in the 
 celebrated Dover's powders ; the pidvis ipecacuanhsc compositixs of the Pharmaco- 
 pceia. 
 
 There is a remedy which has recently come into extensive use, for the relief of 
 chronic rheumatism; I mean the iodide of potassium. It is most certain of acting 
 beneficially when that fibrous part, the periostetnn, is principally aflxjcted. Its vir- 
 tues in the case of venereal nodes (/. e., in venereal inflammation of the periosteuiaj, 
 were first distinctly pointed out by Dr. Williams, of St. Thomas's Hospital. I believe 
 it is equally effectual upon whatever cause chronic inflammation of the same part, 
 with nodes and thickenings, may depend. 
 
 Some of you probably saw a woman who was lately my patient in the hospital, 
 and who had been worn down to a skeleton by the pain she had endured from 
 chronic periostitis giving rise to nodes, which did not appear to be traceable to 
 syphilis. She had been in the habit of lulling the pain by large opiates at night, 
 and begged to have them after her admission. I gave only the iodide in the ordinary 
 dose (five grains thrice daily), and she slept without opium ; and in a week or two 
 lost her nodes, and was perfectly well. 
 
 Cfosely allied to acute rheumatism, and yet distinct from it, is the singular dis- 
 ease which in this country is popularly called the spoilt: which CuUen, in the first 
 .nstacice, was disposed to term arthritis; but as arthritis would imply inflammation 
 of all or any of the joints, he afterwards adopted the ancient name of podagra (foot- 
 pain). 
 
 The same author has given, in his First Lines, an excellent account of the phe- 
 nomena which constitute a paroxysm of gout. It is copied from Sydenham, who 
 drew from nature : for he had himself suffered frequent and severe visitations of the 
 disease during a period of thirty-four years. 
 
 llie attack begins, most commonly, an hour or two after midnight. The patient, 
 who had gone to bed and to sleep in his usual health, and without suspecting wtiat 
 was about to happen, is awakened by a pain in one of his feet, mostly in the first
 
 GOUT. 
 
 joint or ball of the great toe ; but sometimes in other parts of the foot — the heel, the 
 instep, the ankle. With the coming on of this pain there is generally more or less 
 of a cold shivering, which gradually ceases as the pain gets worse, and is succeeded 
 by heat. The pain grows more and more violent and intolerable ; and is spoken of 
 by those who suffer it, as amounting to torture. It is a grinding, crushing, wrench- 
 ing pain ; or a burning sensation as if a hot iron were pressed into the joint. Some 
 humorous Frenchman described it in this way. " Place (said he) your joint in a 
 vice, and screw the vice up until you can endure it no longer. That may represent 
 rheumatism. Then give the instrument another twist, and you will obtain a notion 
 of the gout." The pain is attended with great restlessness and misery, and exquisite 
 tenderness. The patient cannot bear the weight of the bed-clothes upon the affected 
 limb ; nor the jar of a heavy foot-fall in his chamber. In a vain search after comfort 
 he is perpetually shifting his foot from place to place, and from posture to posture. 
 At length, about the ensuing midnight, the pain remits ; sometimes gradually, some 
 times so suddenly that the patient attributes the relief to his having at last found an 
 easy position. He falls asleep in a gentle perspiration, and when he wakes the next 
 morning he finds the part, which had been so painful, to be red, swelled, tense and 
 shining, surrounded by more or less cedema, and by turgid veins. The same series 
 of symptoms recur, in a mitigated degree, for some days and nights; and then the 
 disease often goes entirely off, not to return till after a long interval. 
 
 As the oedema subsides, and the redness fades, the cuticle of the part that has 
 been inflamed peels off; and this process of desquamation is generally attended with 
 troublesome itching. 
 
 Such is a picture of an attack of gout, occurring in an adult subject, for the first 
 time, and in its most regular and genuine form. 
 
 Attacks of this kind are preceded, in most instances, by some marked disorder of 
 the functions of the stomach ; diminished appetite, flatulence, heartburn, nausea per- 
 haps. And during the paroxysm the urine is very high-coloured, and acid, and 
 turbid ; depositing a copious pink, or brick-dust sediment. The stools, also, are un- 
 natural ; pale, or of a dark green, and very offensive. After the fit, when the com- 
 plaint has ceased entirely, it generally (says CuUen) "leaves the person in very 
 perfect health ; enjoying greater ease and alacrity in the functions of both body and 
 mind, than he had for a long time before experienced." 
 
 But the disorder, which has thus departed, is very apt — nay, un-less extreme care 
 be taken to prevent it, and even in spite of all care, it is almost sure — to return. At 
 first, perhaps, it recurs not oftener than once in every three or four years ; but after 
 some time the intervals are shorter, and the attacks become annual, happening about 
 the same time of the year : afierwards they come twice every year ; and at length 
 they return several times during the course of the autumn, winter, and spring. And 
 as the fits are more frequent, so also are they more protracted, till, in the advanced 
 state of the disease, the patient is hardly ever free from it, except perhaps for two or 
 three months in summer. I do not mean that all this occurs invariably in all cases 
 ahke ; but this is a sketch of the general course of the complaint. 
 
 There are other phenomena also to be noticed as time advances, and as the dis- 
 ease is repeated. At first, I say, it commonly appears in one foot only; afterwards 
 every fit includes both feet, the one after the other : and as the disease continues to 
 recur, it not only attacks both feet in succession, but after having ceased in the foot 
 whicli was secondly visited, it will return again into the foot first affected, and per- 
 haps a second time also into the other. It passes, too, into other joints, both of the 
 upper and lower extremities, large as well as small; so that there is scarcely a joint 
 that may not, at one time or another, be seized upon. But as the disease proceeds, 
 and the fits get to be more numerous, the pains are commonly less violent than they 
 Avere at first; the patient is, however, more affected with sickness, and suffers more 
 in his general health. 
 
 Again, after the earlier attacks, the joints usually recover entirely their former 
 strength and pliancy ; but when the disorder has returned again and again, they 
 are not so readily nor so completely restored to their previous condition, but re* 
 58 4 b
 
 914 GOUT. 
 
 main weak and stiff, and sometimes they lose at length their capacity of motion 
 altogether. 
 
 Also, in many gouty persons, but not in all, after the disease has frequently re- 
 curred, what are called chalk-stones form; concretions that look exactly like c'haitf 
 take place around and outside the joint, filling up the areolar tissue, and lyinfr, in 
 general, immediately beneath the skin. The material of these curious concretions 
 is deposited at first in a half fluid state, and resembles soft mortar ; but the more 
 watery ingredients being afterwards absorbed, it becomes dry and hard. Of course 
 when this stuff is deposited in any quantity on the outside of a joint, it must limit in 
 a great measure, or entirely prevent, the motion of that joint. And sometimes matter 
 of the same kind is efiljsed into the joint itself; as I have once seen in a gouty pa- 
 tient who died in the Middlesex Hospital. 
 
 Gout is a disease that was well known, and well observed, by the ancients. In 
 its genuine form it could neither be overlooked nor mistaken. Many very interest- 
 ing facts relative to this painful disorder have accordingly been ascertained : and I 
 proceed to notice the chief of these ; but must do so with as much brevity as I can. 
 
 First, then, gout is an hereditary disease. I do not mean to say that the disposi- 
 tion to it is always a transmitted disposition ; but that the complaint is much more 
 likely to occur in persons in whose pedigree it can be traced, than it is in othei 
 persons. It may, I beheve, be generated by certain habits of life; and, on the othei 
 hand, in spite of an inherited predisposition, ti?e disease may be staved off and 
 averted. Let the son of a rich and gouty nobleman change places with the son of a 
 farm-servant, and earn his temperate meal by the daily sweat of his brow, and the 
 chance of his being visited with gout will be very small. Granting this, we see 
 reason, independent of the general analogy of hereditary disorders, why the gout 
 may be expected sometimes to leap over a generation, just as family likenesses are 
 known to intermit ; while yet the disposition may descend to the children of those 
 who, in their own persons, have never sufl"ered the disease. Among 522 gouty 
 persons, concerning whom Sir Charles Scudamore had collected information, 332 
 could trace their disease to the father, mother, grandfather, grandmother, uncle, or 
 aunt. In the remaining 190 the disease was not known to have existed in either 
 upward branch of the family-tree. 
 
 2. There is a pattern of body which is believed to be favourable to the acquisition 
 of gout. " It attacks (says Cullen) especially men of robust and large bodies, men 
 of large heads, of full and corpulent habits, and men whose skins are covered with a 
 thicker rete mucosimi, which gives a coarser surface." 
 
 3. Whether, in a given individual, there be an inherited tendency to the disorder 
 or not, its access is promoted in a remarkable manner by a full and luxurious mode 
 of Hfe, and b}'' sedentary or inactive habits. 
 
 4. It is observed of gouty persons, that they are usually subject to nephritic com- 
 plaints also, to fits of the gravel, to renal and vesical calculi. These disorders of the 
 urinary organs commonly begin to manifest themselves after the gout has plagued 
 the patient for some time. They do not coincide with the paroxysms of gout, but 
 the two happen alternately: or (vv'hat is equally e.^pressive of the connection between 
 the two forms of disease) the children of gouty and nephritic parents inherit often 
 the one or the other of these maladies ; but " whichever may have been the principal 
 disease of the parent, some of the children have the one, and some the other. In 
 some of them the nephritic affection occurs alone, without any gout; and this fre- 
 quently happens in the female ofl^spring of gouty ancestors." 
 
 The urinary concretions to which gouty people are so subject, and the morbid 
 states of their urine generally, belong to the lithic diathesis. Dr. Prout holds that 
 "the lithic acid, developed principally during the mal-assimilation of the albuminous 
 textures, may be considered as the characteristic feature in gout." And the chemical 
 composition of the chalk-stones which sometimes accompany gout, is in accordance 
 with this statement ; and illustrates strongly the connection between gout and gravel 
 The so-called chalk-stones consists mainly of lithic acid combined with soda ; of the 
 'ithaie or superlithate of soda. Sometimes this very hthate of soda, perfectly white, \t 
 deposited in large quantities in the urine. Dr, Prout says that he has seen it co-
 
 GOUT. 915 
 
 piously secreted of the consistence of mortar, so as to block up the urethra in its pas- 
 sage outwards. Now this is just the stuff which is deposited around, and sometimes 
 within, the joints, and which hardens as it collects. I may mention here again that 
 many persons have the gout long, and severely, without having any of these concre- 
 tions. They are incidental to the more chronic forms of the disorder, in which the 
 pain and the fever, though of long duration and frequent recurrence, are slight in 
 degree. The cuticle at length gives way, and the earthy matter lies bare. A 
 namesake of mine, Mr. Henry Watson, describes, in the first volume of the Medical 
 Communications, the case of a Mr. Middleton, who was accustomed, when playing- 
 at cards, to chalk or score the game upon the table with his gouty knuckles. 
 
 5. Gout attacks especially the male sex. Some few women, however, suffer iU 
 in its regular and decided form ; and generally these women are robust and plethoric. 
 Cullen noticed its occurrence in "several females whose menstrual evacuations were 
 more abundant than usual," But the disease chiefly happens in women after the 
 catamenia have ceased to appear. Heberden knew a female who had numerous 
 sores from chalk-stones. 
 
 6. Cullen observes that the gout does not usually come on till after the age of five 
 and thirty. Heberden, who in his long and extensive practice among the higher 
 classes of society in this town saw as much of this disease as any physician ever 
 did, says that he never met with a case which he could decidedly pronounce to be 
 gout, before the age of puberty. Sir Charles Scudamore has collected a statistical 
 account of 515 examples of gout, in which the period of the first assault had been 
 noted. Of these, 142 began between the ages of 20 and 30 ; 194 between 30 and 
 40; 118 between 40 and 50. The greater number, you will observe, was between 
 30 and 40. 
 
 However, I believe that where the inherited disposition is strong, and the habits 
 of hving are such as to foster that disposition, gout may show itself, occasionally, 
 even prior to the age of puberty : but this is, certainly, the exception to a very 
 general rule. 
 
 7. Gouty persons are subject to various ailments, which spring from the same 
 fountain as the well-marked paroxysm : derangements in the functions of the digestive 
 organs, of the heart and lungs, of the brain and nerves. 
 
 The most familiar of these ailments is indigestion, with its various circumstances 
 of impaired appetite, sickness, vomiting, flatulency, heartburn, acid eructations, gas- 
 trodynia. Pains and cramps occur in several parts of the trunk, and shoot thence 
 into the upper extremities, and are relieved by the extrication of wind from the 
 stotnach. The bowels are irregular ; colicky diarrhoea being sometimes the prevail- 
 ing fault, but more commonly costiveness. With all this the patient is apt to be ex- 
 cessively dejected and hypochondriacal, morbidly attentive to every bodily feehng, 
 disposed to exaggerate his sufferings, and apprehensive of the worst event. 
 
 When the viscera of the thorax are affected, the patient has palpitations, fits of 
 dyspnoea, faintings, or even pangs like those of angina. 
 
 In the head occur pain, giddiness, transient affections of the vision and of the 
 hearing, threaienings of palsy and apoplexy. 
 
 All these, you may say, are feelings and ailments to which any and all persons 
 are liable. True : but the remarkable peculiarity which connects them, in some 
 men, with gout is this; — that they often all clear away and disappear upon the 
 breaking out of a paroxj'-sm of that disease in the foot. 
 
 Hence such symptoms are regarded as indicating one variety of irregular gout. 
 Cullen, led by a questionable theory, classes them under the head of atonic gout. 
 Sometimes the patient so affected is said to have lurking gout ; or masked gout. 
 
 In another variety of irregular gout, the complaint commences, in the ordinary 
 way, in a joint ; but the pain and inflammation do not reach the ordinary degree of 
 intensity, or at any rate do not continue for the usual time and then recede gradually 
 in the accustomed manner, but they disappear abruptly and entirely, while symp- 
 toms of severe and alarming disorder arise, as suddenly, in some internal part. Tills 
 Culli^n names retrocedent gout. It affords an example, as I conceive, of true metas 
 tasis. The internal part most commonly attacked is the stomach. It becomes
 
 916 GOUT. 
 
 affected with a peculiar feeling of anxiety and distress ; with sickness, vomiting, or 
 violent pain, which the patient calls spasm, and which, probably, is of a spasmodic 
 character. More rarely the retrocession is to the heart, when syncope or urgent 
 dyspncea ensues ; or to the head, when it may terminate in a stroke of apoplexy, or 
 a paralysis. 
 
 In a few cases the disorder, thus alighting on some other part than a joint, is 
 plainly inflammatory. The most common example of this is gouty inflammation of 
 the urethra, with scalding and a puriform discharge ; simulating very exactly an 
 attack of. gonorrhoea. So also there is a gouty form of ophthalmia, or gout in the 
 eye ; gout in the testicle ; and a year or two ago an eminent physician of my ac- 
 quaintance suffered a violent and dangerous attack of what was considered to be gout 
 in the throat. Dr. Cullen speaks of these inflanunatory affections under the title of 
 misplaced gout : but they may well enough be ranked under one of the preceding 
 heads of masked, or retrocedent gout. 
 
 The disposition to gout may be engendered, and when inherited will infallibly be 
 strengthened and developed, as I have told you already, by certain habits of life : by 
 sensual indulgences, and (but in a less degree, I believe) by want of bodily exercise. 
 Of this we have the strongest negative evidence in the remarkable immunity from 
 the disease enjoyed by the working poor in our rural districts. One never hears of 
 the gout among agricultural labourers. Sir Gilbert Blanc states that, during ten 
 years in which he was physician to St. Thomas's Hospital, although in his private 
 practice he reckoned 130 patients who had gout, being about one in twenty-six of 
 the whole number, he had not a single case of it among 3406 patients in the hospital. 
 This I think strange, for in the London hospitals it is not very uncommon for us tc 
 meet with gout ; but then it is in persons who have lived fully and inactively : in the 
 servants of wealthy families for instance, butlers, coachmen, porters — men who often 
 live more luxuriously, and more idly a great deal, than their masters. And among 
 the rich, those who are most subject to gout are notoriously those who indulge most 
 in what are called the pleasures of the table ; who eat largely of animal food, and 
 drink much wine, especially if they are indolent withal. Such men generate far 
 themselves the lilhic acid diathesis ; and if the gouty tendency happens to have been 
 born with them, they incur the disease, under these habits, with more or less readi- 
 ness, according to the degree of that innate disposition. Strong exercise certainly 
 remedies, in some measure, the evil effects of this mode of life, by promoting the 
 excretions of the body : but gout used to be exceedingly common in the old-fashioned 
 fox-hunter, who "rode hard," while he also " hved hard." Mere sedentary habits 
 do not produce gout, as we learn from the comparative exemption of females, and of 
 the poor, who, following sedentary employments, are yet compelled by their poverty, 
 which is so far a blessing to them, to be temperate. Men who eat much meat gene- 
 rally indulge themselves in drinking also : the two causes go together, and it is 
 difficult to estimate their separate influence. Butchers, who live fully upon animal 
 diet, are said to be rarely affected with gout, but then they necessarily take a great 
 deal of exercise. It appears that the use of wine, and of malt liquors, fosters the 
 disposition to gout much more than the abuse of distilled spirits. The paucity of 
 gouty patients among the lower classes in this gin-drinking town suffices to show 
 this. I have been told that gout is very little known in Glasgow, where the com- 
 mercial men live richly, and lead sedentary lives, but do not drink much wine, their 
 favourite beverage being rum-punch, of which they are not at all sparing. Dr. Wil- 
 liam Budd says that the disease is common among the " ballasters" o-n the Thames ; 
 that, although they are not a numerous body, many are admitted with gout every 
 year into the JJreadnought. Now these men being much exposed to inclemencies 
 of weather, and using great bodily exertion, which is attended with profuse sweating 
 and much exhaustion, think themselves warranted in drinking (besides spirits) two 
 or three gallons of porter daily. This shows the effect of malt liquor in producing 
 the gouty habit of body. 
 
 On the otiier hand, the inbred gouty tendency may be so strong, as to be scarcely 
 Kept in check by the most abstemious regimen.
 
 GOUT. 917 
 
 A fit uf the gout may be brought on by various circumstances : in other words, 
 the possio.e exciting causes of gout are many. A paroxysm has been frequently 
 known lo follow immediately upon an unusually severe debauch. Strong mental 
 emotion has sometimes the same consequence, especially emotion of a depressing 
 kind. Excessive fatigue — more particularly fatigue produced by too much walking 
 exercise on any one day — is another exciting cause. And this is unlucky, for it often 
 discourages a patient from again making use of a proper and even a necessary amount 
 o\ exercise of that kind. Another exciting cause which frequently operates is exr- 
 ternal injury. The first attack of gout often fixes upon the seat of an old hurt : and 
 a very slight recent injury is sometimes enough to determine a paroxysm — a trifling 
 bruise or sprain, the pressure of a tight shoe ; nay, Dr. Heberden tells us that he 
 verily beheves he has seen an attack of gout brought on by the bite of a flea ; show- 
 ing how easily the disease may be excited, when there is a strong predisposition to 
 it. This it is which makes us so often doubt the accuracy of gouty persons, when 
 they tell us that they are lame from a sprain. 
 
 Dr. Cullen enumerates sundry debilitating circumstances, which, as such, appear 
 to operate in calhng into action the gouty disposition. And there can be no doubt 
 that a state of weakness does often favour the eruption of the malady. A friend of 
 my own had lately a most serious attack of contin jed fever, in the course of which 
 he became hemiplegic, and his fife was despaired of. Soon after the fever had left 
 him, and while he was yet extremely feeble, he had three attacks of gout in quick 
 succession. 
 
 Pains have been taken by several writers, especially by Heberden, to lay down 
 the distinguishing characters between gout and rheumatism. A first assault of gout 
 can scarcely be confounded with an attack of acute rheumatism. The hmitation of 
 the inflammatory redness to one foot, and the restless distress of the gouty patient, 
 contrasts strongly with the helpless and motionless condition of the rheumatic, who 
 is pinioned, so to speak, in many limbs. There may be more room for doubt and 
 mistake in the advanced state of gout, when m.any joints have at length become 
 involved ; but even then you may generally decide by inquiring into the history of 
 the patient, and learning the circumstances of his early attacks. 
 
 The main points of distinction may be broadly and generally stated thus. 
 
 In gout the small joints are first and chiefly affected, especially the joint of the 
 great toe : in rheumatism, the large. The redness of the gouty inflammation is more 
 bright and. vivid than that of the rheumatic ; and the fluctuations between agony and 
 ease are greater and more frequent. Gout usually affects one joint only at a time : 
 rheumatism often many at once. The inflammation in gout is attended with more 
 oedema than in rheumatism ; and is followed, in the majority of instances, by de- 
 squamation and itching, phenomena which we do not notice at the close of rheumatic 
 inflammation. Gout is not attended with those drenching acid sweats which are so 
 characteristic of acute fibrous rheumatism. The gout is decidedly hereditary : rheu- 
 matism, if hereditary at all, is much less distinctly so. The gout occurs rarely or 
 never, whereas rheumatism is not very uncommon, before the age of puberty. In 
 gout, though many functions suffer, there is no tendency to carditis : in rheumatism, 
 with far less general disturbance, that tendency is very marked. Gout is the punish- 
 ment (some have thought it the privilege) of the rich, of persons who live fully, 
 luxuriously, and idly : rheumatism is most frequently the appanage of the poor, and 
 of those who toil. 
 
 LECTURE LXXXII. 
 
 Pathology of Goid. Prognosis. Prejudices respecting the disease. Treatment 
 during the paroxysms ; during the intervals. Cutaneous Diseases. 
 
 1 YESTERDAY described the phenotnena of gout, from its primary outbreak to \\.s 
 crippling consummation. I told you what observation has collected concerning its 
 
 4b3
 
 918 GOUT. 
 
 # 
 
 causes; and I pointed out the circumstances which distinguish it from rheumatism. 
 Let us look a httle closer into the essence of this curious m!\]ad3\ 
 
 The pathology of gout has been the theme of endless controversj'. Humoralists 
 and solidists contend alike for the triumph of including the disease within the palo 
 of their respective theories. The very name, gout, derived through the French 
 goutle from the Latin gutta, expresses summarily the doctrine of those who imposed 
 It: and we trace the same, or a similar idea, in the appellation of the kindred dis- 
 order, rheiimaimm. 
 
 " The opinion (says Cullen) which has generally prevailed, is, that gout depends 
 upon a certain morbific matter, always present in the body ; and that this matter, by 
 certain causes thrown upon the joints or other parts, produces the several phenomena 
 of the disease." 
 
 You will find this doctrine at the bottom of all Sydenham's speculations on the 
 subject. But Cullen doubted it, and even endeavoured, in an elaborate argument 
 which you may read in his First Lines, to disprove it. He held gout to be an 
 afiection of the nervous system. I shall not trouble you by detailing his argument, 
 for I consider it an utter failure. I am satisfied that the ancient doctrine, which 
 asserts the humoral origin of the disease, is the true one. "Morbific matter" (it 
 may well be called a poison) is generated, or detained, under certain circumstances, 
 within the bod}', and silently collects in the blood ; until, after obscure threats, per- 
 haps, and prelusive mutterings, it explodes in the foot ; and then the bodily economy, 
 like the atmosphere after a thunder-storm, is, for a while, unusually pure and tran- 
 quil. To some such conclusion as this the result of all modern research seems 
 clearly and unfailingly to tend. Dr. Holland, for example, in his thoughtful and 
 thought-exciting volume, recently published, expresses his belief in " a materies 
 morbi, which, whatever its nature, is capable of accumulation in the S5'stem, of 
 change of place within the body, and of removal from it." In this, and fn several 
 other propositions relative to gout, enunciated in distinct terms by this learned writer, 
 I fully concur. Some speculations still more lately put forth by Dr. William Budd, 
 in a communication to the Medical and Chirurgical Society, throw a strong light 
 upon this perplexed subject ; and bring the phenomena, not only of gout, but also 
 of many other important complaints, within the operation of one general, compre- 
 hensive, and intelligible law. I shall take leave to refer, in a very cursory manner, 
 to some of Dr. Budd's positions. 
 
 I need not remind you of the various ways in which extraneous matters find en 
 trance into the blood. Poisons, under their proper shape and name ; medicines 
 which misapplied become poisons ; our natural food and drink, which the folly of 
 man converts into poison ; the products or dregs of the secondary assimilative pro 
 cess ; these are common sources of impurities, more or less hurtful, which mix and 
 circulate with the vital fluid. Some of these extraneous matters escape harmlessly 
 by one or more of the waste-pipes and emunctories of the body. Some are entan- 
 gled in its solids : but not indiscriminately ; for different substances have their special 
 or their favourite resting-places. All this is well known to persons conversant with 
 toxicological researches. 
 
 Now, this doctrine of the elective affinity between certain tissues or parts of the 
 body, and certain morbific principles conveyed to them by the blood, is applied by 
 Dr. Budd to elucidate the very curious fact of the symmetrical local manifestations 
 of many disord<?rs ; which disorders ars themselves so far general that they derive 
 their origin from the circulating fluids. This symmetiy he finds the most exact in 
 chronic constitutional complaints, wherein the local morbid changes are effected in a 
 mahner which approximates closely to the processes of heahhy nutrition. He shows 
 good reason for believing (what, if the whole theory be true, we should expect) that 
 the same symmetrical phenomena are mo^tfied by the amount of the poison collected 
 in the system. If there be a certain quantity only, it may settle in some favourite 
 or congenial spot, on one side of the body. If there be more than enough to satu- 
 rate that part, it goes next to the corresponding spot upon the opposite side ; or, per- 
 haps, to an analogous part of the other limb of the same side. If there be more stilJ 
 of the poisonous material, it flies to, and occupies, other parts also. He further
 
 ^^ GOUT. 019 
 
 shows that the elective^Ktiity is more exclusive, and the bond of union stronger, in 
 respect to some m.orbid principles, than to others : and in proportion as the affinity 
 is weak, so is the local manifestation of the disease apt to shift, by metastasis, from 
 place to place. When the matter which has thus entered, or combined with, a cer- 
 tain tissue or organ, is any how loosened and released from that union, or repelled 
 from the part, it is again set afloat in the blood, to " break out" elsewhere ; to tease 
 various organs, perhaps, or to derange the whole economy. The alternation so often 
 to be noticed between certain cutaneous eruptions and internal disorders of function, 
 is a striking and famihar example of this. The eruption affords presumptive evi- 
 dence of the detention of some peculiar morbid principle in that part ; and the 
 internal affection which succeeds the disappearance of the eruption, denotes that the 
 morbid principle has re-entered the blood. Some of these peccant or poisonous 
 matters fix permanently in the affected spot or spots ; and some of them may even 
 be recovered in substance from the dead tissue by chemical means ; the poison of 
 lead, for example, from the symmetrically palsied muscles. Others appear to be 
 expended gradually in the part, and so eliminated from the system. Dr. Budd 
 observes, that the regular arrangement of these local tokens, whether they be out- 
 ward or internal, is disturbed by the presence of fever. Probably the febrile tumult 
 may itself be owing to the quantity of the noxious matter in circulation within the 
 body. He states, also, that, cxteris paribus, this morbific matter is most apt to 
 pounce, in the first instance, upon parts which have been previously hurt, or which 
 are mechanically irritated at the time. For which reason a part that has once been 
 affected by it is more likely than other parts to suffer again. 
 
 Now, see how thoroughly the ascertained phenomena of gout accord with this 
 theory. Certain habits of fife produce fullness, and richness, and impurity of blood ; 
 the same habits which breed the lithic acid diathesis. We may even conjecture this 
 acid, or some of its compounds, to be the actual materies morbi. Lithates are 
 poured forth with the urine, and sometimes deposited in vast masses around and 
 within the gouty joints. At first, after obscurer intimations of the presence of the 
 poison in the system, it thunders in the foot ; and there, perhaps, is all discharged 
 and spent. The chemist, Berthollet, found that the skin of a part affected with 
 gouty inflammation communicated instantly to litmus paper a deep red colour : a 
 large quantity of acid was evidently passing off by exhalation from the inflamed 
 surface. If the poison be too copious to find sufficient vent in one joint, it attacks 
 another, or more than one. "duandoque etiam primis morbi diebus, cum materia 
 peccans adeo exuberat ut ei capiendse pes unus impar sit, utrosque sirnul pari vehe- 
 mentiii fatigat : sed ut plurimum pedes successive, uti diximus, adgreditur." These 
 are Sydenham's words. A chain of repeated paroxysms at length purifies the blood : 
 " Donee tandem materia peccante prorsus absumta, ^ger pristinam obtinuerit sani- 
 tatem." The descent of the disorder upon a particular joint is often determined by 
 a recent blow or sprain, or by the chronic weakness consequent upon an ancient 
 hurt. If the inflammation, after thus settling, be repelled from the foot, the poison, 
 being driven again into the blood, may light upon some vital organ, and place the 
 patient's life in immediate jeopardy. The late Dr. Parry, of Bath, had at one time 
 under his care two patients who- had attempted to cut short or to ease a paroxysm 
 of gout by plunging the affected foot into cold water. This gave instant relief to the 
 pain, and in both instances the inflammation presently abated ; but in both also, 
 hemiplegia occurred a few hours afterwards. 
 
 If these views respecting the pathology of gout be true, it can scarcely be doubted 
 that they are applicable, mutatis niutcuidis, to the cognate disorder — acute rheuma- 
 tism. Dr. Prout, indeed, considers the lactic acid, developed chiefly during the 
 secondary mal-assimilalion of the gelatinous tissues of the body, to have the same 
 relation to rheumatism which the lithic acid, derived from the mal-assimilaticm of the 
 albuminous textures, has to gout. 
 
 The prognosis of gout may be gathered, without much further suggestion on my 
 part, from what has already been said. The inflammation which befalls the joints 
 has no worse event than the thickening, or, perhaps, the chalk-like deposit, which it 
 produces ; so that gout in the extremities is not a mortal disease. But as it Is not
 
 920 GOUT. 
 
 always confined to the extremities, the life of a gouty person is justly held to be 
 insecure. "La goutte articulaire (says some French author) est celle dont on est 
 malade ; et la goutte interne est celle dont on meurt." You will find that all insur- 
 ance companies exact, cseleris paribus, a larger premium from those who have had 
 the gout. When it proves fatal, it is by translation of the disease, or rather of the 
 gouty virus, to some vital part; to the stomach, the heart, the lungs, the brain. 
 
 As the early visits of gout are generally followed by a striking change for the 
 better in the health and feehngs of the patient, it is not to be wondered at that the 
 disease, in its genuine and decided form, should have sometimes been wished for, 
 and even courted. It is commonly thought that a fit of the gout clears the system 
 of all other disorders. It does, indeed, clear it, for the time, of those disorders which 
 resulted from the poison of gout. But this fact has led to great practical mistakes. 
 First, to the error of looking on inertly, and doing nothing to remedy the ailments 
 which are supposed (often very wrongly) to depend upon lurking gout, and to require 
 a fit of the gout for their cure ; and, secondly, to the more dangerous experiment of 
 endeavouring to force on such a fit by excess and intemperance. Men forget, or do 
 not know, that the enemy thus reinforced, instead of evacuating the fortress by its 
 oulports, may retreat triumphant into the citadel. To drop metaphor, such a course 
 of living may, indeed, determine an attack of the disease in the extremities, but in- 
 volves the fearful peril of some fatal internal seizure. Besides, the benefits expected 
 from external gout belong to its earlier returns alone. The more numerous the fits, 
 the faster does the general health break, and the more stubbornly do the associated 
 symptoms cling to the patient : and many persons linger on, martyrs (as they say) 
 to the disease, long after they have ceased to be fit for any of the business of life, or 
 capable of any of its pleasures. Nevertheless, as Heberden observes, " people are 
 neither ashamed nor afraid of it ; but solace themselves with the hope that they shall 
 one day have the gout; or, if they have already sufl^ered it, impute all their other 
 ails, not to having had too much of that disease, but to wanting more. The gout, 
 far from being blamed as the cause, is looked up to as the expected deliverer from 
 these evils." 
 
 And this mistaken ambition is heightened, no doubt, by the notion, still more ab- 
 surd and ridiculous, yet very generally prevalent, that it is a creditable thing to have 
 the gout: a notion which evidently originated in the fiict of its being peculiarly inci- 
 dental to the wealthy and the great, to men of cultivated minds, and intellectual dis- 
 tinction. Nothing can show more strongly the power of fashion than this desire to 
 be thought to possess, not only the tone and manners of the higher orders of society, 
 not their follies merely and pleasant vices, but their very pains and aches, their 
 bodily imperfections and infirmities. All this is more than sufficiently ludicrous and 
 lamentable : but so it is. Even the philosophic Sydenham consoles himself, under 
 the sufferings of the gout, with the reflection that it destroys more rich men than 
 poor — more wise men than fools. "At vero (quod mihi aliisque licet, tam fortunaB 
 quam ingenii dotibus mediocriter instructis, hoc morbo laborantibus solatio esse 
 possit) ita vixerunt atque ita tandem mortem obierunt magni Reges, Dynastae, exer- 
 cituum classiumque, Duces, Philosophi, aliique his similes baud pauci. Verbo dicam, 
 articularis hicce morbus (quod vix de quovis alio adfirmaveris) divites plures interemit 
 quam pauperes, plures sapientes quam fatuos." 
 
 The treatment of a gouty patient naturally divides itself into that which is proper 
 during the paroxysm, and that which is proper during the intervals between the 
 paroxysms. 
 
 It was maintained by the great physician, whose words I have just been quoting, 
 that all artificial evacuations during a fit of the gout are useless or hurtful. He, 
 therefore, discountenanced blood-letting, purging, and the use of diaphoretic medi- 
 cines. It was nature's prerogative, he said, to exterminate the peccant matter in her 
 own way ; namely, by depositing it in the joints, whence it might be dispersed by 
 insensible transpiraiion. Evacuant remedies had no other effect than that of recall- 
 ing into the blood this peccant matter, which nature had already thrust forth to the 
 ext'-emities of the body ; whereby it happened that the virus, which should have 
 been eliminated through the joints, fell upon some of the viscera ; and so the patient,
 
 GOUT. 921 
 
 who was in no clanger before, became in peril of his life. I mention all this to shcv 
 you how entirely identical was Sydenham's theory of the gout with that which is 
 now rapidly regaining its lost ground in this country, and which I firmly believe to 
 be the true one. After his time, and upon his authority, the treatment of gout lapsed 
 into an inert expectancy. Even Cullen came to the conclusion that the best thing to 
 be done is to commit the sick man to " patience and flannel alone." Here and there, 
 indeed, an advocate of more active measures sprang up. Dr. Rush thought that 
 venesection was always safe, and generally serviceable : and some persons, following 
 the bad example of the illustrious Harvey, were for extinguishing the inflammation 
 by immersing the affected joint in cold water. Heberden, however, had clearer and 
 juster views upon the subject. He perceived that one reason why physicians did 
 nothing to check the paroxysm was, that they did not know what would check it. 
 He agreed with Cullen in thinking " that no medicine for curing the gout had yet 
 been found ;" but he did not partake of his belief in "the impossibility of a cure by 
 medicines." 
 
 " The itch (he observes) is supposed to be wholesome in some countries, where it 
 is endemical ; and an ague has been considered as a minister of health, whose pre- 
 sence and stay ought by all means to be courted. These opinions are now pretty 
 generally exploded in England ; and I hope the time will come when a specific for 
 the gout, as certain as those which have been discovered for these two disorders, will 
 ascertain the equal safety and advantage of immediately stopping its career, and pre- 
 venting its return." 
 
 That time has come : for the colchicum, judiciously employed, may fairly be 
 accounted a specific for the gouty paroxysm. And it is remarkable how long this 
 truth has been seen, though not distinctly or steadily. The hermodactyl of the 
 ancients is the modern colchicum, and was in high estimation among them for its 
 efficacy in the same forms of disease as are benefited by the colchicum now. It 
 bore, with some, the name of anima articulorum, the soul of the joints, because (as 
 Gluincy states) it prevented " the lodgment of such gritty matter as occasions the gout 
 and arthritic complaints." And I think there can be no doubt that the active prin- 
 ciple of the quack medicine so much in vogue for the cure of gout some years ago— 
 I mean the eau medicinale — was either the same with that of the meadow-saffi-on, or 
 derived from the same family of plants which DecandoUe has associated together 
 under the title " Colchicaceas." 
 
 This drug has certainly the property of easing, in an almost magical manner, the 
 pain of gout. How it operates is not so clear. It is apt to produce nausea, faintness, 
 and diarrhoea ; but its curative influence is not conditional upon the occurrence of 
 these symptoms. Sometimes the rapid disappearance of the gouty inflammation is 
 its only perceptible eflect. The patient may be in helpless agony, with a tumefied 
 red joint, to-day ; and walking about, quite well, to-morrow. The colchicum is, 
 therefore, plainly an anodyne. It also sensibly modifies the condition of the urine, 
 rendering it less acid, and even alkahne ; and increasing its quantity. These effects 
 are consequent, I presume, upon changes in the blood wrought by this substance, 
 which thus, and there, proves somehow an antidote to the poison of gout. 
 
 There are, as you are aware, various preparations of colchicum in use : the wine 
 of the bulb : the wine of the seeds ; the vinegar of colchicum ; the acetous extract, 
 made by evaporating that vinegar; the inspissated juice of the plant itself. These 
 are all of them active and valuable medicines ; and I should pretend to more know- 
 ledge than I possess, if I undertook to tefl you which of them is the best. 
 
 The mode of adnninistering the remedy, in a regular fit of the gout, is simple 
 enough. For example, you may give forty or sixty minims of the viniim colchici, 
 in a saline draught, at bed-time ; and half a drachm more, in a warm black dose, the 
 next morning; and you may repeat this sequence if the gout continues. Some per- 
 sons give twenty minims every six hours, with a drachm of Epsom salts, and a 
 drachm of syrup of poppies in the draught, till the symptoms yield ; but I prefer the 
 other plan. In this way the pain is usually calmed, and the swelling reduced in a 
 few days ; or even, as if by a charm, in a few hours. 
 
 B<' vou must not be satisfied with thus quelling the pain and inflammation. A
 
 922 GOUT. 
 
 strong prejudice at one time existed, and still exists among some practitioners, against 
 the colchicum. It was said tliat it Jiad indeed the power of cutting short the paroxysms, 
 but that it cut short the patient's life also : that they who trusted to it for getting rid 
 of the gout, very seldom lived more than two or three years afterwards. How far 
 this was true I cannot tell : but even admitting it to be true, it was not, I conceive, 
 so much the fault of the medicine as of the patient, or of the medical man who did 
 not properly admonish the patient. Men were very glad to get rid of their gout on 
 such easy terms ; and they will sometimes say to us now : " I have, as you see, got 
 the gout. This is Monday. I must be in the House of Commons, or attend such 
 and such a meeting, or be at the head of my regiment, on Wednesday : and I expect 
 that you will enable me to do so." Or even sometimes the reason may be that they 
 are engaged to some good dinner two or three days afterwards. Now if patients are 
 content, or are suffered to be content, with expelling the gout from their toe, without 
 observing abstinence more than a day or two, and without any depletion or further 
 medication at the time, we can easily perceive the probability of their being soon 
 attacked by some formidable internal complaint. I apprehend that the proper way 
 to eradicate the lurking residue of the mischief is to continue to give small doses of 
 the colchicum ; five minims of the wine, for instance, two or three times a day, for a 
 while. Moreover, purgatives must be employed, if that remedy does not prove 
 aperient. Not violent purgatives, however, which, by weakening the patient, seem 
 to strengthen the power of the gouty virus. With mild cathartics, moderate doses 
 of mercury will generally be advisable, to correct the subsisting disorder of the 
 hepatic functions ; and the patient must adopt and pursue abstinent, or at any rate 
 strictly temperate habits, in respect to meat and wine. 
 
 And as I think that the dregs, if I may so speak, left behind it by a gouty 
 paroxysm, may be dispersed by the continued use of what, in the usual acceptation 
 of that word, I may call alttrative doses of colchicum (doses, that is, which produce 
 the desired purpose gradually, and by insensible operation), so I think it probable 
 that many a fit of the gout might be averted, if the remedy were given in the same 
 way upon the first occurrence of the ordinary premonitory troubles. Many of those 
 troubles never appear to reach the crisis of a fit. There are headaches, attacks of 
 asthma, derangements of the digestive organs, which, occurring in a gouty person, 
 are presumed to be fainter intimations of the presence of the gouty poison in the 
 blood : and if such symptoms yield (as unquestionably they often do) to colchicum, 
 the presumption draws near to proof. Dr. Holland has well remarked that the 
 meadow-safTron, by its curative effects, may bring sundry maladies, hitherto thought 
 anomalous, under the same law of morbid gouty action ; just as the Peruvian bark 
 has reduced many complaints, that were previously vague in their nature, within the 
 same category of aguish distempers. The same author conjectures that as hypo- 
 chondriasis is certainly often symptomatic of the gouty poison in the male, so may 
 sometimes the kindred disease, hysteria, be in the female. 
 
 Strange stories are recorded — strange, but I believe true — of instantaneous cures 
 of the gout by strong mental emotion ; by sudden terror, by violent wrath. Dr. Rush 
 relates an instance of this. An old man who for several years had suffered an 
 annual attack of gout, was lying in one of these paroxysms, when his son, by some 
 ■iccident, drove the shaft of a wagon through the window of his room, with vast 
 iioise, and a great smashing and destruction of glass. The old man leaped out of 
 bed, forgetting his crutches ; and his wife, on entering the apartment, was surprised 
 to see him walking up and down, and exclaiming angrily against the author of the 
 mischief. The late Professor Gregory, of Edinburgh, was in the habit of mention- 
 ing another example to the same effect, authenticated to him by a naval surgeon. 
 It occurred to the person of an officer who was fieed from an attack of the gout, when 
 at sea, b\' an alarm of fire. Whether this influence of certain states of ihe mind be 
 rightly alleged or not, it is clear that we can never hope to make any practical use 
 of such a remedy. Indeed, a fit of the gout has been sometimes brought on by a 
 mental shock. 
 
 The treatment of a gouty patient in the interval between his attacks of gout, 
 whether regular or irregular, must be chiefly regimenal. The instances are not few
 
 GOUT. 923 
 
 of men of good sense, and masterb of themselves, who, being warned by on'' visita- 
 tion of the gout, have thenceforward resolutely abstained from rich living, and from 
 wine and strong drinks of all kinds, and who have been rewarded for their prudence 
 and self-denial by complete immunity from any return of the disease ; or upon whom, 
 at any rate, its future assaults have been iew and feeble. On the other hand, manj' 
 who are liable to gout are taught by sharp experience that a single debauch, a casual 
 glass or two of champagne, even an unusual indulgence in the use of animal food, 
 may suffice to bring their enemy suddenly upon them. I am sure it is worth any 
 young man's while, who has had the gout, to become a teetotaller. But the case is 
 different with the old, and with those whose health has been broken by the inveterate 
 disease. They must be allowed a certain quantity of their accustomed good cheer, 
 or they become an easier prey to the disease. In such cases you must trim, as well 
 as you can, between opposite dangers ; between the Scylla of excess, and the Cha- 
 rybdis of debility. 
 
 It is the same with respect to exercise. The young ai/d the hearty can scarcely 
 take too much : the old and the dilapidated, by one act of over-exertion, may incur 
 the penalty of an attack. Although I can do little more than point out general prin- 
 ciples for your guidance, I may remark, in reference to exercise, that it should 
 never be violent, lest it excite a paroxysm by straining any part, or by causing great 
 fatigue : that it should be habitual, daily — not used by fits and starts, and interrupted 
 by long periods of indolence or inaction : and that it should be active muscular ex- 
 ercise, as distinguished from passive exercise or gestation. No mode of exercise is so 
 good as that of walking; and with this may be agreeably and beneficially conjoined 
 riding on horseback. 
 
 Early and regular hours are also of much importance ; and the avoidance of severe 
 mental application. Sydenham relates that one of the most atrocious attacks of gout 
 he ever underwent was induced by intense thought and study, in the composition of 
 his medical works. 
 
 The regimen which I have been recommending may require some power of self- 
 control ; yet in reality it implies no severity of inortification. It is perfectly compa- 
 tible with life's best enjoyments ; but to be effectual it must be adopted early, as soon 
 as the disease threatens : and steadily persevered in. Gouty persons, however, do 
 not like these restraints. They are ready to believe that an attack of gout will do 
 them good ; or if they are disabused of that error, they are desirous that some medi- 
 cine may be found which will avert the disease, without their being obliged to forego 
 their accustomed indulgences. "To gratify this desire (says Cullen) physicians 
 have proposed, and to take advantage of it empirics have feigned, many remedies." 
 One of these was the famous Portland powder, of which Heberden remarks : " Unum 
 est ex multis quae vocantur remedis specifices, quorum ortum, et splendorum, et oc- 
 casum vidi." It consisted chiefly of bitters and aromatics, and had descended, with 
 some slight variations in its composition, from the times of Galen. Another pre- 
 ventive has recently been praised by Dr. Graves, of Dublin, as being highly ser- 
 viceable, although (what is a suspicious circumstance) it had, like the Portland pow- 
 der, fallen out of fashion. These are its ingredients : — Two ounces of orange peel, 
 an ounce of powdered rhubarb, and two ounces of the pidvis aloes cum canelld of 
 the Dublin Pharmacopceia, steeped for a week in a quart of brandy. A tablespoon- 
 ful of the strained infusion is to be taken, mixed with two or three spoonfuls of 
 water, night and morning. Sir Henry Halford recommends what I think a betttr 
 form of prophylactic remedy; viz., a few grains of rhubarb, with double the quantity 
 of magnesia, every day : or some light bitter infusion, with tincture of rhubarb, and 
 about fifteen grains of the bicarbonate of potass. 
 
 Now what has been observed respecting preventive remedies of this kind is, not so 
 much that they are inefficacious, as that, when exclusively trusted to, they are unsafe 
 I believe that they are often useful by improving the digestive process ; but they are 
 dangerous substitutes for a course of temperance and exercise. 
 
 When gout attacks the stomach, either by retrocession or primarily, it often proves 
 rapidly fatal. The gastric affection is not, in general, inflammatory ; so we judge, at 
 least, from the jiivantia. The attack, which consists of violent pain, and a sense of
 
 i/24 CUTANEOUS DISEASES. 
 
 weight or of constriction in the epigastrium, with sickness, vomiting, and a disposi- 
 tion to faint, is often reheved by the employment of stimulants. But such remedies 
 would be likely to aggravate inflammation. It will always be Avell when symptoms 
 like these occur, to inquire whether any indigestible food has been lately taken ; for 
 s:oid (so called) in the stomach has sometimes turned out, under the test of an emetic, 
 to have been nothing more than pork in the stomach. In the true gouty seizure, 
 antacids will frequently remove the pain ; magnesia, in full doses, with rhubarb. If 
 this does not succeed, opium may be resorted to; and if it should be vomited, opiate 
 enemata may be injected. Dr. Heberden thought that opium, and hot spices, were 
 more efficacious and less inconvenient, in these cases, than wine and spirits; but 
 when they fail, a glass of brandy will often allay the pain completely. The mus- 
 tard poultice, or the turpentine stupe, applied over the epigastrium, has been follow- 
 ed by strikingly good effects. And it is in these emergencies, contingent upon 
 retrocedent or misplaced gout, that we are justified in the endeavour to induce gout 
 in the extremities ; not, however, by internal stimuli, bat by enveloping the feet in 
 a mustard poultice, and so enticing or provoking the foe to quit his hold of the inte- 
 rior, and to appear at the outposts. And this expedient should be practised, what- 
 ever may be the internal organ upon which the gouty disorder has settled. 
 
 Sometimes, but much less commonly, actual gastritis does seem to ensue ; and 
 therefore all these cases are anxious and alarming cases, I do not know how the 
 inflammatory afl^ection can be discriminated from the non-inflammatory, unless it be 
 by the occurrence of tenderness with the pain, and of fever. You must treat such 
 cases as you would treat an ordinary case of gastritis, taking no further heed of the 
 gout, except by the application of stimulating cataplasms to the feet. 
 
 This concludes what I proposed to say respecting gout and rheumatism ; diseases 
 of which the local seat is not exactly external, nor yet do they belong strictly to the 
 interior of the body, except in their accidental complications. They form a link of 
 connection between the internal and external disorders which fall to the care of the 
 physician; and I proceed, in the next and last place, to speak of those complaints 
 which either concern the integuments alone, or which, at any rate, are attended with 
 some notable affection of the skin. 
 
 Under the general head of cutaneous diseases, are included maladies of very dif- 
 ferent kinds, and of verj^ different degrees of importance. Some are attended with 
 fever, and run a definite course, and are often dangerous to life. Others are chronic, 
 irregular in their progress, troublesome perhaps, and obstinate, and disfiguring, yet 
 implying no peril to the existence of the patient. Some again are contagious, while 
 many are not so. But before I enter upon any further account of these diseases, I 
 wish to make you acquainted with the names by which the various morbid appear- 
 ances presented by the skin have been known, since the time of Dr. Willan. 
 
 That author — whose works have been augmented by Dr. Bateman, so that ptr 
 haps I ought to say those authors — divides cutaneous diseases into eight orders, dis- 
 tinguished from each' other solely by the appearances upon the skin. I shall omit 
 the last of these orders, the order of macidse, such as freckles, and congenital spots 
 and discolorations, because in fact these are not diseases at all. 
 
 The first, then, of the appearances described by Dr. Willan are papidx; pimples. 
 These are little elevations of the cuticle, of a red colour, and solid ; not containing, 
 I mean, any fluid. They are of uncertain duration, and often terminate in scurf. 
 They are supposed to denote inflammation of the papillse of the skin. If you wish 
 for an example of a papular eruption, look at that of small-pox, at its very earliest 
 outbreak. 
 
 The second are squampe; scales. These are small, hard, thickened, opaque, 
 whitish patches of unhealthy cuticle. The subjacent surface is red. They are well 
 seen in lepra and psoriasis, and are very common in syphilitic eruptions. 
 
 The third aie exunlhemata; rashes. They consist of superficial red patches on 
 ihe skin, variously figured and irregularly diffused, and of all sizes. We have exam- 
 ples of them in some of the most important febrile cutaneous diseases ; scarlet fever, 
 measles, and others.
 
 EXANTHEMATA. 925 
 
 It is a pity '.hat some other technical denomination was not chosen to express these 
 '^shes ; for the term exanthemata has long been familiar to the profession as the title 
 of an order of diseases in Cullen's Nosology. 
 
 The fourth are bulls;; blebs, miniature blisters. Large portions of cuticle are 
 detached from the subjacent skin, by the interposition of a thin transparent liquid ; 
 with inflammation beneath them. Such occur in erysipelas sometimes, and in 
 pemphigus. 
 
 The fifth are pustulas; pustules. Circumscribed elevations of the cuticle, con- 
 taining pus, and having red inflamed bases. We have instances of these in common 
 boils, and in the eruption of small-pox when at its height and maturity. 
 
 The sixth are vesiculas; vesicles. Small elevations of the cuticle, covering a 
 fluid which is generally clear and colourless at first, but becomes afterwards whitish 
 and opaque, or pearly. These are exemplified in the eruption of cow-pox, and in 
 the chicken-pox. You will observe that these vesiculae differ very little, except in 
 size, from the bullae, or blebs. They often terminate in small scabs. 
 
 The seventh are tuberculse; tubercles. This also is an unlucky appellation, since 
 the word tubercle is almost appropriated, in the present day, to the scrofulous depo- 
 sits which infest the lungs, and other parts of the body, in pulmonary phthisis. 
 However, these cutaneous tubercles are small, hard, superficial tumours, circum- 
 scribed and permanent; or, if they suppurate at all, the suppuration in them is par- 
 tial. Sometimes they slowly ulcerate at the summit. The imperfectly suppurating 
 pustules of the modified small-pox, and certain red spots which are apt to haunt the 
 face, particularly of young persons, furnish examples. 
 
 Now, it is very convenient, for the purpose of distinguishing different diseases, 
 and of describing them, to know these outward marks when you see them, and to 
 use these names. But they form a very unfit basis for the classification of diseases. 
 Maladies may usefully be classed according to their causes ; according to their inti- 
 Tiate nature ; according to the general plan of treatment they may require. But 
 the superficial markings of disease have no definite relation to any of these heads. 
 Besides, a complaint which is papular to-day, may be vesicular to-morrow, and pus- 
 tular next Saturday. Yet the classification most commonly followed in this country, 
 and in France, is that of Willan and Bateman. Here we find collected under one 
 and the same division, maladies which nature has stamped with broad and obvious 
 marks of distinction : the febrile with the non-febrile ; contagious complaints with 
 those which have not that property; ailments that are local and trivial, with diseases 
 of grave import, and deeply rooted in the system at large. And, on the other hand, 
 distempers which nature has plainly brought together, and connected by striking 
 analogies and resemblances, this methodical arrangement puts widely asunder. I 
 point out, without professing to remedy, these imperfections. I cannot even under- 
 take to give you any full or systematic account of the many disorders comprised in 
 this classification. There is, however, one group so remarkable, so important, and 
 so highly interesting, that I shall consider it as much in detail as I can. I allude to 
 the group which CuUen comprehends under the title exanthemata. With this 
 exception, the advancing year warns me that I must contract what I have to say 
 respecting diseases of the skin within very narrow limits 
 
 LECTURE LXXXIII. 
 
 Exanthemata. They are contagious ; sometimes epidemic. Period of the Erup- 
 tion ; Period of Incubation. Theory of Contagious Febrile Diseases. Conti- 
 nued Fever. 
 
 Of the numerous complaints which are ranked among the diseases of the skm, 
 some, I observed in my last lecture, are attended with fever, and some ar« not 
 
 4c
 
 926 EXANTHEMATA. 
 
 Among the former there is a highly interesting group, distinguished by other and 
 more important characters than the mere presence of fever, or pecuUar marks upon 
 the skin ; characters that enabled Cullen to collect these diseases into a separate 
 order, to which he gave the name of exanthemata. This is his description of them : 
 " Morbi contagiosi, semel tantum in decursu vitas aliquem afficientes ; cum febre inci- 
 pientes ; definito tempore apparent phlogoses, Scepe plures, exiguas, per cutem spar- 
 see." Contagious diseases ; attacking a person once only in his life ; beginning with 
 fever. At a definite period small eruptions appear, often numerous, scattered over 
 the skin. These, you will allow, are \exy remarkable characters. They are not 
 all strictly and universally true, perhaps, of all the forms of disease which I propose 
 to bring now under your notice ; but they apply with more or less exactness to con- 
 tinued fever, to the plague, to small-pox, chicken-pox, measles, scarlet fever, and 
 erysipelas. 
 
 Hooping-cough, and the mumps, might be placed in the same catalogue, although 
 there is no specific eruption on the skin in them: but I have already spoken of these 
 two disorders. 
 
 Before I take up the consideration of any one of these diseases in particular, I shall 
 premise a brief survey of certain circumstances that are more or less common to them 
 all. This preliminary examination of the exanthemata as a class, will give you, I 
 trust, clearer ideas respecting them : at any rate it will enable me to dispense with 
 much needless repetition afterwards, and so to save both your time and my own ; a 
 matter of some consequence at this advanced period of the session. 
 
 In the first place, then, the diseases comprehended in this group are contagious 
 diseases. You will hear persons disputing about the term contagion ; but such dis- 
 putes can only arise from the want of a distinct definition of the sense in which it 
 is employed. I understand a disorder to be contagious, when it is in any way com- 
 municable from one person to another. Some would restrict the word contagion to 
 the cases, in which there must be absolute contact of the healthy body with the 
 sick bod}', or with its visible offscourings. When the disease can be conveyed 
 through the medium of the atmosphere, or by means of other intermediate substances 
 called fomites, they would call it infectious. And there is no objection to such a 
 distinction, provided it is understood b}'' the reader, or hearer, as well as by the writer 
 or speaker. But since in all cases the disease is conveyed to the person of the reci- 
 pient by particles of matter proceeding from the person of the sick, and since it 
 seems very unimportant whether those particles are in a solid or in a gaseous form, 
 whether they are imparted by direct contact of the two human bodies, or by being 
 wafted through the air, or carried upon articles of clothing, I shall include both and 
 all these modes of communication under the single term, contagion. This, in fact, 
 is what is done in common discourse : all disorders that are " catching," I shall take 
 leave to consider contagious. 
 
 In this sense I believe that all the diseases just now enumerated are contagious ; 
 some, no doubt, much more strongly and distinctly than others. Some of them, 
 indeed, are undeniably contagious. For example, we are privy to, and sometimes 
 willing agents in, the communication of small-pox from one individual to another. 
 There are others concerning the contagious nature of Avhich medical opinion is less 
 settled and unanimous. Many persons deny that continued fever is communicable 
 from person to person. The evidence from which I conclude that it is so, I will lay 
 before you when I have described that disorder. Even they who admit that it is 
 contagious, are of opinion, many of them, that it sometimes breaks out spontaneously, 
 without the intervention of any specific virus. No one questions, I fancy, the con- 
 tagious properties of measles ; or of scarlet fever. Whether the plague, and whether 
 erysipelas, be always or ever so produced, has been thought more doubtful. There 
 is everj^ reason for believing that the small-pox, at least, has now no other source than 
 contagion. How it first arose, it may be difficuh to conjecture ; but it is never known 
 to originate spontaneously now-a-days. 
 
 Small-pox may in truth be regarded as the rtopo^styiua, or type, of this group of 
 diseases. I shall, therefore, take by anticipation, some well-ascertained facts in its 
 history, for the sake of illustrating the general subject. It is a malady which could 
 
 1
 
 EXANTHEMATA. 927 
 
 scarcely be mistaken for any other ; and of which the horrible aspect and fatal 
 tendency are so strongly marked, that its appearance has always been watched 
 with affright by mankind in general, and with intense interest by the philosophic 
 physician. 
 
 In the acme of this disease, when it is severe, the whole surface of the body is 
 covered with innumerable httle pustules. A minute portion of the matter contained 
 in any one of these pustules, just so much as may suffice to moisten the point of a 
 lancet, is inserted, we will suppose, beneath the cuticle of a healthy man, who has 
 not been near the sick man. What follows this engrafting? Nothing, apparently 
 for several days : but then febrile symptoms burst forth : and by and by a crop of 
 papulas appear sprinkled over the skin : and these gradually ripen into pustules pre- 
 cisely resembling that from which the engrafted drop was taken. 
 
 The very same phenomena ensue, if a healthy man enters the chamber of a small- 
 pox patient, and breathes, for a certain time, an atmosphere tainted with the 'jmana 
 tions from his body. 
 
 The points to be noticed here are — 1, the manifest introduction of the virus into 
 the sj^stem : 2, its dormancy for a while, in other words, the occurrence of a period 
 of incubation : 3, the breaking out, at length, of a disease identical in its symptoms 
 and in its character with that of the first patient : and 4 (most surprising of all), the 
 enormous increase and multiplication of the poisonous matter. 
 
 I say the history of small-pox leads to the settled behef that this disorder, of which 
 few persons are not readily susceptible, never occurs, except from contagion. It 
 was quite unknown in Europe till the beginning of the eighth century. No men- 
 tion of any such malady is to be found in the Greek or Roman authors of antiquity. 
 Now whatever may have been the deficiencies of the ancient physicians, they were 
 excellent observers, and capital describers of disease : and it is impossible that a 
 disorder so diffusive, and marked by characters so definite and conspicuous, should 
 have escaped their notice, or have been obscurely portrayed (if known) in their 
 writings. 
 
 On the other hand, Mr. Moore, in his learned and interesting History of Small' 
 pox, has shown that it prevailed in China and Hindostan from a very early period • 
 even more than 1000 years before the time of our Saviour. That it did not sooner 
 extend westward into Persia, and thence into Greece, may be attributed partly to the 
 horror which the complaint everywhere inspired, and the attempts that were conse- 
 quently made to check its progress by prohibiting all communication with the sick 
 partly to the limited intercourse which then took place among the eastern nations., 
 but principally to the peculiar situation of the regions through which the infection 
 was diffused ; separated as they were from the rest of the world by immense deserts 
 and by the ocean. 
 
 The disease is said to have broken out in jlrabia at the siege of Mecca, in the 
 year in which Mahomet was born ; i. e., in the sixth century. It was widely pro- 
 pagated by his wars, and by those of the Arabs afterwards ; and, as I said before, 
 it is generally believed to have first found entrance into Europe at the time of the 
 overthrow of the Gothic monarchy in Spain by the Moors ; when to avenge the well- 
 known outrage upon his daughter, " Count Julian called the invaders." Whensoever 
 and wheresoever it came, it spread with fearful rapidity and havoc. 
 
 What I wish you to remark is this : that while almost all men are prone to take 
 the disorder, large portions of the world have remained for centuries entirely exempt 
 from it, until at length it was imported ; and that then it infallibly diffused and esta- 
 blished itself in those parts. 
 
 Of the more modern history of the disease our knowledge is more precise and 
 sure. It tends uniformly to the same conclusion. 
 
 There was no small-pox in the New World before its discovery by Columbus in 
 1492. In 1517 the disease was imported into St. Domingo. Three years later, in 
 one of the Spanish expeditions from Cuba to Mexico, a negro covered with the pus- 
 tules of small-pox was landed on the Mexican coast. From him the disease spread 
 with such desolation, that within a very short time, according to Robertson, three 
 millions and a half of people were destroyed in that kingdom alone. Small-pox wiw
 
 928 EXANTHEMATA. 
 
 introduced into Iceland in 1707, when 16,000 persons were carried off by its ravages ; 
 more than a fourth part of the whole population of the island. It reached Green- 
 land still later, appearing there for the first time in 1733, and spreading so fatally a.', 
 almost to depopulate the country. 
 
 Evidence to the same effect is furnished by the results of vaccination in somr 
 countries. In Mr. Cross's History of a Variolous Epidemic which occurred at 
 Norwich in 1819, it is stated, upon good authority, that vaccination was adopted ir 
 Denmark, and made compulsory, in 1800. After the year 1808, small-pox no longer 
 existed, and was a thing totally unknown. Whereas during the twelve years pre 
 ceding the introduction of the preventive disease, 5,500 persons died of the small- 
 pox in Copenhagen alone. Statements corroborative of this account have been made 
 to me in the present year (1838) by Dr. Blick, an intelligent Danish physician, who 
 was on a visit to London. 
 
 Now it is a very instructive fact respecting this disease, thus rankly contagious, 
 and arising from no other source than contagion, that when it is epidemic in any 
 places, many instances of it occur which we can by no means trace to contagion. 
 Dr. Gregory tells us that of the numerous cases received into the Small-pox Hospital 
 (to which he has long been phj'-sician) not one in twenty is capable of being referred 
 to any known source of infection ; the disease being ascribed by the patient to cold, 
 fatigue, change of air, or some other innocent circumstance. A prisoner shut up in 
 solitary confinement in the Penitentiary at Milbank was seized with small-pox. 
 Surely this should warn us against inferring of analogous disorders (of continued 
 fevers, for example) that they are necessarily not contagious, because we often fail 
 to discover any way in which the poison could have been appHed. If small-pox be 
 produced by contagion alone, and yet the mode in which the contagious matter has 
 been communicated eludes sometimes our closest scrutiny, then we must conclude 
 that the same thing may happen in o//ier contagious diseases, of which the contagious 
 property may not he so strong or so obvious. Nay, the argument from analogy will 
 lead us a step further. If once a disorder of this kind is decidedly proved to be 
 sometimes the effect of contagion (and this I think I shall be able to prove to you of 
 continued fever) — we cannot help entertaining a doubt whether the disorder in ques- 
 tion really ever has any other cause. It is chiefly with a view to the light which 
 ihey throw upon the obscurer subject of continued fever, that I am thus anticipating 
 some points in the history of the contagious nature of small-pox. 
 
 Again, it is noticed of small-pox — and it is the same with the other diseases in 
 this group — that the human body is not always equally susceptible of its contagious 
 influence. Some individuals are more readily affected by it than others: and the 
 same individual more so at one time than at another. There are even some who 
 seem to be incapable of taking the small-pox — ^just as some, who are quite as much 
 perhaps in the way of it as their neighbours, never become infected with the great- 
 pox. Of 215 persons who had not been vaccinated, nor had the small-pox, and who 
 were living at Norwich in the same houses with persons ill of that disease, fifteen 
 did not become affected with it ; and of these fifteen it was ascertained that ten had 
 escaped under similar circumstances of exposure before. I mentioned, on a former 
 occasion, the fact that a certain dog, in Paris, could not be made to take the conta- 
 ion of rabies. 
 It is not at all uncommon for persons to resist the influence of contagion at one 
 period, and to yield to it at another, even when the exposure has appeared to be 
 less complete. Mr. Cross gives a striking example of this. A man, who believed 
 that he had had the small-pox, lived for twelve years as a nurse in an estabhshment 
 for the reception of persons inoculated with that disorder. At the end of that time 
 he caught the small-pox, which proved fatal to him. Now this might have been, 
 and probabl}' was, as the man supposed, a second attack. The late Mr. Lockley 
 told me an instance still more remarkable, as being free from that ambiguity. Nearly 
 the first patient he ever attended, if not the very first, was an old woman, who for 
 years had been in the habit of going from village to village as a nurse ; and of nurs- 
 ing a great number of persons labouring under small-pox, which she had never had, 
 flnd agamsf which she (naturally enough) believed herself proof. At length she
 
 EXANTHEMATA. 929 
 
 was taken ill, and died of small-pox, under Mr. Lockley's observation, at the age of 
 sighty-four. 
 
 In many cases we can assign no reason for these variations and differences. Age 
 seems to have something to do with them. Infants are but little susceptible of the 
 operation of contagions. Debility, howsoever produced, certainly augments the dis- 
 position to be affected by this, as by other causes of disease. The dose and strength 
 of the poison must also be taken into account. As some men can drink a much 
 larger quantity of wine (which is an alcoholic poison) than others, without being in- 
 toxicated, and are differently influenced by the same quantity at different times, so is 
 it also with the animal poisons we are now considering ; so is it, as I showed you 
 before, with the mineral poison of mercury. 
 
 This fluctuating power to resist contagion is most conspicuous, perhaps, when 
 viewed in reference to scarlet fever. After the very earliest periods of life, children 
 catch infectious disorders of all kinds readily enough ; more readily than in mature 
 age. The poison of scarlet fever operates with less certainty upon aduhs than the 
 poisons of small-pox, or of measles. Some medical men escape scarlet fever alto- 
 gether, although brought much into contact with it by their vocation. I do not know 
 that I ever had scarlet fever. 
 
 Another fact, well worthy of notice, is, that small-pox, which is so rankly conta- 
 gious, and which has at present no other source besides contagion, has its alternate 
 periods of slumber and of activity. This metropolis, and most of our large towns, are 
 never entirely free from it. Scattered cases occur here and there ; and when thus 
 thinly disseminated, the disease is said to be sporadic. But there are seasons in 
 which it spreads rapidly and extensively, and assumes the form of an epidemic dis- 
 temper. We are now living (1838) in the midst of one of these epidemics of small- 
 pox. The same is equally true of the other complaints included in this group. 
 Sometimes they are confined to single families ; sometimes they pervade a whole 
 district. 
 
 Hence you can never infer that any febrile disorder is not contagious, merely be- 
 cause it prevails epidemically. Many epidemic diseases are not contagious. But 
 the two properties may and do meet in the same malady. They are not to be set in 
 opposition to each other, or regarded as incompatible properties, as they have been 
 by some ingenious writers. 
 
 With respect to these epidemic visitations of the exanthemata, certam general facts 
 have been ascertained, very useful and necessary to be known. 
 
 1. The strength of the contagion, and the severity and fatality of the disease, vary 
 at different periods of an epidemic. In general the contagion is the most active, and 
 the disorder the most fierce, at the outset of the epidemic. By degrees its violence 
 slackens, and it ceases to spread. This is partly to be explained by the circumstance 
 that the number of persons who are susceptible of the disease, and who have not yet 
 been attacked, are fewer and fewer as the epidemic proceeds. The fire iangfuishes 
 for lack of fuel. But this does not seem to be all. The disease dies out before it 
 has affected all those who are capable of receiving it. We might, I think, expect, 
 prior to experience, that the earlier cases would usually be the severer: for the 
 weak, who are less liable to struggle with the complaint, and those who, by pecu- 
 liarity of constitution, are most susceptible of the morbific influence, are likely to be 
 the first to suffer. 
 
 2. There are great varieties also in the general character of the symptoms that 
 occur in different epidemics of the same disorder. At one time, or in one place, in- 
 flammatory symptoms run high ; in another place, or at another time, there is an 
 early tendency to debihty and sinking. One epidemic is more malign than another. 
 And the practice varies accordingly ; so that these are facts of the greatest importance 
 The prevailing character of the malady is attributed to what is called the epidemic 
 constitution of the season. And when we have made out, by observation, what this 
 epidemic constitution is, we have obtained a clue to the proper management of thu 
 disorder. Thus continued fever, as it has appeared in London during the last twelve 
 years, has required and borne far less depletion than it did for the preceding twelve 
 years or more. 
 
 59 4c2
 
 930 EXANTHEMATA. 
 
 You may learn from this how dangerous it is to apply indiscriminately in one 
 epidemic the remedies that may have been found useful in another : and also how 
 foolish and unfair it is to censure the practice employed and recommended by others, 
 merely because it differs from that which we, in other epidemic visitations of the 
 same disorder, have considered fitting and beneficial. 
 
 These differences in the pre valency of the disease, and in the character of its 
 SA'mptoms, are not to be explained by any variation in the exciting cause, which is a 
 definite animal poison ; nor can they be reasonably ascribed to any appreciable 
 quality or agency of the weather at the time. They must depend upon changes 
 that have been slowly wrought upon the human body : and those changes, consti- 
 tuting an acquired predisposition, are probably due to previous conditions of the 
 atmosphere, which have exercised a long and gradual influence upon all the indivi- 
 duals of a community. 
 
 After stating, in the first clause of his definition, that the exanthemata are conta- 
 gious diseases, Cullen announces, in the next place, the very curious fact, that they 
 occur but once in a person's life. " Semel tantum in decursu vitas aliquem affi- 
 cientes." In this they offer a remarkable contrast to inflammations, which, having 
 happened once, are, for that very reason, more apt to happen again. 
 
 You will take care to observe, that it is not the mere circumstance of the disease 
 being contagions that makes the difference. Those disorders which shield the sys- 
 tem against their own future recurrence are, all of them probably, contagious ; but 
 the converse does not hold. It is not true that all contagious disorders protect the 
 constitution from their own return. Syphihs, purulent ophthalmia, the itch : these 
 not only do not secure a patient from a repetition of the disease, but perhaps they 
 even render him more liable to it in future. 
 
 K*either is the proposition absolutely and invariably true of any disease. Like 
 most general rules, it admits of occasional exceptions. There is not one of the group 
 enumerated in the beginning of this lecture, which has not been known to occur 
 more than once in the same person. Small-pox has, in many instances, affected the 
 same individual twice ; even when the first attack had been so severe as to have 
 engraved deep traces of its visit upon the skin. There are a few instances recorded 
 of its third recurrence. It was believed, at one time, that whenever the disease was 
 thus repeated, it was always, in the first instance, severe, which, taken in conjunc- 
 tion with the rep'^lition, was thought to indicate a strong natural susceptibihty of the 
 disorder. But it has since been noticed that the primary visit is sometimes unusu- 
 ally mild : and this fact (so powerful is the love of theory) has led to the supposition 
 that the first attack was not sufficiently intense to affect the whole mass of blood, and 
 to exhaust the inborn susceptibility. I believe that the two attacks have always been 
 separated by a considerable interval of time. I have myself known one very strik- 
 ing instance, about which there could be no mistake, of the recurrence of measles in 
 several children of the same parents. This proclivity to be again affected by the 
 specific poison seems to run in families. It is less uncommon for scarlet fever to 
 happen a second time in the same individual. No contagious disease therefore fur- 
 nishes complete future protection against itself. But that this privilege belongs, as a 
 general rule, to small-pox, to measles, and to scarlet fever, there can be no doubt : 
 and the validity of the rule is applicable in the order in which I have here mentioned 
 them. It applies, also, though less uniformly, to the other exanthemata. A person 
 who has suffered a well-marked attack of continued fever is far less hable than ano- 
 ther, according to my experience, to have that disease again. The plague is said to 
 afford a temporary safeguard against itself. Very few persons have it twice in the 
 same season. During one epidemic Dr. Russell found that, among 4,400 individuals 
 who underwent the disease, only twenty-eight contracted it a second time. The 
 singular property we are considering is less plainlj?- visible in erysipelas than in any 
 other malady of the group. 
 
 The next clause in CuUen's definition asserts the supervention of the cutaneous 
 inarks, in technical language, of the eruption, at fixed times [dejinito tempore) after 
 the commencement of the general fever. It is clear, therefore, that the cutaneous 
 'nflammation cannot be the cause of the fever, but is itself an effect of the contagious
 
 EXANTHEMATA. 951 
 
 poison. Here again we have a mark of distinction between febrile exanthemata 
 and inflammatory fevers, or what CuUen calls the phlegmasiae, in which the local 
 inflammation commonly precedes the pyrexia. 
 
 In point of fact, the circumstance to which I have just referred shows the impro- 
 priety of ranking these diseases under the head of cutaneous diseases. They would 
 more rightly be called blood diseases. The disseminated cutaneous inflammation is 
 A curious and an important circumstance ; and it is the symptom which, in the ma- 
 jority of cases, is most distinctive of the disorder : but it is not an essential circum- 
 stance. Thus, although there often is a manifest eruption (quite independent of 
 common petechias) in the earlier stage of continued fever, a lenticular mottling, some- 
 what like that of measles, yet it is often absent altogether. And the very same 
 tiling happens in other diseases of the same group — diseases which all the world 
 considers and calls cutaneous. A febrile affection, often a fatal one, but attended 
 with no rash, proceeds sometimes from the contagion of scarlet fever. The fever — 
 or rather the patient — is not scarlet. The worst form of cynanche maligna is of 
 this kind. It is just the same in measles. Authors speak of morbilli sine morbillis ; 
 of scarlatina sine scarlatina ; and even of variolas sine variolis. Catarrhal symp- 
 toms certainly occur sometimes in weakly children who have been fully exposed to 
 the contagion of measles ; and the complaint has proved fatal, without there having 
 been any eruption at all. So in the plague : certain cases occur in which there are 
 no buboes nor carbuncles, yet which undoubtedly originated from the common con- 
 tagion of the prevaihng epidemic. 
 
 The time at which the eruption comes out differs in the different diseases ; and 
 even in the same disease, it is subject to occasional variation. The rule with re- 
 spect to small-pox is, that the spots begin to be visible on the third day ; that on 
 which the sickness and fever commenced being reckoned the first. As far as I 
 have observed, this rule is a very constant one. It has been noticed, however, that 
 when the disease is confluent, and therefore severe, it occasionally shows itself in 
 eruption on the second day ; and when quite distinct and mild, sometimes not till 
 the fourth. 
 
 The regular period for the outbreak of the cutaneous affection in measles is the 
 fourth day : it scarcely ever begins sooner; but it is often later — on the fifth or the 
 sixth day, or even later than that. 
 
 Cullen assigns the fourth day for the ordinary appearance of the rash in scarlet 
 fever also. But in this he is decidedly wrong. Sometimes it is, I believe, percepti- 
 ble on the first day ; but its most general period is the second day. In severe and 
 unfavourable cases it may be postponed till the fourth day, or longer. 
 
 The eruption, which is tolerably constant in some varieties of continued fever, 
 observes less regularity in the time of its arrival. 
 
 The period which intervenes between the reception of the poison, and the super- 
 vention of distinct symptoms — the period during which the virus, though doubtless 
 at work, seems to lie dormant in the system — the period (in one word) of incubation, 
 differs also in the different diseases of this group, and varies even in different cases 
 of the same disease. Although no marked changes occur during this period, I be- 
 lieve that some slight deviation from the usual condition and feeHngs of the patient 
 might often be observed, if they were expected and looked for. 
 
 The period of incubation in continued fever is very uncertain. In a paper upon 
 this curious subject, published in the ninth volume of the Medical Gazette, Dr. 
 Gregory states it as his opinion, derived from much inquiry, that ten days is the 
 average period. Dr. Haygarth reckoned the minimum period at seven ; the maxi 
 mum at seventy-two days. Sir William Burnett, in his Account of a Contagious 
 Fever at Chatham, gives the history of a party of men belonging to the St. George, 
 lying at Spithead, who were sent, on the 3d of January, 1811, to assist in navigating 
 the Dolphin troop-ship ; the crew of which were affected with typhus fever. On 
 the 10th (seven days after exposure) fourteen of these men were sent to the Hos- 
 pital-ship from the St. George, ill with the fever ; and many subsequently, up to 
 the 21st of January (the eighteenth from exposure), after which period no cases 
 occurred
 
 932 CONTAGION. 
 
 The period of dormancy is more definite, yet still liable to some variation, in most 
 of the other exanthemata. "At the Small-pox Hospital," says Dr. Gregory, " abun- 
 dant evidence has been afforded that the period of incubation is usually about twelve 
 days." It is a remarkable fact that, " when the small-pox is received into the system 
 by inoculation, seven days only elapse between the insertion of the virus and the 
 estabhshment of the fever." 
 
 Dr. Bateman puts the period of incubation in measles at " from ten to fifteen 
 days." I have known several instances in which the date of a single short exposure 
 was exactly ascertained, and in which the disease commenced precisely a fortnight 
 afterwards. In scarlet fever, the average period is shorter ; not more than from four 
 to six days. In the plague it is, I beheve, more variable ; but generally not exceed- 
 ing a few days. Dr. Russell tells us that, among those inhabitants of Aleppo who 
 shut themselves up after having been in the way of the contagion, no instance 
 occurred of the appearance of the malady later than the ninth or tenth day. 
 
 To say that a febrile disorder is contagious, is the same thing as to say that it is 
 produced by an animal poison. Now, there are many poisons, very deadly poisons 
 too, which cause diseases that are not communicable from person to person. That 
 particular poison, the malaria, is of this kind. 
 
 Of the inorganic poisons, some are taken into the blood, and emerge again from 
 the body, unaltered, with one or more of the ordinary secretions ; chiefly with the 
 urine. They may induce changes in the body as they pass ; and if these changes 
 be salutary, the substances so inducing them become medicaments. If the changes 
 be destructive or injurious, they are strictly poisons. 
 
 Other of the inorganic poisonous substances do not find so ready an exit from the 
 body. They enter into permanent chemical union with the constituent tissues of 
 particular organs. In this way, to use the words of Liebig, they deprive the organs 
 of the principal property which appertains to their vital condition, viz., that of suf 
 fering and of effecting transformations. If the organs of which the functions are 
 thus destroyed be vital organs, these poisons are fatal. 
 
 But the animal poisons, those at least with which we are now concerned, act in a 
 totally different manner. They effect changes in the blood, whereby they are them- 
 selves abundantly multiplied or reproduced; and the eruptive disease that ensues 
 seems to be the mode provided by nature for the escape or the expulsion of this 
 newly-formed morbid matter from the system. This is the old-fashioned humoral 
 pathology, founded on bold, unproven speculation ; and it is most curious to see 
 these very doctrines, which had sunk into universal discredit and contempt, now 
 again assuming their places, as scientific truths, upon the secure basis of organic 
 chemistry. A wonderful specimen this of the sagacity of the older physicians — of 
 the despised wisdom of our forefathers. 
 
 The ancients attributed various disorders to a fermentation of the animal fluids. 
 The cause of fever, according to Hippocrates, was some morbid matter in the blood. 
 This matter, by a process of concoction, was brought, in a certain number of days, 
 into a state in which it was ready for expulsion from the body. It was then thrown 
 off by hemorrhage, by sweat, by alvine discharges ; or deposited upon the surface 
 in the form of abscess, or cutaneous eruption : and these eruptions or evacuations 
 constituted the crisis of each fever. 
 
 The doctrine thus enunciated by the father of physic is very nearly the same with 
 that which Liebig is teaching in the nineteenth century. This distinguished chemist 
 ascribes the pfienomena which succeed the introduction of certain animal poisons into 
 the blood, to a process exactly resembling fermentation. Let me try, in a few sen- 
 tences, to expound to you his views on this deeply interesting subject. 
 
 You know that the brewer excites the fermentation of his siveelwort by adding to 
 it a small quantity oi yeast. Wort is an infusion of malt, and contains sugar and 
 gluten, with other vegetable matters, in solution. Yeast is putrefying gluten ; and 
 its component particles are, therefore, in a state of intestine motion or transposition. 
 When placed in contact with sugar in solution, it has the property of communicating 
 a similar intestine motion to the elements of the sugar, whereby they arrange them-
 
 THEORY OF CONTAGIOUS FEVERS. 933 
 
 selves into new and simpler forms ; namely, into alcohol and caroonic acid. If there 
 were no gluten in the wort, this would be the whole of the process ; during which 
 the added yeast disappears. 
 
 But the decomposition ov fermentation of the sugar reacts upon the gluten in the 
 wort, and converts it gradually into yeast, which, minghng with the liberated car- 
 bonic acid, rises and floats upon the surface of the fermenting liquid. So that, when 
 the process is completed, there has been produced thirty times as much yeast as was 
 originally added to the wort. 
 
 Now, this is but a type of what happens in other fluids under analogous circum- 
 stances ; and it may be laid down as an abstract proposition in Liebig's, or rather his 
 translator's words, that " a substance in the act of decomposition, added to a mixed 
 fluid in which its constituents are contained, can reproduce itself in that fluid, exactly 
 in the same manner as new yeast is produced, when yeast is added to Hquids con- 
 taining gluten." 
 
 Thus, the virus of small-pox (which virus is formed out of the blood) causes such 
 a change in the blood as gives rise to the reproduction of the poison from the con- 
 stituents of that fluid ; and whilst this process is going on, the natural working of 
 the animal economy is disturbed — the person is ill. The transformation is not 
 arrested until all the particles of the blood which are susceptible of the decomposi- 
 tion have undergone the metamorphosis. 
 
 Liebig shows that similar processes may take place in mixed fluids (and therefore 
 in the blood), without the regeneration of the added substance ; just as the ferment- 
 ation of a solution of sugar is effected by the addition of yeast, without any repro- 
 duction of the yeast, if there be no gluten in the saccharine solution. In such 
 cases, the disease which accompanies or results from the transformations that occur 
 in the blood, is not contagious ; the poison is not renewed. It is thus, apparently, 
 that certain miasms produce disorders which are not communicable from person to 
 person. 
 
 In order that a specific animal poison should effect its O'vn reproduction in the 
 blood, and excite that commotion in the system which results from the formation and 
 expulsion of the new virus, it is requisite that a certain ingredient (analogous to the 
 gluten in the brewer's sweetwort) should be present in the blood ; and this ingre- 
 dient must have a definite relation to the given poison. 
 
 If this ingredient be indispensably necessary to life, the poison which transforms 
 and destroys it, is inevitably a fatal poison. May not this be the modus operandi 
 of the poison of hydrophobia ? 
 
 Again, if this ingredient be wanting, no reproduction of the poison takes place ; 
 nor, of course, any of those symptoms which are consequent upon such reproduc- 
 tion. The poisonous qualities of the animal substance are not developed. It ceases 
 to be a poison. 
 
 And this ingredient, if naturally present, is exhausted and destroyed, for a while 
 at least, by the operation of the poison. Hence, for a while at least, the same dis- 
 ease cannot be again produced by the agency of that poison. 
 
 Supposing the ingredient to be one which is not essential to the composition of the 
 blood, and to have been thus destroyed or exhausted, it may never be replaced. Or 
 it may be replaced only after a long interval. In some persons it may never exist 
 at all, or it may exist at certain periods only of their lives. It may even be acquired 
 by unnatural or peculiar modes of living. 
 
 All this is not only very possible, but probable. A certain number of peculiar 
 substances do certainly exist in the blood of some men which are absent from the 
 blood of others. In childhood and in youth, the blood of the same individual con- 
 tains variable quantities of substances which are not to be found in it at other periods 
 of life. 
 
 This theory of Liebig's ofl^ers, then, a reasonable explanation, the only explanation, 
 indeed, that 1 have ever met with — of the curious facts, that certain contagious dis- 
 orders furnish a protection, temporary or permanent, against their own return ; that 
 thej' have a tolerably definite period of incubation, and run, for the most part, a de- 
 terminate course ; that some persons are less susceptible than others of the influtuca
 
 934 THEORY OF CONTAGIOUS FEVERS. 
 
 of these animal poisons, or not susceptible at all ; and that the same individual may 
 be capable of taking a contagious disease at one time, and not at another. 
 
 Moreover, the light supplied by this theory gives distinctness to our conceptuns 
 respecting certain deviations from the regular course and type of these diseases ; 
 which deviations are not uncommon. 
 
 Thus the symptoms which precede and usher in the eruption are sometimes slow, 
 halting, and irregular in their progress ; appear, and then recede, and reappear, so 
 that we are in doubt what is about to happen, until at length the disease declares 
 itself in its decided and authentic form. 
 
 We may suppose this to depend upon some tardiness or interruption of the pro- 
 cess, whereby the virus is (to use the ancient term) concocted. 
 
 Again, the series or combination of sj'mptoms that marks the specific disease is 
 sometimes, as I stated before, incomplete. We have the eruption of measles without 
 the catarrhal symptoms ; the sore throat without the rash of scarlet fever. And expe- 
 rience has found that,M'here the malady is thus imperfectly developed, the protection 
 it confers against its own recurrence is also incomplete. To explain this double 
 failure we may reasonably infer a corresponding defect in the series of changes which 
 the poison tends to produce in the mass of the blood. 
 
 Glandular enlargements and chronic abscesses are frequent sequelae of these ex- 
 anthematous disorders. They may be considered to represent the dregs of the repro- 
 duced virus, which has been imperfectly eUminated from the system by the usual 
 channels. 
 
 Such is a brief exposition of Liebig's ingenious theory. Do you ask whether I 
 adopt it, with implicit credence in its truth ? I answer, " By no means." Respect- 
 ing points so curious, it is scarcely possible to refrain from speculation altogether. 
 These views come recommended by the authority of a consummate chemist. They 
 furnish a plausible explanation of the main facts of the case : namely, that the disease 
 is produced by an animal poison ; that the specific virus increases prodigiously in 
 quantity within the body during the progress of the disease; and that the suscepti 
 bihty of its influence in that individual, is thereby somehow exhausted. I entertain, 
 the theory, therefore, until a better one is propounded. It has this incidental merit, 
 that it involves no risk of practical error. 
 
 The subtle contaminating effluvia which proceed from the bodies of the sick enter 
 the blood of those who catch the disorder, chiefly, I imagine, by being inhaled into 
 their lungs in breathing. The poison may, perhaps, be capable of being spontane- 
 ously absorbed through the skin : and upon this supposition oil has been smeared 
 over the surface with the view of shutting out the contagion of the plague. The 
 virus may gain direct entrance into the blood ; we know that it sometimes does so, 
 for we ourselves insert it, in inoculation of the small-pox. Dr. Francis Home im- 
 parted measles by engrafting some blood of a person ill of that complaint ; and sub- 
 sequent attempts to excite the disease in that way have been equally successful. 
 Some rash and unfortunate trials have proved that the plague is communicable by 
 inoculation with matter from the buboes. 
 
 Endeavours have been made to estimate the distance to which the influence of 
 different contagious emanations extends. The effluvia in small-pox, measles, and 
 scarlet fever, are the most active ; operate, I mean, at the greatest distance. la 
 continued fever they have a less range ; and in the plague the diameter of the infec- 
 tious circle is probably very small. Some have even supposed that the plague is 
 communicable only by actual contact; but the opposite opinion seems the more 
 likely, namely, that you may touch plague patients with impunity (as Bonaparte is 
 known to have done on a memorable occasion) if you avoid inhaling their breath, or 
 the effluvia proceeding from their bodies. 
 
 The most important practical result of the experiments made by Dr. Haygarth and 
 others, for determining the absolute distances to which the power of the contagion 
 extends in different disorders, was, that where ventilation is complete, in other words, 
 where the gaseous poison is freely diluted with atmospheric air, the sphere of its 
 operation is very limited. 
 
 I 
 
 (
 
 CONTINUED FEVER. 935 
 
 It is an interesting subject of inquiry, worth glancing at for a moment, how far the 
 power of different contagions is modified by differences of temperature. Small-pox 
 is readily propagated either in hot or in cold regions ; in Mexico near the equator, in 
 Greenland towards the pole. The plague does not spread when the temperature is 
 below 60° or above 90*^ Fahrenheit. The vaccine matter loses its property of pro- 
 ducing the cow-pox if it be exposed for a certain time to extreme cold, or to a heat 
 of 95°. Typhus fever, measles, and scarlet fever, are said to be of extremely rare 
 occurrence in the intertropical regions. Dr. Henry has turned these facts to useful 
 account by proposing to decompose and destroy certain contagions lurking in fomites, 
 by the operation of artificial heat. 
 
 Having thus pointed out many circumstances of interest, which are common to 
 all, or nearly all, the diseases grouped together under the title of exanthemata, I may 
 now proceed to a more particular account of those diseases in succession. And I 
 shall begin with continued fever ; because, although it does not afford the best- 
 marked example of the collection of symptoms that compose CuUen's definition of 
 the order, yet a right understanding of the practical points concerned in the manage- 
 ment of this febrile disease will assist us materially towards a just conception of the 
 modifications of treatment that may be required by the rest. 
 
 We hear continuallj'-, both in and out of the profession, d,ifl"erent species of fever 
 spoken of. By the public, typhus fever, brain fever, bilious, putrid, low, nervous. 
 And systematic writers are to the full as particular : mucous fever, ataxic, adynamic, 
 gastro-enteric, and so forth. Now, admitting that fever shows itself under various 
 forms, I am persuaded that the effect upon the mind of all this subdivision is bad 
 and hurtful. It encourages a disposition, already too prevalent, to prescribe for a 
 disease according to its name. There is no fine of genuine distinction between 
 continued fevers that can be rehed on. They run insensibly into each other, even 
 the most dissimilar of them ; and are traceable often to the same contagion. I 
 shall in the first place, therefore, attempt to describe this disease of continued fever 
 as it occurs in its most ordinary and simple form ; and then point out its principal 
 varieties. 
 
 Continued fever does not always commence in the same way. It often happens, 
 that for several days before the disease assumes its distinct and proper aspect, and 
 before the patient is rendered unable to pursue his usual occupations, he is affected 
 with certain morbid symptoms, which may be considered premonitory of the fever ; 
 so that it is sometimes difficult to mark the precise beginning of the disease. These 
 prehminary symptoms result apparently from an altered condition of the nervous 
 system. The poison in the blood disturbs the functions of animal life before it 
 causes any palpable derangement in the mechanism of the circulation. The expres- 
 sion of the patient's countenance alters ; he becomes pale, languid, and abstracted. 
 Those about him observe that he is looking very ill. He is feeble, and easily tired; 
 reluctant to make any exertion of mind or body ; listless, and apprehensive often of 
 some impending evil. He loses his appetite ; his tongue becomes white and inclined 
 to tremble ; the bowels are irregular, often confined, sometimes affected with diar- 
 rhcEa ; his senses lose their natural delicacy. He has uneasiness or wandering pains 
 in various pariS of the body ; and occasionally there is some giddiness : drowsiness, 
 perhaps, during the day, and unsound and unrefreshing sleep at night. To collect 
 all this into one expressive word, the patient evidently droops. 
 
 In other cases these preliminary movements are altogether wanting. Chome 
 gives the following comparative account, deduced from the exact observation of 1 12 
 patients in this particular. In 73 of these cases the invasion of the disease was sud- 
 den, without any warning, in the midst of apparent good health. In 39 there were 
 prelusive circumstances. 
 
 The regular onset of the fever is, very frequently indeed, marked by a shivering 
 fit. Another common phenomenon at the period of the invasion is severe headache: 
 pain or aching across the forehead. According to Chomel, the headache is usually 
 first experienced by the patient when he gets up in the morning. But this certainly 
 is not a constant symptom. There is sometimes a sense of heaviness and vertigo
 
 936 CONTINUED FEVER. 
 
 rather than headache. Another symptom which sometimes, but not so often, sets in 
 with the fever, is diarrhoea; and this is an important circumbtance when it does 
 occur. It is attended, perhaps, with pain or uneasiness in the abdomen. You will 
 also perceive, even when there have been no premonitory circumstances, that symp- 
 toms arise, even thus early, which belong to the nervous system, and denote some 
 disturbance and alteration in the functions of sensation, thought, and voluntary mo- 
 tion. They are comprised under the general phrase, '■'■febrile oppression" and they 
 are different from what we notice when pyrexia supervenes upon inflammation. 
 You will obtain a clearer notion of what this term, febrile oppression, means, by 
 watching at the bedside of one patient in this disease, than by any description T can 
 give you. There is great inaptitude for exertion of the power of thought, or of mo- 
 tion. The expression of the face is dull and heavy, absent, puzzled. The patient 
 presents very much the appearance of a person made stupid by drink ; and he stag- 
 gers a little if he attempts to walk. The muscular power is sensibly enfeebled: 
 sometimes the patient will struggle against this ; but in a few hours, or in a day or 
 two at furthest, he takes to his bed. 
 
 These are the symptoms which mark the outset of the disease we are about to 
 consider. They occur sometimes in other disorders of the class in which I have 
 placed continued fever. In the plague, for example. The patients appear hke people 
 who are drunk. Now these symptoms result, no doubt, from changes which are 
 going on in the blood, and which make an earl}' and a strong impression upon the 
 nervous system. And there is another circumstance which, when it is observable, 
 denotes a depressed state of the nervous power. Practitioners sometimes are in 
 doubt whether the case may not be one of some visceral inflammation : or, perhaps, 
 knowing it to be continued fever, they still think it expedient to bleed the patient. 
 Now faintness or actual syncope is much more easily produced by the abstraction 
 of blood, in continued fever, than it is in inflammation: and this fact may occasion- 
 ally be the means of distinguishing between incipient continued fever, attended, for 
 instance, with catarrhal sj'^mptoms, and pure incipient pneumonia. 
 
 In order the more clearly to describe the course of continued fever, I shall divide 
 it, as others have done, into periods ; weekly periods. Not that there is any such 
 period of seven days allotted to particular symptoms ; but that in the simplest forms 
 of the disease, when it runs its course most evenly and favourably, and therefore, we 
 may suppose, the most regularly also, there is a succession of different sets of symp- 
 toms, which occupy each about that space of time ; nearly enough to allow of my 
 taking it, I say, as a help to the better describing the disease. 
 
 Many of the symptoms which occur during the first stage of the disorder — during 
 the first week, we will say — are such as belong to the sanguiferous system. The 
 pulse becomes more frequent than in health, there is increased heat of skin, and 
 thirst ; headache, and throbbing of the temples. The pulse varies considerably in 
 different cases. Generally, I say, its frequency augments ; but sometimes it is even 
 slower than natural. The acceleration of the pulse is greatest [cxteris paribus) in 
 those constitutions which are the most irritable. In young persons, in females, and 
 in weak or delicate males, it will often rise, soon, to 120: while in stronger adults, 
 it does not so early attain its maximum of frequency, and perhaps does not exceed 
 100 throughout the whole course of the disease. Should the pulse in any instance 
 reach 130 or 140, the disease is severe : and the majority of such patients die. The 
 absolute frequency of the pulse is not, however, of so much importance in this dis- 
 order, as its steadiness. If it shifts from one number to another, that affords a worse 
 prognostic even than its being very frequent ; provided it keeps at the same standard. 
 The skin, during this period, is generally hot and dry, and it feels to a b3'stander 
 very hot and pungent. The actual heat, however, is not so great as the sensation 
 given to the hand might persuade us it was. Dr. Bateman found that, in a m.-ijority 
 of the ciises treated by him, the heat, as ascertained bj^ the thermometer, was about 
 t00° ; and he never observed it higher than 104°. The thirst is usually troublesome 
 for the first few days. The tongue becomes clammy or dry ; sometimes it is clean 
 ana smooth ; more often furred ; its edges and tip will, perhaps, be red, then a white 
 lur will begin, which euher covers the central part of the tongue, or is divided by a
 
 SYMPTOMS. 937 
 
 straight brown streak which occupies its middle portion. This brown streak is often 
 the first step to dryness and blackness of the tongue. 
 
 During the same period a careful examination of the abdomen will detect indica- 
 tions of diseased action there. Sometimes diarrhoea is an early symptom ; generally 
 it is postponed, I think, to the next period ; or to the latter part of the first. When 
 it does occur, the stools are, for the most part, loose and frequent; and either of a 
 dark colour, and fetid, or of a yellow-ochre appearance, like pea-soup somewhat. 
 If you make pressure upon the abdomen, you will find it unnaturally hard and re- 
 sisting, as though its walls were made of pasteboard ; slightly tympanitic, as you 
 learn by making percussion. Frequently, uneasiness is manifested when pressure 
 is made on the belly, particularly over the csecal region ; and Chomel remarks that 
 another symptom, not commonly met with in other diseases, is usually noticeable in 
 the first stage of this, viz., a little gurgling movement, evidently from the intermix- 
 ture of liquid and gas within the bowel, which movement becomes audible, or pal- 
 pable to the hand, upon pressing the same region. This symptom is still more 
 common in the more advanced stages of the disorder. 
 
 There is evidence, frequently, of a slight affection in the membrane lining the 
 air-passages, from nearly the first : some notable quickness of respiration, and some 
 diffused rhonchus and sibilus, audible through the stethoscope. ^ 
 
 And among all the indications of increased action in the circulating system, the 
 symptoms that relate to the nervous centres remain perceptible. The aspect of the 
 patient is peculiar : the features are fixed and inexpressive ; or expressive merely 
 of apathy and indifference. If he is spoken to briskly, he responds ; and although 
 his sensibility seems blunted, his answers are, as yet, rational, and to the purpose. 
 Delirium does not come on, in general, till towards the end of the first week. The 
 muscular power is greatly depressed. The patient lies on his back, motionless ; he 
 sleeps but little, waking often ; and the short snatches of repose which he seems to 
 get, are disturbed, apparently, by uneasy dreams : and he fancies, and says perhaps, 
 that he does not sleep at all. Sometimes, even during the first stage of the disorder, 
 when the bowels are relaxed, the prostration of strength is so great, or the tendency 
 to stupor and indifference is so marked, that the stools are passed under him as he 
 hes in bed, without any apparent endeavour on the part of the patient to prevent it ; 
 and without any notice of his wants being made to his nurse. The urine, during 
 the same stage, is scanty, and high-coloured, and ill-smelling often. Towards the 
 very end of the first weekly period, the eruption which is peculiar to continued fever 
 sometimes begins to show itself: but this is commonly postponed to the next stage ; 
 and I shall describe it in connection with the other symptoms that are apt to occur 
 in the second week of the disorder. 
 
 It is seldom, except in very mahgnant forms of continued fever, that death takes 
 place during its primary stages. Of forty-two cases treated by Chomel, one alone 
 was fatal in that period. 
 
 LECTURE LXXXIV. 
 
 Continued fever, continued. Phenomena of the second week ; Delirium, an Erup 
 tion, Diarrhcea: of the third week; Recovery, or death in the way of Coma, 
 of Jipnoea, of Jlsthenia. Symptoms that usher in those anodes of death ; morbid 
 changes found after them. 
 
 In the last lecture I commenced the consideration of that important disease, which 
 IS best known, in this country, under the name of continued fever. I told you my 
 opinion that there is but one species, although there are many varieties, of continued 
 fever. Sometimes this disease is preceded by symptoms of a shghter disturbance 
 of the system ; and sometimes it sets in suddenly, in the midst of apparent health 
 
 4d
 
 938 CONTINUED FEVER. 
 
 Whatever premonitory symptoms may take place, they indicate some alteration in 
 the functions of the nervous system, upon tvhich many pathologists have supposed 
 that the first and most direct impression is made, by the exciting cause of the fever. 
 But the exciting cause, in most cases, probably in all, is a specific poison received 
 into the blood : and all analogy is in favour of the belief that the primary change is 
 wrought upon the blood itself. The whole mass of the blood is gradually vitiated ; 
 and the first evidence of the circulation of this altered fluid, is depression of the 
 powers and functions of animal hfe. Among the earlier symptoms of the declared 
 disease, shivering, headache, and occasionally diarrhcea, take the lead. 
 
 For the convenience of description I divided the course of the disorder into three 
 weekly stages : not that it necessarily runs its course in three weeks, but because 
 the sets of symptoms which succeed each other while the disease is in progress, 
 occupy, in the cases which seem to proceed the most regularly, about the space of 
 seven days each. 
 
 Now the symptoms present during the first week are expressive of disorder both 
 of the sanguiferous and of the nervous system. The patient is hot, flushed perhaps, 
 and thirsty, and he has a frequent and hard pulse. Besides this he manifests in- 
 difference and stupor ; his senses are blunted ; his intelligence is diminished. His 
 muscular strength is reduced in a remarkable manner ; so that he cannot sit up ; in 
 many cases he cannot even lie on his side, or turn himself about well in bed, but 
 remains in the supine position : and if he be purged by medicine, or spontaneously, 
 the stools are apt to pass from him into the bed, without his knowing it, or without 
 his taking any cave to prevent it. This, however, is more common, and more 
 marked, in the second period or week ; the phenomena of which I next go on to 
 sketch. 
 
 In the first place, in mild cases, and in some epidemics, the patients begin to 
 improve soon after the first week. Dr. Welsh, in his account of fever as it occurred 
 some years since in the Q,ueensbury-House Establishment in Edinburgh, says that 
 of 743 patients, 373 (that is fully one-half) had passed the worst, or had begun to 
 get belter, by the ninth day ; and several of the physicians who witnessed the fever 
 that prevailed in Ireland in the earlier part of the present century, concur in declaring 
 that, in a vast majority of cases, the disease had " taken the turn," and the patient 
 began to mend, by that time. But the epidemics, in these cases, were undoubtedly 
 mild. In general no change for the better takes place at the end of the first seven 
 or eight days ; but what are called the typhoid symptoms develop themselves more 
 distinctly. 
 
 The changes that occur are usually the following : — The pulse becomes more 
 frequent, weaker, and more compressible. The tongue grows drier and browner. 
 More sordes, and of a darker colour, accumulate on the teeth and lips : and it is in 
 this period that delirium is most apt to ensue ; and that certain eruptions are most 
 often observed. But the symptoms that relate to the nervous system are often still 
 the most prominent. The patient generally loses his headache. His voluntary 
 movements, however, become very much weakened, and are sometimes exercised 
 irregularly. The posture which the patient in this stage almost always assumes is, 
 I say, indicative of this weakness ; he lies on his back, and he sinks down in the 
 bed, slips towards the foot of the bed. He is unable to make or bear that degree of 
 voluntary exertion which would be necessary to place him upon his side. Hence 
 we hail it as a good omen — because it is an indication that the patient still retains 
 some strength — if we find him on his side, or even on his back with his knees drawn 
 up. Other proofs of muscular debility, approaching to palsy, are apt to present 
 themselves. The voice becomes feeble ; the patient can scarcely utter an audible 
 fcound. Perhaps he is unable to swallow. This is a very bad symptom, though it 
 is one that has been recovered from. Sometimes it seems that the power of degluti- 
 tion is not lost, but the sick man is too listless to try to swallow ; or the dry and 
 parched stale of his tongue and throat renders it difficult and painful for him to 
 attempt to do so. The patient is apt to lie with his mouth open : and breathing 
 thus through the mouth tends to dry the tongue. Hence it is well to desire the sick 
 per on to swallow a mouthful or two of water, and so to moisten his tongue, before
 
 SYMPTOMS. 939 
 
 you decide upon the state of that organ, or upon his facility of deglutition. Often, 
 m bad cases especially, there are little convulsive startings of the tendons, {siibsultiis 
 tendinum is the technical name of the symptom,) and other irregular and involuntary 
 actions of the muscles : tremulous movements, especially of the tongue and of the 
 hands ; and sometimes the patient is unable to put out his tongue at all. There are 
 two symptoms which present themselves in the majority of instances in the second 
 vi^eek of the fever, and which deserve your particular attention: I mean delirium, 
 and the eruption which belongs to the disease. 
 
 The delirium is peculiar. The patient wanders, at first, in the night only ; and 
 the deliriurti commonly appears on his awaking from disturbed sleep. Sometimes 
 ne is desirous of getting up, and talks incessantly and earnestly in a loud voice, and 
 can only be kept in bed by the imposition of some restraint. Usually, however, his 
 rambling is of a tranquil kind, and without agitation. His nrind seems elsewhere : 
 he is inattentive to all that passes around him ; but he lies still, muttering disjointed 
 words or sentences, like a man talking in his dreams. From this state of typho' 
 mania the patient may sometimes be roused by loud speaking addressed to him, or 
 by the sight of a strange face ; so that, though incoherent and dehrious just before, 
 he may become collected when his medical attendant enters the room. But he 
 presently relapses. During the delirious state there is a great deficiency of sensa- 
 tion, and insensibihty to impressions. The patient is deaf. This deafness you may 
 hear spoken of as being a good omen, or favourable sign ; but it is so only by com- 
 parison : it indicates a condition of brain less perilous than its opposite, in which the 
 sense of hearing is morbidly acute. Imperfection or loss of vision is much rarer, 
 and much more dangerous, than deafness ; yet the eye is generally dull — unlike the 
 brilliant eye of acute phrenilis ; it corresponds with the expression of the counte- 
 nance, which is perplexed rather than wild. Sometimes, however, as the disease 
 advances, black spots, like flies on the wing, muscse voUtantes, appear before the 
 patient's eyes : in consequence, it is presumed, of partial insensibility of the retina. 
 The patient attempts to grasp or catch these in the air, or to pick them from the bed 
 clothes. This is Q.a\\eA./loccifatio. After these symptoms recovery is not common. 
 The mouth and tongue are dry ; yet the patient no longer complains of thirst. The 
 taste, the smell, the sense of touch, are all impaired ; even external inflammation may 
 take place, especially about the hips and sacrum, and go on to gangrene, without any 
 complaint of pain from the patient. He seems altogether careless about the issue of 
 his disorder. If, at this period of the fever, you ask him how he does, he will pro- 
 bably declare that he is quite well. I hive already alluded to the involuntary 
 passage of the feces : this may depend, in }>art, especially in the advanced stage of 
 the disorder, upon debility or paralysis of the sphincter muscles. The urine also 
 dribbles away frequently: and these are points which must always be looked after; 
 first, for the sake of keeping the patient as clean and dry as possible, the irritation of 
 the urine and fecal matters tending to produce sloughing ulceration; and, secondly, 
 with the view of preventing the bladder from becoming unduly distended. Reten- 
 tion of urine, and all its bad consequences, may otherwise occur. It is a good general 
 rule, therefore, to examine the hypogastric region every day with the hand ; and also 
 to ask to see the urine, not for any purposes of prognosis, but to ascertain that it is 
 regularly discharged. ^ -■ 
 
 It is also, I repeat, in this stage of the disorder that the rash or eruption, which so 
 often accompanies it, very frequently shows itself. Sometimes it is noticed earlier. 
 It consists of small rosy blotches, of a roundish or lenticular shape ; scarcely raised, 
 if raised at all, above the general surface of the skin on which they appear. Ohomel 
 states that they vanish under pressure ; but it is not so. I have again and again ob- 
 served that they diminish or become fainter under the pressure of the finger ; but 
 they are not effaced even for an instant. They are sometimes few ; sometimes so 
 numerous as to dapple the whole surface of the abdomen, or of the thorax, or of both. 
 Upon the limbs they are less common, and less closely set. I believe that they often 
 besprinkle the back, although they are seldom looked for there. They vary in 
 intensity of colour, and, therefore, in distinctness. The whiter the skin, the mofH
 
 940 CONTINUED FEVER. 
 
 obvious do the spots become. In brunettes they may easily escape notice. In this 
 form of disease the entire skin is often unnaturally duskjr, • 
 
 The eruption does not come out all at once : nor is its duration always the same. 
 Sometimes it disappears entirely after two or three days. Sometimes, on the other 
 liand, it lasts a fortnight, or more. In the latter case it is probable that successive 
 crops of the spots continue to arise. 
 
 The rash now described stamps continued fever with one of the most striking 
 characters of the exanlhematous group of febrile diseases : but it certainly is less 
 constant than the cutaneous phenomena of small-pox, measles, or scarlet fever. It 
 occurs much more regularly in some epidemics than in others. Fever is very rife in 
 St. Giles's, and in other crowded parts of this town, just now (1838). Our wards at 
 the Middlesex are full of it; and scarcely a case presents itself without these spots. 
 We speak of it familiarly as the spotted fever ; or, (from the resemblance which the 
 rash bears to that of measles, hereafter to be described) as the rubeoloid fever. 
 
 You cannot well confound this mottled rash with petechise, which are little specks, 
 or dark circular spots, resulting from a minute extravasation of blood beneath the 
 cuticle. The specific rash and these petechiae are, however, sometimes mingled 
 together. 
 
 It may not be superfluous to caution you against mistaking Jlea-hites, which are 
 common to nearly all our hospital patients, for this specific eruption, which is pecu- 
 liar to the fever patients. The round red stain, with a dark point for its centre, 
 sufficiently distinguishes the mark of the insect from the rose-coloured blotches of 
 the disease- 
 There is another eruption described by the French as occurring in this disease 
 without being peculiar to it. In this country it is now very rare ; but it used, whea 
 the hot plan of treatment was in vogue, to be very common indeed here, in various 
 febrile complaints ; and it was, and is, occasioned by profuse sweating. Sudariiina, 
 the vesicles composing the eruption are called. They are small, hemispherical, 
 transparent elevations of the cuticle, containing a clear watery fluid. The vesicles 
 are frdm a quarter of a line to half a Hne in diameter ; they have no red bases ; and 
 they are so perfectly pellucid, that when you look upon them in a direction perpen- 
 dicular to the skin on which they stand, they may readily elude observation. Viewed 
 sideways, they present bright surfaces, and look like so many drops of w^ater, and 
 you may feel with your hand that they roughen that part affected with them. These 
 sudamina are mostly met with on the thorax, along the sides of the neck, and about 
 the axillee. By degrees, the limpid fluid disappears, and they shrivel up ; the cuticle 
 becomes wrinkled, and dries into a whitish powder. 
 
 Diurrhcca is another marked symptom observed in many cases of continued fever, 
 though not in all, at this period of the disease. When the stools are involuntary, 
 when they are passed in bed without notice on the part of the patient, they add ma- 
 terially to his danger, by the irritation and the sores, which are liable to result from 
 their contact with the skin. There is seldom much pain of the abdomen complained 
 of by the patient ; but if you make pressure, especially about the situation of the 
 cscum, you may often remark that he winces, or that a transient expression of suf- 
 fering passes across his features. The character of the evacuation remains the same, 
 and is almost distinctive of the disease : thin, yellowish, ochrey, like pea-soup. 
 When in fever, such stools persist day after day, and several of them every day, 
 you may safely infer that there is ulceration of the bowels, although there should be 
 no pain complained of, even when the abdomen is pressed. 
 
 And the same conclusion will become still more certain when hemorrhage from 
 the bowels occurs, as it is apt to do, in this stage of the fever. It often takes place 
 unexpectedly, sometimes in considerable quantities, and rapidly exhausts the patient: 
 or it recurs at intervals to a smaller amount, wasting his strength as efl^ectually, 
 thougn more slowly. The bleeding is probably owing, in general, to the division or 
 opening of some of the mesenteric veins, by the ulcerating process which I shall 
 more fully describe by and by. This is not, however, a necessary consequence of 
 the ulceration ; for the vessels are usually obliterated previously to their erosion. 
 Boraetimes blood may be thus poured into the bowel without being voided. Andral
 
 SYMPTOMS. 941 
 
 relates a case in which a raan died suddenly, and unexpectedly, at an advanced 
 period of continued fever. Large clots of black blood filled the lower two-thirds of 
 the small intestines, which were crowded with patches of ulceration. No part of 
 the blood had passed the valve of the csecum. 
 
 Hemorrhage from the bowels occurs also in continued fever sometimes in another 
 way ; in connection with other putrid symptoms, as they are not unaptly called : 
 petechicB, purple spots, bruise-like blotches, and extreme depression of the vital 
 powers. In these cases the hemorrhage is strictly of the passive kind, and it is a 
 symptom of the worst omen. Like those effusions of blood from the same parts that 
 happen in scurvy and purpura, it depends upon a morbid condition of the blood. 
 This is no matter of speculation, for by this time the sensible qualities of the blood 
 are manifestly changed : its natural tendency to coagulate when withdrawn from the 
 body is diminished, the crassamentum is large and loose, and fills the cup, and some- 
 times is rather an incoherent sediment than a clot. When these putrid symptoms 
 are strongly marked, a pecuhar fetor is exhaled by the patient's body ; his tongue 
 becomes dry, black, and fissured ; his teeth are covered with dark sordes ; sloughs 
 form from the mere pressure of the bed on which he lies ; in extreme cases the toes 
 have mortified ; and Dr. Roupell relates one terrible instance in which both legs rot- 
 ted away to the bones, which it became necessary to saw through : yet this patient 
 recovered. 
 
 Death may take place in this, the second period of continued fever. Of forty-two 
 patients who died under his care, Chomel counted nine in which the fatal event 
 occurred between the eighth and the fifteenth days. 
 
 The phenomena belonging to the third period of the fever vary considerably 
 according as the disease is about to terminate in death, or in recovery. Among 
 Chomel's forty-two fatal cases, I have already mentioned that one death took place 
 in the first week, and nine in the second ; the remaining thirty-two all occurred in 
 the third period. And the tendency of the fever to terminate during this period is 
 equally well-marked in the cases which recovered. Of twenty-four such patients 
 one alone began to be convalescent in the first week ; and of those whose symptoms 
 were at all serious, not one showed marks of convalescence before the end of the 
 second. 
 
 When the disorder is about to end favourably, the more formidable of the symp- 
 toms diminish and abate. The patient begins again to attend to questions that are 
 put to him ; the air of stupor which had hung over his countenance clears away ; 
 he once more shows an interest in what is going on around him ; the temperature 
 of his skin becomes more natural, the tongue moist and cleaner at its edges, and the 
 frequency of the pulse is Jess. The evacuations from the bowels are less numerous, 
 more consistent, and more healthy ; and the patient is aware when the necessity for 
 passing them arrives, and he gives notice, or asks for assistance. Generally, at the 
 same time with these tokens of improvement, the emaciation which has taken place 
 becomes remarkably conspicuous ; perhaps it is the more observable on account of 
 the patient's resuming a more natural expression of countenance. 
 
 In many instances, the amendment is so gradual that we can scarcely say when 
 it begins. In other cases the favourable crisis is preceded by an aggravation of 
 most of the former symptoms, and a marked increase of the general distress. This 
 is a very curious circumstance ; and it did not escape the notice of our great dra- 
 matist. 
 
 Before the curing of a strong disease, 
 Even in the instant of repair and health, 
 The fit is strongest. Evils that take leave, 
 In their departure most of all show evil. 
 
 Certain evacuations are also sometimes observed to accompany or to be connected 
 with the favourable change ; and the most common of those is the evacuation of 
 sweating. 
 
 On the other hand, when the disease is about to terminate in death, that event may 
 take place in different ways ; in either of those modes, in short, which I took some 
 pains to distinguish in the earlier part of this course of lectures. I told you then thai 
 
 4d3
 
 942 CONTINUED FEVER. 
 
 I had been taught the importance of studying the tendency to this or that mode of 
 dying, in reference especially to fever, by Dr. Alison. My own experience has 
 since sufficiently approved to me the wisdom of his teaching. CuUen inculcates the 
 necessity of "obviating the tendency to death." To do so, we must ascertain the 
 direction of that tendenx:y. We do not so much cure these exanthematous maladies, 
 as keep our patients alive while they recover. If we would prevent their dying we 
 must know in what manner they are in danger of dying. 
 
 The most common mode of death in continued fever is certainly that of coma. 
 The organic life survives the animal life. The muttering, half-conscious, dream-like 
 stupor, from which the patient may be roused for a while, becomes, by degrees, 
 more profound, and death begins in the head. This mode of death, occurring in the 
 second or third week of the fever, is associated, frequently, with the symptoms of 
 putrescency already described. But as the stupor deepens, the pulse generally 
 grows weak, and the extremities become cold. So that death does not come purely 
 in the way of coma ; but we have a compound of coma and asthenia, in which the 
 coma takes the lead. 
 
 Now coma may result from at least two different kinds of cause. One cause is 
 pressure, which is mechanical. Another, which is probably chemical, is the circu- 
 lation of some noxious or narcotic substance (such as opium) in the blood. And 
 there are, doubtless, many physical conditions of the nervous mass itself which are 
 capable of arresting the cerebral functions, and producing coma. To which kind of 
 cause are we to ascribe the stupor that supervenes during the progress of fever ? 
 That is an interesting, and in reference to practice, an important, question. 
 
 Physicians have diligently attempted its solution, by examining the dead brain. 
 I cannot tell you how often I have looked, and looked in vain, for some palpable dis- 
 organization, or some effusion implying pressure. All who are familiar with the 
 dead-house of a hospital are aware that this fruitless search for some physical expla- 
 nation of the comatose state, after death by fever, is of very common occurrence. 
 
 Chomel — one of the latest, and a very able and accurate French writer on fever — 
 gives the following statement in respect to 38 fatal cases, in which the brain was 
 carefully and minutely inspected by him. In 15 of the 38, no morbid appearance 
 at all was perceptible : in 13 there was some serous fluid, from a teaspoonful to a 
 tablespoonful, in the ventricles : in 7 there was what he calls (edema of the meninges, 
 effusion, that is, in the meshes of the pia mater : in 6 general but slight diminution 
 of consistence : in 2 some alteration of density : in 5 a speckled appearance of the 
 cerebral substance. Now to what conclusion do these facts lead us ? Why, in the 
 first place, to the conclusion that those pathologists are in error who maintain (as Dr. 
 Clutterbuck does, for whose experience and talents I entertain a sincere respect,) 
 that the essence of continued fever is inflammation of the brain. Not only do we 
 fail to discover, in many instances, any traces of inflammation, upon inspecting the 
 dead brain, but we find that, during the life of the patient, measures which would be 
 likely to aggravate any inflammatory mischief — strong stimulants, for example, wine 
 or brandy, — do actually and obviously, in cases innumerable, relieve the comatose 
 symptoms, and benefit the patient. The inference seems unavoidable, that the coma, 
 in such cases, has some other cause than that mechanical pressure which arises 
 sometimes from the effusion of fluid upon the surface of the brain, or within its ven 
 tricles ; and that other cause is supplied by the poisoned blood. Here again we 
 may adopt the pathology of Shakspeare : — 
 
 The life of all his blood 
 Is touched corruptibly : and his pure brain 
 (Which some suppose the soul's frail dwelling-house) 
 Doth by the idle comments that it makes 
 Foretel the ending of mortality. 
 
 In some malign epidemics the nervous system is overwhelmed at once, in the very 
 outset, by the force of the poison. The patient becomes stupid or bewildered ; his 
 surface is cold, clammy, purplish, and his pulse feeble : the coma rapidly augments, 
 and deatn may ensue within twenty-four hours. We sometimes see this fearful 
 train of symptoms in small-pox ; and still more often and more strikingly in the 
 
 I
 
 MORBID APPEARANCES. 943 
 
 worst forms of scarlet fever. I believe that in these cases, there is no deviation, cog- 
 nizable by our senses, from the healthy texture and appearance of the parts within 
 the skull. 
 
 Nevertheless, there maybe, and there often is, in these fevers, actual inflammation 
 of the brain or its membranes : but this is an incidental complication. We conjec- 
 ture that, in addition to the influence of the poison upon the nervous system, there 
 may be a low degree of inflammation going on within the head, when we find it 
 externally hot, when the patient has flushed cheeks, and a vascular eye, and com- 
 plains of dull headache. And there are some instances in which we recognize more 
 distinctly the outward signs of encephalitis — severe pain in the head, high and fierce 
 delirium, intolerance of light and of sound, with much heat of skin, and a hard pulse. 
 When coma succeeds such symptoms as these, we naturally ascribe it, in part at 
 least, to the effects of the inflammation : and rightly, for we find traces of inflamma- 
 tion after death ; serous effusion beneath the arachnoid and in the cerebral ventri- 
 cles ; shreds of coagulable lymph ; and more rarely suppuration. T suspect that 
 genuine encephalitis, which is, of course, attended Avith pyrexia, is sometimes mis- 
 taken for continued fever with intercurrent inflammation of the brain. Great atten- 
 tion, and some skill and judgment, are required for discriminating those cases of fever 
 in which such inflammation occurs, and for directing the appropriate treatment. 
 
 The death in fever by apncea is certainly much rarer than that by coma : yet it 
 is not very unfrequent. It often mingles itself with the death by coma. From the 
 earhest period of the fever we may, in most cases, notice some increased quickness 
 of respiration, which is not entirely owing to the mere fever, or to acceleration of the 
 circulation ; for the ear, when applied to the parietes of the chest, discovers rhon- 
 chus, and sibilus, at least. Frequently there is considerable dyspnoea for some 
 hours, or for a day or two, before death : and this may be apparent only, in conse- 
 quence of the stupor ; or it may be real, and proceeding from a low degree of pneu- 
 monia, which, by interfering with the due arteriahzation of the blood, may aggravate, 
 or even give rise to the coma : and such pneumonia is apt to be masked by the 
 fever; declaring itself by none of the ordinary symptoms of cough, rust-coloured 
 sputa, or pain in the thorax. The inflammation, thus latent, is discoverable, how- 
 ever, by the sense of hearing. 
 
 Now what does dissection teach us with respect to the condition of the lungs after 
 death from continued fever 1 Why, the most common unnatural appearance met 
 with in the pulmonary substance is engorgement : a state similar to that which oc- 
 curs in the first stage of pneumonia. But here the engorgement is probably in a 
 great measure mechanical, and takes place during the last few days of the patient's 
 life. As the vital powers diminish, the laws which govern the physical world re- 
 sume their empire. The fluids, and the blood especially, accumulate in the most 
 depending parts of the viscera ; and the lower and posterior portions of the lungs in 
 particular become loaded. But besides this, it is not unusual to find large portions of 
 the lungs in a state of hepatization, and even infiltrated with pus : and the bronchial 
 tubes clogged up by viscid and frothy mucus. 
 
 The mode of death by asthenia or syncope is not very common as existing by 
 itself; but it is often combined with one or both of the two other modes. In some 
 cases of fever, however, death does appear to take place from mere debility of the 
 heart; there having been no pulmonary embarrassment, and the head having remained 
 clear. Death, in such cases, is preceded by those symptoms of debiHty which have 
 been already described. The pulse becomes small and weak, and hke a thread ; the 
 patient lies on his back, and sinks down in the bed ; the features sharpen ; the eyes 
 are hollow and dim, as though glazed ; the sphincter muscles fail to contract ; the 
 extremities grow cold ; cold sweats appear on different parts of the body : and at length 
 the heart ceases to beat and the patient to exist. 
 
 Death occurring in this manner does not occur early. It happens at an advanced 
 period of the disease. It is noticed sometimes in persons who have been largely 
 bled, or too actively depleted at the commencement of the fever: and in those who 
 have suffered a good deal from diarrhoea. In short, as the two previous modes of 
 ieath are connected, often, with morbid conditions of the head and chest respectively,
 
 944 CONTINUED FEVER. 
 
 so death in fever occurring purely or chiefly by asthenia, connects itself with morbid 
 conditions existing within the belly. 
 
 And we trace the vestiges of disease much oftener in the abdomen than either in 
 the brain or in the thorax ; and the mischief which we there discover is more con- 
 stant and definite than elsewhere. It is proper, therefore, to inquire somewhat more 
 closely into the morbid appearances observed in the abdomens of those who die of 
 continued fever. 
 
 I need scarcely remind you that the intestinal canal is largely furnished, on its 
 inner surface, with glands, or follicles, which consist of little more than crypts, and 
 of which the precise office has not yet, I think, been accurately determined. Some 
 of these glands are sprinkled (one may almost say at random) over the whole tract 
 of mucous surface. These are accordingly called solitary ghtnds. Till I was better 
 instructed by Professor Todd, I used to speak of them as being the glands of Brunner ; 
 whereas the glands discovered and described bj^ that anatomist are limited to the 
 duodenum. Other glands or folhcles are collected into groups, and are named glan- 
 didx agminatse, or often the glands of Peyer, who has given a capital description 
 of them. Now the arrangement of these glands of Peyer is peculiar : and, in refer- 
 ence to the morbid anatomy of continued fever, very necessary to be known. They 
 are met with in the ileum alone : they are, mostly, oblong in form : and they occupy 
 that part of the bowel which is opposite its mesmeric attachment. They are largest, 
 and most numerous, and consequently most thickly set, in the lower end of the ileum, 
 which, in some instances, is almost entirely covered with them ; they are found also 
 upon the ileo-csecal valve ; but beyond that they do not go in that direction. Ascend- 
 ing from the cascum towards the jejunum, these groups or patches become smaller, 
 shorter, more circular, and less numerous ; they are separated by longer and longer 
 intervals, till at last they cease to be visible at all. Where there are valvuke conni- 
 ventes, there the situation of these patches is very obvious ; for the valvulae conni- 
 ventes are interrupted, and never run across them. This fact has sometimes led to 
 curious mistakes. I have seen in the museum of the College of Surgeons a prepa- 
 ration put up by Mr. John Hunter (but not labeled, I presume, by him), professing 
 to be an example of the destruction of portions of the valvulte conniventes by ulcera- 
 tion. It is nothing more than one of these natural patches, rather more plainly de- 
 veloped than usual. 
 
 These glands, in their healthy state, are much more conspicuous in some bodies 
 than in others. Yoii may see, if you look at them attentively, that they are made 
 up of a congeries of mucous folhcles, of which the orifices are obsourely apparent. 
 Now the main alterations met with in the abdomen after death, in continued fever, 
 are alterations of these very glands : of the solitary glands, to wit ; and still more con- 
 stantly and remarkably of the agminate glands. 
 
 The changes which these glands undergo are of the following kind. In the first 
 place they become enlarged, and more perceptible than they are in the natural state. 
 They then present a grayish transparent surface, dotted over with black points ; 
 which black points mark, I conceive, the excretory mouths of the several follicles. 
 Then, as the inflammation, for such it is, advances, the patch becomes reddish per- 
 haps ; and the follicles burst or ulcerate, or slough away : not altogether, but partially 
 and by piecemeal ; so that an irregular ragged ulcer is generally left, having thicken- 
 ed edges. Sometimes, however, the follicles disappear without there being much 
 redness or thickening: the mucous membrane immediately adjacent, and even the 
 '•emaining part of the patch of folhcles, being pale, and level. Sometimes the patch 
 pufls up into a sort of fungous swelling, in which all trace of the follicular structure 
 Is lost. The colour of the ulcerated surface is various, as well as its form and ap- 
 pearance. Sometimes it is pale and grey ; sometimes red ; oftentimes yellow, as if 
 the exposed cellular and other tissues were stained by the ochrey fluid which had 
 been poured from the bowels during hfe. What I have hitherto stated relates to 
 Peyer's glands ; but the sohtary glands participate, usually, in the change. They 
 become, in the first place, large and hard, and present a whitish-coloured projection 
 from the surface, which, by a mistaken analogy, has sometimes been called a pustule.
 
 MORBID APPEARANCES. 945 
 
 At length a loss of substance takes place in these also ; beginning at their summit, 
 and producing a small, but sometimes a deep ulcer. 
 
 And of these changes it is further to be observed, that they are more common, 
 more numerous, more extensive, more advanced, in proportion as we approach the 
 caecum. It is natural that we should meet with more ulcers near the cascal valve, 
 because there are more glands there; but undoubtedly the ulcers are (in general) 
 further advanced there than higher up in the bowel. 
 
 Going along with this ulceration of the mucous glands of the intestines, and above 
 all of the aggregate glands of the ileum, you will frequently find inflammation (j, e., 
 redness, hardness, and swelling) of the corresponding mesenteric glands. This would 
 seem to be a consequence of the inflammation and ulceration of the mucous glands. 
 The inflammation of the mesenteric gland is, I conceive, secondary ; and bears the 
 same relation to the ulcers seen in the bowel, as a bubo in the groin bears to a chancre 
 on the glans penis. 
 
 These alterations are extremely interesting, because they aflx)rd a plausible ex- 
 planation of many of the symptoms of continued fever. They account for the 
 diarrhoea ; they account for one form of occasional hemorrhage from the bowels ; 
 they account for the uneasiness of pain which is experienced when the abdomen is 
 pressed, and teach us why that uneasiness is greatest in the situation of the caecum. 
 Nay, we can even understand why, although these ulcerations exist, there may be 
 no pain occasioned by them. This may be partly owing to the general insensibility 
 to impressions and sensations of all kinds, produced by the stupor; but partly, also, 
 it probably depends upon the depth to which the ulceration goes. The mucous 
 tissues are possessed of but little sensibility even under inflammation ; but if the 
 muscular and peritoneal coats become involved in the inflammatory process, then 
 pain begins to be felt. I remember, a few years ago, attending a young lady ill of 
 fever, with a very well-informed practitioner, but one of the old school, for he had not 
 turned his attention much to the state of the intestines in that disease. One day we 
 learned that our patient had had hemorrhage ; from the uterus her friends supposed; 
 but when I saw the discharge, I was certain, by its appearance, and by its odour, 
 though it was not mixed with any feces, that it had come from the bowels ; and I 
 stated my conviction that there was ulceration in the lower portion of the ileum. But 
 she had no pain in the abdomen. You might press any part of it without exciting 
 the smallest uneasiness. So, distrustful of my opinion, they called in an eminent 
 accoucheur, who also pressed and examined the belly : but neither could he detect 
 any tenderness or undue sensibility. He next examined the uterus per vaginam ; 
 but could discover nothing wrong there. Some few nights afterwards the general 
 practitioner was called out of his bed to this patient. He was told that the hemor- 
 rhage (or flooding as they called it, for they persisted in believing that it was uterine,) 
 had returned ; and before he arrived at the house the patient was dead. We next 
 day opened the body together. The uterus was perfectly natural ; there was no 
 vestige of discharge or bleeding in the vagina; but the ileum, for about a foot above 
 its entrance into the caecum, was in a state of superficial but ragged ulceration, and 
 universally red and smeared with blood. I mention this as a strong fact in illustra- 
 tion of the possibility of there being much disorganization of the inner surface of 
 the intestines, without any pain to reveal it. 
 
 Now the alterations I have last been sketching — the thickening, redness, tumefac- 
 tion, and ulceration or sloughing of the glands of Peyer, and also of the solitar}'- 
 glands — are so common in fever, particularly in some epidemics, that many patholo- 
 gists are of opinion that fever is essentially inflammation of these glands, and nothino- 
 else. But this, I am sure, is an error. In the first place, if this doctrine were true, 
 it would almost follow of necessity that the severity of the case, and the intensity of 
 the symptoms, should be in proportion to the number, depth, and extent of the 
 ulcerations. But this is far from being so. In cases in which the symptoms have 
 :)een of the worst kind, there have been found very ievf ulcerations, and those small 
 and apparently insignificant. On the other hand, when the complaint has run a 
 moderate course, but at length has terminated fatally, it is not uncommon to discovei 
 a frightful amount of disorganization in the ileum. 
 60
 
 9-16 CONTINUED FEVER. 
 
 But what is more conclusive is, that the occurrence of this inflammatory condition 
 of the mucous follicles of the intestines is not constant, in continued fever. If one 
 well-marked instance of the disease should occur, without any trace of a morbid 
 action having been going on in the mucous follicles, that instance would, of course, 
 suffice to overturn the theory. But scores of such cases have occurred. I have seen 
 many such myself; and other persons have seen more. Since attention has been 
 drawn to the subject, the patches of glands, and the whole tract of mucous mem- 
 brane, from the stomach to the rectum, have been diligently explored : and the result 
 seems to be that, at certain times and places (in other words, in certain epidemics) 
 the ulceration of the inner surface of the intestines is far less common than at others. 
 It was comparatively rare in an epidemic of which I witnessed some part in Edin- 
 burgh. Then I came to London ; and for several years I never saw a body opened 
 after death by continued fever, without finding ulcers in the bowels. More recently, 
 however, and especially during the present epidemic (1S38), I have looked for them, 
 carefully, in many cases that have proved fatal in the Middlesex Hospital, and have 
 discovered neither ulceration nor any other apparent change in the folhcles of the 
 intestines. Still, in my own experience, such ulcers have been vastly more often 
 present than absent. Chomel, during five years' investigation of this matter in the 
 Hotel Dieu, never met with an exception to the general rule of their occurrence ; or 
 of some degree or form of that kind of alteration in the mucous glands, of which the 
 ulcer is the last stage. 
 
 We must conclude, upon the whole, that although an inflammatory state of the 
 solitary and aggregate glands, which strew the surface of the mucous membrane of 
 the alimentary canal, is not the essence of fever, yet that it is a very frequent com- 
 panion of continued fever. 
 
 But when it does occur, is this state of things always, or necessarily fatal ? By 
 no means. It may be fatal, in more ways than one. It may lead to death, by ex- 
 hausting diarrhnea, in the way of slow asthenia ; it may kill by laying open a large 
 mesenteric blood-vessel, and so producing copious hemorrhage and mortal syncope ; 
 it may, and often does, destroy the patient, by perforation of the bowel; the ulcer 
 penetrates the mucous and muscular coats, and reaches the peritoneum : and some- 
 times that membrane gives way, and sometimes it does not. The consequence of iis 
 rupture or perforation — the escape, I mean, of the contents of the bowel, and the 
 supervention of intense and uncontrollable peritonitis — I need not again dwell upon. 
 But the ulcers may, and doubtless often do, heal : and the scars which they leave 
 behind them are frequently to be seen. The ulcerated surface seems to clothe itself 
 afresh, by degrees, with a new mucous membrane ; which is thin, however, and 
 adherent to the subjacent tissues, and does not sHde over them when pressed between 
 the finger and thumb, as the healthy portions of the coats of the bowel will do upon 
 each other. And in the place of the cicatrix there is usually to be seen a manifest 
 puckering, and a number of little wrinkles or lines, radiating from a common centre. 
 
 The spleen — I may observe, before I conclude this lecture — is more frequendy 
 found altered in texture after death by continued fever, than any other part except 
 the glands of which I was last speaking. It is usually enlarged, of a dark colour, 
 and "of soft, and sometimes almost rotten, consistence. 
 
 To-morrow I shall endeavour to point out some of the most important varieties 
 that have been found to occur in this disease of continued fever. 
 
 LECTURE LXXXV. 
 
 Varieties of Continued Fever. Its Causes. Exciting and Predisposing. Pro- 
 phylaxis. 
 
 Having traced, in the last lecture, as clear an oudine as I could, of the ordinary 
 course and the diflerent terminations of continued fever, I wish to touch, briefly, to- 
 day on some of its principal varieties ; and then to inquire into its causes.
 
 CONTINUED FEVER. 947 
 
 Although fever is, as I have stated, a specific disease, it assumes divers forms ; 
 atid so dissimilar are some of its phases that they might seem to belong to totally 
 different maladies. These variations relate not only to individual cases, but to whole 
 epidemics. In some places and seasons, the inflammatory type predominates, marked 
 by excitement of the sanguiferous system ; in others, depression of the nervous 
 system, characteristic of the typhoid type, is the prominent feature of the disease. 
 Most generally of all, the disorder commences with inflammatory fever, and ends 
 with typhoid symptoms. The distinctions drawn by Cullen, now well nigh obsolete, 
 were founded in nature. To the inflammatory form he gives the name of synocha, 
 which he thus defines: "Calor plurimum auctus ; pulsus frequens, vahdus, et durus; 
 urina rubra ; sensorii functiones parum turbatse." With this he contrasts his typhus. 
 "Calor parum auctus; pulsus parvus, debilis, plerumque frequens; urina parum 
 mutata ; sensorii functiones plurimum turbatEe ; vires multum imminutte." These 
 forms I would have you bear in mind : not that you are likely to meet with many 
 instances of pure synocha, nor of pure typhus, but because they furnish standards 
 of comparison, towards which, in opposite directions, the fevers of different epide- 
 mics approach. The most usual variety of continued fever is represented by the 
 synochus of the same author, which is a compound of the two others. "Febris ex 
 synocha et typho composita : initio synocha, progressu et versus finem typhus." 
 The unsoundness of many of Cullen's theories, and the conceit of later and far in- 
 ferior writers, have thrown his First Lines into undeserved neglect ; but his clear, 
 succinct, and faithful pictures of disease, will not easily be surpassed, and are worthy 
 of your attentive study. 
 
 The difference is very striking between the kind of fever that I witnessed in Lon- 
 don for ten years before the arrival of the spasmodic cholera in this country, and the 
 kind of fever that has since prevailed, and is now (1838) so rife around us. During 
 the first of these periods, the antiphlogistic regimen was indispensable in the outset 
 of the disease; in most instances, bleeding, either general or topical, was required, 
 and well borne ; there was no eruption to be seen upon the skin ; the glands of 
 Peyer, according to my own experience of the fatal cases, were almost invariably 
 affected ; and the mortality was very moderate. This was an inflammatory phase. 
 The present epidemic offers a marked contrast in all these points. A large per 
 centage of those who contract the fever die ; after death we seldom detect any dis- 
 ease of the agminate glands of the intestine ; the peculiar rash scarcely ever fails to 
 show itself; we are taught b}'' experience to refrain as much as possible from blood- 
 letting ; and almost from the beginning, or quite, we find it necessary to sustain our 
 patients by a liberal allowance of strong animal broths. The typhoid is now the 
 prevailing type. You might, I say, almost suppose that I have been speaking of 
 two distinct maladies. But, during each of the periods in question, some scattered 
 cases have occurred, bearing most of the characters proper to the other period. 
 Moreover, all acute diseases have assumed, wnthin the last ten years, in this town at 
 least, an unusually asthenic character. So that the differences observed in the aspect 
 and phenomena of continued fever, depend more, I conceive, upon an acquired dis- 
 position of the human body, produced by some obscure general influence, and there- 
 fore affecting the entire London community, than upon any change in the essential 
 nature of the disease, or in the virus which (as I beheve) occasions it. 
 
 The inverse relation between the rash and the intestinal ulceration is remarkable. 
 When the one is prevalent, the other is rare. It would seem, in conformity with 
 Dr. William Budd's views, that the specific poison displays its elective affinities by 
 settling sometimes upon the mucous glands, sometimes upon the cutaneous tissues, 
 and sometimes by sharing itself, though unequally, between the two. 
 
 I have incidentally alluded to the duration of the fever. In this particular, also, 
 there is much variety; a fact which is apparent even to the vulgar, and expressed 
 in their ordinary discourse. They talk of the one-and-twenty day fever, and of the 
 fourteen-day fever, according as the disorder "takes the turn" in three weeks or in 
 a fortnight. It appears from the report made some years ago to the government 
 upon the state of fever in Ireland, that the fever there generally began to depart on 
 the fifth day ; wherefore it was called, in that part of the kingdom, the five-day fever
 
 948 ^CONTINUED FEVER. 
 
 Of the fever patients whom I saw in the Edinburgh Infirmary, almost all were fairly 
 convalescent, or dead, before the end of the third week. In this place, the disease 
 runs out longer; lasting three, four, or five weeks. I observed also, in Edinburgh, 
 that many of those who recovered had a tedious convalescence, in consequence of 
 very troublesome sloughs and ulcers which formed upon the sacrum and hips. In 
 London, these bed-sores are comparatively uncommon. 
 
 The symptoms attending the fever seem to vary also, cseteris paribus, according 
 to the season of the year, and the situation of the patient : whether, I mean, he be 
 surrounded with pure and cool air, or with a foul and hot atmosphere. In the colder 
 months there is greater risk of inflammatory complications, and especially of pectoral 
 affections : in the autumn we look more for diarrhoea, or for dysenteric complaints, 
 engrafting themselves on the disorder. Where the air is close and foul, the symp- 
 toms show a much greater tendency to the typhoid type, and the deaths are more 
 numerous, than where it is pure. 
 
 It is of great importance to hold correct notions as to the exciting cause of conti- 
 nued fever; respecting which there has been, and there still is, a perplexing contra- 
 riety of opinion among medical men. You are aware, from what has already been 
 stated, that I consider the disorder to originate in an animal poison, and to be conta- 
 gious ; communicable, I mean, from one who is labouring under the complaint, to 
 another who is not. 
 
 When the same disease attacks many persons in the same house or neighbour- 
 hood, at about the same time, the popular suspicion soon arises that the disease is 
 catching. Yet you know that disorders may be widely prevalent without being 
 contagious. Agues, for example, engendered by malaria ; ordinary catarrhs and 
 sore throats, produced by vicissitudes of the weather. When an epidemic malady 
 affects large masses of the people suddenly and at once, it is presumably not conta- 
 gious ; at any rate, it must have some other source besides contagion. When, on 
 the contrary, it begins in a certain spot, and gradually spreads thence as from a centre, 
 the presumption is in favour of its propagation from person to person. In investi- 
 gating this subject, if we trace the fever among persons who have had intercourse 
 with the sick, and more frequently in proportion as that intercourse has been close 
 and continued; and if we find that other persons, living in the same place, and 
 under precisely the same circumstances, except that they have had no known com- 
 munication with the sick, escape the fever ; we have in these facts convincing evi- 
 dence that the disease has been spread by such intercourse ; in one word, that it is 
 contagious. 
 
 Have we, then, facts of this kind ? We have, in the amplest abundance. 
 
 We find, even in hospitals, where cleanliness and ventilation are prized and en- 
 forced, that fever attacks many of the persons who come most often and most inti- 
 mately in contact with those already ill of that disease : chiefly the nurses, next the 
 clinical assistants and the most assiduous of the students, and the medical officers; 
 rarely the other patients, even in the same ward. The separation of a few feet, if 
 due regard be had to ventilation, is sufficient to render the poison inoperative, by 
 diluting and diffusing it in the surrounding purer atmosphere. Three of our nurses 
 in the Middlesex Hospital have fallen ill of fever during the epidemic now prevail- 
 ing, and two of the three have died. I am now attending a pupil of the Charing 
 Cross Hospital, who is persuaded that he caught the fever while watching some bad 
 cases of it there. It is only when our wards are unusually full of fever patients 
 that these disasters occur; but they happen very often, indeed, constituting the rule 
 rather than the exception, wherever many fever patients are collected together: as 
 in hospitals which are exclusively appropriated to their reception, or in the fevei 
 loards of certain general hospitals. In such places, the effluvia which proceed from 
 the bodies of the sick are, in spite of all care, the most abundant and the most con- 
 centrated. 
 
 Dr. Welch, whose book I have referred to before, has the following statement in 
 point : " In this hospital (that is, Queensbury House in Edinburgh, which was opened 
 for the sole use of fever patients during the prevalence of a severe epidemic in that
 
 EXCITING CAUSE. 949 
 
 City, in the years 1817, '18 and '19), since it was opened (which was the year before 
 the time when Dr. Welch was writing), my friends, Messrs. Stephenson and Chris- 
 tison, the matron, two apothecaries in succession, the shop-boy, washerwoman, and 
 thirty-eight nurses, have been infected ; and four of the nurses have died. With the 
 exception of but two or three nurses, who have been but a short time in the hospital, 
 I am now the only person who has not caught the disease, either here or at the 
 infirmary, within the last eight or ten months." 
 
 I may quote a passage from Dr. Alison, in illustration of the same thing. He is 
 speaking of a more recent epidemic, which occurred in Edinburgh in 1827 and 1828. 
 He says: "During this epidemic, as well as that of 1817-19, many of the clerks 
 and nurses employed in the Royal Infirmary have taken fever. Since November 
 last, six of the clerks employed in the clinical wards only, four of those employed 
 in the ordinary wards, and twenty-five nurses or servants, have taken fever. All 
 these persons had necessarily frequent and close intercourse with the fever patients 
 in the house, having been employed more or less constantly in the fever wards, 
 excepting only four of the servants. Of these four, two had been employed in the 
 laundry where the linen from the fever wards was washed ; one was a porter em- 
 ployed at the gate, who would of course have communication with the fever patients 
 at their entrance or dismissal, as well as with their relations coming to visit them ; 
 and one was a nurse employed in the servants' ward, but who was in the habit of 
 visiting the fever wards." Now, mark the contrast. He adds that, "in this very 
 place and season, those of its inhabitants who have not had intercourse with fevet 
 patients have almost uniformly escaped the disease. Of the inhabitants of the 
 ground-Jloor of the house (including patients in the lock-ward), none but those 
 already mentioned as having washed the linen from the fever wards, and the barber 
 who shaved the heads of the fever patients, have taken the disease. Yet in the 
 case of malaria" (to which I must apprise you that many medical men of great 
 authority ascribe the occurrence of continued fever,) " it is the ground-floor of the 
 house that is generally found the most dangerous. No one of the nurses, whose 
 duty has confined them to the medical or surgical wards where no fever patients 
 were admitted, has taken fever, with the single exception of the woman in the serv- 
 ants' ward above mentioned. And of the numerous patients in these ordinary 
 wards, the only one who has taken the fever, within my knowledge, during the pre- 
 sent year, was a patient in the men's general chnical ward, who lay in the bed next 
 the door that communicates with the clinical fever ward. If there be malaria in 
 this house, therefore, it would seem to restrict \i?,e{{ in point of space, as at Queens- 
 bury House in point of time, to the immediate vicinity of fever patients." To under- 
 stand this last remark, you should know that, in ordinary years, the inmates of 
 Glueensbury House escaped fever. 
 
 We have similar testimony nearer home ; in this metropolis. "Every physician 
 connected with the London Fever House, with one exception (writes Dr. Tweedie), 
 has been attacked with fever ; and three out of eight have died of it. Also the re;u- 
 dent medical officers, matrons, porters, laundresses, domestic servants not connected 
 with the wards, and every female who has performed the duties of nurse, have, one 
 and all, invariably been the subjects of fever. And to show that the disease is capable 
 of being engendered by fomites, or clothes, the laundresses, whose duty it is to wash 
 the patients' clothes, are so invariably attacked with fever, that few women will un- 
 dertake the loathsome and disgusting office." 
 
 Now, it is in vain to attempt to escape from this kind of evidence, by saying thai 
 the situation of the Fever Hospital is infested with some local miasm ; for the in- 
 mates of the Small-pox Hospital, which is immediately adjacent to it, are not affected 
 in this way with continued fever, but remarkably exempt from it, as Dr. Gregory 
 testifies. 
 
 Evidence of a somewhat different kind, but leading to the same conclusion, is 
 to be found in the fact, that when persons, having the fever upon them, are trans- 
 ferred to some distant spot that was previously free from fever, they frequently 
 form centres from which the disease begins, thenceforward, to spread. It is im 
 
 4£
 
 950 CONTINUED FEVER. 
 
 parted, i-n this way, even in the country, from family to family, and from village to 
 village. 
 
 I was summoned home from Edinburgh on account of my mother's serious illness 
 with continued fever. She was living in a village where there was little or no fever 
 prevailing. While she was recovering my sister took the disease, and had it se- 
 verelj'. It had evidently been introduced into the house by a man-servant, whose 
 family lived in a neighbouring villag-e. This family had the disease raging in their 
 house, and he was in the habit of going thither occasionally, and always of sending 
 his linen to be washed there. He first, in our house, had the disorder, then two of 
 the maid-servants, and next my mother. 
 
 The cook of Trinity College, Cambridge, living in a street called the Petty Cury, 
 had a daughter in London who fell ill with continued fever, and who insisted upon 
 going home. At that time there probably was no case of fever in Cambridge : 
 certainly none in the Petty Cury, as Dr. Haviland (who gave me the account) satis- 
 fied himself by inquiry. The girl was very ill indeed, after she reached her father's 
 house ; but she ultimately recovered. Every inhabitant of that house, except an 
 old, seasoned nurse, became affected with the fever ; and three or four of them died. 
 But no fever existed in the other houses of the same street. When one of the sick 
 persons was convalescent, it was thought her recovery might be accelerated if she 
 were put into a lodging at Trumpington, a small village two or three miles from 
 Cambridge, in which there certainly was then no fever. Here she and the old 
 nurse were waited on by a servant belonging to the Trumpington House. That 
 servant soon sickened of the fever, and was sent to Addenbrook's Hospital, where 
 she died. 
 
 Take one more instance to the same effect, related by Dr. Alison. " Some years 
 ago, at a time when there was no great number of fever cases in Edinburgh, I met 
 with a case in the son of a shoemaker, who was lying in a room in which his father 
 and two apprentices were at work. I could not prevail upon the father to remove 
 his son to the hospital, although I stated the danger of the apprentices being affected. 
 AVithin two or three weeks after, I found that the two apprentices were lying ill of 
 fever in their own houses : one of them two hundred yards, the other half a mile 
 distant from the workshop, and Avidely distant from each other. These young men 
 likewise lay at home during the fever; and each of their cases was speedily followed 
 by a succession of others in the inhabitants of the rooms which they occupied, and 
 of those immediatel}- adjoining, who had never been at the workshop. In one of 
 these houses seven, and in the other twelve, were thus affected. Now, on the sup- 
 position of the fever being contagious, all this was to be expected, and all corresponded 
 to the predictions which were hazarded on that belief. But on the supposition of 
 such succession of fever cases depending on miasmata, there must have been at 
 least two, more probably three, separate and accidentally concurring miasmata to 
 explain the phenomena here observed ; one at the workshop, and one at each of the 
 houses of the apprentices : and there must have been this extraordinary coincidence, 
 that at each of these last the malaria sprung up just at a time when a patient was 
 lying ill there of fever, which he had apparently contracted elsewhere. Further, 
 the three houses in which these successions of fever cases were observed, are in 
 situations very different from one another; and all of them have been, to my know- 
 ledge, perfectly free from fever for years together, both before and since that time, 
 notwithstanding that fever has been much more generally prevalent, and that they 
 have been inhabited by successive families. What probability is there (continues 
 Dr. Alison) that three separate miasmata should have arisen in these three houses, 
 just at the time when their presence was required in each to produce an effect 
 which had been foretold as the consequence of another cause undeniably operating 
 i)n all?' 
 
 If we contrast facts such as I have been advancing, with other cases, in which all 
 die circumstances appear to have been precisely the same, except the presence of the 
 alleged cause of the disease — making our observations always upon as large a scale 
 us possible — we approach, as nearly as the subject will admit of, to a demonstrative 
 l^roof that continued fever spreads by contagion.
 
 EXCITING CAUSE. 951 
 
 The reports which were made by the accredited physicians, to a committee of the 
 House of Commons, respecting epidemic fever in Ireland, contain abundant and 
 valuable evidence on this point also. Dr. Chejme states that the farmers and house- 
 holders in some parts of Wicklow, who would not harbour or admit into their houses 
 strolling persons, nor go to wakes or funerals, remained free from the disease. In 
 Ballytore a committee was formed of persons who took pains to instruct the inha- 
 bitants as to the precautions to be observed against infection : such as refusing admis- 
 sion to wandering beggars, absenting themselves from wakes and other assemblies ; 
 and even, under certain circumstances, from places of worship. These precaotrons 
 were so effectual that not a case of fever occurred. Four villages in the neighbour- 
 hood of Lismore are stated by Dr. Barker to have been preserved from the fever, 
 chiefly by the exertions of some Roman Catholic clergymen, who persuaded the 
 inhabitants to avoid all communication with Lismore, and with another town in its 
 vicinity, where the fever was rife. 
 
 Tt was observed also that bodies of persons collected together, and fenced about by 
 barriers which precluded intercourse betAveen them and places infected with the 
 fever, remained exempt from it ; children in charity schools, soldiers in barracks, 
 and even prisoners in the jails. In the same parliamentary report you may see a 
 letter from Dr. M'Donald, who had established a fever hospital at Belfast, which 
 hospital alone, at one period, contained 190 cases of typhus. Very near the hospital 
 was a school, containing 700 or 800 young persons ; a poorhouse with 800 inmates ; 
 and a barrack with 1000 soldiers. These places were never more free from fever 
 than at that time. 
 
 Facts to the same purpose abound in the medical reports of the army and navy. 
 Those of the navy are especially valuable and instructive in this matter, because the 
 whole of the circumstances in which the patients are placed come under the certain 
 and immediate cognizance of the medical officers superintending them. I cannot go 
 into particulars here, but must content myself v.'ith referring you to the writings of 
 Dr. Lind, Sir Gilbert Blane, and Dr. Trotter. You will there find that ships which 
 had, for a great length of time, been quite free from fever, have had that disease 
 spread rapidly from one individual, recently imported, so as to affect almost all the 
 crew. This was often the case when raw recruits were drafted from the receiving 
 ships. It appears, from reports made to Dr. Trotter by different naval surgeons, 
 and published in his Mcdidna Naiitica, that the fever was conveyed to a great 
 number of vessels forming the Channel Fleet, from the receiving ship called the 
 Cambridge. 
 
 It is, moreover, found, that when persons ill of fever are taken away from their 
 own close crowded houses, and when means of purification are employed, the fever 
 ceases to spread in those houses. This well-ascertained fact it is which gives to 
 fever hospitals their greatest, nay, almost their only value. They would otherwise, 
 as we have already seen, be detrimental or dangerous to all concerned with them, by 
 concentrating the poison that produces the fever; without equivalent benefit. As it 
 is, they cause, indeed, a certain amount of disease and of death ; but by affording 
 opportunities for cleaning an infected neighbourhood of the seeds of the fever, and 
 by so preventing its diffusion among a large and healthy community, they save many 
 more lives than they sacrifice. 
 
 You may be surprised that I should appear to labour this point ; and should take 
 so much pains to prove what may seem to you, as I confess it seems to me, to be an 
 undeniable proposition. But I do so because many have denied, and do still deny 
 it ; and plausible reasons are given, by men of name and character, for discarding 
 altogether the notion of continued fever being propagated by contagion. Some even, 
 who have begun by expressing their belief that the disorder was contagious, have 
 ended by becoming strong, ay, violent anti-contagionists. The late Dr. Armstrong 
 was one of these ; and there are living men, of high and deserved repute, both in 
 this country and abroad, who hold what I cannot help thinking erroneous — and if 
 erroneous, then manifestly dangerous — opinions on the subject. Chomel informs us. 
 that not one in a hundred of the profession in Paris believes that typhoid fever is a 
 communicable disease. Upon a subject so important it is right that vou should bo
 
 952 CONTINUED FEVER. 
 
 furnished with data for forming a correct and settled judgment. But I scarcely ex- 
 pect that the facts I have now brought forward will carry the same conviction to you 
 all ; for I agree with Dr. Christison in believing that the discrepancy which exists 
 upon this, as upon some other controverted questions, depends, in part, upon the dif- 
 ferent constitution of men's minds, and their peculiar habits of thought. Most of the 
 anti-contagionists whom I have known have belonged to that party in this country 
 which advocates what are called liberal opinions in pohtics and in religion. If this 
 should prove to be generally true, it must be regarded as a curious psychological 
 fact. 
 
 I have laid before you some of the positive evidence which goes to prove the con- 
 tagiousness of continued fever. You may naturally ask, and it is but fair that I 
 should tell you, what are the arguments on the other side of the question. 
 
 First, then, it is asserted that continued fever cannot be contagious, because some, 
 nay many persons, who JiCive intercourse with the sick, do not contract the disease. 
 
 But the force of this reasoning is completely broken by the well-known fact that, 
 in respect to diseases which are on all hands acknowledged to be contagious, and 
 which are even propagable by inoculation, small-pox for example, the same kind of 
 exemption notoriously happens. Some of those who so escape may have had the 
 fever before ; and have thereby become less capable of being re-infected by the 
 poison. I believe it to be uncommon for a person to have genuine continued fever 
 for a second time, unless he is exposed to the contagious matter in a very concen- 
 trated state, or for a long time together. Some may, by original peculiarity of con- 
 stitution, be proof against its power; but probably in most cases, the immunity arises 
 from the circumstance that the person has been fortunate enough, or careful enough, 
 to escape imbibing an effective dose of the poison. You may breathe, for a good 
 while, without much hazard, an atmosphere but faintly imbued with the contagious 
 effluvia ; and you may, though with somewhat more of hazard, breathe, for a short 
 time, air which is strongly tainted by them, and yet go free. 
 
 Allowance must also be made, in some cases, for the effect of habit in fortifying 
 the system against contagion. Persons who are much and often exposed to these 
 effluvia, are thereby seasoned, in some degree, to the noxious atmosphere : just as 
 drunkards and opium eaters become at length impassive under such a dose of their 
 customary stimulus as would intoxicate or stupefy a novice. Upon this principle has 
 been explained the comparative immunity from contagious diseases, (under like cir- 
 cumstances of exposure,) of medical practitioners, and nurses ; of the keepers of filthy 
 lodging-houses, while the new-coming inmates suffer ; and even of prisoners, who, 
 without having had the disease themselves, may nevertheless carry forth and com- 
 municate the infection : as is said to have happened at the celebrated " black as- 
 sizes" in Oxford ; and again at the Old Bailey in the year 1750. 
 
 This argument, that the fever cannot be contagious because many of those who 
 come near the sick are not affected with it, has been happily ridiculed by comparing 
 an epidemic to a battle. A man might say, " I was in the battle of Waterloo, and 
 saw many men around me fall down, and die, and it was said that they were struck 
 down by musket balls ; but I know better than that, for I was there all the time, and 
 so were many of my friends, and we never were hit by any musket balls. Musket 
 balls, therefore, could not have been the cause of the deaths we witnessed." And 
 if, like contagion, they were not palpable to the senses, such a person might go on to 
 affirm that no proof existed of there being any such things as musket balls. 
 
 It must not be forgotten that this same argument, whatever may be its validity, is 
 equally' potent against any other general cause: against local miasms; against an 
 undefined something in the air. 
 
 Again, the disorder does not spread, say they, in the houses of the rich. But why 
 should it not do so, if it proceeds from any cause which strict attention to cleanliness 
 and ventilation does not disarm ? The fact, when rightly considered, is a strong cir- 
 '.•umstance in favour of the theory of contagion. 
 
 But then the disorder often occurs when we can trace no contagion : and the full 
 answer to this argument is to be found in the fact that the same difficulty applies to 
 diseases which are not only confessedly contagious, but which are believed to have,
 
 ALLEGED CAUSE. 953 
 
 now, no other source than contagion ; even, as I showed you before, to small-pox 
 All that the argument can amount to, is a presumption that the distemper may 
 sometimes originate independently of contagion. A person may be exposed to the 
 agency of the contagious matter quite unconsciously, by coming into contact with 
 fomites, or by approaching another person who is just convalescent from the disease. 
 A nobleman died here, in the prime of life, last year, of scarlet fever. The story 
 goes that he had just come to town, and was dining out, and by his side sat a young 
 lady who had just recovered from that complaint ; and that from her he unwittingly re- 
 ceived it. Tn such a place as this there are a thousand unsuspected ways in which 
 contagion may be disseminated. It may lurk in a hackney coach ; you may catch 
 the complaint from your neighbour in an omnibus, or at the theatre, or at church ; 
 your linen may be impregnated with the subtle poison in the house of your laundress ; 
 or your coat may convey it from the workshop of your tailor. So that, when con- 
 tinued fever occurs, it is very difficult indeed to be sure that it has not arisen from 
 contagion ; and it becomes a very interesting question whether the disease ever pro- 
 ceeds from any other cause. It is, however, of primary importance to determine 
 whether it be, or be not, communicable. By our belief in this matter the lives of 
 our neighbours and clients may be saved, or lost. Even if we doubt about the con- 
 tagiousness of the disease, we are bound to act as if we had no doubt upon the sub- 
 ject ; and I would admonish you (although that is a lower and poorer motive) that 
 your own reputation and success may be endangered by mistakes in this very thing. 
 I have been told of one instance which may serve as a warning. A lady came from 
 the country to London, to see a sister, who was ill of fever. She asked the medical 
 attendant if there was any danger of infection. He happened to be a staunch non- 
 contagionist ; and he said " no danger whatever." Upon the faith of that assurance, 
 the lady resolved to sit up with, and to nurse her sister ; but she fell sick herself of 
 the disease, and died. I believe this did not shake the medical man's opinion. He 
 attributed the mischance to some local miasm. But he could not persuade the lady's 
 friends of this. They maintained that her death lay at his door ; and whether 
 they were right or wrong, the affair was so much talked of, and was so injurious to 
 him, that he was obliged to leave that part of the town, and to seek for practice else- 
 where. 
 
 Many sporadic cases occur of febrile disorder, which do not belong to the category 
 of continned fevers, and yet are liable to be confounded with them. All the phleg- 
 masice are attended with pyrexia, and the local inflammation may be slight, or very 
 obscurely marked, and easily overlooked ; but the febrile symptoms are much the 
 same as those which constitute the more inJJammatory forms of continued fever. In 
 hke manner severe bodil}'' injuries, compound fractures, for example, sometimes give 
 rise to constitutional symptoms precisely resembling the most prominent phenomena 
 of its typhoid forms. Excluding all such spurious resemblances of the genuine dis- 
 ease, I confess my own opinion to be, that continued fever, hke small-pox and 
 measles, originates, in all cases, from a specific poison. With respect to all these 
 disorders, I conceive that, in every large community, there is constantly kept up a 
 sufficient stock of contagious matter, to act as a sort of leaven, whenever circum- 
 stances favourable to the development of the disease, as an epidemic may chance to 
 arise. 
 
 Continued fever has been ascribed, by those who deny its origin in contagion, to 
 certain other causes ; some of which demand attention, not merely on account of the 
 interest that belongs to the whole inquiry, but also because they really are important 
 agents in the extension of the disease. 
 
 First, then, it was, and is, a common belief, that continued fever may be generated 
 by the effluvia constantly proceeding from the human body, even when healthy, if 
 these effluvia be accumulated and condensed by the crowding tofjether of many per- 
 sons m close, dirty, and ill-ventilated places. It is unquestionable that, when once 
 introduced, the disease spreads, under such circumstances, with fearful rapidity ; but 
 the point at issue is whether it be ever so caused de novo. I must refer you, for good 
 evidence that it is not so engendered, to Dr. Bancroft's book on the yellow fever. 
 He shows that typhus fever does not spring up in places where it could scarcely fail 
 
 4e^
 
 954 CONTINUED FEVER. 
 
 to appear if that theory were true. He instances the natives of the arctic regions, 
 who, in order to shelter themselves against the extreme cold of their chmate, live 
 during the greater pan of the j^ear in close subterraneous dwellings, from which the 
 fresh air is studiously excluded, and of which the atmosphere becomes so offensively 
 foul as to be scarcely supportable by a stranger: yet continued fever is not known 
 among them. A similar exemption from that disease is observed within the tropics, 
 in the African slave ships, where " the poor wretches are crowded together below 
 the deck, as close as they can possibly lie, in a sultry climate, barred down with iron 
 to prevent insurrection." Although many of them die from suffocation, and from 
 fluxes, 5'et Dr. Trotter, who was himself, at one time, surgeon to a slave ship, de- 
 clares that "contagious fevers are not their diseases." Dr. Bancroft quotes also a 
 narrative of the sufferings of 193 Europeans, w'ho, during the time of the French 
 Revolution, were "deported" to Cayenne, in the Decade frigate. They were 
 crowded, and even squeezed together, in so small a space, and for so long a time, 
 that the sentinels, who were placed at the hatchways to guard them, and who were 
 thus exposed to the hot and fetid air which came from their hole of confinement, de- 
 manded that their period of offensive duty might be shortened. Yet none of these 
 miserable persons perished, nor did fever, properly so called, arise among them. 
 Neither did that distemper present itself in any of the survivors of the Black Hole at 
 Calcutta ; the frightful account of which, by one of those survivors, Mr. Howell, is 
 abstracted in an appendix to Dr. Bancroft's work. 
 
 Fever used to infest our English jails ; but that it was always imported, and never 
 engendered there by filth and defective ventilation, and by the accumulation of 
 human effluvia, may be concluded from the fact that the benevolent Howard, when 
 he visited the prisons on the continent, found, to his great surprise, that they were 
 free from fever, although they were no less close, crowded, and impure than our 
 own. He brings the result of his observations and inquiries concerning the cause of 
 the jail-fever, to this pointed conclusion : — " If it were asked," says he, " what is the 
 cause of the jail-fever, it would in general be readily replied, the want of fresh air 
 and cleanhness ; but as I have found in some prisons abroad, cells and dungeons as 
 offensive and dirty as any I have observed in this country, where, however, this dis- 
 temper was unknown, I am obliged to look out for some additional cause for its pro- 
 duction" — which additional cause can be no other than the contagious poison ema- 
 nating from the bodies of those who have the fever. It is true that fever is most 
 frequently met with, and most rapidly propagated, where men are crowded together 
 in jails, or in close and ill-ventilaied places ; but this affords no reason for supposing 
 that it is ever generated there, any more (to use a homely illustration of Dr. Ban- 
 croft's) than the general prevalence of lice and other parasitic vermin in such places, 
 proves that these vermin are generatedhy fihh, by pent-up human effluvia, and vv'ant 
 of ventilation, instead of being merely fostered thereby. 
 
 Again, continued fever has been attributed with great confidence, to a vitiated 
 state of the air, from the putrefaction of dead animal and vegetable substances. Dr. 
 Bancroft deals with and demolishes this error also : showing that neither the putrid 
 atmosphere of dissecting-rooms (respecting which you must have some personal ex- 
 perience), nor the noisome effluvia from full and ill conducted burial-grounds, nor 
 those to which tallow-chandlers, soap-boilers, glue and cat-gut makers, and the 
 melters of whale blubber are exposed, nor the foul air of sewers and privies, have 
 ever been known to produce anything like continued fever. In some parts of Essex, 
 near the coast, where the farmers are in the habit of manuring their fields with shoals 
 of sprats, I have seen large tracts covered with these fish in a state of putrefaction. 
 The stench they occasion is horrible ; but no disease results. Dr. Chisholm, in a 
 paper to which I can only refer, but which I would recommend you to look at, in the 
 sixth volume of the Edinburgh Medical and SurgicalJournal, brings forward other, 
 and very satisfactory, instances, to the same purpose : from a bone manufactory, near 
 Briton, in Gloucestershire; from an establishment (now relinquished) on the banks of 
 the Avon, for converting the flesh of dead animals into adipocire ; from manufactories 
 for refining sugar, where the blood of slaughtered animals is kept for that use by 
 butchers ; from the leather-dressing business ; — all tending, I say, to the conclusion,
 
 ALLEGED CAUSE. 955 
 
 that air, contaminated by ihe decomposition of animal substances, is not necessarily 
 noxious to life ; still less productive of that specific disease which we are now con- 
 sidering. The old belief, therefore, was unfounded, that the exhalation from the 
 dead and putrefying bodies of men and horses, lying unburied on the field of battle, 
 is capable of producing a pestilence. Many instances to the contrary are on record: 
 one, of an early date, is thus stated by Biemerbroek: — "Anno 1G42, in agro Julia- 
 censi maxima strages facta est, et ad minimum 8000 militum occisi fuerunt, praster 
 majorem adhuc famulorum, rusticorum,aurigarum, puerorum et mulierum numerum, 
 atque equorum copiam innumerabikm ; corpora inhuraata sub dio computruerunt, 
 nulla tamen pestis insecuta est." 
 
 It has been said that fever is produced by some unknown condition of the air, im- 
 perceptible by our senses, but distinct from contagion. I believe this is a very 
 popular notion ; but it is perfectly gratuitous and untenable, and inconsistent with 
 observed facts. You may have fever raging in certain parts of a town, and yet the 
 parts in the immediate vicinity of these be quite exempt from it. Now this could 
 hardly be, if there were some general property diffused through the atmosphere 
 capable of engendering continued fever ; and, as I stated before, this notion is severely 
 pressed by one of the arguments which the non-contagionists themselves are fond 
 of employing If the disease depend upon contagion, some persons in the commu- 
 nity may come less near the sick, or imbibe a less dose of the contagious poison, 
 than others, and so escape : but if the cause of fever were spread abroad throughout 
 the whole atmosphere, all must be exposed to its influence, and fevv, we may sup- 
 pose, could avoid suffering from its operation. 
 
 Exposure to cold is another cause to which fever has been sometimes attributed. 
 But this is an agency so widely prevalent that if it alone could excite fever, that 
 complaint Avould be far more general than it really is, and we should be able to trace 
 it oftener and more distinctly than we can, to the alleged cause. That, by its debili- 
 tating effect, cold will predispose the body to be affected by the contagion of fever, 
 I well believe : and the same remark is appUcable to another cause that has been 
 assigned ; namely, deficiency of nourishment. Dr. Alison, in his admirable essay 
 On the Management of the Poor in Scotland, has clearly proved that the preva- 
 lence of contagious fever amongst the lower orders is always in direct proportion to 
 their state of physical destitution. The association of pestilence with famine is pro- 
 verbial. But we do not find that continued fever is ever created by the mere want 
 of nutriment. In persons who have sought to starve themselves to death — among 
 sailors who have of necessity been kept upon very short allowances of food — in cases 
 of insulation by snow storms, or by the accidental closure of a mine — we find, indeed, 
 that disease is produced by the privation of nourishment ; but it is not continued 
 fever. The condition into which the sufferers are brought is more like scurvy. So 
 that although a want of sufficient aliment may be, and doubtless is, a powerful aux- 
 iliary in prornoting the effect of the contagious poison, there is no ground for sup- 
 posing that it ever primarily or solely occasions fever. 
 
 In fact, all the circumstances which I have now been considering act as predis- 
 posing causes. They render the human body an easier prey to the real exciting 
 cause, which is a specific animal poison. You will remark that they are all debili- 
 tating circumstances ; and where several of them co-exist, their joint influence ir 
 subduing the system, and bringing it into subjection to the contagion, is very great. 
 For the same reason, depression of spirits, however produced, has a strong predis- 
 posing effect ; as strong, perhaps, as any other single cause. Of this I have seen, 
 if I mistake not, some remarkable examples. Upon this principle we may explain 
 the fact, that continued fever is especially apt to attack those of the lower classes 
 who have recently come to reside in the metropolis ; who are often living anxiously, 
 and with persons to whom they were not previously known. We have had nume- 
 rous opportunities, in the hospital, of noticing this curious circumstance ; and it is 
 mentioned by almost all the French writers on fever. To the same principle also 
 we must attribute the tendency to fall down in fever, observed in young soldiers and 
 sailors. You will find statements to that effect in Dr. Trotter's works, and in those 
 of Dr. Lind and of Sir Gilbert Blane. When fever appears in a ship, the raw
 
 956 CONTINUED FEVER. 
 
 sailors are always the soonest attacked by it : and it is the same with the recruits in 
 the land service. In a defeated, dispirited, or retreating army, its ravages are often 
 frightful. Here we have, combined, fatigue, a deficiency of wholesome food, and 
 mental depression. 
 
 However paradoxical the assertion may seem, a predisposing cause may even be 
 applied, and operate, after the exposure to the exciting cause — and so render the 
 latter effective when it might not, otherwise, have been so. Dr. Russell observed 
 the plague sometimes to " hang ambiguously" about persons for several days. In 
 this state, an overheated bath, or a sudden impression of fear, especially fear of the 
 disease, has roused the lurking poison into activity. It is a suggestion of Dr. Hen- 
 ry's, that atmospheric variations may call into action contagious poisons already 
 admitted into the system, but not yet manifested by the usual phenomena ; and, 
 operating thus over a wide space, and upon numbers at once, may occasion those 
 sudden and violent outbursts of epidemic disease, of which numerous examples are 
 on record. 
 
 You must, I think, perceive the importance of distinguishing between the one 
 exciting cause and the many predisposing causes of fever. The latter are generally 
 beyond our control. We cannot hope to remedy extensive destitution ; nor to sepa- 
 rate it effectually from its concomitants of filth, and despondency of mind. But we 
 may, by timely diligence, root out the specific contagion, or confine it within narrow 
 bounds. When the sick can be at once removed from their crowded homes to a 
 fever hospital, and their impure apartments ventilated, cleansed, and whitewashed, 
 the disease may often be kept in check, if not entirely stopped ; and the yet healthy 
 persons of the infected district be preserved from its grasp. For, as I stated before, 
 there is reason to believe that the poison, unless pent up, does not remain active at 
 any great distance from the person from whom it proceeds ; not even many yards, 
 or feet. It is very rare, I apprehend, to meet with instances of the disease being 
 communicated in the open air. It is almost always caught, if at all, in the interior 
 of houses. It is extremely uncommon for it to extend from one bed to anothe" in 
 our general hospitals, where great attention is paid to cleanliness and ventilation. 
 The noxious qualities of the poison are diminished, and at length destroyed, by its 
 dilution with common air, just as those of other gaseous poisons are : and hence, in 
 private houses, in the better ranks of society, where the rooms are spacious and airy, 
 and proper precautions are taken, the disease hardly ever spreads. 
 
 What are those proper precautions ? They are simple, and may be stated in a 
 very few words. 
 
 Where choice can be made, a large apartment should be selected for the sick per- 
 son. Unless the weather be very hot, there should be a fire in the room, for it acts 
 as a ventilator. The air of the chamber should be kept fresh by having a window 
 or door (according to the weather) always open : or both window and door. Bed 
 and window curtains, carpets, and all superfluous articles of furniture, should be 
 removed. Great diligence should be used in keeping the patient clean, by the 
 requisite ablutions, and by frequently changing his sheets and his bod}^ linen ; and 
 these should be immersed at once in water; and all discharges from the sick per 
 son's body should be instantly carried out of the room. 
 
 All unnecessary intercourse with the patient, by his family and friends, should, 
 for his sake as well as theirs, be forbidden. As life advances, the susceptibility of 
 the disease appears to diminish : for which reason the nurses and personal attendants 
 of the patient should not be very young : and all who do approach the sick bed 
 should take care to avoid, as much as possible, inhaling the patient's breath, or the 
 emanations which proceed from his person. Friends who visit the apartment at 
 intervals only, should never enter it fasting. 
 
 And you may, if you please, employ the chloride of lime as a disinfecting agent, 
 in aid of the simple measures I have just recommended ; but by no means instead 
 of them. People hang a big of camphor round their necks, and think themselves 
 safe against infection. The mental confidence which that expedient is calculated to 
 inspire, may perhaps afford some degree of protection ; but camphor has, in reality, 
 no prophylactic virtue ; and all these artificial scents are objectionable, inasmuch
 
 TREATMENT. 957 
 
 as they tend to conceal offensive odours which might otherwise reveal the actual 
 danger. 
 
 I shall speak of the treatment of continued fever when we next meet. 
 
 LECTURE LXXXVI. 
 
 Continued Fever, concluded. Treatment. Small-pox. Its essential symptoms. 
 Distinction into discrete and confluent. Periods and modes in which it proves 
 fatal. 
 
 The treatment of continued fever has been, at all times, a stumbling block to young 
 practitioners ; and a subject of dispute even among physicians who have built it upon 
 their own experience. Before I attempt to trace out any plan, or to lay down any 
 principles for your guidance, it may be useful to inquire how it happens that the 
 practice in this disease has been so fluctuating and unsettled. 
 
 In the first place, then, it is very difficult to estimate the value and efficacy of any 
 particular plan of treatment, and still more of any particular remedial substances, in 
 this disease. Continued fever, like other disorders which run a definite course, and 
 have no direct or necessary operation in spoiling the structure of vital organs, has a 
 strong natural tendency to terminate in health. We see this tendency when the 
 disease is left entirely to itself, and it equally exists when remedies are employed to 
 regulate its course, or to abbreviate its duration. No one can doubt, who has had 
 much experience in fever, that this tendency is sometimes thwarted by the nimia 
 cura medici; and that patients get well in spite of the well-meant but mischievous 
 interference of the doctor. This tendency to recovery is a constant source, therefore, 
 of fallacy in our observations upon the behaviour of this disease under different plans 
 of treatment ; and upon the effects and utility of remedies. It leads us, loo oftenv 
 into the danger of ascribing to drugs what is really due to the workings of nature : 
 of confounding antecedents and sequences with causes and effects ; of counting re- 
 coveries as cures. And this danger is increased by the circumstance that continued 
 fever, although it observes a certain definite course, is nevertheless liable, even when 
 left altogether to itself, to sudden and remarkable changes in the symptoms, some- 
 times for the worse, and sometimes for the better ,' and often we cannot perceive any 
 obvious reason for these fluctuations. But if this happen when no medicine is given, 
 so also will it happen when the disease is submitted to treatment; and it requires 
 more than a Uttle care and discretion to avoid attributing the changes which so occur 
 to the remedy which was last employed. For example, the abatement or cessation of 
 headache, after a few days have elapsed, is a natural phenomenon : whereas an 
 inexperienced or a careless person might easily persuade himself that it had yielded 
 to his method of treatment, and that it was a favourable omen : neither of which 
 conclusions would, however, be warranted by the circumstance upon which it was 
 founded. 
 
 There is yet another source of difficulty connected with this subject. I have 
 shown you that not only individual cases of fever, but different epidemics, vary 
 much in their character ; so that a plan of treatment which was well suited to 
 one epidemic, may be improper and even hurtful if indiscriminately applied in 
 another. 
 
 These considerations may serve in some measure to teach us how it has happened 
 that so many different, and sometimes opposite remedies and modes of treatment 
 have been recommended by different practitioners for the cure of this disorder. The 
 tendency to a termination in health was very plainly visible in the epidemic fever in 
 Ireland, to which I have more than once referred. The mortality among the patients 
 who were placed in sheds upon straw, with very little medical care, and even with 
 out any great personal attention from others, was very small indeed. No one can 
 form even an approximate judgment of this tendency, who has not seen the disease
 
 958 CONTINUED FEVER. 
 
 under several varieties of practice. Doubtless one rule which we derive from a 
 clear perception of the same tendencj'' is, that we should not interfere unnecessarily. 
 Aoxftf rtfpt to. vovsr^uata. hvo, (says Hippocrates) a^iXsew, rj fxri j57Mrf(£iv, There are two 
 things to be considered in the treatment of diseases : first, that we do the patient 
 good ; secondly, that at least we do him no harm. In all these exanthemata, he 
 must be reckoned the safest and the best practitioner who knows when to abstain 
 from acting, as well as when to act ; in other words, who has learned when, and to 
 what extent, the case may be left to the salutary processes of nature. 
 
 However, there is an opposite error to that of mischievous activity. The tendency 
 to recover which manifests itself under different modes of treatment, and even in 
 spite of opposite modes, has induced, in some minds, a degree of scepticism as to the 
 utility of any remedies, that may easily be carried too far. It does not follow, be- 
 cause the majority of patients under continued fever would at length emerge into 
 health, although no remedial measures were employed, that the disease ought there- 
 fore to be abandoned to what Cullen calls the vis medicatrix naturae. It is not quite 
 correct to say, with the older pathologists, that the whole disorder is merely an effort 
 oi nature to throw off something noxious to the system, and therefore is not to be 
 interfered with. The true view of the matter I apprehend to be that which a toxi- 
 cologist might take. The disease is produced by a poison of which the injurious 
 impression upon the animal economy at length ceases, or passes off, of itself; in the 
 same manner, only more slowly, as the influence of a dose of opium will spontane- 
 ously pass away. But during the natural course of the fever, as in many other cases 
 of poisoning, morbid processes are apt to be set up, which, if suffered to proceed 
 unchecked, would inflict irreparable injury upon important organs, and which are 
 fairly within the scope of remedial management. Our object must be, when the 
 fever is once established, to conduct it to a favourable close ; to "obviate the tend- 
 ency to death." Upon this point I agree most entirely with Pitcairn, who, being 
 asked what he thought of a certain treatise on fevers, declared, " I do not like feve. 
 curers. You may guide a fever ; you cannot cure it. What would you think of a 
 pilot who attempted to quell a storm ? either position is equally absurd. In the storm 
 you steer the ship as well as you can ; and in a fever j^ou can only employ patience 
 and judicious measures to meet the difficulties of the case." 
 
 When some immediate change ensues in the symptoms or in the feelings of the 
 patient upon the administration of remedies that are generally followed by sensible 
 effects, we are warranted in ascribing the change to those remedies. But even here 
 comes in the fallacy already noticed, arising from the sudden and spontaneous changes 
 that are apt to occur in fever : and this fallacy is to be got over only by multiplying 
 our observations. 
 
 After all, the best guide that j'-ou can have in determining upon the general 
 principle of treatment in a given epidemic, or even in an individual case, is that 
 which Dr. Alison has so ably enforced in his lectures and in his writings upon 
 this subject. I mean the observed tendency to this or that mode of dying. The 
 manner and circumstances of the deaths are of more practical importance than of 
 the recoveries. 
 
 After briefly passing in review some of the principal remedies that have been em- 
 ployed and recommended for this disease, I propose to sketch the plan which I am 
 myself in the habit of pursuing in the management of fever patients. 
 
 It was once a favourite practice with physicians to attempt to cut short the fever 
 at its outset: and the two expedients which were chiefly relied upon for that purpose 
 were emetics, and the cold ciffusion. They have both of them, in this country, gone 
 very much out of fashion. In truth, neither reason nor experience encourages us to 
 look for such a result from such measures. If fever depend (as I believe it does) 
 upon a poison in the blood, it is not to be dislodged by the act of vomiting, nor washed 
 out by the forcible descent of cold water upon the skin : and in the few instances 
 in which the one or the other of these remedies may have seemed to arrest a fever, 
 or to check its progress, that effect has always occurred at the very commencement 
 »f the complaint : so that we cannot be sure (and the probability lies the other way) 
 that these were really cases of fever at all, or that they would not have ceased even ii
 
 TREATMENT. 959 
 
 nothing had been done for them. Perhaps emetics may, in the present day, be too 
 much neglected. 1 have no notion of their stopping the fever; but when given 
 early, especially if gastric disturbance is a prominent symptom, they are sometimes 
 followed by a marked abatement of many morbid sensations. " It is astonishing," 
 says the observant Sydenham, " how it happens, that a vomit, which does not pro- 
 duce either a large or a morbid discharge from the stomach, should so materially re- 
 heve the nausea, restlessness, anxiety, and furred tongue of the patient." 
 
 The cold affusion is not more effectual in cutting fever short than the treatment by 
 emetics; and it has these great disadvantages, that it fatigues and alarms the patient: 
 and when the vital powers are naturally feeble, or are much depressed by the disease, 
 the very shock of the affusion may be attended with injurious consequences. 
 
 A modification of this expedient is, however, often of great use in abating the 
 morbid heat, and soothing the uneasy feelings of the patient. I mean the practice 
 of cold or tepid sponging of the surface. This is one of the remedies which, when 
 the symptoms appear to indicate it, deserves to be tried ; and the propriety of con- 
 tinuing or of discontinuing it may be determined by a very simple test; namely, the 
 feehngs and wishes of the patient himself respecting it. It is most adapted to the 
 more inflammatory, and least adapted to the more typhoid types of the malady. 
 
 Great controversies have been maintained in regard to the effect of blood-letting 
 in fever. They who hold that the fever consists in a general disturbance of the sys- 
 tem, growing out of some local inflammation, and they especially who believe that 
 continued fever is nothing else than inflammatioa of the brain and its membranes, 
 would naturally seek to cure it by the remedies of inflammation. But although local 
 inflammation, and even inflammation of the brain, is very apt to spring up in the 
 course of continued fever, there is no reason for thinking that inflammation anywhere 
 is essential to the fever ; but very much reason for the opposite opinion. The active 
 use of blood-letting has been in favour and out of favour, with the medical world, 
 again and again : and this very circumstance would of itself make us doubt the pro- 
 priety of its indiscriminate adoption. 
 
 The late Dr. Armstrong gave a strong and unfortunate impulse to the practice of 
 free blood-letting in continued fever, by the publication of his well-known and inge- 
 nious treatise on the disease. I have no doubt that great mischief was done by that 
 work. I may say so without scruple, since Dr. Armstrong is gone, and neither his 
 feelings, nor his success, can be hurt by the expression of such an opinion : and I 
 do so the rather, because it is well known here that Dr. Armstrong saw reason, as 
 his experience increased, to qualify those views respecting the nature and manage- 
 ment of fever, which his earlier observation of it in the country had led him to form. 
 This change in his sentiments was probably justified and produced by a change in 
 the character of the fevers that he witnessed ; but it does not appear in his book. 
 You have heard me state already that whereas the fevers which occurred in London 
 for some time previously to the year 1831 or 1832, not only bore, but required the 
 abstraction of blood, in some way or another, — since that period, and especially since 
 the epidemic cholera visited us, i-t has been necessary to abstain, whenever we could 
 with safety, from taking blood at all ; and still more necessary, even if we take away 
 blood with one hand, to uphold the patient with the other: while, in the former pe- 
 riod, wine and stimulants of all kinds seemed generally superfluous, if not pernicious. 
 
 Dr. Williams, of St. Thomas's Hospital, has shown very clearly, I think, in his 
 recent publication on " Morbid Poisons," that the evidence against the eflicacy and 
 the safety of bleeding in continued fever — of bleeding largely, I mean, from the arm — 
 far outweighs that in its favour : and I venture to advise you, as the result of all that 
 I have seen of the disease in London and elsewhere, not to draw blood from a vein, 
 even early, merely because the disease is or appears to be fever ; not to order vene- 
 section unless there be some other manifest reason for it — i. e., unless the febrile 
 symptoms run unusually high, or unless some local inflammation is unequivocally 
 present : and, when you do bleed, do not take a drop of blood more than seems ab- 
 solutely necessary to answer the desired end. Bleed your patient, therefore, if at all, 
 m the upright posture. 
 
 Purgatives. — What are we to say in general with respect to them ? This, I
 
 960 CONTINUED FEVER. 
 
 believe — that the intestines should be cleared by an active aperient in the outset: 
 and that laxatives should be continued if the bowels do not act every day without 
 them. When the typhoid type is strongly marked, and when the symptoms indicate 
 ulceration of the intestinal glands, purgatives are not to be pressed. 
 
 Much contrariety of opinion has prevailed also among practitioners, and does pre- 
 vail, about the administration of mercury in this disorder. Without attempting to 
 strike the balance between these conflicting judgments, it is my business and duty 
 to state my own belief, to tell you what is the result of my own observation, upon 
 this and other disputed points. I must repeat, then, that my practice has altered, 
 in several particulars, within the last iew years. In the fevers which I treated, or 
 saw others treat, in London, prior to the breaking out of the present epidemic, mer- 
 cury, in one shape or another, was ahnost constantly prescribed : and a great num- 
 ber of the patients were brought, sooner or later, under the specific operation of that 
 mineral : and in these patients (with one exception only, where the mercury appeared 
 to do neither good nor harm) a decided improvement was almost immediately appa- 
 rent upon the supervention of soreness of the mouth ; and all such patients ultimately 
 recovered. I am aware, however, and I wish you to be aware, of an alleged source 
 of fallacy in this matter. The gums in that variety of fever to which I am at present 
 referring, did not readily take on the mercurial action ; and it might be (though such 
 is not my own impression), it might be that the affection of the mouth by mercury 
 was attributable to the mildness or to the cessation of the disease, rather than the 
 cessation of the disease to the effects of the mercury upon the system: that the im- 
 provement was the cause, and not the consequence, of the mercurial action. 
 
 In the form of fever that is ??o?<j epidemic (1838), I do not think mercury so proper. 
 Last year the spotted fever broke out in a patient of mine while he was in the hos- 
 pital, and while his gums were sore. I found, upon inquiry at that time, that of 
 twelve fever patients who had been recently treated in the hospital, by my colleagues 
 and myself, with mercurials in greater or less quantity, four had died, in all of whom 
 the gums were affected : whereas, of sixteen others, who took no mercury, three only 
 died ; and cjf these three, one was pulseless at her admission, from uterine hemorrhage, 
 and the other two were so feeble and exhausted that they were scarcely able to swal- 
 low. I should give mercury very cautiously, therefore, if at all, in this typhoid 
 variety of the fever. 
 
 Besides a strict enforcement of the antiphlogistic regimen, my own mode of treat- 
 ing continued fever is somewhat of this kind. I am always desirous that the patient's 
 hair should be cut off. The mere removal of it is often attended with benefit : the 
 headache and confusion of thought are relieved, and the patient is calmed. We can 
 then also, with much greater convenience and effect, apply cold washes to the head. 
 Patients sometimes demur to this shaving of their heads : but they generally consent 
 if you explain to them that their hair will at length fall off, in consequence of the 
 fever ; and that the head, if on that account only, had better be shaved at once. 
 The head and shoulders should be somewhat raised, and thin strips of hnen, kept 
 constantly wet with some cold lotion, should be continually applied upon the forehead 
 and scalp. It should be the business of one person to attend to this. You would be 
 surprised at the rapidity with which the cloths sometimes dry. 
 
 Now, with regard to this remedial measure, you need not have any difficulty. It 
 will do good, and should be steadily employed, so long as it is grateful to the feel- 
 ings of the patient ; and it ivill, generally, be pleasant and agreeable to him, so 
 long as the head remains morbidly hot. If the temperature of the scalp be not 
 above the natural standard, and especially if the cold application make him shivery 
 or uneasy, and give him annoyance instead of comfort, then it must be at once 
 discontinued. 
 
 If the patient suffered intense headache, and his face were flushed, and the heat 
 of the surface great, and he weore wildly delirious, and his pulse were full and hard, 
 I might perhaps deem it right to take blood from his arm, while he sat up. But, 
 even under these circumstances, I should generally think it better to apply leeches 
 to his temples, or behind his ears, or to remove a few ounces of blood from his neck 
 by means of cupping-glasses, and, at the same time, to ply assiduously the cold lotion
 
 TREATMENT. 96T 
 
 If the bowels have not been already purged by nature or art, it is right to give 
 three or four grains of calomel at once, and to follow this up by a black dose. After 
 that, I was formerly in the habit of prescribing, in the early periods of the fever, 
 unless the bowels were irritable, a pill composed of two grains of calomel with two 
 grains of James's powder, every six hours ; washing it down with a common saline 
 draught. In hospital practice, I frequently omitted the sahne draught ; allowing the 
 patient to drink toast and water, or barley water, as often as he wished. If there 
 was diarrhoea, or early prostration, I gave, instead of the combinatfon just mentioned, 
 five grains of the hydrargyrum cum cretd. At the same time, I carefully investi- 
 gated the state of the abdomen ; and if I found tenderness at the epigastrium, or in 
 the coecal region, in both of which situations tenderness was common, I applied, over 
 the tender spot, from six to ten leeches, and covered the leech-bites with a light poul- 
 tice. If the diarrhoea ran on profusely, I added to the hydrargyrum cum creta a 
 certain quantity of Dover's powder, or of the extract of poppy. 
 
 In those forms of fever (whereof the prevailing epidemic affords you a well- 
 defined specimen) in which there is a strong and early tendency to typhoid symp- 
 toms, a signal loss of strength, a confused and dusky countenance, a mottled state 
 of the skin, simulating the eruption of measles, a dark dry brown tongue, a feeble 
 pulse — in these forms I begin very early to give the patient a full allowance of beef 
 tea; and if the typhoid and nervous symptoms become more pronounced, I 
 add ammonia, Hoffman's sether, and, what is better still, wine ; and I omit the 
 mercury. 
 
 Under this kind of management the patients will often go on, in a doubtful state, 
 for some days, and at length begin to recover. Many of them, especially in the 
 more typhoid varieties, sleep heavily, as the disorder passes slowly off. 
 
 There is one point in the treatment of fever, of exceeding importance, and of 
 some nicety: I mean the use of opiates. If they are given inopportunely, they are 
 apt to puzzle and perplex the case. You do not know how much of the disposition 
 to coma is owing to the disease, and how much is the consequence of the remedy. 
 Again, you may easily augment the natural tendency to coma, and lull your patient 
 into a fatal stupor. But, when judiciously administered, opium will often save a 
 patient who would inevitably sink without it. 
 
 It is in that form of fever which the French call the fievre ataxique, — when the 
 patient is affected with delirium, restlessness, wakefulness, and spasm, and the dis- 
 turbance of the nervous system outruns the disturbance of the sanguiferous system, 
 — that opium is so beneficial. The condition of the patient resembles that of a person 
 in delirium tremens. It is said that these symptoms occur most commonly amang 
 patients in those ranks of life that are above the lowest rank; and it probably is so: 
 but they are apt to take place in any patients, high or low, rich or poor, who have 
 had the mind over-wrought, and the nervous system unstrung, whether by dissipa- 
 tion and intemperance, or by anxiety of any kind. Sydenham was quite aware ol 
 the existence of this particular set of symptoms, and of the remedy for them. Of 
 all these symptoms, sleeplessness is the most urgent. Dr. Grattan and Dr. Latham 
 have both written in praise of the same opiate treatment, under such circumstances, 
 as was recommended by Sydenham. Dr. Grattan observes, with great truth, that 
 two or three nights, spent in restless delirium, are followed by the worst conse- 
 quences ; and that patients who pass three nights in succession in that way, almost 
 invariably die. If the symptoms be well marked, the best mode of proceeding is to 
 give a tolerably full dose of opium in the evening; one-third of a grain of acetate 
 of morphia is a common prescription with me. The amendment of the patient, on 
 the following day, is often very striking. Unless the same symptoms recur, it is 
 better, I think, not to repeat the anodyne. But, as Dr. Latham cautions us, "there 
 are cases, where the indications for the employment of opium are doubtful. Wild 
 delirium, and long wakefulness, and a circulation weak and fluttering, seem to call for 
 a considerable dose of opium. Yet, withal, there is a certain jerk in the pulse, so 
 that we cannot help suspecting that the blood-vessels have something to do with the 
 sensorial excitement. Under such circumstances, I have certainly seen (says he) 
 twenty minims of laudanum produce tranquil sleep, from whi-ch the patient has 
 01 4f
 
 962 CONTLXUED FEVER. 
 
 awoke quite a new man. But I have also seen the same quantity produce a fataL 
 coma, from which he has never been roused. Now, (continues Dr. Latham,) since 
 it is a fearful thing to strike a heavy blow in the dark, where the akernative is of 
 such magnitude, it is the safest and the best method to administer a small dose, at 
 intervals of an hour or two : so as to stop short of actual mischief at the first glimpse 
 of its approach, or to be led, by a plain earnest of benefit, to push the remedy to its 
 full and consummate effect. Many doses may be required for this purpose ; but we 
 shall see, after the first or second, whether to go on or to desist." 
 
 When, as is sometimes the case, the stress of the disorder falls upon the thorax, 
 and there is much dyspnoea, with the sounds that denote inflammation of the bron- 
 chial membrane, or of the pulmonary substance, leeches or cupping-glasses may be 
 applied to the chest; and, in milder cases, a blister, or a mustard cataplasm. 
 
 These remedies — cold to the shaven head ; the local abstraction of blood wherever 
 there happens to arise evidence of local inflammation ; an active purge at first, and 
 mild aperients afterAvards, if the bowels are confined or sluggish; moderate astrin- 
 gents, if there is much or urgent diarrhosa, a few grains of Dover's powder, for ex- 
 ample, or of the extract of catechu ; opium in a more efficient dose, when the nervous 
 symptoms are prominent, particularly sleepless delirium and restlessness ; in certain 
 cases small and repeated doses of some preparation of mercury ; and in certain cases, 
 earlij support by animal broths, and even by wine — these remedies, adapted to the 
 particular circumstances of individual patients, form the staple of the treatment of 
 continued fever, according to the best of my judgment and experience. 
 
 After what has been said, I need scarcely again admonish you to study carefully, 
 not merely the symptoms of any particular case to which you may be called, but the 
 general character of the fevers that are at the same time prevalent, and the manner 
 of dying in the fatal cases. If you find that they who die, die chiefly in the way 
 of asthenia, that will be a strong reason for caution in respect to the removal of blood, 
 and for the early employment of beef-tea, and other means of support. In the form 
 of fever which has of late years been common in the most crowded and unhealthy 
 parts of London, I am sure that the risk of beginning this sustaining treatment a little 
 too early is much less than the risk of commencing it a little too late. If plenty of 
 beef-tea does not suffice, you must give the patient wine, and that sometimes to a 
 considerable amount, or even brandy ; the egg-flip of the Pharmacopoeia for instance, 
 the mistura vini gallici. The object is to keep him alive, to keep the heart in mo- 
 tion, until the depressing influence of the exciting cause of the disease shall have 
 passed by. If the wine should flush or excite him, or render the pulse hard, it must 
 be diminished in quantity, given less frequently, or omitted altogether. If there be 
 indications of local inflammation — pain (for example) in the caecal region, increased 
 by pressure — leeches may be used, and wine given at the same time. There is 
 nothing inconsistent in such mixed practice. We seek to remove the local inflam- 
 mation by unloading the capillary blood-vessels of the part, while we uphold the 
 general powers of the constitution which are ready to sink. The great art of getting 
 a lever patient through a bad attack, is to have him judiciously and perpetually 
 watched, by night and by day. The remedy that is proper one hour may do harm 
 if pushed during the next. And there is another reason, which I may mention en 
 paasunt, why the sick person should never be left alone, even for a moment. I have 
 heard of moie than one or two instai.ces, of patients, in the delirium which attends 
 the disease, getting out of bed, and out at the window, during the temporary absence 
 of their nurse, and perishing from the fall. 
 
 If the patient relishes and wishes for the beef-tea, or the wine, that is no small 
 vvarranl of the propriety and usefulness of its administration. 
 
 A word or two more may be proper, even in this cursory sketch, respecting cer- 
 ;ain incidental points of practice that are apt to arise. 
 
 Often, when there is no longer any detectible uneasiness produced by pressing 
 tne oelly, the diarrhoea will persist, and meteorismiis will come on ; a tympanitic 
 dis^tension of the intestines with gas. When this happens, especially in the latter 
 periods of the fever, a large blister, laid over the abdomen, has often very happy 
 t'lfects, both upon the diarrhoea and the meteorismus. The diarrhoea, whea very
 
 CONTINUED FEVER. 963 
 
 urgent and obstinate, nnay often be checked by opiate entmata. In some cases I 
 have recently found catechu of great use, in these long-drawing forms of diarrhosa 
 during fever. 
 
 Again, if the patient sinks into profound coma, a blister should be applied to the 
 shaven scalp. The sick man. will sometimes awake from deep stupor while the 
 blister is still rising. 
 
 It is always a matter of importance, as I stated before, to inquire carefully, every 
 day, into the condition of the bladder of these fever patients. In the state of stupor 
 and indifference in which they often lie, they appear not to be sensible to the want 
 of passing the urine, which collects in the bladder, and distends it enormously ; not 
 only increasing the present hazard of the patient, but laying the foundation, some- 
 times, of future disease of the kidneys, in case he recovers from the fever. You must 
 not take the assurances of the nurses upon this point. They will often tell you that 
 the patient has made plenty of water, when in fact the urine has been dribbling away 
 from him, overflowing, while the bladder is stretched to the utmost. Feel, therefore, 
 with your hand, and percuss the hypogastric region, as well as that of the caecum, 
 at every visit. 
 
 It is requisite, too, that the under surface of the patient's body should not only be 
 kept scrupulously dry and clean, but be looked at every day, or twice a day. If the 
 projecting points, the hip bones, the sacrum, the shoulders, the elbows, should become 
 red, that is a sign that they are likely to slough or ulcerate. This evil consequence 
 of continued pressure upon parts of which the vital power and healthy tone are lower- 
 ed, may often be prevented by washing the erythematous spots with brandy. Should 
 the skin be already broken, the place may be covered with soap-plaster. An adjust- 
 ment of pillows and of posture — or the water-bed — may sometimes supersede the 
 necessity of these local expedients. 
 
 When ulceration of the mucous follicles perforates the bowel, that catastrophe does 
 not cdways so distinctly declare itself in fever, as in other cases. I have seen such 
 perforation, and its resulting, peritonitis, when no complaint of pain had been made 
 by the patient, so great was his insensibihty. In general, however, the accident is 
 denoted by symptoms which cannot be mistaken. When it does occur, there is but 
 little chance of the patient's recovery ; and that little will be best husbanded by the 
 adoption of the plan of treatment which I formerly laid down : opiates, to check the 
 peristaltic movements of the intestine ; and a rigid adherence, for some days, to the 
 horizontal posture. 
 
 I have seen a few instances, in which an oedematous swelling of one leg and thiffh 
 has occurred in the advanced stage of fever, hke that which is incidental to parturient 
 women, and depending upon the same cause — inflammation and obstruction of the 
 great vein that returns the blood from the limb towards the heart. I believe that 
 the inflammation extends itself, in such cases, from some of the smaller veins of the 
 mesentery, and is excited in them by the intestinal ulceration. Fomentation of the 
 affected limb comprises all the remedial treatment which this accident requires or 
 admits of. 
 
 The management of the patient during convalescence is scarcely of less import- 
 ance than during the progress of the fever. The chief danger is, that his desire to 
 be allowed to get up, and his wish to eat animal food, shoulcf be too soon indulged. 
 The latter of these errors is more frequently the cause of a relapse than any other 
 circumstance ; and relapses are often more perilous and difficult to remedy than the 
 original malady. You must be prepared, therefore, to withstand the solicitations of 
 the patient and of his friends, who think that if strength be wantino-, strono- drinks, 
 and plenty of meat, are the things to impart it. Until the tongue is quite clean and 
 moist, and of its natural colour, and the pulse has lost all its hardness, and the skin 
 its excess of heat, the patient must be kept to broth, jellies, puddings, and prepara- 
 tions of the well-known farinaceous articles of food. Then he may begin with some 
 boiled white fish, and so gradually eat his way, through chicken, and a mutton-chop, 
 to his ordinary diet again. 
 
 Such, I say, is the general plan of treatment which some observation of this dis- 
 order has persuaded me is the best. Summarily expressed, it consists in the exercisio
 
 964 BILIOUS REMITTENT FEVER. 
 
 of incessant vigilance, and the adoption of the proper remedy at the proper moment. 
 It lies between a timid or scepticaJ abandonment of all known resources, and a med- 
 dlesome rashness in applying them. The flame of life may be suffered to expire 
 for want of timely succour, by the practitioner who folds his arms, and looks on ; 
 as it may be rudely extinguished by a restless or routine interference which has 
 no definite or intelligible purpose. Boerhaave, in the preface to his Aphorisms, 
 professes that he knows of nothing which can be fitly termed a remedy, "quin 
 solo tempestivo usu tale fiat." In fevers the wisdom of this maxim is eminently 
 conspicuous. The rational objects of treatment are, to mitigate the urgency of 
 symptoms that cannot be wholly subdued ; to redress (so far as art may redress) 
 those dangerous complications which are incidental, but not essential, to the dis- 
 ease ; and to aid the conservative efforts of nature, when these manifestly languish 
 and fail. 
 
 Dr. Williams holds that enemata of warm water and syrup of poppies will do all 
 that can be done beneficially. For some time he lost only one patient out of sixty- 
 three thus treated. This was a most encouraging result. But then, when the fever 
 changed its type, as it did about the period of the arrival of the epidemic cholera, 
 he lost one in every four or five ; a very large mortality. These facts illustrate, in a 
 strong manner, the necessity, which I have so often endeavoured to inculcate, of 
 taking into the account, when we would estimate the value of a particular remedy 
 or plan, the difference which obtains in different epidemics, whether bad,-good, or no 
 treatment at all be adopted. A far surer method is to compare (if you would expe- 
 riment at all) two or more different modes of practice in different cases of the same 
 epidemic. Thus Dr. Latham, finding during one season that his wards were full of 
 fever, while yet its type was so mild that scarcely any died, thought this a favour- 
 able opportunity for trying whether mercury had any beneficial operation upon the 
 disease. Accordingly he treated half his cases with small doses of the hydrargyrum 
 cum creld ; and the other half with the liquor aminonix ucetatis, and so forth, and 
 no mercury ; and he found that the patients in the first of these classes were, on the 
 average, convalescent sooner than those in the last. Chomel fancies, from some trials, 
 that the chlorate of soda is a useful remedy, in addition to the general plan of man- 
 agement ; but further experience seems wanting to settle this question. 
 
 [Although the present note may be considered somewhat out of place, considering the 
 class of diseases with which Dr. Watson has associated Continued Fever, )'et as circumstances 
 prevented us from introducing an account of Bilious Remittent Fever, after the author's lec- 
 ture on Intermittents, while that portion of the work was passing through the press, we knovr 
 of no place where it can now be introduced with more propriety than the present : the dis- 
 ease holding a kind "of middle rank, as to external character, between intermittent and 
 continued fevers," it matters little in connection with which it is studied. 
 
 Bilious Remittent Fetek. — With the exception of the intermittent, the most common 
 form of fever prevalent in the middle, southern, and south-western sections of tlie United 
 States, is the remittent, or, as it is generally denominated, from the evidences of more or 
 less derangement of the hepatic function by which it is attended, the bilious remittent, or, 
 simply, bilious fever. It constitutes the summer and autumnal endemic of many of our states, 
 and even in those which are exempted from its annual occurrence, it occasionally prevails, 
 during seaso»s of unusual heat and dryness, sporadically, or as a severe and widely-spread 
 e-pidemic. It is this form of disease to the attack of which individuals, from the cold and 
 temperate sections of our union, are so peculiarly liable on removing to those localities 
 where it is endemic, or on visiting them during the summer and autumn. The bilious remit- 
 tent fever is not peculiar to the United States; it prevails extensively in the southern portions 
 of France and Italy, and other parts of the south of Europe, in Africa, and in the East and 
 West Indies: it is in fact the endemic of the paludal districts of all hot climates. A high 
 degree of atmospherical temperature has a very marked influence in the production of this 
 form of fever; either by eliminating an aeriform morbific matter, or by predisposing the sys- 
 tem to the action of the morbific causes by which it is constantly surrounded. Its prevalence, 
 us well as violence, is almost invariably in direct proportion to the heat nf the season, white, 
 in many of the more northern states, where the disease is not one of ordinary occurrence, 
 during a summer of extreme heat, it will prevail, often to a considerable extent — and 
 marked, occasionally, by symptoms of extreme violence ; it being limited, however, almost 
 exclusively to tho3e situations, noted in other seasons for their insalubrity, or in which the
 
 BILIOUS REMITTENT FEVER. 965 
 
 causes of disease are ready to be developed upon the occurrence of any unusual degiee of 
 atmosplierical heat. 
 
 Notwithstanding the bilious remittent fever can scarcely ever be mistaken by the least 
 experienced jiractitioner, it exhibits, nevertheless, considerable diversity in many of its phe- 
 nomena in ditTerent seasons and localities, and often in diflerent individuals. While, in 
 many cases, the remissions are well-marked, approaching in some to a complete intermission, 
 in others the remissions are so slight that the fever has almost a continued form. There are 
 always, however, certain prominent symptoms, invariably present, an attention to which 
 will lead at once to an accurate diagnosis : — Th'ese are, gastric irritability, a sense of oppres 
 sion and distress at the epigastrium, pain of the head, back, and limbs, and the great pros- 
 tration of strength early exhibited by the patient. 
 
 Bilious remittent fever is closely allied in its nature, the localities in which it chiefly pre- 
 vails, and in many of its phenomena, to intermittent fever, of which by many it is considered 
 as a mere modification. It is presumed, and with much plausibility, that " a more intense 
 operation of the same morbific cause required for the production of intermittent fever engen- 
 ders remittent," and that "the more violent the latter, the more remote is its character from 
 that of intermittent ; or, in other words, the less perceptible the remissions." That a more 
 pow^erful action of the morbific cause is demanded for the production of remittent fever, is 
 supposed to be indicated "by the circumstance, that when periodic fevers are prevailing in 
 certain countries, the jiermanent residents are often observed to have the disease in the form 
 of ague only, and the mortality among them is small; but strangers, unhabituated to the cli- 
 mate and its diseases, suSer from remittents, with a proportionably greater loss of life. la 
 more sickly seasons remittents will be the prevailing form among both classes of persons, 
 but strangers are more violently afiected, and the mortality among them is greater. Its 
 affinity to intermittent is shown, too, by the tendency which it has to pass into that form, 
 and. inversely, by the proclivity of ague to assume the remittent type." (Brown; Cydopcedia 
 of Prad. Med.) 
 
 There is a very striking analogy between the milder and more ordinary form of the bilious 
 remittent fever, in its course and progress, and the periods of a double tertian ague. Although 
 the exacerbations occur daily, yet there is almost always a very manifest aggravation of all 
 the symptons on the odd or alternate days. When the disease assumes, as it does occasion- 
 ally, a quotidian type, the exacerbations generally occur several hours earlier than those of 
 the double tertian form — the former happening usually about nine or ten o'clock, and the 
 latter not until towards noon, or an hour or two later. 
 
 The milder and more simple form of bilious remittent fever is generally preceded, for 
 some days, by listlessness, languor, a bitter taste in the mouth, nausea, aversion from food, 
 an indescribable uneasiness and sense of fulness about the epigastrium, sometimes costive- 
 ness, and, very generally, more or less pain and heaviness over the eyes. The attack is 
 usually ushered in by a slight chill, or merely by a sense of coldness, particularly about the 
 back, which, after one or more hours, and often sooner, is followed by increased heat of the 
 whole surface — the skin becoming, at the same time, dry and constricted, the face flashed 
 and turgid, the eyes red and suffused, the respiration hurried and uneven, the pulse quick 
 and frequent, but rarely tense; there is great prostration of strength, with considerable rest- 
 lessness and watchfulness. The patients complain of pain and a sense of fullness, weight, 
 and tension of the head, pain of the back and of the extremities, particularly of the calves 
 of the legs ; — and of a sense of weight or oppression, and often of pain at the epigastrium, 
 which part generally exhibits more or less tenderness upon pressure, even when no pain is 
 complained of. The stomach is more or less irritable — some cases being attended with 
 distressing nausea, while in others, everything swallowed is instantly rejected. Spontaneous 
 vomiting is a not unfrequent symptom — it is often present from the commencement of the 
 attack, but more generally it does not commence until the second or third day, or even later; 
 the matter vomited is of a bitter taste, and of a yellow, greenish, or bright-green colour. 
 The tongue is usually moist, red at the sides and edges, and coated on its upper surface with 
 a whitish, light-brown, or yellowish fur, which often acquires considerable thickness. There 
 are usually considerable thirst, a costive state of the bowels, and a diminished amount and 
 increased coloration of the urine ; and, after the disease has continued for some days, the 
 skin acquires a yellow tinge, which is sometimes very dec'ded, and extends to the adnata of 
 the eyes. The exacerbation lasts from eight to twelve hours, when a gradual abatement of 
 all the prominent symptoms takes place, and often a slight moisture breaks out upon the sur 
 face, and the patient falls into a refreshing sleep ; more generally, however, the skin conti 
 nues dry after the heat has declined, and the patient during the remission continues restless, 
 uneasy, and disinclined to sleep. The duration of the remission varies with the violence of 
 the attack ; gradually, however, the heat of tlie surface increases, and an exacerbation ot the 
 fever follows, marked by the same degree of intensity as the former, or even by increased 
 violence. 
 
 All the preceding symptoms, in an aggravated degree, with long-continued exacerbation^ 
 And less distinct remissions, naark what has been termed the highly inflammatory form of 
 
 4f2
 
 966 BILIOUS REMITTENT FEVER. 
 
 the disease. lAiring die exacerbation the skin is intensely hot, the eyes are suffused, of a 
 muddy, yellowish hue, and often dull and languid; there are intense pain, and a sense 
 of insupportable weight and tension of the head ; aversion from light and sound is ordina- 
 rily present, and occasionally delirium ; there are great thirst, and a feeling, often almost 
 insupportable, of oppression at the chest ; the respiration being quick and laborious, fre- 
 quently irregular ; the pains in the baclc and extremities are often of great severity ; the 
 pulse is quick, frequent, and more or less tense ; occasionally it exhibits some degree of irre- 
 gularity ; the nausea and vomiting are generally peculiarly distressing — the matter discharged 
 being a thick ropy fluid, of a yellow, darkish-brown, or green colour; the bowels are costive, 
 or if open, discharge, with tenesmus and griping, a thin watery fluid: when evacuations are 
 procured by appropriate means, they are large in quantity, dark, slimy, tenacious, and offen- 
 sive. There is always an intolerable sense of oppression or constriction at the epigastrium, 
 accompanied by a degree of tenderness which renders the slightest amount of pressure 
 insupportable — or a severe pain and burning, attended in many cases with great nausea, 
 and frequent ineffectual efforts to vomit, are experienced. There is great restlessness, with 
 jactitation, and continued watchfulness. In the course of the disease, the skin acquires, 
 most generally, a brownish, bronzed, or more frequently, a deep yellow tinge, which is par- 
 ticularly marked upon the face and breast. A symptom mentioned by Rush, as generally 
 present in cases of bilious remittent — namely, a screatus, or constant hawking and spitting 
 of a small quantity of tough, glairy matter — we have repeatedly noticed. 
 
 The succeeding exacerbations are marked by an increased violence of all the predominant 
 symptoms of the disease, and unless the intensity of the fever is relieved by an appropriate 
 course of treatment, the powers of life gradually sink; the surface, at length, becomes cool, 
 and covered, generally or partially, with a cold clammy sweat; the pulse becomes small and 
 weak; the tongue covered with a dark, thick coating, and occasionally dry and chapped; 
 the respiration short, quick, and difficult; the abdomea sometimes swollen and tympanitic; 
 stupor or coma often ensues ; not unfrequently, repeated, and at length involuntary, dis- 
 charges take place from the bowels, of a dark, offensive matter, and finally death ensues. 
 
 In the milder forms of the disease, or when it has been from the commencement of the 
 attack subjected to an appropriate treatment, instead of an increased violence in the pheno- 
 mena of each succeeding paroxysm, there is less decided heat of the surface, the pulse 
 becomes slower and less frequent, there is less gastric distress, less pain and tenderness of 
 the epigastrium; less pain of the head and back; the exacerbation is of shorter duration, 
 and as it declines, the skin becomes softer and more moist, the tongue less coated, the coun- 
 tenance more cheerful, and the patient obtain.s often several hours of quiet and refreshing 
 sleep ; the remissions are more distinct, and of longer continuance, until finally a complete 
 intermission occurs, followed by a state of convalescence — which is usually protracted. 
 
 There generally takes place in the milder and uncomplicated forms of bilious remittent, a 
 distinct exacerbation, followed by an evident remission, once in every twenty-four hours: 
 but in the more violent and decidedly inflaminatory form, the remissions, as we have already 
 remarked, are so short and slight as almost to pass unnoticed, and hence the inflammatory 
 bilious fever is described by many writers as a continued fever. 
 
 The duration of the disease varies with its degree of violence and its simple or compli- 
 cated character — it may terminate in a few days or run on for several weeks — but its usual 
 duration is froin nine to fifteen days. It is not uncommon. Dr. Dickson, of South Carolina, 
 reiTiarks, especially among the most perfectly acclimated adult natives resident in malarious 
 localities, and strangers long familiarized to them, to find bilious remittent fever of very pro- 
 tracted duration ; " the patient sinking, after the tenth or twelfth day, into a low form, resem- 
 bling the less severe grades of typhus, and hence obtaining among us the designation of the 
 typhoid stage of bilious fever. Here the well-marked lines which separate the period of 
 exacerbation and remission, are almost effaced ; the characteristic periodicity almost obli- 
 terated ; the fever degenerates nearly into the continued type, and the patient, in the lan- 
 guage of the older practitioners, ' M'ades through' the attack with no definitely regular 
 changes observable from time to time, until, by the success or failure of our efforts in his 
 behalf, he recovers or is lost. The pulse is small and chorded, the tongue throws off its fur, 
 and is smooth, red, and dry, or smeared over, like the teeth and lips, with foul sordes; the 
 stomach loses its irritability, and the vomitings cease; the stools are dark or even black; 
 meteorism occasionally shows itself; there is muttering delirium or disposition to heavy stu- 
 por and coma; the countenance is dull and inexpressive; muscular languor and great debi- 
 lity ensue, with nervous tremors on motion, and perpetual subsultus tendinum." Dr. DicV 
 son has known cases of this kind protracted, in three instances, to thirty, thirty-five, and fifty 
 ((ays, though the average, he observes, would scarcely reach beyond fifteen or twenty. 
 
 A carefal analysis of the phenomena of bilious remittent fever shows, very conclusively, 
 iliat the organs chiefly affected are the liver and stomach, and the results of post-mortem 
 examinations confirm the accuracy of this deduction. In many cases, it is true, the symp- 
 toms during life, and the lesions detected after death, indicate more or less affection of the 
 jungs or brain ; but this latter is to be viewed as an accidental complication, and not essea
 
 BILIOUS REMITTENT FEVER. 967 
 
 tial to the disease. Busing our conclusions upon the investigations of Dr. Stewardson, 
 (American Journ. Med. Scien., April, 1841, and April, 1842,) which are confirmed by the sub- 
 sequent observations of Dr. Svvett, (i6i(/, Jan., 1S4.5,) and correspond in many particulars 
 with those of Mr. Twining (^Diseases of Bengal, chap, v.), a morbid condition of the liver 
 would appear to be invariably present in remittent fever — to be indeed diagnostic of the 
 disease ; it is nevertheless very certain that few cases of bilious fever, of any intensity, occur 
 without being attended also by indubitable symptoms of gastro-enteric disease — the evidences 
 of which are very generally detected in those who die of the fever. In many cases the 
 indications of hepatic disease predominate, wliile in others those of gastric adection are 
 most prominent; in general, however, both are sufficiently well marked in the same case. 
 It has been proposed to distinguish the fever, according as the phenoiTiena of hepatic or 
 gastro-enteritic disorder predominates, by the terms hepatic and gastric. Hepatic remittents 
 being characterized by intense febrile heat; violent pain of the head; fullness and tension 
 of the right hypochondrium, with pain and pulsation of this part and of the epigastrium ; 
 excessive irritability of the stomach ; frequent and forcible vomiting, the ejections being 
 without any trace of bile; a clean state of the tongue in the early stages; a decidedly yel- 
 hiw colour of the skin and adnata of the eye ; great torpor of the bowels, until towards the 
 decline of the disease, when a copious discharge takes place from the bowels of a dark or 
 pitch-like tenacious matter, which may be considered as in some degree critical. 
 
 Gastric remittents are distinguished by a bitter taste in the mouth; great thirst, with 
 a craving for cool and acidulated drinks; frequent vomiting of a green or dark-brown fluid; 
 total loss of appetite, and generally disgust for every kind of food; a feeling of great weight 
 and anxiety at the pra'cordia ; pain and tenderness, chiefly at the epigastrium ; intense pain 
 of the loins and knees, and soreness of the calves of the legs ; severe and constant pain of 
 the forehead ; the tongue coated in the centre with a thick layer of yellowish mucus, and 
 red at the sides pnd tip; the remissions distinctly marked ; bowels costive, or when dis- 
 charges from them take place, these are thin and watery, and often attended with griping 
 and tenesmus : in the course of protracted cases the stools not unfrequently consist of a red- 
 dish fluid resembling the washings of meat. In the progress of the disease, the tongue 
 becomes dry, cracked, and covered with a dark-brown or blackish crust ; upon the separation 
 of which the tongue presents a smooth, shining, and red surface. In the advanced stage, 
 there is often retention of urine, difl3culty of swallowing fluids, meteorism of the abdo- 
 men, &.C. 
 
 Although we frequently meet with cases in which the predominance of hepatic or of gas- 
 tric disorder, but especially of the first, is thus strongly marked ; nevertheless, in the gene- 
 ral run of cases, there is a complete blending of the two sets of phenomena. 
 
 There is one form of bilious intermittent stiU to be described, with which " the experience 
 of the last ten years"' has made the practitioner of the southern and south-western portions 
 of the United States, "unhappily, too well acquainted, under the denomination o( congestive 
 fever. In certain localities, indeed, remarks Dr. Dickson, the ancient inflammatory features 
 of malarious endemics seem to have disappeared, and to have become supplanted by the 
 more hideous and pestilential modification thus entitled." 
 
 The form of the disease to which we allude is marked by a diminished temperature and 
 decreased sensibility of the whole surface of the body — the skin being, at the same time, 
 soft, contracted, and often clammy, or wet with a copious perspiration ; when a partial reac- 
 tion takes place, the heat is never considerable, and it is often confined to particular parts of 
 tl)e surface. There are considerable and universal lassitude and debility ; the head is con- 
 fused and affected with vertigo, and sometimes with a deep-seated pain or a sensation of 
 oppressive weight or tension ; the eyes are heavy, suffused and dull ; the countenance is 
 haggard, and the face j)ale, and of a dingy, muddy appearance; the pulse is small, frequent, 
 and indolent, or struggling, compressible and variable ; the tone of the voice is often 
 changed, the articulation slow and drawling, or imperfect and stammering. The respiration 
 is anxious and laborious, with frequent sighing. The tongue exhibits, at first, but little 
 change, but soon becomes dark-brown or black, especially in those cases in which the earlier 
 stages of the disease have been marked by some degree of excitement. The stomach 
 is occasionally irritable ; the epigastrium and right hypochondrium are tender upon pressure, 
 and more or less tinnid ; the bowels are torpid, and when stools are procured, they are dark- 
 coloured and ofiensive, and often attended with tormina and tenesmus. The mind is gene- 
 rally dull, indifferent, or confused, from the commencement of the attack, and, in the progress 
 of the disease, sinks into a state of more or less complete stupor, or of low muttering deli- 
 rium. The remissions of the fever in the congestive form are not well marked, or rather, 
 there is an entire absence of the febrile exacerbations and remissions, the phenomena of the 
 disease presenting but little other change than a rapid or a gradual augmentation in intensity 
 In fatal cases, death, which may take place between the fifth and fifteenth days, or even 
 later, is often preceded by hiccup, subsultus tendinum, involuntary stools, hemorrhage fiom 
 the stomach or bowels, petechice. &c. 
 
 The congestive form of bilious remittent fever may attack suddenly, when it is apt '«■
 
 968 BILIOUS REMITTENT FEVER. 
 
 assume a peculiarly malignant form, and to terminate rapidly in death ; in many cases, how 
 ever, it is preceded by the same symptoms as the milder and more open forms of tlie dis- 
 ease. In the more violent attacks of congestive fever, "the system seems," to use the words 
 of Dr. Dickson, " to sink at once prostrate before the invasion or exacerbation, which can 
 scarcely, at times, be called febrile. Reaction, to use our technical phrase, does not take 
 place, or very feebly, if at all. The skin is cold, and covered with a clammy sweat, as in 
 rhe collapse of cholera; the pulse is weak and fluttering; the stomach is very irritable, with 
 frequent and painful, but usually inelfectual, eiforts to vomit ; the countenance is shrunken 
 and pale or livid; there is often low muttering delirium, with shivering and fainting. In 
 some cases, no complaint is made, a lethargic insensibility seeming to oppress the patient; 
 in others, the most extreme anguish is endured by the miserable sufferer, who in his agony 
 often utters groans or loud cries. The vital powers are speedily and irrecoverably exhausted 
 by the recurrence of a few such exacerbations, although the remissions in this class of cases 
 are usually well defined, and full of transient relief and hope. The third, fourth, or fifth 
 return of the train of symptoms delineated, for the most part, puts an end to the distressing 
 scene." 
 
 The phenomena of congestive fever are evidently the result of defective innervation, and 
 an impeded action of the heart and lungs; the blood, imperfectly decarbonized, accumulates 
 in the interior organs, and thus presents the full and regular exercise of their functions. The 
 impression of the morbific causes by which the disease is produced is, in all probability, 
 made primarily upon the nervous centre, and by depressing the energy of its action, gives 
 rise to all the other phenomena which characterize this form of fever. 
 
 The propriety of denominating these cases of congestive disease bilious remittent fever, 
 when they frequently run their course without exhibiting the slightest indication of febrile 
 reaction, has been doubted by some. They are, however, produced by the same causes as 
 the bilious fever, and, when the congestion is early reduced, the case often assumes all the 
 characteristics, and runs the same course as in the ordinary form of bilious fever, showing 
 that the phenomena of the latter were merely masked or suspended by the congestive state 
 of the principal vital organ. 
 
 The convalescence from an attack of all the forms of bilious remittent fever is always 
 protracted, and relapses, from slight irregularities of diet or too early exposure, are not unfre- 
 quent. After severe attacks, the hair often falls entirely off, and is only slowly and imper- 
 fectly renewed, or the patient remains permanently bald. The functions of the stomach and 
 alimentary canal, generally, are imperfectly performed for a long period after recovery, and 
 require the utmost circumspection on the part of the patient to insure their complete restora- 
 tion. Jaundice is a very frequent consequence of bilious "remittents. This, Dr. Dickson 
 states, "was noticed generally in the summer "and autumn of 1824 ; very few patients reco- 
 vering from the fever in that year without becoming icteric. Nor is it rare to meet with 
 hepatic enlargement and induration, attended by a long succession of saflerings from visceral 
 obstructions and mechanical impediments to the performance of the abdominal functions, 
 and to the transmission of the abdominal circulation. Hence ascites and anasarca, and hence 
 diarrhoea and dysenteries called hepatic, and occasionally melcena and true intestinal hemor- 
 rhage. The spleen suffers from remittents of malarious origin, as from their kindred iiiter- 
 mittents, though not by any means so uniformly, sometimes undergoing a permanent and 
 inconvenient increase of size or hypertrophy."' 
 
 With the pathological anatomy of remittent fever we are but imperfectly acquainted ; very 
 few facts in relation to it have been recorded, and of these few many are loosely and imper- 
 fectly detailed, while those upon the accuracy of which reliance can be placed, are derived 
 from too limited a series of observations to allow of any positive general conclusions being 
 based upon them. That, however, the stomach and liver are the organs in which indications 
 of disease are the most luiiformly detected, all the facts in our possession very clearly prove, 
 although the exact nature of the morbid lesion is not very clearly made out. "The closest 
 attention to clinical observations," remarks Mr. Twining (Diseases of Bengal, chap, v.), "as well 
 as the result of post-mortem examinations, convince me, that remittent fevers in Bengal art 
 invariably connected with loral congestions, which often run rapidly into inflammations, attended 
 with much interstitial effusion. The seat of these local affections is foimd principally ir the 
 stomach, intestines, cellular structure about the duodenum, and at the root of the mesocolon, 
 more especially where it passes across the spine. The principal disease is also often found 
 in the spleen, liver, brain, or lungs." Dr. Gerhard, of Philadelphia, maintains, as the result 
 of his observations, that the anatomical character of the more severe forms of intermittent 
 fever is to be detected in the spleen, liver, and stomach ; the bilious and remittent fevers 
 being " ])robably referable to the same class as the malignant remittents." These conclusions 
 are confirmed by the observations made by Dr. Stewardson, in the Pennsylvania Hospital ; 
 by those of Dr. bwett, made in the New York Hospital ; and by the results of dissections in 
 single cases, as reported by Dr. Howard and others. Dr. Boyd describes the indications of 
 disease, after death, in the bilious fever of Minorca, as occurring in the brain, lungs, liver, 
 and stomach ; the liver, he states, was in most instances enlarged, often inflamed, with jt«
 
 BILIOUS REMITTENT FEVER. 969 
 
 inferior margin livid ; the gall-bladder distended with viscid bile. The stomach and intes- 
 tines were often inflamed ; the villous coat being of a dark colour. 
 
 The appearances in the stomach are variously described ; but in general, they are stated 
 to be injection, M'ith increased redness of the mucous membrane — sometimes thickening and 
 occasionally softening of that membrane. In many instances, the same appearances are 
 described as being present in the duodenum. The glands of Brunner, in this intestine, were, 
 according to Dr. Stewardson, " develof)ed in a remarkable manner," in the cases examined 
 by him ; a similar development did not, however, occur in the fatal cases which fell under 
 the notice of Dr. Swett. 
 
 In all the dissections made by Drs. Stewardson and Swett, and the one reported by Dr. 
 Howard, the liver was found to be flabby, of a bronze colour, the two substances composing 
 the organ being blended together in such a manner as to be scarcely distinguishable. The 
 spleen was much enlarged and softened. The peculiar condition of the liver, just described, 
 Dr. Stewardson considers to constitute " the essential anatomical character'' of remittent 
 fever: he thinks it highly probable that the same alteration of the liver will be found 
 to exist in intermittents which prove fatal in their early stage ; these and intermittents being, 
 in his opinion, essentially the same disease. 
 
 Drs. Gerhard, Stewardson, Swett, and Howard, never detected in any case, after death from 
 remittent fever, the glands of Peyer, and the other intestinal follicles, in a diseased condition ; 
 and although we believe that these parts will generally be found in a perfectly healthy state, 
 nevertheless, it is certain that cases do occur, particularly of the more protracted forms of 
 the disease, in which the evidences of follicular inflammation of some portion of the small 
 intestines, terminating occasionally in ulceration, especially of the glands of Peyer at the 
 lower end of the ileum, are present after death. Such cases are referred to by Dr. Geddings, 
 of Charleston, Drs. Stevens and Vache, of New York, Dr. Harrison, of Cincinnati, as quoted 
 by Dr. Dunglison, (^Practice of Med., 2d ed., vol. ii., p. 450.) A diseased condition of the glands 
 of Peyer is stated to have been present also, in all the cases examined by Dr. Richardson in 
 the New York Hospital, in 1840, (^Dr. Swett, American, Tourn. Med. Sciences, January, 1845 ;) and 
 the same lesion was noticed by Dr. Mc William in the African remittent fever. 
 
 The indications of congestion and of inflammation so frequently met with in the brain 
 and lungs, point out, it is true, the tendency there exists in remittent fever to disease of those 
 organs, but tliey are not invariably present, nor are they essential to the disease. 
 
 In cases of congestive intermittents, the anatomical lesions are the same as those de- 
 scribed above, excepting, that when death takes place previously to the occurrence of 
 complete reaction, there is very generally extensive hyperemia of tlie brain, lungs, liver, and 
 spleen. 
 
 The diagnosis in bilious remittent fever will depend, in a great measure, upon the charac- 
 ter which the disease presents in different localities and in different years, as well as upon 
 the constitution and other circumstances connected with the individuals attacked by it. In 
 the milder forms of the disease, with distinct exacerbations and remissions, and no marked 
 tendency to disease of the more important organs, particularly when they occur in persons 
 of temperate habits, and of constitutions neither broken down on the one hand by previous 
 disease, fatigue, or the depressing passions, &,c., nor on the other, marked by undue plethora, 
 or a tendency to congestive or inflammatory affections of tlie central organs ; by a judicious 
 treatment, early commenced with, a favourable result may very generally be obtained. 
 Even the more strongly marked inflammatory form of the fever seldom terminates fatally 
 when vigorously treated from its onset. The congestive or malignant form of the disease is 
 one in which the prognosis is much more unfavourable ; in epidemics of congestive bilious 
 fever the mortality is often truly appalling. Remittent fever, generally speaking, attacks 
 with less severity, and is more readily controlled in those acclimatized, as it is termed, to the 
 districts of country in which it occurs as an epidemic — that is, persons who, having passed 
 through the disease, continue to reside in those districts. A stranger, recently arrived, par- 
 ticularly if a high liver, or of intemperate habits, or whose occupation subjects him to 
 exposure and fatigue, is not only more liable to be attacked than the former class of indivi- 
 duals, but in such a one the disease will usually be marked by greater severity, and be more 
 liable to terminate fatally. The favourable symptoms, in individual cases, are, the mildness 
 and comparative shortness of the exacerbation, the completeness and long duration of the 
 remission, particularly when this is accompanied by a free and diffused perspiration, and 
 the patient falls into a quiet and refreshing sleep; the postponement of the succeeding exa- 
 cerbations beyond their anticipated periods; the diminution or removal of the tendency to 
 disease of particular organs; the occurrence of more regular and healthy discharges from 
 the bowels; the tongue becoming cleaner and the pulse slower and less frequent, &c. 
 
 The bilious remittent fever, as we have already remarked, is a disease of hot climates ana 
 of the season of greatest heat; thus, while it constitutes the summer endemic of the south- 
 ern portion of our Union, it seldom occurs in the middle and northern states, excepting 
 during those summers that are marked by an unusual elevation of temperature; and here, as 
 well as in the places where it prevails endemically, it ceases as the winter approaches.
 
 J70 BILIOUS REMITTENT FEVER. 
 
 Whether the fever can be produced by exposure alone to a high degree of atmospherical 
 temperature, is a question that has been frequently raised ; and while many maintain the 
 affirmative, others as positively assume the negative. It is very certain, however, that the 
 long-continued action of excessive heat upon the body, by predisposing it to the action 
 of other morbific agents, will, in this manner, often bring on an attack of bilious fever, inde- 
 pendently of malarious influences. Thus, nothing is more common than for the disease to 
 immediately occur in those who, after exposure to the midday sun, or many hours of severe 
 labour in intensely hot weather, allow their bodies to become chilled by sleeping on the 
 ground in the open air after night; by neglecting to change their clothing when they become 
 wet by a shower of rain or other cause; or, while the perspiration is running in streams from 
 every pore, by throwing oii" a portion of their clothing, and sitting or lying in a draught of 
 air, j)articulaily after sundown. But while many of die sporadic cases are produced in this 
 manner, and the same species of imprudence is a common exciting cause of the fever, wlien 
 it prevails as an endemic or eiDidemic, a large number of incontestable facts would seem to 
 prove that its more common cause is a poison produced by the action of high degrees of solar 
 heat upon such portions of the earth's surface as are ordinarily covered or soaked with water, 
 when these are accidentally laid bare, or rendered dry by long-continued heat and drought. 
 The presence of substances, whether vegetable or animal, liable to decomposition, is to be 
 included among the causes capable of generating bilious fever in liot climates, and in the 
 more temperate climates during summers of unusual heat. In our larger cities the disease 
 always prevails most extensively, and in its more malignant forms, in the most confined and 
 filthy districts, to which it is often entirely confined ; or, when it makes its appearance in 
 other parts of them, it can generally be traced to the presence of some local cause of infec- 
 tion. In Philadelphia, where bilious remittent fever was formerly a common disease of the 
 summer and early autumnal months, it is now of rare occurrence, excepting in its mildest 
 form; and this disappearance of the disease from our city is to be ascribed more to tlie better 
 construction and cleanliness of our docks, and the greater attention which is paid to the 
 paving, draining, and sewerage of our streets; to the filling up of the numerous ponds 
 which formerly existed in and about the city, and to the preventing any mass of putrefiable 
 materials from being stored in the city proper and surrounding districts, than to any very 
 decided diminution in the temperature of our summers. 
 
 In the treatment of bilious remittent fever, the first and most important question that pre- 
 sents itself is, the propriety of direct depletion by the lancet. This must be determined 
 solely by the character of the symptoms and condition of the patient in each case. In the 
 more decidedly inflammatory cases, when the exacerbation is well-marked and prolonged — 
 when it is attended by a hot skin, flushed and turgid face, severe pain of the head and back, 
 great oppression about the prascordia, and a firm or chord ed pulse — and when the intermis- 
 sions are short and imperfect — more particularly in cases occurring in young, robust, and 
 plethoric habits, and who have but lately arrived from a colder climate, there can be no doubt 
 of the importance of blood-letting. In such cases a vein in the arm should be opened at the 
 early period of the attack, and a sufficient amount of blood drawn off at once to reduce the 
 violence of the exacerbation: one sufficient bleeding at the onset of the disease is far more 
 efficacious and better adapted to prevent local determination than the repeated detraction of 
 small quantities of blood during its course. A repetition of the bleeding will seldom be de- 
 manded when the first operation has been carried to a sufficient extent ; should, however, 
 the succeeding exacerbation be marked by any degree of violence, we should not hesitate 
 again to resort to the lancet; but the loss of a less amount of blood will be required to 
 reduce the excitement than in tlie first instance. If direct depletion by the lancet has been 
 neglected in the early stage of the disease, it will seldom be admissible subsequently — or, 
 should symptoms seem to demand it, it should be employed with the utmost caution, and 
 only to a moderate extent. 
 
 That numerous cases of bilious fever occur in which venesection is altogether unneces- 
 sary, is unquestionably true ; in those, however, that are marked in their early stage by 3 
 high degree of arterial excitement, and a tendency to local hypera;mia or inflammation, the 
 remedy cannot be dispensed with without danger to the patient. When timely employed, 
 we have repeatedly been surprised at the \ery great and prompt relief produced by it — the 
 violence of the exacerbations becoming reduced, the intermissions more complete, the skin 
 cooler and more relaxed — the pain of the head relieved — the bowels readily acted upon; 
 and a state of calmness, often of refreshing sleep, will often succeed to the previous rest- 
 lessness and distress. 
 
 Local blood-letting is a remedy more generally demanded in bilious remittent fever than 
 bieeding from the arm. In all cases attended with intense pain of the head, throbbing of 
 the temples or delirium — or with pain or decided tenderness of the epigastrium and right 
 hypochondrium, or with pain, and a sense of tightness or oppression about the thorax — in 
 oonjunction with general bleeding, or where this has not been judged necessary, the appli- 
 cation of leeches or cups in the neighbourhood of the local suffering, in numbers propor- 
 tionate to its intensity and to the age and condition of the patient, will invariably be followed
 
 BILIOUS REMITTENT FEVER. 971 
 
 by decided and, geneially, permanent relief. The very great suffering which many patients 
 experience from pain in the back and loins, we have, in repeated instances, known to be 
 completely relieved by cups applied along the spine. 
 
 In regard to the propriety of cathartics in the treatment of bilious remittent fever, there is 
 a much greater unanimity of opinion than in relation to blood-letting. There are few, if any 
 cases, in wliich their operation will not be found beneficial, by removing from the intestines 
 the vitiated secretions with which they are often filled — procuring regular stools, and by 
 assisting to reduce the congestion of the portal system, and thus restoring the healthy func- 
 tions of the liver and digestive organs generally. 
 
 It is not, however, every purgative from which good effects are to be anticipated in bi- 
 lious fever. Under the free employment of certain cathartics the patient will often be found 
 gradually to become more and more debilitated, and finally to sink into a state of stupor, 
 with suffused eyes, weak, fluttering pulse, and other symptoms of extreme exhaustion ; in 
 such cases it will be found that the discharges from the bowels consist of a thin, serous 
 fluid ; whereas, under the employment of such purgatives as produce consistent, viscid, and 
 dark-coloured stools, the indications of improvement in the symptoms of the disease are often 
 prompt and striking. Calomel is probably one of our best cathartics in this disease. It may 
 be given either alone, in a full dose, and followed by occasional doses of castor oil — senna 
 tea — calcined magnesia — or laxative enemata ; or the calomel may be combined with rhu- 
 barb, or jalap ; or, what is frequently a more effectual plan, a full dose of the calomel ad- 
 ministered at first, and then, every three or four hours, according to the effects produced, 
 moderate doses of the blue mass and rhubarb, with the addition of a small portion of 
 ipecacuanha. By these means we shall generally succeed in freeing the bowels of the 
 dark-coloured, viscid matter with which they are often loaded, and procuring more regular 
 and healthy stools — after which, an occasional dose of the milder laxatives will alone be 
 required. 
 
 In all -Cases of bilious remittent fever attended with a hot and dry skin, the application 
 of cold to the surface, either by sponging it with cold water or cold water and vinegar, or by 
 the application of cold water in the form of affusion, will have the effect, while it reduces the 
 morbidly increased temperature, of relaxing the skin, and promoting perspiration, and in this 
 manner of shortening the exacerbations and inducing a complete intermission ; even the ex- 
 posure of the body to a current of cool air — by throwingoff the clothing and opening the doors 
 and windows of the patient's chamber, will in most cases be productive of the most beneficial 
 effects. The mere immersion of the hands and arms in cold water, by carrying off a portion 
 of the morbid heat and allaying thirst and restlessness, will be found grateful to the patient, 
 who not unfrequently will fall immediately afterwards into a refreshing sleep: whenever, 
 however, the exacerbation is attended by intense heat of the surface and other symptoms of 
 violent excitement, it is from the application of cold water to the surface by affusion or spong- 
 ing that the most prompt and permanent advantage is to be obtained. Dr. Dickson ranks 
 it among the most efficient of our febrifuge measures — far above the lancet, both in the 
 extent of its adaptation, and in its degree of specific utility. All that we can hope or anticipate 
 from blood-letting may be obtained, in the majority of cases, from the use of the cold bath, 
 while the latter possesses this striking and obvious advantage, that we can repeat it as often 
 as the symptoms are renewed that require its employment. The local determination which it 
 controls most promptly, he very correctly remarks, is that to the brain, shown by headache, 
 flushed face, red eye, delirium, &c., with a full, hard, bounding pulse. In such cases, the 
 patient being seated in a convenient receptacle, a large stream of cold water should bo 
 poured over his head and naked body froin some elevation, and continued until he becomes 
 pale, or his pulse loses its fullness, or his skin becomes corrugated and he begins to shiver; 
 he should then be dried and placed in bed, with just so much covering as he feels to be 
 comfortable, the chamber being, at the same time, fully and freely ventilated; or without 
 removing the patient from the bed, he may be su])portetl in a leaning posture over its edge, 
 and the cold water poured from a pitcher over the vertex. 
 
 The application of cold water to the surface is proper only when the temperature of the 
 latter is considerably and permanently increased over the whole body, and at the same time 
 the surface is perfectly dry — when the skin is cool or covered with moisture, the use of the 
 cold water is inadmissible ; it is also of doubtful propriety when there exists a decided tend- 
 ency to hyperemia or inflammation of the lungs, or in cases attended with diarrhoea. Its 
 repetition is forbidden when it has occasioned a protracted chill or rigor ; or the patient 
 continues to feel cold or uncomfortable after its use. 
 
 Tiie testimony of Dr. Dickson in relation to the curative powers of cold water applied to 
 the surface in the bilious remittent fevers of the south is strong and pointed, and is fully 
 borne out by the experience of physicians of other portions of the United States and of 
 Europe, who have extensively employed it in the disease under consideration. Equally 
 important with the external employment of cold water is its use internally: — allowing the 
 patient to drink freely of cold, or even iced water or iced lemonade, is not only highly
 
 972 BILIOUS REMITTENT FEVER. 
 
 grateful to liim, Lut it tends to diminish the morbid excitement, relax the skin, and promote 
 a free and uniform diaphoresis. 
 
 Diaphoi-f^tics, particularly a combination of tartar emetic, nitre, and calomel, have been 
 recommended and highly extolled by many practitioners, in the inflammatory forms of 
 bilious fever. We have occasionally employed the combination just mentioned, but have 
 never seen any decidedly beneficial effects produced by it, while the emetic tartar, in how- 
 ever minute doses administered, we have found, very generally, to augment the irritability 
 of the stomach, and increase in this manner the distress of the patient. The neutral mixture, 
 .spirits of mindererus with the sweet spirits of nitre, or a weak solution of nitre in water, we 
 have occasionally employed, but we must frankly confess, that we are not aware of any 
 benefit resulting in a single case from the administration of either. 
 
 Upon the propriety of blisters in bilious remittent fever, there exists not a little dispute, 
 their use being entirely condemned by some practitioners, while others rank them among 
 our most valuable remedies. In the more inflammatory forms of the disease, until the 
 violence of the exacerbation has been reduced by the remedies already detailed, from the 
 application of blisters more injury than good will unquestionably result; but as soon as the 
 exacerbations have become less intense, and the remissions more marked, in all cases where 
 considerable gastric distress remains, or any considerable affection of the head or lungs, 
 from blisters over the epigastrium and right hypochondrium, to the nape of the neck, along 
 the spine, or to the chest, very considerable and j^rompt relief will always be obtained. 
 
 In many cases of bilious fever there is so great a degree of irritability of the stomach, 
 that not only is everything taken into it rejected as soon as it is swallowed, but the patient 
 is tormented with almost constant vomiting or frequent ineffectual efforts to vomit. This 
 distressing symptom will, very often, be completely removed by the abstraction of blood 
 from the arm, whenever this is admissible, or by cups or leeches over the epigastrium, or 
 by a large blister applied to the latter part. Relief will also be obtained from small portions 
 of ice held in the mouth, from the effervescing draught, the artificial mineral water of the 
 shops, taken perfectly cold, or from iced lemonade or toast water. Minute doses of calomel, 
 say a third to half of a grain, suspended in some simple mucilage, and repeated at short inter- 
 vals, wiil, very generally, promptly relieve the gastric irritability and suspend the vomiting. 
 In cases where every other remedy has failed in relieving the irritable state of the stomach, 
 we have repeatedly seen it promptly removed by a grain of the acetate of lead, given every 
 hour or two, dissolved in a small quantity of water. 
 
 By a few practitioners, a mercurial course is recommended in all the more violent forms 
 of bilious remittent fever. Calomel is directed to be given first, in large doses, as a purga- 
 tive, and subsequently, in small doses, continued until its specific effects are obtained ; our 
 own experience is not, however, in favour of this practice. In the inflammatory form of the 
 disease, a mercurial impression is calculated rather to protract than to diminish the suffering 
 and danger of the patients, while the milder forms of the fever may be readily controlled 
 without it. Cases, however, occasionally occur in which an alterative course of mercury 
 will be found, we are convinced, highly advantageous. We have repeatedly observed, that 
 after the violence of the exacerbations has been reduced, the patients will continue to be 
 affected by a low form of fever, marked by a dry skin, a small irritated pulse, a dry dark- 
 brown tongue, frequent watery discharges from the bowels, restless nights, and a total want 
 of appetite, and have found this condition of things to be speedily removed by a cautious 
 mercurial course, carried to the extent of producing a slight tenderness of the gums. In 
 these cases small doses of calomel, or, wirat is preferable, the blue mass, combined with a 
 portion of opium and ipecacuanha, may be given every three hours until the desired effect 
 results. A form of the disease, somewhat similar to the one just referred to, is described 
 by Eberle as occurring "when, either from the imprudent employment oiirritatmg purges, 
 or from other causes, the mucous membrane of the intestinal canal is brought into a state of 
 high irritation or subacute inflammation. The disease then generally loses its remittent 
 form, and often assumes a low typhoid character, with almost constant delirium, a tender 
 and tympanitic state of the abdomen ; a dry, dark-brown, or black crust on the tongue, with 
 clean red edges; watery and reddish stools; great prostration; and a very dry and hot skiru 
 Cases of this kind frequently run on for several weeks, and the convalescence is always very 
 gradual and tedious." The treatment directed by Dr. Eberle is leeches to the abdomen, fol- 
 lowed by a large emollient poultice; small doses of calomel and opium — one-sixth of a grain 
 of the former to a quarter of a grain of the latter — every two or three hours. The bowels to 
 be kept open by laxative enemata, and the patient directed to partake freely of some bland 
 mucilaginous fluid — such as barley water, very thin oatmeal gruel, or a solution of gum aca- 
 cia in water; no other article of food being allowed. "In such cases,'' he remarks, "I have 
 thought that considerable benefit was derived from epispastics on the legs just above the 
 ankles; this measure is particularly useful when the extremities are cool, while the skin of 
 the body is hot — a circumstance which is not uncommon in instances of this kind. An 
 emulsion of balsam copaiba may aito be frequently employed with unequivocal advantage. 
 I havb so often seen the most decided benefit derived from this article, in cases attended
 
 BILIOUS REMITTENT FEVER. 973 
 
 with great irritation or sv\bacute inflammation of the bowels, that I should consider myself 
 neglecting an important curative means, were I to omit prescribing it in diseases of this cha- 
 racter." "Although very considerable prostration often occurs in such cases, stimulants or 
 tonics are by no means admissible." 
 
 Throughout the entire course of bilious remittent fever, little desire for food will be 
 expressed by the patient, nor should any be allowed until after the disease is fully subdued ; 
 and then only barley or rice water, thin gruel or panada, in very moderate quantities. To 
 allay the thirst, which is always present and frequently very urgent, the cold drinks, already 
 pointed out, will be the most suitable. Perfectly cold toast water, slightly acidulated with 
 lemon or orange juice, tamarinds, or currant or plum jelly, forms generally a very palatable 
 beverage, of which the patient may partake at short intervals. Small quantities of cold 
 acidulated fluids, slowly swallowed, it is to be recollected, are far more efficacious in allay- 
 ing thirst than large draughts hastily swallowed. Frequently sponging die patient's mouth with 
 cold water, cleaning his tongue with a slice of orange, or allowing him to suck the juice of 
 the latter, will aid very materially in abating his sense of thirst, and is always refreshing 
 to him. 
 
 The chamber of the patient should be kept perfectly clean and cool, and while a free ven- 
 tilation is kept up, it should be guarded from any glare of light. His body shouhl be slightly 
 covered with bed-clothes, which, together with his linen, should be frequently changed. At 
 all times the patient should be kept perfectly quiet, and the most perfect calmness and quiet- 
 ness should be maintained within and around his apartment. 
 
 In our enumeration of the symptoms of bilious fever, it was stated that great restlessness 
 and wakefulness were very commonly present. So long as the period of increased excite- 
 ment lasts, or there is any tendency to disease of the brain, the only means by which the 
 restlessness of the patient is to be subdued and sleep procured, are the general remedies that 
 have been already enumerated ; but after the morbid excitement, and whatever cerebral 
 affection that may exist, have been reduced, a state of restlessness and an inability to sleep 
 often still continue from mere nervous irritability, when the exhibition of an opiate in the 
 form of Dover's powder, about bed-time, will very generally be found advantageous : by 
 some practitioners, the extract of hyosciamus, combined with ipecacuanha, is preferred to 
 any preparation of opium ; while others, again, recommend the tincture of opium, combined 
 widi a vegetable acid, as tinct. opii 3ss., acid, citric, gr. v. to viij., aq. puree gij., M. ; of 
 which a tablespoonful, or half an ounce, is a dose, to be repeated, if necessary, after a short 
 interval. 
 
 We have now presented a general outline of the treatment of bilious remittent fever, in 
 its mild and inflammatory forms. It is hardly necessary for us to repeat, that the extent to 
 which each remedy is to be carried, and the propriety of its repetition and continuance, as 
 well as the period and particular circumstances of the disease to which it is adapted, must 
 be determined by the application of the general principles of pathology and therapeutics to 
 each case we are called upon to treat; and although this will demand a degree of judgment 
 in the practitioner, which he can only acquire by habits of close attention and nice discri- 
 mination, and a somewhat extended field for observation, it is the only course from which 
 success can be anticipated in the treatment of a disease, which, like the one under considera- 
 tion, varies so much in its character in dilFerent seasons and localities, and even in diflerent 
 individuals attacked at the same place and during the same period. 
 
 When the disease, notwithstanding our best directed eflbrts, runs on to that stage when its 
 symptoms resemble those of the last stage of typhus fever, nothing is left us but to endea- 
 vour to sustain the patient's strength, and to remove or relieve any urgent cause of distress or 
 danger. He should be allowed such nourishing food as is easy of digestion, as beaf tea, 
 sago, arrow-root, and the like, with wine-whey, wine, pure or diluted, porter, milk-punch, or 
 brandy, in quantities adapted to the emergency of the symptoms and the effects produced. 
 Sinapisms or blisters may at the same time be applied to the inside of the thighs or calves 
 of the legs, and to the epigastrium. If diarrhoea be present, this we should attempt to abate 
 or suspend by opiate and astringent injections. The singultus, which is often present to 
 a very distressing degree, may be frequently allayed by the camphor julep ; and the meteor- 
 ism of the abdomen may often be considerably relieved by the spirits of turpentine, thirty 
 drops of which may be given every two or three hours ; this latter is said indeed to be among 
 the safest and most useful remedies at this stage of the disease ; it will often be found to pro- 
 duce a beneficial impression upon the diseased mucous membrane of the alimentary canal, 
 to suspend the frequent griping stools, and to correct the morbid character of the discharges. 
 In the sinking stage of bilious remittent fever, the effects of ammonia, with a strong decoc- 
 tion of serpentaria or valerian, or combined with the aromatic confection, have been repre- 
 sented as peculiarly beneficial ; but, unfortunately, when the disease has arrived at this stage, 
 every remedy will too often be found unavailing, and our best directed efforts to save the life 
 of the patient ineffectual. 
 
 A question has been agitated both as to the propriety of and proper period for the adnii 
 nistration of cinchona or quinia in remittent fever. Without attempting to detail the varion* 
 
 4g
 
 974 BILIOUS REMITTENT FEVER. 
 
 and opposite opinions that have been advanced upon this subject, we shall merely remark, 
 thai in the simple and inflammatory forms of bilious remittent fever, it would be reasonably 
 inferred from the character of the disease, that the bark or quinia is not a remedy adapted 
 to contrpl the symptoms of its earlier stages, and the correctness of this inference has been 
 very fully established by the result of experience. So soon, however, as a complete inter- 
 mission has been obtained, and no indications of visceral hyperaemia or inflammation are 
 present, a cautious administration of the cold infusion of the cinchona, combined with ser- 
 pentaria or some agreeable aromatic, will be found, in general, to cut short the remaining 
 symptoms of tlie disease and accelerate the period of convalescence. The quinine may be 
 given in solution with the addition of a few drops of the elixir of vitriol, and to the extent 
 of from three to five grains, repeated at such intervals as the circumstances of the case )Ray 
 demand. The more violent the form of disease has been, the more important is the 
 administration of the quinine, so soon as a complete remission has been obtained, and the 
 larger should be the dose of the remedy. 
 
 During the period of convalescence, the patient should be guarded from the effects of any 
 sudden transitions of temperature, and from incurring the least degree of fatigue by sitting 
 up too soon or for too long a period ; and while his mind should be occupied and amused, at 
 proper times of the day, by the conversation of his friends, or some light occupation, fatigue 
 from this source must also be avoided. His bowels are to be kept regularly open, which 
 may generally be done by allowing him to partake, in moderation, of any of the perfectly 
 ripe subacid fruits of the season ; if they, however, should become closed, some mild laxa- 
 tive should be occasionally administered. In regard to diet much caution is to be observed. 
 The patient should be confined at first to moderate quantities of the more agreeable farina-' 
 ceous articles ; and if his strength has been greatly prostrated, a glass or two of sound wine 
 will not be improper. As his digestive powers improve, he may be allowed plain beef oi 
 chicken broth, oysters slightly cooked, parboiled eggs, and finally, the lighter and more rea- 
 dily digested meats, jolainly but nicely cooked. The appetite often remains, for a long time, 
 weak and capricious — and frequently, some agreeable bitter infusion, as Colombo, quassia, or 
 the wild cherry tree bark, will be proper, to augment the tone of the stomach. In all cases, 
 the food of the patient should be presented to him in small quantities, and served with great 
 neatness ; large masses of food, slovenly prepared and served, will in general disgust, and 
 thus destroy what little appetite may exist. In regard to exercise and exposure to the open 
 air, the convalescent should undertake them, only so soon as he has acquired some degree of 
 strength, when a trip to some agreeably situated watering-place will often restore him to per- 
 fect health, more quickly than can be effected during his continuance at home, where his 
 mind is too early directed with anxious care to the concerns of his family and of his pro- 
 fession. 
 
 In the congestive form of bilious fever, the indications of cure are, to rouse the nervous 
 energies of the system, to relieve as quickly as possible the central organs from their state 
 of hypersemia, and to restore to the capillaries of the surface their healthy action. Among 
 the most important of the remedies calculated to effect these objects, is the external appli- 
 cation of heat to the surface of the body in the form of the warm or hot bath, the vapour 
 bath, or in a dry form by bags of heated bran, salt or sand, bottles of hot water, &c. We 
 shall often succeed in rousing the patient by immersing the whole of his body, as early as 
 possible after he is attacked, in water, of a temperature proportioned to the urgency of his 
 Bymptoms ; that is, of a greater or less degree of heat, within proper limits, according as 
 the temperature of the skin, the state of the pulse, and the general strength is more or less 
 depressed, and the greater or less degree of torpor of the nervous system ; at the same time 
 applying brisk friction with a soft brush or a flannel cloth, to the whole surface, and particu- 
 larly to the epigastric and abdominal regions. On coming out of the bath the patient is to 
 be rubbed dry with heated flannels, put into a well-aired bed between blankets, and supplied 
 with some mild diaphoretic drink, as the infusion of serpentaria, of tepid warmth. A 
 full dose of the Dover's powder, or a combination of opium, camphor and ipecacuanha, 
 one grain each, with ten of nitre, given at this period, will often be found particularly 
 beneficial. 
 
 Next in efficacy to the warm bath, we may rank external stimulants ; sinapisms should, 
 therefore, be early applied to the extremities and over the epigastrium, while frictions, with 
 some stimulating liniment, are made along the spine. By some practitioners internal stimu- 
 lants have been strongly recommended, as a means of rousing the central organs from their 
 r>tate of torpor, and bringing on a general and moderate reaction: it is probable that in certain 
 cases, where the state of congestion is very considerable, and it is not promptly and perma- 
 nently relieved by the remedies already recited, some mild stimulant, as the ammonia, or 
 turpentine, or wine-whey, may prove advantageous, if cautiously administered and its effects 
 carefully watched ; as a general rule, however, the free use of stimulants, particularly of the 
 more active ciass, is calculated to produce injury rather than good. 
 
 An active cathartic, as the combii ation of calomel or blue mass with aloes and extract of 
 colocvnth, followed in a few hours 1 y the compound infusion of senna, will very generally
 
 SMALL-POX. 975 
 
 cause a copious discharge from the bowels, of a dark-coloured, tenacious matter, and by thus 
 assisting to unload the j^ortal system, will often produce a marked improvement in the general 
 symptoms of the disease. In the treatment of congestive bilious fever, the abstraction of 
 blood from the arm, in the first period of the attack, or subsequent to the use of the warm 
 bath and frictions to the surface, has been recommended by many practitioners as an imporant 
 remetly — one indeed from which more prompt and certain relief is to be obtained than from 
 any other that we can employ. The evidence in its favour is certainly very strong; and we 
 believe that there are many cases in which prompt reaction maybe produced, and the danger 
 of permanent local disease prevented by its employment. The greatest judgment and 
 caution, however, are demanded in the use of the lancet in all cases of congestive disease; 
 the effect produced upon the pulse must be carefully watched, and the flow of blood instantly 
 stopped if any disposition to sinking is detected. To determine beforehand the amount of 
 blood that it will be projier to take away is impossible — the effects produced — the relief 
 obtained, are the only guide. Even, however, when during the flow of blood the pulse 
 becomes more free and developed, but a moderate quantity should be taken away at once — 
 should we have to repeat the operation after a short interval. Occasionally but a drop or 
 two of blood will escape from the vein when it is first opened, but, after a short time, the 
 circulation becoming more free, the blood flows in a full stream, with decided relief to the 
 patient. It is only, however, in the early stage of the highly congestive forms of bilious fever 
 that venesection is admissible, and even in these the flow of blood should be instantly 
 arrested if the pulse is found to sink, or even to remain oppressed and undeveloped after a 
 small quantity has been lost. 
 
 When prominent symptoms of hyperemia of the brain, lungs, or other important viscera 
 present themselves, the application of cups to the head, chest, or in the neighbourhood of the 
 aifected organ, will often be found decidedly advantageous. 
 
 As soon as reaction takes place, the use of quinia should be commenced with, in large 
 doses, repeated at short intervals. Of the curative jiowers of the quinia in this form of fever 
 we have the fullest and most unquestionable testimony. Many of the physicians of the 
 southern and western portions of the United States place their chief reliance, in congestive 
 remittent fever, upon the sulphate of quinia prescribed in enormous doses — twenty, thirty 
 and even fifty grains, repeated at short intervals until a solution of the disease is obtained; 
 but although we are convinced of the propriety of large and frequent doses, those a^Uuded to 
 are certainly excessive and uncalled for. 
 
 The period of convalescence from the congestive form of bilious fever will require the 
 same management as that from the more open and inflammatory forms. 
 
 In the highly malignant remittent, occasionally met with, in which the vital forces, crushed 
 at once by the overwhelming intensity of the morbid cause, fail apparently to exhibit any 
 resistance or reaction ; they must be sustained, to use the words of Dr. Dickson, {Essays on 
 Pathol, and Therapeut., vol. i., p. 319,) by every means within our power, while we have 
 immediate recourse to the most impressive revulsives. The hot bath, sinapisms, vesications, 
 must be quickly and assiduously applied, while we stimulate, by the freest use of internal 
 remedies — carefully selecting such as are best adapted to the circumstances presented. If, 
 as is often the case, the patient suffers severely from pain in the chest or abdomen, large 
 doses of opium or morphine must be administered, while Ave keep up his sinking strength 
 by brandy, ammonia or ether. In the superintendence of such cases we should rather incur 
 tlie risk of over-stimulating transiently, than fall below the requisite point of excitement in 
 our use of stimulants. Dr. Dickson is fully persuaded, that he has seen more than one patient 
 die from the timidity of his physician in this respect; •who, keeping at a cautious distance 
 behind the disease, would not venture on the exhibition of any excitant adapted to the feeble 
 excitability, until the vital energies upon which alone stimulants can act, had become worn 
 out and exhausted. If the stomach will bear it, it will be proper to administer, also, some 
 of the preparations of cinchona. The sulphate of quinia in full doses will be often retained 
 and do good. "-Alternate, combine, and recombine your stimulants, the effects of which may 
 perhaps be aided by warm and nutritious fluids, wine-whey,»arrow-root with wine, wine 
 alone or spiced, brandy with milk or in mucilage. These energetic measures will usually 
 be found effective within a very short period — improving the pulse, and arousing the general 
 powers of the system. Yet you must not permit yourselves to be disheartened into inaction 
 by their apparent inefiicacy or slowness of impression. Persevere, not only while there is a 
 reasonable hope, but even after all hope seems extinguished ; and you will feel yourselves 
 amply repaid by the gratification, which will not perhaps be denied you, of saving more than 
 one fellow-creature from the destruction which seems inevitably to await him." — C] 
 
 I pass, without pausing, from the consideration of continued fever, to that of small' 
 pox or variola : a disease, fortunately, less common in this country than it used to 
 De, yet still sufficiently frequent and formidable to require that we should acquami 
 ourselves with the phenomena it is accustomed to present; and very prevalent hero
 
 9T6 SMALL-POX. 
 
 as it happens, at present (1838). I have already mentioned, by anticipation, severa 
 points in its history. 
 
 This frightful disease sets in with smart febrile symptoms : rigors, followed by 
 heat nnd dryness of skin, a hard and frequent pulse, pain in the epigastrium, with 
 nausea and vomiting, and headache. Sometimes wild delirium, sometimes convul- 
 sions, mark its outset. Then, to use the words of Cullen's definition, " tertio die 
 incipit, et quinto finitur, eruptio papularum phleginonodearum, qua3 spatio octo dierum, 
 in suppurationem et in cruslas demumabeunt, ssepe cicatrices depressas, sive foveolas, 
 in cute relinquentes." 
 
 When small-pox is fully formed, it cannot be mistaken for any other complaint : 
 but it is of some importance to recognize it at its very commencement, for the force 
 of the impending disorder may sometimes be lessened by judicious measures adopted 
 at that early stage. The symptoms, however, that mark the outset of all febrile 
 diseases are necessarily very much the same. If the pyrexia set in when small-pox 
 is prevalent in the neighbourhood, if the person in whom it occurs be an " unpro- 
 tected" person {i. e., one who has neither been inoculated nor vaccinated previously), 
 and especially if he be known to have been exposed, within from nine or ten days 
 to a fortnight, to the contagion of variola, we may well suspect that the disease will 
 turn out to be small-pox, and act upon that suspicion. 
 
 Nevertheless there are some symptoms which, being common in the commence- 
 ment of variola, and not common at the beginning of continued fever, or of the other 
 exanthemata, may assist the early diagnosis. Vomiting is one of these ; pain of the 
 back another. When these symptoms are violent, they usually usher in a severe 
 form of the disease. The same may be inferred from a continuance of the nausea 
 and vomiting, after the coming out of the eruption ; which is very unusual. 
 Heberden noticed that acute pain in the loins was almost always followed by a 
 severe disorder ; that pain higher up, between the shoulders, was of better augury ; 
 and that it was to be reckoned in all cases a good sign, if there was no pain of the 
 back at all. Early delirium, stupor, or convulsions, announce severity in the subse- 
 quent course of the malady. Yet not always, especially in children. W^ithin the 
 last month I was asked to see a child which had been suddenly attacked with con- 
 vulsions, followed by coma. In due time the eruption of variola appeared, and the 
 aisease ran a mild course, with little aid from medicine, although the child was 
 previously unprotected. 
 
 The peculiar eruption almost always begins to show itself on the third day of the 
 fever. The earlier it comes, the severer generally does the disorder prove. In 
 judging of the date of the eruption, you must bear in mind that parents and servants 
 are apt to state its accession to have been later than it was in reality : for the spots 
 are at first so minute that they often escape observation. They also frequently begin 
 Jio come out in the night ; and the morning of the second day of the eruption is called 
 the first day. 
 
 The eruption comes out first on the face, then on the neck and Avrists and on the 
 trunk of the body, and lastly on the lower extremities. Such is the rule ; so that 
 (as is specified in the definition) it does not cease to come out till the fifth day : and 
 it keeps a-head, in that order, throughout the disease. There are, indeed, some 
 exceptions to this rule. Occasionally the spots appear first upon the extremities, but 
 this is very rare. In some instances straggling papulse continue to spring up after 
 the main crop is fairly completed ; but these stragglers seldom arrive at the same 
 size with the others. 
 
 The pimples, or papulae, ripen gradually into pustules, the suppuration being 
 complete by their eighth day ; and on that day the pustules generally begin to break, 
 and crusts or scabs to form. In four or five days more, the scabs are falling off. 
 There are some variations in all this, also. In children, the crusts are sometimes 
 visible on the seventh day ; and in adults, when the disease is severe, they sometimes 
 do not begin to form till the ninth day. In all cases, some of the pustules are hable 
 to be prematurely broken, by accident, or by the patient's scratching ; and these will 
 crust over earlier than they otherwise would have done. So that, in fijcing the period
 
 SMALL-POX. 977 
 
 of incrustation, you are to regard those pustules or^ly of which the ;ialural progress 
 has not been interfered with. 
 
 All that I have hitherto been saying, applies, with more or less exactness, to the 
 disease in all its varieties. But its severity differs oicceedingly, as I have already 
 hinted, in different cases. Its severity, in truth, is almost always in direct relation to 
 the quantity of the eruption. The number of pustules indicates, in the first place, 
 the quantity of the variolous poison which has been reproduced in the blood. In 
 the second place, it is also a direct measure of the extent to which the skin suffers 
 inflammation. Sometimes there are not more than half a dozen pustules ; some- 
 times there are many thousands. If all these were collected into one, it would be 
 an enormous phlegmon. For both these reasons, the system sufiijrs commotion, dis- 
 tress and peril, in proportion to the quantity of the eruption. 
 
 When the pustules are very many, they run together ; when they are ^ew, they 
 are separate from each other. And this affords a broad line of distinction, which 
 can neither be overlooked nor mistaken, between the variola discreta, and the variola 
 confiuens. In the one, the pustules are distinct, and of a regularly circumscribed 
 circular form. In the other they coalesce, and their common outline becomes 
 irregular. Now, the discrete form of the disease is scarcely ever dangerous ; the 
 confluent form is never free from danger. The distinction, therefore, is of the great- 
 est importance and interest. For its full estimation, each form must be considered 
 separately. 
 
 In the discrete variety, in which the disorder may be presumed to run its most 
 natural course, the eruption is at first, according to the phraseology of Willan, papu- 
 lar. The pimples gradually increase in magnitude ; but it is not till the third day 
 of their appearance that they begin to contain a little fluid on their summits. 
 
 For two days after this they increase in breadth only, and a depression is observ- 
 able in the centre of many of them. The cuticle is bound down there somehow, 
 for a time, to the cutis vera. It is the eighth day of the disease, or ihejifth day of 
 the eruption, before the pustules become perfectly turgid and hemispheroidal. During 
 the time in which they are thus filling up, the face swells ; often to so great a degree 
 that the eyelids are closed, and the natural aspect is completely changed or concealed. 
 The skin between the pustules on the face assumes a damask-red colour. About the 
 eighth day of the eruption, a dark spot makes its appearance on the top of each 
 turgid pustule, and at that spot the cuticle breaks, a portion of the matter oozes out, 
 and the pustule dries into a scab. When this crust at length falls off^ it leaves be- 
 hind it either a purplish red stain, which is still very characteristic of the disease, 
 and which very slowly fades ; or a depressed scar, which is indelible. In the latter 
 case, the patient, or more properly his skin, is said to be pitted with the small-pox, 
 or pock-marked. The swelling of the face begins gradually to diminish after the 
 eruption has become thoroughly pustular. 
 
 This is the course which the eruption pursues on the face, where the pustules, 
 even in the discrete form of the disease, are usually thicker set than on any other 
 part of the surface. And it pursues the same course, only two or three days later, 
 upon the extremities, where it also begins later. The feet and hands swell just as 
 the face swelled, but they begin to tumefy as the features begin to subside. Some 
 of the pustules, especially on the extremities, do not burst at all, but shrivel up. 
 
 In this, the distinct variety of the disorder, the fever generally ceases entirely upon 
 the coming out of the eruption ; the headache, the pain of the back, the vomiting, 
 the restlessness, abate and disappear ; the pulse resumes its natural force and fre- 
 quency, and the skin its natural temperature. About the seventh or eighth day of 
 the eruption there is commonly, for a day or two, a recurrence of fever. This is 
 called the fever of maturation. 
 
 You are to observe that we judge of the eruption as it appears on the yace. Th«^ 
 disease is of the confluent kind, when the pustules are confluent there, whether thej 
 be so or not upon the trunk and extremities. Sometimes they are neither strictlv 
 confluent nor strictly separate, but stand just thick enough to touch each other, with- 
 out absolutely coalescing; every pustule preserving its circular outline. In thai 
 case, the disease is said to be of the cohering form. When the pustules are conflu- 
 «3 4g3
 
 978 SWALL-POX. 
 
 ent over the whole bodj', their number is often prodigiously great, and their progress 
 is less regular than in the discrete and milder variety of the complaint. 
 
 In the first place, the eruptive fever itself is usually more violent and tumultuous 
 m the confluent disease ; the disturbance of the sensorial functions is more common 
 and more decided, the sickness more distressing, the pain of the back and loins more 
 severe. The eruption comes out earlier, and more confusedly ; the pimples being 
 at first very minute, and crowded together in patches, and not seldom accompanied 
 by a rash like that of scarlet fever, or er}'sipelas : whereby the diagnosis, in so far 
 as it depends upon the appearance of the skin, is rendered for a while uncertain. I 
 have at present in the Middlesex Hospital a patient in whom the papulae of small- 
 pox were, at the outset, so intermingled with the appearances and sensations of urti- 
 caria, that I doubted, for twenty-four hours, what the true character of the eruption 
 might be. It is sometimes like that of measles; but the similarity and the uncer- 
 tainty are soon at an end, for the pimples soon begin to exhibit a fluid on their sum- 
 raits. They do not, however, as they advance and pass into pustules, fill up so 
 completely as in the distinct form ; they are flatter, less plump, more irregularly 
 depressed, and even of a different colour ; being at first whitish, and then of a brow'n 
 tint, and seldom of the yellow purulent hue which is seen in the variola discreta. 
 Sometimes they are even bluish, or purple. In the confluent form there is commonly 
 some abatement of the febrile distress upon the coming out of the eruption ; but the 
 remission is much less marked than in the discrete. About the fifth or sixth day, 
 fresh rigors are apt to occur, marking the fever of maturation. Most of these points 
 of distinction between the two varieties of the disease are well marked in Cu lien's 
 definitions. The distinct form he defines thus: " Variola (discreta) pustulis paucis, 
 discretis, circumscriptione circularibus, turgidis ; febre, eruptione facta, protinus ces- 
 sante." And of the confluent kind his definition is, "Variola (confluens) pustulia 
 numerosis, confluentibus, circumscriptione irregularibus, flaccidis, parum elevatis; 
 febre post eruptionem perstante." 
 
 But the most important difference between the two forms is in what is called the 
 secondary fever, which sets in about the eleventh day of the disease, or the eighth 
 of the eruption, just when the maturation of the pustules is complete, and they begin 
 to desiccate. This secondary fever is slightly marked in the distinct small-pox, and 
 very intense and perilous in most instances of the confluent. It is at this period of 
 the disorder, that death, in the fatal cases, oftenest occurs. Of 168 such cases, 
 recorded by Dr. Gregorj', the deaths happened in tw^enty-seven (nearly one-sixth of 
 the whole) upon the eighth day of the eruption. That, therefore, is the most perilous 
 day, as the second is the most perilous iceek. Thirty-two died in the first week, 
 ninety-nine in the second, twenty-one in the third. The early occurrence of death 
 denotes a peculiar inalignancy in the disease. The nervous system appears to be 
 overwhelmed by the force of the poison. During the second week the disorder 
 proves fatal chiefly in the way of apnoea ; from some affection of the respiratory 
 passages. After that period the characters of asthenia commonly predominate. The 
 patient sinks under some casual complication, or the powers of life are gradually 
 worn out by so much irritation of the surface, and so large an amount of suppuration. 
 
 So much for the ordinary course of small-pox, and of the symptoms that are essen- 
 tial to that disease. There are, however, other concomitant circumstances, with 
 which you ought to be acquainted: and these I will endeavour to specify at our 
 next assembling. 
 
 LECTURE LXXXVII. 
 
 iSinall-pox, continued. Inoculation. Vaccination. Their comparative advantages 
 
 Treatment of Small-pox. 
 
 In the last lecture I brought before you, in a rapid sketch, the ordinary course, 
 hod th.e essential symptoms of small-pox ; both in its distinct and in its confluent
 
 SMALL-POX. , 979 
 
 form. I have yet to mention some other circumstances that are very frequently to 
 be noticed in connection with that disease. 
 
 Both kinds are accompanied by sore throat ; the tonsils and fauces are tumid and 
 red : and with this sore throat there is associated, about the period when the face 
 swells, sometimes in the discrete variety, and almost always in the confluent, more 
 or less salivation, which lasts for several days. At first the discharge is thin and 
 plentiful ; but, towards the period of maturation, it often becomes viscid and ropy, 
 and is with difficulty got rid of by the patient. This salivation is of some importance 
 as a prognostic symptom. If it cease abruptly, and especially if at the same time 
 the swelling of the face suddenly and prematurely subside, the peril is great. Besides 
 this, Sydenham regarded the ptyalism as a diagnostic circumstance ; as a mark which 
 identified with true small-pox a fever called by him the variolous fever, the variolas 
 sine variolis of De Haen and others. " The resemblance (says he) which this fever 
 bore, in its symptoms, to small-pox, induced me to give it the title of variolous fever, 
 which seemed indeed so much the more appropriate, as the fever raged at the same 
 time with small-pox, and got well under the same treatment. The two diseases 
 belonged evidently to one family, and there was no difference between them, saving 
 that in small-pox the morbific matter was directed towards the skin, in the shape of 
 an eruption ; while in the variolous fever this matter was expelled from the system 
 by the salivary glands." Notwithstanding this statement, it is difficult to believe 
 that any such disorder as variolse sine variolis ever proceeds from the contagion of 
 small-pox. 
 
 This affection of the salivary glands does not so often occur in children ; but diar- 
 rhoea appears sometimes to take its place. 
 
 The soreness of the fauces. often depends, in great measure, upon pustules there 
 situate. You may see that the tongue, the roof of the mouth, the inside of the 
 cheeks, the uvula, and the velum palati, are thickly studded with them. It is 
 affirmed by some writers that the pustules of small-pox occur in various internal 
 parts of the body, and especially upon the mucous membrane of the intestinal canal. 
 I believe this to be a mistake. The enlarged solitary follicles often put on very 
 much the appearance of pustules. Cotunnius, who has written a good book, De 
 sedilms variolariim, asserts that pustules appear only upon the skin, and upon those 
 parts of the mucous membranes which are freely exposed to the air. In one soli- 
 tary instance he met with them in the trachea so low as its third ring. He fancied 
 that previous desiccation of the part was necessary to their formation. He says that 
 none appear on the cornea, while it is kept moist. He denies that they are seen in 
 the interior of the body, or upon the fostus in utero : but in this last point he is cer- 
 tainly wrong : and this is a strong objection to his theory. The most striking facts 
 which he alleges in support of his opinion of the necessary presence of air — besides 
 the fact of the eruption being more copious on parts usually exposed to the atmo- 
 sphere, as the face and hands — are, that pustules do not form on the inner surface 
 of the eyelids, except in cases of ect r opium ; that they appear on hemorrhoidal 
 tumours only when these project beyond the margin of the anus ; and that that por- 
 tion alone of the glans penis is ever affected by them which is uncovered by the 
 prepuce. 
 
 Dr. Gregory, however, states that true variolous pustules do not form upon the 
 conjunctival membrane: and that the blindness of one or both eyes which is so com- 
 mon a result of small-pox, especially in children, is produced by an intense kind of 
 ophthalmia, which sets in at the period of the secondary fever, and rapidly involves 
 and spoils the transparent tissues of the organ. 
 
 During the period of maturation, a peculiar greasy, disagreeable odour, quite sui 
 generis, proceeds from the body of the patient. If taken into the sick chamber blind- 
 folded, one might name the disease at once by this smell. About the same time also 
 many patients are tormented by itching of the surface ; so that they are provoked to 
 scratch oft' the heads of the pustules : and by so doing they often ensure the formation 
 of pits. In many cases of confluent small-pox this itching appears to constitute the 
 chief part of the patient's suffering. 
 
 There are various troublesome complications to which, in severe cases of the con
 
 980 SMALL-POX. 
 
 fluent form, the patients are liable during the secondary fever; erysipelatous inflam- 
 mation involving the subcwtaneous areolar tissue in various parts of the body, and 
 leading to the formation of abscesses; glandular swellings in the groins and axilla;, 
 going on sometimes to suppuration; sloughing sores on the hips and sacrum; 
 phlebitis ; and in two or three instances I have seen the large joints, after death, full 
 of matter. One of the most serious symptoms, at this period of the disease, is 
 dyspnoea. The air-passages, and especially the larynx, become clogged by viscid 
 mucus, the arterialization of the blood is interfered with, and the patient is in danger 
 of suffocation. Occasionally life is suddenly extinguished by oedema of the glottis, 
 supervening upon that affection of the fauces which I mentioned just noAV. 
 
 In one most fearful phase of this always formidable disorder, symptoms indicative 
 of what is called the putrid diathesis manifest themselves — petechise, vibices, hemor- 
 rhages from various parts of the body. The pustules, instead of being plump and 
 yellow, are flat, red, purple, or blue ; that is, they contain blood, or a sanious ichor, 
 in the place of pus, constituting the variolse nigrx of Sydenham, the bloody small- 
 pox of Mead. I believe that these appearances augur in all cases a fatal result. 
 Hemorrhage from the uterus is not uncommon ; and in pregnant women abortion, 
 and then, most commonly, death. Heberden says that he examined, in many in- 
 stances, the fcstuses so parted with, but never could perceive upon them any traces 
 of small-pox. His experience, therefore, agreed with that of Cotunnius ; and we 
 may conclude that infection of the foetus in utero is very rare. Yet, unquestionably, 
 it sometimes happens ; and the circumstances under which it has been noticed are 
 various and interesting. In one instance, related by Mr. Flinders, the disorder was 
 eight or ten days later in the foetus than in the mother. A woman, near her full 
 time, took small-pox. The pustules were mature about the 10th or 11th of June, 
 On the 18th she gave birth to a full-grown boy, upon whose face and body there 
 were many pustules, discrete, and nearly ripe. The child died the same iiight. It 
 is a very curious fact that the foetus has caught the disorder, doubtless through the 
 medium of the mother, although she, having had it previously, was unaffected by the 
 contagion. Dr. Mead relates that "a certain woman, who had formerly had the 
 small-pox, and was now near her reckoning, attended her husband in this distemper. 
 She went her full time, and was dehvered of a dead child. It may be needless to 
 add, that she did not catch it on this occasion ; but the dead body of the infant was a 
 horrid sight, being covered all over with pustules." In the first volume of the 
 Medico-Chirurgical Transactions, Dr. Jenner gives an account of an infant which, 
 upon the fifth day of its age, became indisposed, and on the seventh exhibited the 
 eruption of small-pox ; so that the contagion must have been communicated to it 
 while yet in the womb. A few days before her confinement the mother of this child 
 had seen, in the street, a person covered with small-pox pustules, the smell and sight 
 of whose body had sensibly affected her. I see no reason, therefore, for doubting 
 that the unborn being may pass safely through the disease while in the womb, and 
 derive from that attack the customary immunity for the future. My namesake. Sir 
 William Watson, describes in the Philosophical Transactions, an instance in which 
 the scars left by the pustules were visible upon an infant at its birth. The child was 
 afterwards inoculated without taking the disease. Its mother, who had formerly had 
 it, nursed, when far advanced in pregnancy, a servant ill of small-pox. Dr. Pearson 
 met with a similar example. Mary Spooner was inoculated by him in her sixth 
 month of utero-gestation, and had the disease severely. Her child was twice inocu- 
 lated with small-pox matter, but without effect. 
 
 Like all these contagious exanthemata, small-pox has its periods of dormancy and 
 of activity. Every now and then, at irregular intervals — and, as it would seem to 
 our ignorance of the cause, capriciously — it overspreads a district or country as an 
 epidemic. At this moment (1838) it is more prevalent in London, and in many 
 parts of England, than it has been known to be for many years past. W'hen epi- 
 demic, it is also, in general, more than ordinarily severe ; although different epidemics 
 vary much in that respect. 
 
 There is no contagion so strong and sure as that of small-pox : none that operates 
 at so great a distance. Dr. Haygarth states, "that during his long attention to this
 
 SMALL-POX. 981 
 
 subject, not a single instance had occurred to prove that persons liable to the small- 
 pox could associate in the same chamber with a patient in the distemper, without re- 
 ceiving the infection." It is readily communicable in every way ; by inoculation, by 
 breathing a contaminated atmosphere, by the contact or vicinity of fomites. Naj^ it 
 may be caught from the dead body. Mr. Ctesar Hawkins has recorded an interesting 
 example of this. The body of a man who died of small-pox, was brought into his 
 dissecting room in Windmill street; and four students took the disease from that 
 source. Of these, one only had touched the body. 
 
 There is one appearance which I think curious, although, perhaps, it has not any 
 great practical interest ; and which I omitted to notice in the last lecture, when de- 
 scribing the course of the eruption. Without going minutely into the anatomy of 
 the pustules, you may distinctly see, if you closely examine them when they are 
 about five or six days old — you may see, at least, in many of them — two colours, 
 viz., a central whitish disc of lymph, set in, or surrounded by, a circle of yellower 
 puriform matter. In truth, there is, in the centre, a vesicle, which is distinct from the 
 pus. You may puncture the vesicle, and empty it of its contents, without letting out 
 any of the pus ; or you may puncture the part containing the pus, and let thai out, 
 without evacuating the contents of the vesicle. The vesicles have even, by careful 
 dissection, been taken out entire ; and they are said to consist of several little cells. 
 It is most probable that the lymph contained in this separate vesicle is the purest 
 part of the variolous poison. 
 
 Before I say anything of the measures to be adopted during the progress of small- 
 pox, I have to bring under your notice two expedients of still greater interest and 
 importance ; the one of them contemplating a mitigation of the disorder, the other its 
 total prevention. You anticipate that I am about to speak of inoculated smali-pox in 
 the first instance, and of the vaccine disease in the second. 
 
 I have many times stated, and all the world knows, that small-pox maybe imparted 
 to a healthy person by inserting beneath his cuticle a minute quantity of the matter 
 taken from a variolous pustule. This, perhaps, is not very surprising; but it is sur- 
 prising that the disease, so received, should be much milder than if it had been con- 
 tracted in what is called " the natural way," by breathing an atmosphere charged 
 with the contagious poison. Why it should be so it is difficult to conjecture. The 
 fact is sometimes expressed by saying that the disease is milder when the virus is 
 admitted through the cutaneous, than when through the mucous tissues. But I am 
 not at all sure that the hypothesis involved in this proposition is true. No attempts 
 have been made, that I know of, to introduce the poison artificially through a wound 
 in any mucous surface. I should rather guess that the small quantity of the poison 
 conveyed by inoculation into the blood may make the difTerence. But whatever the 
 explanation, the fact is unquestionable, and obviously of the highest importance. By 
 what accident it was first learned (for it evidently could not have been reasoned out) 
 we do not know. The Chinese claim to have been in the habit, for many centuries, 
 of sowing the disorder, by putting some of the crusts into the nostrils. But this is a 
 different thing from inoculation, the surface being entire, and the effluvia from the 
 crusts being drawn into the lungs by the act of inspiration. It is said that a true 
 engrafting of the virus has been in use by the Brahmins in India, time out of mind. 
 It certainly was practised in Turkey at the very beginning of the last century, and 
 perhaps somewhat earlier. In 1713, Dr. Emanuel Timoni, an Oxford graduate,' 
 who had settled at Constantinople, wrote to Dr. Woodward, in London, giving him 
 an account of the new process, and testifying to its success. This account was com- 
 municated to the Royal Society, and published in its Transactions the following year. 
 In 1715, Mr. Kennedy, an English surgeon who had travelled in Turkey, gave 
 similar information to the English public in his Essay on External Remedies. And 
 in the Philosop/iical Transactions for 1716 you may see a notice of the same pro- 
 cess, as described by M.Pylarini, the Venetian consul at Smyrna. But these stare- 
 ments were neglected, or had no practical result. We owe the actual introduction 
 of the practice of inoculation into Great Britain to the good sense and courage of an 
 English lady, whose lively epistles have taken their permanent place in our country's 
 literature. Lady Mary Worlley Montagu, the wife of our ambassador at the OttO'
 
 982 SMALL-POX. 
 
 man Court, writes thus, from Adrianople, in the year 1718: "The small-pox, so fatai 
 and so general amongst us, is here entirely harmless by the invention oi engraftino;, 
 which is the term they give it. Every year thousands undergo the operation ; and 
 the French ambassador sayc, pleasantly, that the}' take the small-pox here by way of 
 diversion, as they take the waters in other countries. There is no example of any 
 one who has died in it ; and 3'ou may believe I am well satisfied of the safety of this 
 experiment, since I intend to try it on my dear little son. I am patriot enough to 
 take pains to bring this useful invention into fashion in England." In fact, she re- 
 commended it by her own example. The first person inoculated with small-pox in 
 England was her daughter. Then a child of a physician. Dr. Keith, who had visited 
 Miss Wortley ; afterwards some condemned felons, who were pardoned on condition 
 of their submitting to the experiment ; and at length some of the royal family. But 
 the practice was not thoroughly established, nor properly appreciated, by the English 
 public, until the middle of that century. 
 
 Its efficacy in mitigating the severity and danger of the disease, in saving life and 
 preventing deformity, was signally great. The mortality in the natural small-pox 
 was estimated at one in five. But Baron Dimsdale, a great inoculator, declared that 
 not one in fifteen hundred died of the engrafted disease. Two brothers, named 
 Sutton, who had introduced, or rather revived, a very improved method of treating 
 the disorder, professed to have inoculated 20,000 persons without fairly losing one. 
 But these, doubtless, were exaggerated statements. Among 5964 individuals, inocu- 
 lated at the Small-pox Hospital in 1797, 1798, and 1799, there were nine deaths; 
 », e., one in six hundred and sixty-two. We may take Dr. Gregory's estimate of 
 one death in five hundred cases, as being probably within the mark. 
 
 In the inoculated disease the period of incubation is comparatively short; the pus- 
 tules are seldom numerous, and still more seldom confluent; and the secondary fever 
 is generally slight or awanting, 
 
 I may mention here, also, that the eruption is not unfrequently preceded by a rash, 
 something like that of scarlet fever, and called by Willan the roseola variolosa. 
 It fades in the course of a day or two, and then the small-pox pustules are seen 
 emerging just in the same state that they would have been in, at the same period, if 
 no such rash had appeared. The efflorescence happens oftener in the inoculated 
 than in the casual disease. In the former it is looked upon as rather a favourable 
 sign ; in the latter, especially if the rash be of a dark red colour, it is considered un- 
 favourable, and as the herald of a severe confluent disorder, 
 
 A far superior expedient has since been discovered, in the practice of vaccination, 
 which has rendered the inoculation of small-pox not merely unnecessary, but, in 
 most cases, perfectly unjustifiable. Yet circumstances do sometimes arise, even now, 
 in which it may be allowable and right to engraft the matter of small-pox ; as when 
 an unprotected person is unavoidably exposed, or has recently been exposed, to the 
 contagion of that disease, and there is no vaccine matter at hand. The advantage 
 of inoculating in such a case is, that the inoculated or milder form gets the start of 
 the natural and severer; the fever commencing sooner than it would otherwise do. 
 To show you the value of the practice in such cases, and the degree of protection 
 which it aflbrds to individuals whom we cannot vaccinate, I may mention a fact 
 which Professor Gregory, of Edinburgh, was in the habit of relating, and which 
 "vas told him by a naval surgeon. The small-pox was introduced among the crew 
 «)f a man-of-war, in a tropical climate, where no vaccine matter was to be procured. 
 The men were almost all unprotected. Sixteen of them took the disease in the 
 natural way; and of these, nine, or more than one-half, died. Of 303 who were 
 inoculated, under the disadvantages of a hot climate, and no preparation, not one 
 perished. 
 
 That a disorder communicated to the human animal from one of the brutes should 
 protect the former aaainst the contagion of small-pox, is one of the most interesting 
 ^acls in the Avhole history of medicine. How glimpses of a truth so remarkable 
 were first revealed to the casual observation of certain peasants, and how the result 
 of this chance observation was gradually " matured into a rational and scientific form 
 bv a mind deeply imbued with the best principles of sound philosophy," I have not
 
 VACCINATION. 983 
 
 leisure to tell you in detail. And it is the less necessary that I should do so, as you 
 may find the whole subject thoroughly naiTattd and discussed by Dr. Baron, in his 
 interesting biography of Edward Jenner. 
 
 Dr. Jenner found among the great dairy farms in Gloucestershire a popular belief 
 that no person who had had the cow-pox (an eruptive vesicular complaint communi- 
 cated from the udder of the cow to the hands of the milkers) could " take the small- 
 pox." Satisfied, by inoculating with small-pox matter several individuals who had 
 had the vaccine eruption, that this was not an unfounded notion, he at length con- 
 ceived the great and happy idea of propagating the cow-pox from one human being 
 to another, and so preventing, in all cases, the perilous distemper of small-pox, which 
 he hoped might thus be finally expelled from the earth. 
 
 By degrees. Dr. Jenner ascertained that some persons, who had had sore hands 
 from milking, were not thereby rendered proof against the contagion of small-pox; 
 but this difBculty was soon cleared up by the discovery that the teats of cows were 
 liable to different kinds of eruption, and he learned, by close observation, which of 
 these was the peculiar eruption that produced in the human frame the protecting 
 disorder. 
 
 Dr. Jenner set himself to trace, if possible, the origin of the disease of the cow. 
 First, he found that it was peculiar to certain dairies; then, that in those dairies men 
 were employed in milking. Following up this clue, he further made out that those 
 men had also the charge of the farm-horses. Next, he learned that the teats of the 
 cows generally began to exhibit the specific eruption at that time of the year when 
 a complaint called " the grease" chiefly prevailed among the horses. Hence he 
 concluded, that the malady was conveyed "to the cows by the hands of the men who 
 had been dressing the heels of horses affected with the grease. Subsequent inquiries 
 have, however, shown that this conclusion was not strictly correct. 
 
 Another difficulty which lay in Dr. Jenner's way, and which his patience and 
 sagacity surmounted, was this. He found that some who were casually infected from 
 the true complaint in the cow were not protected. This depended, as he afterwards 
 ascertained, upon the period of the disease in the cow, at which the virus was com- 
 municated to the milker. The thick matter proceeding from the vesicle late in its 
 progress produced indeed a severer local sore than the thinner matter of its earlier 
 state, but it did not confer the desired protection. The same thing is observed in 
 respect to small-pox. If the matter used for inoculating be taken from a fully 
 matured pustule, it does not so surely excite the disease as when taken from a more 
 crude one. 
 
 The next important step in this most interesting investigation was to determine 
 whether the vaccine disease could be transmitted, by engrafting from one human 
 being to another, and whether, if so transmitted, it retained its protecting power. 
 The 14th of May, 1796, was the birth-day of vaccination. On that day, " matter 
 was taken from the hand of Sarah Nelmes, who had been infected by her master's 
 cows, and inserted by two superficial incisions into the arms of James Phipps, a 
 healthy boy of about eight years old. He went through the disease apparently 
 in a regular and satisfactory manner; but the most agitating part of the trial still 
 remained to be performed. It was needful to ascertain whether he was secure from 
 the contagion of small-pox. This point, so full of anxiety to Dr. Jenner, was 
 fairly put to issue on the 1st of the following July. Variolous matter, immediately 
 taken from a pustule, was carefully inserted by several incisions — but no disease 
 followed." 
 
 It is scarcely necessary for me to notice the objections which were made to the 
 practice of vaccination. Some of them were merely foolish — as, that it was unna- 
 tural and impious to engraft the diseases of a brute upon a Christian. Others were 
 untrue — as, that it introduced into the system new disorders, distinct from the cow- 
 pox. It triumphed over all these cavils ; and in six years from its first promulgation 
 the discovery was known in every region of the world. 
 
 It was soon found, however, that some, who had apparently had the cow-pox by 
 inoculation, were nevertheless not incapable of taking the small-pox ; and that these 
 failures were, many of them at least, attributable to the mistakes that were made in
 
 984 VACCINATION. 
 
 the time or manner of performing the operation. It became necessary, therefore, to 
 ascertain precisely the conditions requisite for the production of the genuine disease. 
 And these conditions have been successfully investigated by Dr. Jennerand by sub- 
 sequent surveyors. 
 
 You will learn to recognize the true vaccine vesicle only by repeatedly examining 
 it for yourselves. Yet a brief description of its characters and progressive changes 
 may be useful to you. 
 
 On the second or third day after the insertion of the vaccine matter into the arm, 
 the punctures look red and inflamed, and on the fourth or fifth day the vesicle becomes 
 perceptible ; a pearl-coloured elevation of the cuticle enclosing a minute quantity of 
 a thin transparent liquid. It gradually increases in magnitude till the eighth day, 
 when it should measure from a quarter to half an inch across. Like the pustule of 
 small-pox, it is more prominent at its circumference than at its centre, and it consists 
 of small cells, from ten to fourteen in number. By puncturing carefully one of these 
 cells, a drop of the virus may be let out, the other cells remaining full. Up to the 
 seventh, or eighth, or even to the beginning of the ninth day, the inflammation around 
 the vesicle should extend to only a very small distance from it. After this, it spreads, 
 and what is called the areola is formed ; a circular red border, which continues to 
 increase during the ninth and tenth daj^s, and begins to fade on the eleventh, passing 
 through shades of blue as it dechnes, and leaving a degree of hardness behind for 
 two or three days more. By this time, a brown or mahogany-coloured crust has 
 formed over the vesicle, of a nearly circular shape; this becomes gradually harder 
 and darker, and finally detaches itself about the twentieth day. The cicatrix which 
 it leaves should be somewhat less than an inch broad, circular, slightly depressed, 
 marked by radiating lines, and dotted with little pits which seem to correspond to 
 the cells of the vesicle. 
 
 About the eighth day there is usually some slight febrile excitement manifested, 
 which soon subsides. This is analogous to the secondary fever of cimall-pox : and 
 it appears to furnish the condition of the desired protection. 
 
 Of course it is of much moment to determine whether the cow-pox has run its 
 proper course or not ; and it is not always easy to say how far the progress of the 
 vesicle may deviate from that which has just been described, without failing of its 
 protecting influence. A very ingenious teat of this, free from all ambiguit}% has 
 been devised by Mr. Bryce. His plan is this. He vaccinates the other arm, or 
 some other part of the body, four or five days after the first vaccination. If the con- 
 stitution has been properly affected by the first operation, the inflammation of the 
 second vesicle will proceed so much more rapidly than usual, that it will be at its 
 height, and will decline and disappear as early as that of the first: only the vesicle 
 and its areola will be smaller. In fact, from the time of the formation of the areola, 
 the second vesicle is an exact miniature of the first. If the system has not been duly 
 influenced by the first vesicle, the second will run its own course, increasing up to 
 its eighth day, and so on. Should this be the case, the second vesicle should be 
 tested by a third. 
 
 We find the germ of this criterion in the early history of vaccination. Dr. Jenner 
 vaccinated the children of his friend Mr. Hicks, the first gentleman who consented 
 to adopt the practice. This Mr. Hicks became afterwards an expert vaccinator him- 
 self, and it was his custom, in a doubtful case, to perform a second vaccination in a 
 few days after the first : and he remarked that the second vesicle made " immense 
 strides to overtake the first." 
 
 After some time it became apparent that Dr. Tenner's estimate of the protecting 
 power of the vaccine disease had been set too high. He had hoped and believed, 
 as others also had, that the cow-pox would in all cases prove a perfect and permanent 
 protection against the small-pox ; but those hopes have been disappomted. Doubt- 
 less complete protection is the rule ; but — how thoroughly and regularly soever the 
 vaccine malady may have proceeded — it is most certain that very many exceptions 
 1.0 tins rule have taken place, and are daily taking place around us. 
 
 And this fact, which has become too glaring to be denied or explained away, has 
 flepreciated the value of the process of vaccination, in the public esteem, far moie
 
 SMALL-POX. 985 
 
 than, if rightly considered, it should have done. For it is a remarkable and most 
 important truth that the disease which, in some duly vaccinated persons, follows ex- 
 posure to the contagion of small-pox, is much milder and shorter even than the 
 inoculated, and a forliori, than the natural smalt-pox. The disorder thus occurring 
 is, therefore, denominated the varioloid disease, or (more conveniently, in my opinion), 
 the modijied small-pox. 
 
 The constitutional symptoms of this modified disease are, in general, at the outset, 
 and for several days, much the same with those of the regular small-pox. The 
 eruptive fever is of equal length and intensity. There are frequently much head- 
 ache, and sickness, and sometimes even delirium. The eruption begins about the 
 third day ; it is often copious, and sometimes confluent ; and in the confluent cases 
 the eruptive fever does not entirely subside as soon as the crop of pimples has come 
 out. 
 
 It is in its subsequent progress that the complaint is modified : in respect both to 
 the appearances presented by the skin, and to the constitutional symptoms. 
 
 Three distinct kinds of eruption have been observed — 
 
 1. The eruption sometimes approaches in its character and course very nearly to 
 that of the ordinary small-pox. The pustules fill up, have the central depression, 
 and ultimately crust over, and the face swells. But this course is performed in a 
 shorter time than that of the ordinary disease, and the pustules are usually smaller. 
 This is the severest and the least common form of the modified small-pox. 
 
 2. Sometimes the papulae show a little fluid on their tops only, but never fairly 
 suppurate nor break ; but the vesicles dry up, and hard prominences, with livid bases 
 and horny summits, remain. 
 
 3. There are other cases in which a great part of the eruption consists of red 
 pimples, which soon become livid, but contain from first to last, no fluid whatever. 
 
 In the majority of instances of modified small-pox, all these forms of eruption co- 
 exist. Some of the papulae go on to suppuration, others become crowned with a 
 horny summit, and others never exhibit any fluid at all. 
 
 Bnt the most important characteristic of the modified disease, is the total absence 
 of secondary fever. The constitutional disturbance which, for the first week, may 
 have been as severe as in the ordinary small-pox, generally subsides entirely when 
 the eruption has reached its acme. The patient is convalescent just when, in the 
 unchecked and regular form of the malady, his danger is beginning to be most 
 urgent. 
 
 These two circumstances, then — the short duration of the eruption, and especially 
 the absence of secondary fever — furnish the broad distinctions between the regular 
 and the modified small-pox : and almost always, when vaccination has been tho- 
 roughly effected, and small-pox occurs afterwards, it occurs in this modified form ; 
 and the modified form of small-pox is seldom fatal, though some instances of death 
 resulting from it have certainly happened. 
 
 Several questions of the greatest practical moment and interest here present them- 
 selves: but it is impossible that T should discuss them. I will state some of them, 
 however, that you may bear them in mind in your future opportunities of observa- 
 tion ; especially as they are yet, for the most part, undecided questions ; and ques- 
 tions which can be answered only after repeated and careful observation. 
 
 The first is, whether the protecting influence of cow-pox upon the human frame 
 diminishes by lapse of time, and at length wears out. There seems reason for sus- 
 pecting that such may, sometimes at least, be the case. Certainly in many, but not 
 in all, of those who have gone through the vaccine disease, revaccination at a distant 
 period reproduces, in a greater or less degree, its primary effects. A friend of mine, 
 who was vaccinated in 179!), has a son nine or ten years old, who was vaccinated at 
 the age of three weeks. Both of them have lately been revaccinated. Tht- boy 
 was somewhat afl^ected by the renewal of the operation ; the father not at all. It yet 
 remains to be determined whether all those who are susceptible of some impression 
 from a second vaccination, are liable to be affected by the contagion of small-pox: 
 and whether a repetition of the operation of engrafting the cow-pox renews, or adds 
 to, their security against small-pox. At any rate, the practice of revaccination is p. 
 
 4h
 
 986 SMALL-POX. 
 
 safe and advisable precaution. Dr. Gregory says of it, " we have sufficient facts 
 before us to state with confidence that it need never be recommended prior to the 
 tenth year of life ; and that the age best fitted for it is from the period of puberty to 
 that of confirmed manhood." 
 
 But, secondly, is there any ground for supposing that the wished-for protection 
 ever fails to be conferred, because the operation is performed too early ? It has been 
 suspected that it is less likely to produce the requisite, or an enduring, effect upon 
 the constitution when it is done while the child is at the breast. But most children 
 are vaccinated within that period. We know that this is a time when they are but 
 little susceptible of contagious disorders in general. If this suspicion be well-founded, 
 Dr. Gregory's first proposition requires correction. 
 
 A third question is, how far the frequent failure, in late years, of complete protec- 
 tion can be ascribed to the circumstance that the vaccine virus has been repeatedly 
 transmitted from one human being to another, and its supply thus kept up, without 
 any fresh recurrence to the cow, the original source of the disorder. Dr. Jenner was, 
 himself, not without apprehension that this might prove a cause of failure. But the 
 analogy of other animal poisons supplies no warrant for such a belief. For one year 
 I had a seat, as the Senior Censor of the College of Physicians, at the National Vac- 
 cine Board, and I then had opportunities of satisfying myself that lymph which had 
 been transmitted without interruption from person to person ever since the time of 
 Jenner, continued to generate as perfect a cow-pox vesicle as at first. If, as Dr. 
 Heim asserts, there are no less than five kinds of spurious cow-pox^ all communicable 
 by inoculation from the teats of the animal to the human body, I cannot help thinking 
 that recourse should not be had rashi}' or needlessly to lymph recently obtained from 
 the cow. 
 
 In the fourth place there are yet moot points, respecting the number of vesicles, 
 and the degree of constitutional disturbance, which are requisite to ensure, and to 
 prolong, the protective power of vaccination. The constitutional effect will bear 
 some proportion to the number of vesicles ; and of these, it would seem, there should 
 be several ; and one or two of them, at least, should be suffered to pursue their entire 
 course untouched. 
 
 With regard to a fifth question, the most important of all, we may speak very de- 
 cidedly ; and it is a question concerning which it is of the utmost consequence that 
 medical men should form, and disseminate among the public, correct opinions : 1 
 allude to the comparative merits and advantages of inoculation with smcdl-pox and 
 vaccination. 
 
 The advantages of the practice of inoculation to the individual, supposing him 
 doomed to have small-pox, were great and obvious ; to the community at large they 
 were very doubtful. It gave the undoomed individual, for certain, an ugly disease, 
 which was comparatively free from danger, in exchange for the chances, on the one 
 hand, of contracting a very hazardous form, and on the other, of escaping altogether 
 from any form, of variola. We need not inquire which is the most eligible branch 
 of this alternative ; we know which was by most men actually chosen. But the 
 practice of inoculation, by carrying the virus and the disease into every village 
 throucrhout the length and breadth of the land, filled the country with contagion; 
 ensured the disease to all who were subjected to the operation; and diminished to 
 all who were not, the chances of escaping it. No doubt the distemper was produced 
 artificially in many more persons than would have caught it naturally, had inoculation 
 never been thought of. So that while the relative mortality, the per centage of 
 deaths from small-pox, was lessened by this practice, the absolute mortality was 
 fearfully increased. Such at least is the judgment expressed by most who have 
 thought and written on the subject. Dr. Heberden compared the number of deaths 
 ascribed in the London bills of mortality to small-pox during the first thirty years of 
 the last century, and he found that they had increased from 7*4 per cent, to 9-5 per 
 cent. To be sure, some allowance must be made for the increase in the whole 
 population of London during that interval ; but on the other hand we must take into 
 account the deaths (not noted in those bills) which followed the inoculation of small- 
 pox in secluded villages, where but for that practice, the poison might seldom have 
 
 I
 
 SMALL-PCX. 987 
 
 been found. It is right, I say, that this matter should be steadily contemplated, in 
 all its lights, and in all its shadows, in order that the inestimable blessing conferred 
 upon mankind by the researches of Dr. Jenner may be fairly set forth, and adequately 
 appreciated. The vaccine virus produces a shght disorder, which is attended with 
 no risk, and which (unluckily I may say) is not communicable except by direct en- 
 grafting. It not only does not disseminate a dangerous and deadly poison, but if 
 rightly used, it affords the means of eradicating from a well-regulated community, 
 or at least of confining within narrower limits, the most loathsome pestilence which 
 the world has known. Where vaccination is, the contagion of small-pox need never 
 come. In Denmark, as I told you, variola had at one time disappeared before the 
 defensive influence of compelled vaccination. Chance, and a careless security, en- 
 gendered by the absence of the pest, have led to its re-introduction there. It is much 
 to be regretted that the boasted liberty of this countr}'" renders it almost impossible to 
 enforce by law a practice which would be so conducive to the public weal. Some 
 good might be done by enacting that no person should be eligible to even any paro- 
 chial office of trust or profit who could not produce a certificate that he had been 
 duly vaccinated. And the benefits which this safeguard confers on the individual 
 are scarcely inferior to those which it is calculated to bestow upon society. It un- 
 fortunately does not give complete protection against small-pox to all, but it gives 
 complete protection to many. And you must recollect that small-pox itself is not a 
 universal and absolute assurance against its own return. But the cow-pox relieves 
 all from the necessity, imposed by inoculation, of coming within the sphere of the 
 variolous contagion. It renders many, I repeat, impregnable to that poison, if they 
 do chance to be within its range ; and its advantage to the comparative few who 
 suffer the double misfortune of being exposed to the contagion of small-pox, and of 
 being affected by it, is this, that it gives safety, though not exemption ; that it takes 
 away the sting and peril of the variolous disease, by curtailing it of the secondary 
 fever. At the very worst, it leaves the individual liable, by a twofold ill luck, to 
 contract a form of small-pox less dangerous than that which he would voluntarily 
 accept by submitting to the operation of inoculation,* 
 
 It is difficult to adduce exact numerical comparisons in illustration of this reason 
 ing ; but I may quote two short series of facts as samples. 
 
 During an epidemic in Scotland, Dr. John Thomson saw from June, ISIS, to De- 
 cember, 1819, 550 cases. Of these 205 had previously had neither small-pox nor 
 cow-pox, and 50 of them died ; nearly 1 in 4. Forty-one took the small-pox for the 
 second time, and Dr. Thomson knew of 30 other such cases, making 71 in all, 
 whereof 3 died ; or 1 in 23. Three hundred and ten had been previously vaccinated, 
 and among these there was but one death. 
 
 The population of Marseilles at the time of an epidemic there, in 1S28, was esti- 
 mated at 40,000; that is to say, of 30,000 vaccinated, 2000 variolated, and 8000 
 unprotected. Among the 30,000 vaccinated, about 2000 were attacked with small- 
 pox, and 20 perished; 1, namely, in 100. Of the 8000 unprotected, 4000 were 
 attacked ; and 1000, or 1 in every 4, died. And out of the 2000 variolated, 20 took 
 the disease a second time, and 4 died ; or 1 in 5. 
 
 There yet remains a highly interesting, but a less practical question. Dr. Jenner, 
 as I stated before, believed that he had traced the cow-pox to its origin in the heels 
 of the horse afflicted with the grease. It has since been made out that the disease 
 which, in the horse, corresponds with and produces the specific malady of the cow, 
 is a vesicular eruption, having no necessary connection with the grease, but extend- 
 ing sometimes all over tlie animal's body. Now the question is, whether these two 
 disteinpers, occurring in the cow and in the horse, are identical in their essence and 
 nature with the small-pox of man. If so (as Dr. Jenner believed, and Dr. Baron 
 strongly maintains), a part of the mystery attending the whole subject vanishes. 
 The . protection furnished by the cow-pox resolves itself into the more familiar law, 
 
 *[Tlie accuracy of this latter statement is contravened by statistical results, derived from 
 -foment epidemics of small-pox in this country. But neither the tendency, nor the foice of 
 ibie main argument, is much affected by this admission. — C.]
 
 988 SMALL-POX. 
 
 that certain diseases engendered by animal poisons, happen to the same individual 
 out once, and shield the body against their own recurrence. In conformity with 
 this theory, Dr. Baron names the disorders respectively, variolee, variolse vaccinae, 
 and variolfe equinfe. 
 
 The notion, you see, is this, that the vaccine disease is in truth small-pox, rendered 
 mild by passing through the system of the cow. The great object of inoculating 
 the small-pox is to produce a benignant form of that disease, by diminishing the 
 number of pustules. The cow-pox diminishes the number to one; and while it 
 reduces the severity of the disorder to a minimum, it absolutely takes away its 
 j)ower of propagating itself, except by a direct engrafting of the visible virus. The 
 disease is not sufficiently intense to taint the air with poisonous effluvia. At the 
 same time it affords (but less surely and less permanently) the customary protec- 
 tion. Such is the theory, which is intelligible and plausible, and supported by strong 
 facts and persuasive reasoning ; for all which I must needs refer you to Dr. Baron's 
 book. 
 
 To avoid breaking the thread which connects the different parts of the main 
 subject, I have postponed to the last what I have to say respecting the treatment of 
 small-pox. ' 
 
 This, for a long time, was conducted upon an erroneous principle, and eminently 
 disastrous. The older physicians attempted to force out, through the skin, the mor- 
 bid matter existing in the blood. The eruption they considered to be the natural 
 and only cure: and adopting the vulgar maxim, that "it was better out than in," 
 they did all they could to promote a copious eruption, by a hot regimen, by covering 
 the patient with bed-clothes, by keeping the doors and windows jealously closed, and 
 excluding every breath of fresh air, and sometimes by administering wine and cor- 
 dials. The celebrated John of Gaddesden, the author of that curious book, the Rosa 
 Anglica, improved even upon this. He surrounded the half-suffocated patient with 
 red curtains, red walls, red furniture of all kinds : everything he saw was to be red ; 
 for in that colour there was, he pretended, a peculiar virtue. This John of Gaddes- 
 den, by the way, was a very sad knave, and the first Englishman, I believe, who had 
 the luck to be made court physician. He had one medicine so good as to be fit for 
 the rich only; and he recommended a double dose for the wealthy. "Duplum sit, 
 si pro divite." He flourished in the fourteenth century. 
 
 Sydenham was the first, in this country, to employ the opposite or cool regimen 
 in small-pox ; and although his prejudiced cotemporaries refused to follow his exam- 
 ple, and adopt his practice, he confidently predicted its final triumph — " obtinebit 
 demum me vita functo." 
 
 But it was subsequently to the introduction of the method of inoculation that the 
 rooling treatment was fairly established, by the Suttons — two brothers, one of whom, 
 Robert, lived at Bury St. Edmunds ; the other, Daniel, at Ingateslone, in Essex. 
 
 These men, wiser in their generation than the regular physicians, had the good 
 sense to pursue the same plan of general management which had been so prosperous 
 in the East, whence the practice of engrafting was originally imported. Daniel, in 
 particular, became famous for his successful inoculations : and the great secret of his 
 success seems to have consisted in his making one puncture only ; exposing his 
 patients much and often to a cool atmosphere ; supplying them freely with refrigerant 
 drinks ; and restricting them to a spare diet. Under this course, Cullen, who adopted 
 it from the Suttons, declares that ninety-nine times in the hundred, inoculation imparts 
 a distinct small-pox, and very generally of the mildest form. 
 
 Now the same principle applies to the casual disease when we have reason to 
 suspect that it is impending, or to have the opportunity of treating it at its commence- 
 ment. The object is to prevent, if possible, a copious eruption ; upon which, as we 
 have seen, the severity and peril of the disorder entirely depend. It has been thought 
 that venesection, by its antiphlogistic power, and, perhaps, by letting out, with the 
 blo^^G, some portion of the regenerated virus, might lessen the number of the forth- 
 coming pustules. But you cannot ensure this effect by blood-letting : and you mUol 
 bear in mind that, should the eruption prove confluent, suppuration, to a large amount.
 
 SMALL-POX. 989 
 
 is inevitable, and — like that of an extensive bum — will require in order to go on 
 favourably, a certain degree of constitutional vigour. 
 
 You may abate the force of the eruptive fever, and keep down, it is believed, the 
 number of pustules, by saline purgatives, so exhibited as to produce two or three 
 loose stools every day, and by free ventilation of the surface of the body. The skia 
 may even be sponged with tepid water, if the temperature be very high. 
 
 When the eruption is all come out, if the pimples on the face be very few and 
 distinct, the danger is over, and there is no more to be done. At this period Cullen 
 dissuades the further use of purgatives, as being sometimes hurtful. 
 
 But if the pimples on the face be many, and confluent, the patient will still re- 
 quire a great deal of attention. Our business is to look out for, and to meet, unto- 
 ward symptoms. 
 
 About the eighth or ninth day, wakefulness, and restlessness, and sometimes tre- 
 mors, are apt to come on ; and the proper remedies for this set of symptoms, in small- 
 pox as well f.s in continued fever, are opiates. In variola, when given in full doses 
 at bed-time, their good effects are often very conspicuous the next day. 
 
 If the maturation of the pustules should proceed tardily, if they should not fill up 
 properly, nor their contents become purulent, then strong broths may be of use, or 
 even wine. But the effects of these must be carefully watched, and their amount 
 adjusted to the necessities of the case. 
 
 When the pustules are livid, and intermixed with petechia, and typhoid symp- 
 toms occur, the disorder generally proves fatal. In such cases it is customary to pre' 
 scribe bark and acids, in addition to the wine and opiates. 
 
 The proper plan of managing the patient during the continuance of the secondary 
 fever, is to keep his bowels moderately open by gentle laxatives, or by enemata ; and 
 to give opiates once or twice a day. These are the more necessary on account of 
 the irritation of the skin. The cooling regimen must now be given up ; and the 
 strength must be supported by a nourishing diet. Wine and cordials are indicated 
 if the pulse be feeble ; but the swelling of the hands and wrists often makes it diffi- 
 cult to feel the pulse. 
 
 Various external applications have been tried, with the view of relieving the into- 
 lerable itching : which often induces the patients to scratch and tear their faces, and 
 to ensure the formation of scars. Cold cream is used for this purpose : or a solution 
 of common salt, applied lukewarm ; or a liniment composed of equal parts of olive 
 oil and lime-water. This may be smeared, from time to time, over the itching sur- 
 face, by means of a soft camel's hair pencil. 
 
 The dj'spncea which sometimes comes on late in the disease, is a very ugly 
 symptom. I know of nothing that can be done for it beyond blistering the throat 
 and chest. 
 
 [The following presents a very fair exposition of the views of a large portion of the phy- 
 sicians of the Continent of Europe in relation to the protective powers of vaccination. It 
 is the substance of a report made to the Academy of Sciences of France, on the 25th of 
 February, 1845, by the Committee on Vaccination, to which were referred the various essays 
 sent in by the competitors for the prize proposed by the Academy for the most satisfactory 
 solution of the following questions: — • 
 
 \. Is the preservative power of vaccination absolute, or merely temporary? If it is tem- 
 porary only, determine, by accurate experiments and authentic facts, what is the period for 
 which the vaccine matter exerts its protective influence against small-pox? 2. Has vaccine 
 matter, taken directly from the cow, a more certain and durable protective power than vac- 
 cine matter transmitted a greater or lesser number of times through the human subject? 3. 
 If the protective power of vaccine matter becomes enfeebled, should it be renewed ; and if 
 so, how? 4. Is it necessary to vaccinate the same individual several times, and if so, after 
 how many years should the vaccination be repeated ? The portion of the report of which 
 the following is an abstract, relates to the first two questions only. 
 
 The protecting power of vaccination being definitely established, the question arises — is 
 it possible, after forty-five years' experience, to determine the limits of that power ? Ths 
 answer to this question is extremely difiicult, as it embraces inquiries not in France alone, 
 but throughout the whole world : in fact, a general investigation of every case in which vac- 
 cination had been formed could alone supply the fundamental elements of the problem to be 
 answered. The competitors for the prize have particularly examined how vaccinated per 
 
 4 II 2
 
 990 SMALL-POX. 
 
 sons are circiiinstaneed during the prevalence of epidemic small-pox; in other words, what 
 is the proportinn of vaccinated persons in the entire nun:ber of those attacked with small- 
 pox. The protective power of vaccination is, by this mode of investigation, reduced to a 
 numerical question. An attentive examination of what occurred during thirty epidemics of 
 small-pox in France, shows two important facts: — First, that somewhat more than one-third 
 of the entire number of persons attacked with the small-pox had been vaccinated; secondly, 
 tliat the mortality among the vaccinated persons was very small. According to the author of 
 one of the memoirs, more than one-third of those attacked in the epidemics which occurred at 
 Montbeillard had been vaccinated, but there was no corresponding increase in the amount 
 of mortality amongst the vaccinated patients ; and the same result was observed in the epi- 
 demic of 1828, at Marseilles. The same results follow, also, from an examination of the 
 epidemics that have occurred in England, Sweden, Denmark, Italy, IMalta, Geneva, &c. 
 
 The fact, then, being established, that vaccinated persons can become affected with small- 
 pox, and the proportion so attacked during epidemics being nearly determined, a most im- 
 portant problem remained to be solved — viz., what was the condition of the vaccinated per- 
 sons affected as regarded the mere fact of their vaccination'? The authors of all the memoirs 
 agree in stating that vaccinated persons were not afiected indiscriminately or by chance, as 
 it were; on the contrary, the small-pox seems to make a kind of selection from amongst 
 them. With some exceptions, the small-pox attacks those who have been vaccinated since 
 a long period, and spares those who are recently so. An examination of the tables published 
 in various parts of Europe proves positively, that children are seldom attacked with small- 
 pox before the ninth year after vaccination ; and also the converse fact, namely, that it 
 attacks in preference persons who had been vaccinated fifteen, twenty, thirty, or even thirty- 
 five years previously. A general fact, which may be anticipated from the history of erup- 
 tive complaints is, that after the age of thirty-five years, the aptitude of vaccinated person? 
 to contract small-pox becomes so slight that it may be considered as having vanished. 
 
 An investigation of the facts relative to the occurrence of small-pox in vaccinated person? 
 leads to the three following conclusions: — First. Tile protective power of vaccination is abso- 
 lute and general for the first five or six years, and even to the eleventh or twelfth year, tc 
 judge from the experiments on re vaccination. Second. After the foregoing period, a part, bu' 
 a part only, of those vaccinated again become liable, especially under the influence of at 
 epidemic, to contract small-pox. Third. The greater number of those vaccinated proba- 
 bly remain completely protected from small-pox during their entire life. 
 
 Has the cow-pox, taken directly from the cow, a more certain and permanent protective 
 power than vaccine matter that has been transmitted more or less frequently through the 
 human constitution? The experiments contained in several of the memoirs confirm the 
 observations made by the Committee on Vaccination, at Paris. The greater intensity of the 
 new vaccine matter, as compared with that long in use, is a fact definitely established by 
 experience in England, Germany, Italy, and France. But is this greater intensity coupled 
 with a greater preservative power ? or, as the report puts the question — Is there any relation 
 between the lesser or greater intensity of the local phenomena and the protective power of 
 the variolous matter? The experiments made on tliis point show that the protective power 
 of vaccine matter is not proportionate to the intensity of the local symptoms, but that vac- 
 cination with matter taken from the cow is more certain than with old vaccine matter. Ad- 
 mitting that the protective power of vaccine matter diminishes with time, should it be 
 renewed, and if so, how? 
 
 As to the means of renewal, the first mode employed was the transmission of the vaccine 
 matter from man to the cow — an experiment frequently performed as a matter of curiosity, 
 but only recently sought to be rendered a means of restoring to the vaccine matter its lost 
 energy. The authors of several of the memoirs maintain that the cow, when thus vaccin- 
 ated, restores the vaccine matter unaltered, and therefore unregenerated ; but the commission 
 of the Academy thinks this conclusion too absolute : in fact, it has been established by the 
 experiments of the author of one of these memoirs, that vaccine matter taken from man is 
 regenerated during its transmission through the cow. The same fact results from thousands 
 of experiments made in Bavaria under the direction of the government. Vaccine matter 
 tlius regenerated failed in less than one case in a hundred, while the failures of the old vac- 
 cine matter were nearly //tree ^cr cent. Would it not be better to transmit the vaccine matter 
 through several cows in succession than through one only? The mode, however, which 
 should be preferred to all others — the only one on which we can entirely rely — is, as recom- 
 mended by Jenner, to obtain vaccine matter from its original source. Several circumstances 
 seem to show that the cow-pox is perhaps of less frequent occurrence than is commonly sup- 
 posed, and the commission suggests, that those who happen to meet with it should not con- 
 tent themselves, as has been done hitherto, with transmitting jt to man, but transmit it to 
 other cows, and thus regenerate the infection. 
 
 Is it necessary to vaccinate the same person several times? and if so, after the lapse of 
 how many years should the revaccination be performed ? On this head the report first referi 
 to the fact that the revaccinations, performed for a considerable period after the discovery cf
 
 SMALL-POX. 991 
 
 vaccination, did not succeed, except in some rare cases, because they were performed too 
 soon alter the primary vaccination. But when, at a later period, experience showed tliat the 
 protective power of vaccination diminished with time, the practice of revaccination was 
 resumed, &ad then succeeded beyond expectation. la some parts of Germany, especially, 
 revaccination has been practised universally in the army, and even in civil life. Physicians, 
 also, who had had small-pox, in some instances revaccinated themselves with success, of 
 which Dr. Heim is a remarkable example. He attended on his brother for three weeks, 
 while he laboured under confluent small-pox, and three weeks after having gone through 
 this decisive trial, he vaccinated himself, and had pusttiles almost of the ordinary size. M. 
 Moreau, the celebrated accoucheur, who had small-pox in early life, revaccinated himself 
 three times with success. 
 
 A document published by the Government of Wurtemberg, which showed that of 1677 
 persons affected with small-pox, between the years 1831 and 1S3G, 1055 had been vaccinated, 
 contributed greatly to extend the practice of revaccination in Germany, and in the north of 
 Europe. In France, the statistics of epidemic small-pox show that the number of vaccinated 
 persons attacked with small-pox constitute more than a third of the whole number of patients 
 affected. It is impossible, therefore, to doubt the propriety of practising revaccination. It is 
 during epidemic small-pox, especially, that the utility of revaccination becomes obvious. Not 
 only have individuals been thus protected, but the spread of the epidemic has been arrested. 
 In Prussia revaccination has been practised in the army since 1833, and the small-pox has 
 been almost entirely extirpated. In Wurtemberg, but one case of variola occurred in five 
 years, among 14,384 revaccinated soldiers, and three only among 29,684 revaccinated civil- 
 ians. Epidemic small-pox has not appeared in France since 1830, the period when revac- 
 cination was commenced. The authors of the memoir agree that during epidemics it is 
 prudent to revaccinate after about the eighth or ninth year. 
 
 The answers given by the competitors for the prize to the questions proposed by the 
 A-cademy, may be thus summed up : — 
 
 1st. The preservative power of vaccination is absolute for the majority, and temporary for 
 a small number ; and even in the latter it is absolute until adolescence. 
 
 2d. Small-pox rarely attacks those who have been vaccinated in infancy before the age of 
 ten or twelve ; from which age, however, until thirty or thirty-five, they are particularly 
 liable to small-pox. 
 
 3d. In addition to its protective power, vaccination so modifies the animal economy, that 
 it attenuates the symptoms of small-pox, abridges its duration, and considerably diminishes 
 its danger. 
 
 4th. Vaccine matter taken directly from the cow causes local symptoms of greater inten- 
 sity; its effects are also more certain than those of old vaccine matter, but after being trans- 
 mitted for a few weeks through the human subject, the local intensity disappears. 
 
 5th. The preservative power of vaccine matter does not seem to be intimately connected 
 with the intensity of the symptoms of vaccination ; nevertheless, it is prudent to regenerate 
 vaccine matter as frequently as possible, to preserve its protective power. 
 
 6th. The only mode of regenerating vaccine matter deserving of confidence is to procure 
 it from the cow. 
 
 7th. Revaccination is the only known method of distinguishing those vaccinated persons 
 that remain protected from those that do not. 
 
 8th. The success of revaccination is not a certain proof that the person in whom it suc- 
 ceeds was liable to contract small-pox ; it merely establishes a tolerably strong presumption 
 that they were more or less liable to be so. 
 
 9th. In ordinary periods, revaccination should be practised after fourteen years, but sooner, 
 as already remarked, during an epidemic. 
 
 See also, on this subject, Condie on Diseases of Children, p. 458, et seq. — C] 
 
 LECTURE LXXXVIII. 
 
 Chicken-Pox. Measles. Scarlet Fever. 
 
 I MUST not omit a short notice of the disorder called chicken-pox; for although a 
 very unimportant complaint, it has given rise to many disputes. Other names which 
 it has borne are varicella, crystalli, variolse pusillge. 
 
 Connected with the small-pox, and arising from the same contagion, there are 
 several forms of eruptive disease. I mentioned the chief of them in the last lecture, 
 as varieties of modified small-pox. Now these mild and irregular forms of variola.
 
 992 CHICKEN-POX. ' 
 
 both parents and medical men, wishing, I suppose, to believe nothing in disparage- 
 ment of the protecting power of vaccination, are very apt to consider, and to call, 
 chicken-pox : and this error having been discovered, some persons have rushed to, 
 or rather revived, the opposite opinion — equally erroneous in my judgment — that 
 there is no such substantial disorder as chicken-pox ; but that all the eruptions which 
 have passed under that name have reall}^ been forms of modified small-pox. Dr. 
 John Thomson, of Edinburgh, is one of the stoutest maintainers of this doctrine. No 
 doubt an eruption of short duration, and vesicular through the greater part of its pro- 
 gress, is often caused, especiall}' in persons who have been vaccinated, b)^ the conta- 
 gion of small-pox: but a similar eruption proceeds also from another distinct contagion, 
 that, namely, of chicken-pox. 
 
 The best description of the true chicken-pox that I am acquainted with has been 
 given by Dr. Gregory. The disorder is almost pecuhar to infants, and children of 
 tender years. Willan has, however, described one unambiguous example of it, in a 
 gentleman thirty years old ; and another genuine instance was seen by Dr. Gregory, 
 at the Small-pox Hospital, in the person of an adult female. The eruption is pre- 
 ceded by little or no premonitory fever, commencing usually on the shoulders, neck, 
 and breast, affecting almost always the scalp, but sparing very much the face — which, 
 in small-pox, never escapes. 
 
 The eruption is composed, from the very first, of perfectly transparent vesicles, 
 surrounded by a very slight degree of superficial redness. They are usually numer- 
 ous, but distinct. Dr. Gregory says that when the eruption is very copious, the 
 body has the appearance of having been exposed to a momentary shower of boiling 
 water, each drop of which had occasioned a minute blister. Crops of vesicles ap- 
 pear in succession for two or three days ; and while new ones_are forming, the first 
 are beginning to shrivel. The vesicles that remain after the second or third day 
 become slightly opaque, and hke pearls. AVhen irritated by friction, they some- 
 times take on so much inflammation as to be converted into pustules. The scabs 
 are small and gummy, dry quickly, and crumble off', instead of being detached in 
 one r.)ass. In a few instances, shallow cicatrices are left by the vesicles. During 
 the short progress of this eruptive disease there is no constitutional disturbance of 
 any consequence. 
 
 It has been ascertained of this genuine chicken-pox, or varicella lymphatica, that 
 it occurs once only to the same person ; that it spreads by contagion ; that never- 
 theless, it is not communicable by inoculation — whereas the matter of modified small- 
 pox, when engrafted, produces genuine variola; that it occurs equally among those 
 who have, and those who have not, been vaccinated ; that its course is not afl^ected 
 bv antecedent vaccination ; and that the vaccine vesicle and disease proceed with 
 perfect regularity after the occurrence of chicken-pox. Now this never happens 
 after small-pox. 
 
 It appears, from Mohl's work De Varioloidihus et Varicellis, that from the year 
 1809 to 182:3, chicken-pox was annually observed at Copenhagen without concomi- 
 tant small-pox; and that both diseases have since prevailed at intervals epidemically, 
 but always under circumstances which satisfied the physicians of the town that theii 
 sources were distinct. 
 
 It must, therefore, I think, be admitted, tnat there is a separate disease, called 
 chicken-pox, which springs from a specific poison; produces a vesicular eruption ; 
 runs a definite course ; has no tendenc5% when undisturbed, to suppuration ; occurs 
 but once ; and affords no protection against small-pox ; while, on the other hand, 
 small-pox affords no protection against it. 
 
 The main point of practical importance is, however, this ; that if we meet with 
 any eruption which is at all equivocal, we should use the same precautionary mea- 
 sures for preventing the extension of the disease as if we were sure that it was modified 
 small-pox. But this salutary rule is often, I say, neglected or infringed, to the darv- 
 ger and detriment of those unprotected persons who happen to be in the vicinity of 
 the sick child. 
 
 The treatment required in chicken-pox is abundantly simple ; it is the same, in
 
 MEASLES. 993 
 
 fact, which has been already recommended for the mildest cases of the discrete 
 small-pox. 
 
 Another of these blood diseases is the measles; called, also, by nosologists, rubeola., 
 and morbilli. 
 
 Like different human faces, all the complaints belonging to this group have the 
 same set of features, and therefore a mutual resemblance, while the separate linea- 
 ments differ so much in their character and relative circumstances, as to give to each 
 disease its distinctive aspect. There are also minor shades of difference between in- 
 dividual cases of the same specific malady. 
 
 Measles, accordingly, has its introductory fever, its period of eruption, its peculiar 
 kind of eruption, its course by stages. It is communicable from person to person, 
 and it generally occurs but once to the same person. On some of these points 1 
 spoke before. 
 
 The introductory fever is sometimes severe, and nearer in its type to synocha 
 than to typhus. Like all fevers, it begins with lassitude, and shivering, which is 
 soon followed by heat of skin, acceleration of the pulse, anorexia, and thirst. But 
 the pecuharity in the fever which precedes the eruption of measles is, that it is very 
 constantly attended with an imflammatory condition of the mucous membranes ; 
 especially of those which are proper to the air-passages. The eyes become vascular 
 and watery, the eyelids heavy, turgid, and red. The membrane which lines the 
 nasal cavities, the fauces, the larynx, trachea, and brcnchial tubes, is affected. Flence 
 we have, generally, as symptoms, much sneezing, as Avell as lachrymation, a copious 
 defluxion from the nostrils, soreness of the throat, and an obvious redness of the fauces, 
 and most commonly a dry, hoarse, pecuhar cough. In short, the symptoms which 
 usher in an attack of measles are the symptoms of coryza and catarrh. In some 
 instances there is diarrhoea also, indicating a simultaneous affection of the mucous 
 membrane of the intestines; and not unfrequently vomiting: but the vomiting, as in 
 small-pox, ceases upon the coming out of the eruption. 
 
 The regular period for the appearance of the eruption is the fourth day of the 
 disease; seldom earlier, frequently later : sometimes as late as the eighth or tenth 
 day from the commencement of the catarrh. The eruption itself is a rash, consisting, 
 at first, of minute papulae, which, as they multiply, coalesce into blotches that have, 
 more or less, a horse-shoe or crescentic shape, and leave the intermediate portions 
 of skin of their natural colour. It is two or three days in coming out, beginning on 
 the face, neck, and arms, then reaching the trunk of the body, and so travelling 
 down to the lower extremities. In this course it resembles the eruption of small- 
 pox. It fades in the same order, standing out three days at least on the face before 
 it begins to decline ; so that its whole duration comprises a space of six or seven 
 days. It becomes browner as it fades. You may feel that it is slightly elevated 
 above the general surface of the skin, especially upon the face, which is somewhat 
 bloated and swollen. The parts which the rash has recently occupied are left covered ' 
 with a dry, small scurf. The cuticle does not peel off in large flakes, as I shall have 
 to tell you that it oftentimes does in scarlet fever, but a great part of it crumbles 
 away in a fine branny powder. Occasionally, yet very seldom I beheve, the rash is 
 intermixed with a few small and short-lived vesicles. 
 
 This termination of papulae is very unlike what happens in variola ; and connected 
 with the eruption there are two other important particulars in which the measles 
 differs essentially from the small-pox. In the first place, the fever does not cease, 
 nor even abate, upon the emergence of the eruption ; but sometimes increases in 
 intensity. And, in the second place, the disorder is not more severe, nor more dan- 
 gerous, because the eruption is plentiful, or early. So far from it, indeed, that iu 
 some of the worst and most perilous cases the eruption is apt to be partial, and to 
 appear late and irregularly. 
 
 The eruption is the distinguishing feature of measles ; but the catarrhal affection 
 
 IS, in every way, the most important. Indeed, the rash may, and sometimes does, 
 
 happen without the fever and the catarrh ; and nosologists recognise a variety of thi; 
 
 disorder under the title of rubeola sine catarrho. But it is observed of this variety 
 
 63
 
 994 MEASLES. 
 
 that, it confers no protection whatever against the recurrence of the malady ; in truth, 
 It is most commonly succeeded in a few days b}'' an attack of measles in its regular 
 and complete form. 
 
 f need not stop to repeat what I told you in a former lecture about the other gene- 
 ral features of this eruptive complaint. The period of incubation is from ten days 
 to a fortnight. The contagion is active enough, though certainly it is less strong and 
 diffusive than that of small-pox. When once introduced into a family or school, the 
 disease rapidly spreads to those individuals who have not already had it. It is capa- 
 ble, though with much less readiness and certainty than small-pox, of being propa- 
 gated by inoculation ; but as the disorder is not rendered milder by Being so intro- 
 duced into the system, this process has no utility or interest, and is never resorted to. 
 Occasionally, rubeola visits the same individual twice ; but this is the exception to 
 the general rule. Perhaps, in some reputed instances of its recurrence, the first 
 accession may have been without fever and catarrh, and therefore an ineffectual 
 safeguard for the future. I myself know, however, two large families in which 
 most of the children have suffered a repetition of the genuine unmitigated disease. 
 
 The measles resembles the other diseases of the group in this also, that at times it 
 pervades a community as an epidemic ; at times occurs here and there only, spora- 
 dically. The general character of the symptoms varies considerably in different 
 epidemics. Morton and Sydenham, and after them Sir William Watson, have 
 described visitations of what they call putrid measles. Sir William Watson was 
 physician to the Foundling Hospital, and he witnessed two epidemics of this putrid 
 kind among the children in that institution. He states that the eruption appeared 
 unusually early, so early as the second day of the disease; and that, besides cough 
 and d\'spnoea, the complaint was marked by extreme debility, and attended with 
 dysenteric diarrhcEa. More seemed to die of the intestinal affection, than of the 
 pectoral. He lost, in one of these epidemics, nineteen out of one hundred and 
 eighty-three patients. The malignant character of the disorder was manifested by 
 the frequent occurrence of gangrene, both externally and internally. In this more 
 typhoid variety of measles, the rash is often irregularly and imperfectly developed, 
 and of a livid colour. 
 
 Sydenham found that measles of an unusually bad kind prevailed in London in 
 the years 1G70 and 1G74 ; the very same years in Avhich small-pox was also remark- 
 ably malignant and fatal. This illustrates what I have stated before, viz., that the 
 typhoid tendencies of these and other febrile disorders depend less upon any pecu- 
 liar virulence in their exciting causes, than upon some change previously effected 
 in the human body by the silent and gradual influence of certain predisposing 
 causes. 
 
 The diagnosis of measles is seldom difficult. In the outset of the fever, you may 
 guess what is coming by the coryza, catarrh, and hoarse cough; especially if the 
 disease be about. On the very first day of the eruption, the small, red, and hitherto 
 separate spots, are very like the incipient pimples of small-pox. Do not, therefore, 
 at this period, express too confidently your opinion respecting the nature of the com- 
 plaint. Parents and nurses might be uncharitable enough to attribute your mistake 
 to inexperience or ignorance. The progress of the disease will soon remove all 
 doubt. The eruption of small-pox presently exhibits some fluid, while that of mea- 
 sles has none — unless, indeed (what is uncommon), a k\v miliary vesicles mix them- 
 selves with it. But these make no advance in twenty-four hours. Ordinarily, the 
 isolated pimples visible upon the first day soon augment in number, and collect them- 
 selves into semicircular groups ; and if any question at all arises, it is whether the 
 disease be measles or scarlet fever. I shall presently describe the latter disorder ; 
 and then I will point out the marks of distinction between the 'wo. 
 
 The prognosis in measles is governed chiefly by the mildness or the severity of 
 the pectoral symptoms. The most common cause of death, in the fatal cases, is 
 inflammation of some one or more of the textures that compose the lungs. And 
 even when this immediate danger has passed by, the disease too often leaves chronic 
 pulmonarj' mischief behind it. In scrofulous children, and j^oung persons, it fre- 
 quently awakens the slumbering germs of consumption. And when that specific
 
 MEASLES. 
 
 ddS 
 
 effect is not produced, it is apt, in adults, to inflict upon the constitution a blow which 
 is never thoroughly recovered from ; the patient becoming, from that time forwards^ 
 delicate and valetudinary. The prognosis is always unfavourable when the eruption 
 does not stand out well, is of a livid colour, and accompanied with typhoid symp- 
 toms, or with a disposition to gangrene. 
 
 We augur favourably of the case when the thoracic symptoms are not severe ; 
 when the fever moderates upon the coming out of the rash ; and when the rash is 
 steadily persistent, and there is no excessive prostration of the strength. 
 
 Being contagious, and occurring for the most part but once, measles is principally 
 seen in children ; although no period of hfe is exempt from its attacks. In many 
 children, the disorder is so slight as to require little more than judicious domestic 
 attentions. The free application of cold air to the surface, which is so beneficial in 
 small-pox, would in measles be unsafe, on account of the pectoral symptoms. For 
 this reason, the patient should be kept in bed ; with no more clothes, however, or 
 warmth of the apartment, than he is accustomed to in health. The antiphlogistic 
 regimen must be adopted ; and, if the bowels are not quite open naturally, gentle 
 laxatives should be given. It may be well, also, to prescribe some diaphoretic medi- 
 cine ; a draught, for example, containing two or three drachms of the liquor ammonise 
 acelatis, with half a drachm of the spiritics xtheris nitrici, and an ounce of cam- 
 phor julep, to be taken three or four times in the twenty-four hours. 
 
 The most important part, however, of the treatment relates to the remedies to be 
 employed for the pulmonary symptoms, which, in the outset, depend almost always 
 upon bronchitis. But the inflammation is apt, in severe cases, to spread insidiously 
 from the mucous to the other tissues — the bronchitis becomes pneumonia — and we 
 find, after death, some portions of the lungs hepatized ; usually small portions. For 
 the most part, however, it is extensive inflammation of the bronchial mucous mem- 
 brane that we have to dread. And really I cannot give you any better or fuller 
 directions in respect to the management of these inflammatory affections, than I 
 endeavoured to lay down when I was speaking of bronchitis and pneumonia, as 
 they occur idiopathically. You will judge of the extent and severity of the inflam- 
 mation, partly by the common symptoms, partly by the help of your ear ; and j^ou 
 must apportion your remedies to that intensity, so judged of. You will take blood 
 from the arm, or from the chest, apply a blister, and give tartar emetic. And it is 
 of importance that whatever kind or amount of depletion is adopted, should be 
 resorted to early. 
 
 When the rash is about to decline, a spontaneous diarrhcea often sets in, and 
 appears to have a beneficial effect in abating the febrile symptoms. If this natural 
 curative process should fail to occur, it may be imitated by the exhibition of gentle 
 aperients. 
 
 In weakly children blisters are apt to cause troublesome sores ; and in some epi- 
 demics of measles, the sores thus produced show a disposition to become gangrenous. 
 When any such tendency is noticed, blisters had better be avoided altogether. At 
 other times, the inconvenience to be apprehended from a blister may be prevented 
 by one of two plans ; either by interposing a piece of silver paper between the 
 blistering plaster and the skin ; or by suffering the blister to remain upon the part 
 three or four hours only, then taking it off, and applying a pouUice. The cuticle 
 will rise under the poultice, and the sore will not, in general, be a troublesome one. 
 
 If the eruption disappear prematurely, it may sometimes be restored by putting 
 the patient into a warm bath. And if he be at the same time in a low state, espe- 
 cially if typhoid symptoms threaten or show themselves, you must treat the case 
 upon that indication, just as you would in continued fever; giving wine and support, 
 with great caution and watching of their effects. 
 
 It is of considerable importance to protect the patient from danger after the disease 
 has subsided ; by warm clothing, by preventing him from going out of doors too 
 early, or being in any way exposed to cold. Pneumonic inflammation, and dysenteric 
 purging, are frequent consequences of the want of prudence in this respect. 
 
 I proceed, in the next place, to the consideration of scarlet fever.
 
 996 SCARLET FEVER. 
 
 This also is a contagious febrile disease, attended almost always, during a part of 
 its course, by a rash, and by sore throat. It seldom comes on a second time. 
 
 There are some distinct varieties of this disorder, concerning which it is necessary 
 that I should say a few words. 
 
 The two striking and important features of the disease are the affection of the 
 throat, and the affection of the skill. They may both be well marked ; or only one 
 of them may be well-marked : and this circumstance has led nosologists to divide 
 one and the same complaint into two independent maladies ; to which Cullen and 
 others have assigned the respective names of cynanche maligna, and scarlatina. 
 When, in an earlier part of the course, I was treating of the diseases of the throat, I 
 purposely omitted the cynanche maligna ; because that is only another name for a 
 particular form of scarlet fever. If you look to CuUen's definitions of these com- 
 plaints, you will see how very much alike they are. They both specify inflamma- 
 tion of the fauces, a cutaneous rash, and fever. But in the definition of scarlatina, 
 the rash is dwelt upon and described, and the fever is called synocha ; while in that 
 of cynanche maligna, the ulceration of the throat is more insisted on, and the fever 
 is said to be typhoid. The truth is, that these two kinds of disorder both spring 
 from the same contagious poison. The malignant sore throat may be caught from a 
 patient who has mild scarlet fever ; and mild scarlet fever may, in like manner, be 
 contracted from one who is labouring under the malignant sore throat. The two 
 forms graduate insensibly, in different cases, towards each other ; and it would be 
 impossible, even if it were desirable, to draw any strict line of separation between 
 them. 
 
 For convenience, however, of description, and for the better direction of the treat 
 ment, authors generally make three varieties of scarlatina. Scarlatina simplex, ir 
 which there is a florid rash, and httle or no affection of the throat ; scarlatina anginosa 
 in which both the skin and the throat are decidedly implicated ; and scarlatina ma 
 ligna, in which the stress of the disease falls upon the throat. The epithet maligna 
 marks truly the fearful character of this form of the malady, 
 
 I need scarcely remind you of a sort of mystification which prevails among the 
 public about this complaint, and which many practitioners, for no good reason that I 
 can see, seem disposed to encourage. Mistaking the Latin and scientific name of 
 the disorder for a mere diminutive, you will hear mammas say, " Oh, my children 
 have not got the scarlet fever, but only the scarlatina.'''' I always disabuse them of 
 this absurd error, when the opportunity of doing so occurs. It can produce nothing 
 but confusion, and a disregard of requisite precautions. 
 
 Like measles, and for the same reasons, scarlet fever, though persons of all ages 
 are susceptible of it, is eminently a disease of children ; but it is much more to be 
 dreaded than the measles. 
 
 It is somewhat strange that scarlet fever was not recognized, in this country at 
 least, as a distinct disease, till about two centuries ago. In all probability it had long 
 existed, and had been always confounded with measles, Morton speaks of it under 
 the name of morbili confluent es ; and Hoffman calls it, by a similar mistake, rubeola 
 rossalia. The febris scarlatina described by Sydenham must have been of a very 
 mild kind; for he does not mention any ulceration of the throat. Dr. FothergiU, in 
 1748, was the first to describe, as a new and separate disorder, that perilous form of 
 the complaint which Cullen designates cynanche maligna ; and it was long called 
 the FothergiU sore-throat. The identity of this affection with genuine scarlef fever 
 has been slowly established by subsequent observers. The characteristic differences 
 between scarlet fever and measles were first fully specified by Dr. Withering. 
 
 The disease begins, as the exanthemata in general begin, and as continued feverj 
 which I have grouped with them, is apt to begin, with shivering, lassitude, and rapidly 
 augmenting debihty ; headache, frequently severe, sometimes with delirium, occa- 
 Bionally with nausea and vomiting. Then, generally, on the second day (and Cullen 
 is wrong when he says it is generally on the fourth), the eruption begins to come 
 out. In some of the worst forms of the disease, it may, indeed, be deferred till the 
 fourth day. 
 
 Although scarlet fever and measles were so long confounded together, the differ-
 
 SCARLET FEVER. 997 
 
 ences between them are well pronounced, and, when once pointed out, are easily 
 enough recognized. 
 
 Rubeola is distinguishable, then, from scarlatina — 
 
 1. By the presence, at the outset, of catarrhal symptoms — by the sneezing, the 
 cough, the defluxion from the eyes and nose, which precede the rash. There is, 
 doubtless, in many cases of scarlatina, a running from the eyes and nose, but not tiJl 
 late in the disease ; at any rate not prior to the eruption. 
 
 2. By the absence of severe inflammation and ulceration of the throat ; symptoms 
 which always accompany severe cases, at least, of scarlet fever. 
 
 3. By the characters of the eruption itself. The rash in measles is more elevated 
 above the surface than in scarlatina, and of a darker colour. In measles it is said to 
 present somewhat the tint of a raspberry, and in scarlet fever to be that of a boiled 
 lobsters. In measles the papulae are collected into semilunar clusters, leaving inter- 
 stices between them of healthy skin. The redness of scarlatina commences in 
 minute points, which speedily become so numerous and crowded, that the surface 
 appears to be universally red. They begin on the face, neck, and breast, and extend 
 to the extremities, pervading at last every part of the skin. The scarlet colour is 
 deeper, in general, about the groins, and in the flexures of the joints, than elsewhere. 
 Lastly, the rash of measles, in its most regular form, appears on the fourth day of 
 the disease ; that of scarlet fever on the second. 
 
 On the arms and legs the eruption of scarlatina occasionally difl^ers somewhat 
 from that which is visible on the trunk ; is more spotty, more papular, and the 
 papulte are somewhat prominent, while over the body there is a general diffused 
 blush. 
 
 In some cases of scarlet fever (probably in some epidemics, for I observed the 
 phenomena I am about to mention in four or five cases in succession which were 
 brought into the Middlesex Hospital within the space of a month or six weeks), 
 some parts of the red surface are closely studded with little transparent vesicles, con- 
 taining a thin colourless liquid, and resembhng what I described to you before as 
 sudamina. In all the instances in which I have seen them, these minute vesicles 
 have been most thickly set on the thorax, and on the front and sides of the neck. 
 The liquid is soon re-absorbed, and the cuticle under which it had been enclosed 
 shrivels up, turns white, and comes off" in a thick white scurf: so that the part from 
 which it separates looks at first sight as if it had been powdered. I have recently 
 seen two cases of this vesicular form of scarlatina in private practice. I show you 
 Rayer's delineation of the vesicles. 
 
 The eruption, in the most regular and favourable cases, stands out for three or four 
 days, and then begins to fade and decline, becoming by degrees indistinct, and disap- 
 pearing altogether, in the majority of instances, before the end of the seventh day. 
 About this time desquamation of the cuticle begins to take place, in smaller scurf or 
 scales from the face and body, in large flakes frequently from the extremities. The 
 scarf-skin of the hands and of the feet sometimes separates almost entire. A glove 
 or a slipper of cuticle comes away at once. You may see such things in most 
 museums. 
 
 In that variety of the disorder which we call scarlatina maligna, the rash is apt to 
 come out late, and imperfectly, and sometimes not at all; and instead of being bright 
 and florid, to present a bluish or hvid tint. Sometimes it suddenly recedes ; and 
 then, perhaps, appears again : and occasionally it is diversified by purple spots. 
 
 Willan and Bateman have given the name oi roseola to an eruption which is also 
 attended with inflammation of the throat, and between which and scarlatina it is cer- 
 tainly difficult, if not impossible, at first to discriminate. The roseola, however, is 
 not contagious, and has more of a chronic character than scarlatina. It comes and 
 goes, and has no settled or definite course. Dr. A. T. Thomson lays down this dis- 
 tinction between them ; but I do not know that we can trust to it : — " In scarlatina 
 (he says) the rash first attacks the face, and then extends to the trunk of the body, 
 passing off' by the extremities ; whereas in roseola the extremities ^xe first affected." 
 
 The appearances of the tongue in scarlet fever are also peculiar and characteristic 
 In the scarlatina simplex, and anginosa, it is often covered, at the outset, with a 
 
 4i
 
 998 SCARLET FEVER. 
 
 thick, white, cream-like fur, through which are seen projecting the red and exagcre. 
 rated papillae ; the edges of the tongue being likewise of a bright red colour. The 
 red points gradually multiplj^ and the white fur clears away, and at length the 
 whole surface of the tongue becomes preternaturally red, and clean, and raw-looking: 
 and after becoming thus clean, as well as red and rough, and like a strawberry, it 
 will sometimes, when the disease goes on unpromisingly, get dry, and hard, and 
 brown — as you know it is apt to be in certain forms and stages of continued fever. 
 
 The first thing of which the feverish patient usually complains is sore throat, with 
 some stiffness of the neck : and if you inspect the fauces, you will see, without in 
 general so much swelling of the tonsils as occurs in common quinsy, a diffused red- 
 ness, sometimes of a dark claret colour, including a large part of the palate. In a 
 short time you may perceive that the tonsils and vellum are covered irregularly with 
 whitish exudations, or gray aphthous crusts : or, perhaps, you see a sloughy kind of 
 ulceration left by the separation of these crusts. 
 
 The progress of the distemper, and its degree of severity and of danger, differ very 
 greatly in different cases. Sometimes the deviation from the feelings and condition 
 of health is so very slight as scarcely to deserve the name of a disease ; sometimes 
 the disorder defies all treatment, and the deadliest forms of plague are not more fatal. 
 
 In these mahgnant and terrible cases, the eruption, if it appear at all, is livid and 
 partial, and fades early, and is attended with a feeble pulse, a cold skin, aiid typhoid 
 depression. Sometimes the patient sinks at once, and irretrievably, under the viru- 
 lence of the poison, and life is extinguished in a few hours. A gentleman called one 
 day at my house, and not finding me there, followed me between twelve and one 
 o'clock to the hospital. He wished me to visit his wife, four or five miles out of 
 town, who had been taken ill that morning. He feared that she was about to have 
 scarlet fever, but he was not much alarmed for her safety ; for when he found that 1 
 could not be at his house before six, he said that that hour would not suit the gene- 
 ral practitioner in attendance upon her, and he begged me to fix some time for seeing 
 her the next day. I did so ; but the same afternoon rapid sinking came on, and the 
 patient was dead very soon after the hour at which I had first proposed to visit her. 
 
 In other cases of scarlatina maligna, the typhoid symptoms rapidly deepen ; and 
 death, in children, is apt to occur on the fifth day of the complaint ; and not uncom- 
 monly as soon as the third. The pulse becomes frequent and feeble; the tongue 
 dry, brown, and tremulous; the debility extreme; the throat is ulcerated and gan- 
 grenous ; and the respiration is impeded by viscid mucus which collects about the 
 fauces. Over this variety of the disease, medicine has comparatively little control. 
 
 The chance of recovery is much greater in the scarlatina anginosa, when the 
 eruption is florid, and stands well out. But even in this form of the disorder there 
 are many sources of danger, and various ways in which it may prove fatal. 
 
 In the first place many of the patients die, apparently from inflammation or effu- 
 sion within the head. They have violent headache, with furious dcHrium, which is 
 followed by coma, and death. 
 
 And secondly, the state of the throat is full of peril. As the disease proceeds, 
 although the rash may be steadily persistent, the throat becomes foul and sloughy, 
 an acrid discharge from the nostrils, which are so stufft'd and swollen internally that 
 the patient can scarcely breathe through them, runs over and frets the upper hp ; 
 the parotid and sub-maxillary glands swell, sometimes enormously; and fever is 
 lighted up afresh. In this way many cases prove fatal in the second week of the 
 disorder. The cervical swelling causes constriction of the fauces and stiflriess of the 
 neck ; and sometimes, doubtless by interfering with the free return of the blood from 
 the head through the jugular veins, they produce a tendency to coma. With these 
 sj'mptoms there are often also purging, and an excoriated anus. 
 
 The acrid matters furnished by the ulcerating and gangrenous throat irritate the 
 nasal membrane in me one direction, and that of the alimentary canal in the other. 
 We thus account for the running from the nose, the soreness of the aloe nasi and 
 upper lip, and the smarting diarrhosa : and the swelling of the parotids and neigh- 
 bouring glands is evidently caused by absorption of the irritating and poisonous mai- 
 \ri from the ulcerated throat. There is just the same relation and dependency
 
 SCARLET FEVER. 99^ 
 
 between these different local alterations, as between the enlarged mesenteric glands, 
 and ulceration of the follicles of Peyer in continued fever; between a bubo in the 
 groin, and a chancre on the glans penis. It is the condition of the throat that gives 
 rise, in these cases, to the most formidable symptoms. The system is reinoculated 
 from that source. Whenever I see the glands much enlarged at the angle of the 
 jaw, and beneath the jaw, in a child labouring under scarlet fever, I augur ill of the 
 case. Sometimes the mischief extends into the larynx, and so destroys the patient. 
 But this is probably a very rare event. There is, however, still another, and a very 
 common consequence of the throat affection — I mean inflammation of the Eustachian 
 tube, reaching sometimes the tympanum itself, and causing permanent deafness, 
 either by closintr up the tube, or by the destruction of the membrana tympani, and 
 of the little bones belonging to it. In one case, which was under my own care, I 
 observed that, for a short time before death, every time the child swallowed, a part 
 of the fluid food ran out immediately at one of its ears. I had no opportunity of 
 examining the state of the part after death, but the disorganization arising from the 
 sloughing ulceration of the throat must have been frightful. 
 
 Scarlet fever sometimes befalls parturient women ; and then it almost always 
 proves fatal. I have seen three instances only of recovery from this perilous com- 
 plication. 
 
 Scarlatina simplex is scarcely, I repeat, a disease. Sydenham has said of it that 
 it is "fatal only through the officiousness of the doctor." 
 
 Even when the patient has escaped from the complaint itself, he is often exposed 
 to great hazard and distress from its consequences. Children who have suffered a 
 severe attack of scarlet fever are liable to fall into a state of permanent bad health, 
 and to become a prey to some of the many chronic forms of scrofula : boils, strumous 
 ulcers, diseases of the scalp, sores behind the ears, scrofulous swellings of the cervical 
 glands and of the upper hp, chronic inflammation of the eyes and eyelids. The same 
 afiiicting results are very common after small-pox also, and measles. 
 
 I have several times, when the rash of scarlet fever was disappearing, known pain 
 and sweUing of the larger joints to supervene, simulating very closely the local phe- 
 nomena of subacute rheumatism : and I have noticed that the painful joints were 
 eased and benefited by friction ; a circumstance which may help to distinguish this 
 articular affection from true rheumatism. Another distinctive circumstance seemed 
 to be that, although all these patients were children, the heart in no instance became 
 implicated, in connection with the tumid joints. Upon this point, however, my own 
 experience may have been fallacious. Dr. Scott Alison has recently invited atten- 
 tion to the subject, in an interesting essay " On Pericarditis, a complication and 
 sequela of Scarlatina." Accepting his facts, I should ascribe the articular affection, 
 and the cardiac affection, whether they occurred together or separately, to one and 
 tlie same cause ; namely, to the retention in the blood of a poisonous excrement, by 
 the default of the principal emunctories, and especially of the kidney. 
 
 But certainly the most common, and a very serious sequel of scarlatina, is ana- 
 sarca, sejous infiltration of the subcutaneous areolar tissue, accompanied often with 
 dropsy of the larger serous cavities. So common is this that Cullen has even intro- 
 duced the circumstance as a part of his definition of scarlet fever. He found the 
 dropsy a very manageable complaint ; but it really is, in many — nay, in most cases, 
 if we look to its probable ultimate consequences — a most formidable one. This 
 affection belongs to the class o{ febrile dropsies. It appears to have no relation, or, 
 if any, an inverse relation, to the violence and danger of the preceding exanthem. 
 It is much more common after a mild than after a severe disease. This, in all pro- 
 bability, is owing to the circumstance that less care and caution are observed in the 
 milder cases during the dangerous period of desquamation and convalescence; a 
 •oeriod more dangerous, in that variety of scarlatina, than any other. In the graver 
 cases the convalescence is slower, and more doubtful ; and accidental or carele.-s 
 exposure to cold is more guarded against, or takes place later: whereas, in the 
 slighter kinds of the disorder, the patients are apt to go out while the new cuticle is 
 still forming. If you carefully trace the histories of dropsy succeeding to scarlet 
 fever, you will almost always find that the fever had been trifling ; and that the
 
 1000 SCARLET FEVER. 
 
 patient, considering himself well or nearly so, had heedlessly encountered a cold or 
 damp atmosphere so soon as he fell himself strong enough to leave the sick chamber. 
 Plenciz, who has written well on this subject, and who was quite aware of its im 
 portance, remarks that those patients who have had much desquamation of the 
 cuticle are the most liable to the dropsy ; that it is more frequent in winter than in 
 summer ; and in such as are early exposed to the open air after having passed 
 through the fever, than in those who remain longer at home. When the desquama 
 lion is over, and the new surface has become in some degree hardened, the peril is 
 past. According to the observations of Dr. Wells, the dropsical symptoms com- 
 monly show themselves on the twenty-second or twenty-third day after the commence- 
 ment of the preceding fev^er. They have been known to begin as early as the 
 sixteenth, and as late as the twenty-fifth day. When no dropsy took place before 
 the end of the fourth week, Dr. Wells always ventured to state that it was no longer 
 to be dreaded. 
 
 This anasarca is seldom observed except in children and young persons. The age 
 of the oldest patient that Dr. Wells had known to be so affected was seventeen. Of 
 ten instances of the disease seen by Dr. Blackall, six occurred in children not exceed- 
 ing the age of ten, and two others in persons who were respectively ten and sixteen 
 years old. 
 
 We cannot infer, from this, that the susceptibility of this dropsical condition lessens 
 as years increase. The great prevalence of this variety of dropsy in early life has 
 no direct relation to age as a predisposing cause. The fact is explained by the 
 accidental peculiarities of the antecedent disease. The contagion of scarlet fever is 
 active and widely diffused. Few children escape its agency. Few are capable 
 of taking the disorder a second time. It follows that scarlet fever is rare in adult 
 life : and as dropsy succeeds that disease in a very limited number of instances only, 
 drops}' arising in connection with scarlet fever must, at the adult age, be still mor^ 
 Mncommon. 
 
 Yet it is not unknown. One of Dr. Blackall's ten patients was thirty, another 
 forty-two years old. Both of these were women. 
 
 In this, as in other species of febrile dropsy, the urine is ver\'- constantly troubled, 
 bloody, albuminous ; and it is an interesting fact, that the chronic form of renal 
 dropsy, manifesting itself at some distance of time, has been distinctly traced back 
 to its source in the acute anasarca immediately consequent upon scarlet fever. The 
 sequence has occurred, in all probability, much oftener than it has been noticed. 
 There is scarcely room for doubting that the series of organic changes in the kidney, 
 described by Dr. Bright, do frequently date their origin from an attack of febrile 
 anasarca: and in proportion as facts, accurately observed, accumulate on this sub- 
 ject, the chain of connection becomes more clearly visible between acute febrile 
 dropsy, dropsy succeeding scarlet fever, and chronic renal dropsy. It is evident, 
 indeed, that the first two of these three are, in their characters and exciting causes, 
 identical, the only difference between them consisting in the remarkable predis- 
 position towards the second, impressed upon the body by the preceding exanthem. 
 Both of them again are, in many instances, initiative of the third. 
 
 It is natural therefore to expect that in the variety of lebrile dropsy now under 
 consideration, as well as in those which I formerly described, ii\flammation, and 
 especially inflammation of the serous membranes, should be common, and evidenced 
 by its unequivocal effects. And it is so. But the dropsy, I am persuaded, has no 
 essential connection with common inflammation of any part, unless the state of the 
 kidney be of that kind. I have examined the body very carefullj' in fatal cases, and 
 found the serous cavities full of clear liquid, without a trace of redness or of any of 
 the unmistakeable products, or events, of inflammatory action. 
 
 The earliest threatenings of this formidable complamt demand attention. It is 
 iisualh' preceded, for a day or two or longer, by languor and peevishness ; frequently 
 by nau.'iea and vomiting, and a costive state of the bowels. The pulse, in the out- 
 set, has been found slow, and Beating with irregular intervals ; but it afterwards 
 becomes frequent. The urine, at first, is scant}' as well as altered in appearance. 
 The face becomes pale, and chuffy. Sometimes, as the disease proceeds, violen*
 
 SCARLET FEVER. 1001 
 
 headache, dilatation of the pupils, convulsions, or palsy, denote effusion within the 
 head. Much more frequently the pleurae are the seat of the internal dropsical accu- 
 mulation, and dyspnoea is a prominent symptom. Ascites, to any considerable 
 amount, is rare. 
 
 The contagion of scarlet fever is active, but uncertain. It is not so strong, nor so 
 uniform in its operation, as that of small-pox ; but it seems to be pecuharly subtle 
 and tenacious. Fomites infected with the variolous poison soon lose their power to 
 excite the disease if they are freely exposed to fresh air. But the contagion of scarlet 
 fever lurks about an apartment, or chngs to furniture and clothes, for a very loner time, 
 even after some care has been taken to purify them. Of this I have known several 
 remarkable examples. You will be asked at what period the danger of impartino- 
 the disease on the one hand, or of catching it on the other, is over; and I would 
 recommend you to answer that you do not know. I am sure I do not : and therefore 
 I always decline the responsibility of giving an oracular opinion on the matter. 
 
 I may arrange what I have to say of the treatment of scarlet fever, according to 
 the three varieties of it already mentioned, the scarlatina simplex — anginosa — and 
 maligna. 
 
 The first of these requires nothing more than confinement to the house ; and the 
 observance of the antiphlogistic regimen in regard to diet ; and regulation of the 
 bowels. 
 
 With respect to the management of the severer forms of scarlet fever, great differ- 
 ences of opinion have prevailed. I should recommend you to look into Dr. Williams's 
 book on Morbid Poisons, for some interesting and satisfactory information on this 
 head. Satisfactory to me at least it is, because the result of it goes to justify that 
 kind of practice which I have always considered to be the safest and the best in this 
 disorder. 
 
 Tn the scarlatina anginosa, the treatment I employ is very much the same as that 
 which I consider proper for many cases of continued fever. If the heat of the surface 
 be very great and distressing, I should certainly recommend the cold affusion, but 
 cold or tepid sponging will be very refreshing and beneficial. If dehrium should 
 come on, I would shave the scalp, and apply cold to it, and take away some blood 
 by leeches : and the leeches I would apply to the throat rather than to the temples; 
 for the tonsils, in this form of the disorder, are more swelled and inflamed, and pro- 
 bably a part of the head aff^ection may arise from disturbance of the balance of the 
 cerebral circulation, produced by the tumefaction around the great veins that return 
 the blood from the head. By leeching the throat you relieve that part, and at the 
 same time the head also. U the fever were extreme and the delirium violent, I 
 would take blood cautiously from the arm, while the patient was sitting up, and care- 
 fully watch the effect. 
 
 When none of these untoward head symptoms declare themselves, all that we 
 have to do is to keep the bowels open by moderate laxatives. The patient may take 
 sahne draughts, which are grateful and cooling. The citrate of ammonia thus ad- 
 ministered, is what I frequently prescribe : and if the pulse be without hardness, and 
 feeble, I order an excess of the carbonate of ammonia, so that four or five grains of it 
 in each dose may remain unsaturated by the lemon-juice. 
 
 With respect, then, to this form of the complaint, the principles of treatment are, 
 not to interfere unnecessarily; to take blood when certain symptoms require it, but 
 to take no more than seems likely to be sufficient for the purpose in view ; to bear in 
 mind that the system is labouring under a morbid poison, which we cannot eliminate 
 from the blood, but the dangerous effects of which we are to watch and obviate. 
 
 In that worst form of scarlet fever, the scarlatina maligna, all our care will too often 
 be in vain. There appear to me two main sources of danger. The one arises from 
 the primary impression of the contagious poison upon the body, and particularly upon 
 the nervous system, which is overwhelmed by its influence. The patients sink often 
 at a very early period, with but littla affection either of the throat or of the skin. If 
 we can save such patients at all, it must be by the liberal administration of wine and 
 bark, to sustain the flagging powers until tlie deadly agency of the poison in some 
 measure passes by. But another source of danger arises from the gantrrenous ulrera 
 
 4i2
 
 1002 SCARLET FEVER. 
 
 tion which is apt to ensue in the fauces, when the patient is not killed by the first 
 violence of the contagion. The S3'stem is re-inoculated, I believe, with tlie poisonous 
 secretion from the throat. Now under these circumstances also, quina, or wine — and 
 upon the whole I should give the preference to wine — are to be diligently, though 
 watchfully given. And something may be done, by way of gargles, to correct the 
 state of the throat, and to prevent the distressing and perilous consequences which 
 would otherwise be likely to flow from it. A weak solution of the chloride of soda 
 may be employed for this purpose; and if the disease occur in a child that is not 
 able to gargle, this solution may be injected into the nostrils, and against the fauces, 
 by means of a syringe or elastic bottle. The effect of this application is sometimes 
 most encouraging. A quantity of offensive sloughy matter is brought away ; the 
 acid discharge is rendered harmless ; the running from the nose, and diarrhoea, cease ; 
 and the disease is converted into a form which approximates to the scarlatina angi- 
 nosa. This is a great improvement upon the old plan of ordering capsicum gargles. 
 
 Of late I have been in the habit of directing a solution of the chlorate of potass in 
 water, (a drachm to a pint,) as a drink for patients in scarlet fever, and in the typhoid 
 forms of continued fever. This practice was suggested to me by Dr. Hunt, who 
 tells me he has long emplo5'ed it with advantage. Under the use of a pint, or pint 
 and a half, of this solution daily, I have remarked, in many instances, a speedy im- 
 provement of the tongue, which, from being furred, or brown and dry, has become 
 cleaner, and moist. 
 
 From several distinct and highly respectable sources, chlorine itself has been 
 strongly pressed upon my notice, as a most valuable remedy in the severest forms 
 of scarlet fever. My informants have stated, that whereas they formerly dreaded 
 to be summoned to cases of that disease, they now, having had experience of the 
 virtues of chlorine, felt no misgivings in undertaking its treatment. Since these 
 representations were made to me, I have not had opportunities enough of trying 
 this drug to enable me to speak confidently of its sanative power ; but I shall cer- 
 tainly employ it in future. I presume that its disinfecting properties may, in part, 
 account for the good it does. It probably deprives the foul secretions of their noxious 
 qualit3^ 
 
 In the fourth volume of the Medical Gazette, INIessrs. Taynton and Williams, of 
 Bromley, write in high praise of this remedy. I will give you the formula for its 
 preparation. 
 
 Two drachms of the chlorate of potass are to be dissolved in two ounces of 
 hydrochloric acid, previously diluted with two ounces of distilled water. The solu- 
 tion must be put imm.ediately into a stoppered bottle, and kept in a dark place. 
 
 Tv\'o drachms of 'this solution, mixed with a pint of distilled water, constitute the 
 chlorine mixture ; of which a tablespoonful, or two, according to the age of the pa- 
 tient, may be given for a dose, frequently. 
 
 We must not omit, in this, as well as in the other forms of the complaint, to 
 pay attention to the state of the bowels, and by no means to allow them to remain 
 costive. 
 
 I have seldom used blisters in this disease ; but an experienced phj'sician has 
 lately told me that, when appli'^d early to the neck and throat, they seem to render 
 the affection of the fauces mild. 
 
 When the patient is at length convalescent, he will require careful watching till 
 that period has gone by at which the dropsical symptoms are apt to appear. It is 
 by neglect or imprudence that these symptoms are brought on. The patient should 
 be sedulously protected from all exposure to cold, and wet, and fatigue ; indeed he 
 ought not to be permitted to go out of the house until the process of desquamation 
 is fairly over ; and I would not willingly let a patient go out till some little time after 
 ihis. AVhen dropsical symptoms do occur, if they be very slight, they may be re- 
 moved in general by purgatives, and by digitalis. The hitartratc of potass is a good 
 remedv too in such cases, and the use of the warm bath, v.-hich may be repeated 
 every night. 
 
 But if there be anj- indication of inflammatory disease within, we must adoj/4 
 •^nore active measures. We have not, now, to contend with the depressing influence
 
 SCARLET FEVER. 1003 
 
 of the 6riginal poison, but we have to dread the consequences of acute inflammation ; 
 or of the sudden effusion of fluid, the mere presence and pressure of which may 
 fatally oppress vital organs. We should have for our object to arrest the inflamma- 
 tion — or to promote the removal of the effused fluid — by blood-letting, and by the 
 exhibition of purgative medicines, and of mercury. The worst case of this kind that 
 I ever witnessed occurred in a boy of fifteen, the son of a tradesman in my neigh- 
 bourhood. He had had scarlet fever, mildly, and had got well, or nearly well, of it, 
 as he believed ; and he went, one evening, into his father's stable, and stayed there 
 some time in the cold, during the period of desquamation. A day or two afterwards 
 he began to have headache, and in a few hours more was seized with convulsions 
 of one side of the body, coma, and at length hemiplegia ; and his face and extremi- 
 ties became at the same time anasarcous. A large quantity of blood vi'as taken from 
 his arm, he was cupped on the temples, and took mercury, till in a short space of 
 time he was profusely salivated. Under this treatment the coma and dropsy rapidly 
 disappeared, and he presently recovered the use of his palsied limbs, and got quite 
 well. I make no doubt that some effusion took place within the cranium, as well 
 as into the subcutaneous areolar tissue. The plan of treatment followed in this 
 case, modified according to particular circumstances, is that which I should again 
 pursue, and therefore what I should recommend you to pursue, in similar emer- 
 gencies. 
 
 You are probably aware that belladonna is believed by many to exert a preventive 
 and protecting influence upon the body against the contagion of scarlet fever. Hah- 
 nemann, the author of the Homoeopathic hypothesis (and thereby of much mischief 
 to mankind), was the first to assert this. It is said that belladonna administered in 
 small doses causes sometimes a rash resembhng that of scarlatina. It certainly is 
 apt to produce dryness and redness of the fauces. I know nothing by my own expe- 
 rience of the alleged conservative power of this vegetable ; but, in the small quan- 
 tities recommended, there can be no harm in trying h, provided that its employment 
 does not lead to a neglect of other precautions. Three grains of the extract of bel- 
 ladonna are dissolved in an ounce of distilled water; and three drops of the solution 
 are given twice daily to a child under twelve months old, and one drop more for 
 every year above that age. It is affirmed that if this remedy does not prevent the 
 disease, it will render it mild ; and that if it be taken four or five days before exposure 
 to the contagion, the resulting scarlatina never proves fatal. 
 
 [The question in relation to the prophylactic properties of the belladonna in this disease 
 is a highly interesting one. The severe and fatal character of scarlet fever, particularly when 
 it occurs as an epidemic, renders every means of prevention that can be depended upon 
 with any degree of certainty, of vast importance. In proof of the power of the belladonna 
 to guard those who have been placed under its influence from an attack of scarlatina, we 
 have certainly some very strong and respectable testimony. In a paper published by 
 Bayle, in 1830, it is stated that of 2027 individuals to whom the belladotma was adminis- 
 tered, 1948 were preserved from scarlet fever, and 79 were attacked. Dusterberg reports, 
 tliat all who were placed under the influence of the belladonna for the space of two weeks, 
 were preserved from the scarlet fever. In order to ascertain the real value of the article, he 
 purposely omitted to administer it to one child in ea,ch family, and this one alone, according 
 to his report, was seized with the disease. He adds, however, that occasionally a child 
 who had only been taking the remedy during three or four days, was attacked, but the fever 
 was in such cases always mild, and often only manifested its presence by the occurrence 
 of desquamation. Zeuch, physician to the Miliary Hospital for Children, in Tyrol, after 84 
 of the cliildren were attacked with scarlet fever, was induced to try the prophylactic powers 
 of belladonna on the remaining 61 children: with a single exception, all of these were 
 preserved from the fever, although it prevailed all around them. Schenk, Berndt, Kiihler, 
 JVIeglin, De Lens, and many other respectable practitioners, speak in equally high terms of 
 the preservative properties of the belladonna. We have ourselves given the belladonna to 
 a number of children, on several occasions when the scarlet fever was prevailing epid°mi 
 caily, witli a view of testing its prophylactic powers; but although redness and dryness oi" 
 the throat, and a diffuse scarlet effervescence were produced by it, yet in the majority of 
 cases, we never found it in any instance to exhibit the sliglitest influence in shielding those who 
 took it from an attack of the disease, or in mitigating in any degree its severity. In one case, 
 the efflorescence produced by the belladonna was kept up for forty-eight hours; in a week 
 afterwards the child was attacked bv the fever in its most violent form, and died on the >biir».)i
 
 J 004 ERYSIPELAS. 
 
 day. Recently, however, Dr. Stievenart, of Valenciennes, has published the results of a 
 very extensive trial of the belladonna, as a prophylactic during the prevalence of epidemic 
 scarlatina: Avhich results, if they are correctly stated, and all sources of error have been 
 carefully guarded against in tlie performance of the experiments upon vi^hich they are 
 founded, go very far to prove that the belladonna does actually possess the property of 
 shielding the constitution from an attack of scarlet fever. An epidemic of the disease 
 ravaged, during the winter of 1840-1, several villages in the neighbourhood of Valen- 
 ciennes, when Dr. Stievenart was induced to try the prophylactic properties of belladonna. 
 The fatality of the epidemic was such that 30 had already died out of 96 attacked ; conse- 
 que,ntly any means of prevention was a subject of vast importance. In a small village, 
 out of 250 individuals, 200 took the belladonna, and were all preserved from the attack of 
 scarlet fever. Of the fifty others, 14 were seized with the fever, and four of them died. At 
 the village of Curgies, Dr. Stievenart administered the belladonna to the children at the 
 public school, and allowed them to continue at their lessons, and have free co<nraunicatioa 
 with the other children of the village. All to whom the belladonna was r^ministered 
 escaped the scarlet fever, while a few who refused to take it were seized with th«5 disease. 
 
 The belladonna was administered in two forms — in solution, or as a powder. Two grains 
 of the recent alcoholic extract of belladonna were dissolved in an ounce of any aromatic 
 infusion, and of this two drops were given to a child of one year old, daily, for niie or ten 
 days : an additional drop being given for every additional year of age. The largest daily dose 
 was, however, limited to twelve dro]TS. When the belladonna was used in the form of 
 poMaler, half a grain of the powdered root was mixed with a small quantity of sugar, and 
 , divided into ten doses. One of these was given — morning and evening — to children of 
 from one to two years old; two powders, at the same periods, to those from three to five; 
 three powders to those from six to nine ; four to those from ten to fifteen, and five to 
 adults. These small doses never produced the toxocological effects of belladonna ; in fact, 
 they scarcely exhibited any marked action. In five or six cases Dr. Stievenart observed a 
 rash similar to that of measles ; and, in a few other cases, headache, with dilatation of the 
 pupils, dryness of the fauces, and a slight soreness of the throat, but which had no resem- 
 blance to that of scarlatina anginosa. In all the other cases no sensible or apparent effect 
 resulted from the administration of the remedy. Dr. Stievenart, generally, continued xhe 
 use of the belladonna for from nine to ten days ; in some cases, it was given for fifteen days. 
 He thinks this period sufficiently long to put the system under the influence of the preserva- 
 tive powers of the remedy : but recommends to resume its use if the epidemic returns or 
 breaks out again with renewed violence. — C] 
 
 LECTURE LXXXIX. 
 
 The Plague. Erysipelas. Erythema Nodosum. Urticaria. Prurigo. Scabies 
 
 Of that group of contagious exanthemata of which I undertook to give you some 
 general account, two only remain to be noticed, viz., the plague and erysipelas. 
 
 Concerning one of these, the plague — as I have never seen, and hope never to 
 see it ; and as, with Cullen, I " think it unfit for a person who has never seen the 
 disease to atietnpt its particular history" — I shall not presume to offer you any obser- 
 vations in detail. It is a very malignant kind of contagious fever; prevailing, at 
 certain times and places, epidemically ; attended with a sort of eruption, namely, 
 with buboes and carbuncles ; and not furnishing, apparently, any sure or permanent 
 security acrainst its future recurrence. In Dr. Forbes' Select Medical Bibliography, 
 you will find a long list of works on the plague, I would second Dr. Culien's 
 recommendation, that you should consult those authors only who have themselves 
 had personal experience of the disease. Among the publications that fall within 
 this rule may be mentioned. Dr. Russell's History of the Plague as he saw it in 
 Aleppo ; Sir James M'Grigor's Medical Sketches ; Sir Arthur Brooke Faulkner's 
 Account of the Plague which occurred at Maka in 1813; Desgenettes' Histoire 
 Medicale de I'Armee d'Orient ; and Assalini's description of the malady as he wit- 
 nessed it when in attendance upon the French army in Egypt,
 
 ERYSIPELAS. 1005 
 
 I proceed, therefore, to erysipelas. And I wish, in the first place, to fix and define 
 fhat specific complaint of which alone I propose at present to speak. The term ery- 
 sipelas has been employed by medical men in a very loose and vague manner. Any 
 diffused redness and inflammation of the skin is apt to be set down as erysipelas ; 
 and hence we have disputes as to the distinction between erysipelas and erythema. 
 But it would tend, in my humble judgment, to the formation of more settled opinions 
 in respect to erysipelas, if the term were restricted to that disease in which the inte- 
 guments of the yace and head become diffusely inflamed. The phrase erysipelatous 
 inflammation may properly enough be applied to other cases, similar to this, in so 
 far as the condition of the shin is concerned ; but in what I should consider true 
 erysipelas, in the medical sense of the word, there are other characters belonging to 
 the disorder, quite as important as, and more distinctive than, the cutaneous affection. 
 What is usually spoken of as erysipelas of the face and head, and what I would 
 call simply erysipelas, falls naturally within that group of exanthematous diseases 
 which includes small-pox, measles, scarlet fever, the plague, and continued fever. 
 It is an idiopathic inflammatory disorder, running a tolerably regular and definite 
 course; attended by inflammation of the integuments of the body, or, in other words, 
 by an eruption; ohen prevailing epidemically, and capable of being communicated. 
 under circumstances favourable to its propagation, from one person to another. Its 
 power to protect the constitution from its own recurrence is less certain ; but in truth, 
 so many different affections have been lumped together under a common name, that 
 the proper phenomena of true erysipelas have not been made sufficiently an object 
 of separate study to enable us to speak with any confidence on this point. I recol- 
 lect, however, a certain female who has been three or four times my patient in the 
 hospital with erysipelas : and one of the night nurses there, whom I treated for that 
 complaint some time ago, is now lying ill of the same disorder, under the care of one 
 of my colleagues. 
 
 Erysipelas, in the sense now explained, called in Scotland the rose, and in this 
 country St. Anthony^s fire, resembles other disorders of the same group in these 
 points also, that the fever precedes the local inflammation, that certain premonitory 
 symptoms frequently go before the outbreak of the disease, and that sore throat is an 
 early, and almost a constant, accompaniment of the complaint. The patient feels ill — 
 shivery, feeble, languid, and often drowsy. The actual attack generally sets in with 
 distinct rigors ; and the pulse is often very frequent from the first, for many hours, 
 perhaps, before the redness commences. Very commonly there is also manifest dis- 
 turbance of the alimentary canal, marked by nausea and vomiting, and not unfre- 
 quently by diarrhoea. Then some part of the face, usually one side of the nose, or 
 one cheek, or the rim of one of the ears, begins to feel hot, stiff", and tingling: and upon 
 examining it you find it to be of a deep continuous red colour, and to be swelled and 
 hard. The redness and swelling gradually, and sometimes rapidly, extend them- 
 selves : they are defined by a distinct elevated margin ; which advances, and invades 
 progressively the neighbouring heakhy surface, until the whole of the fa^e, or of the 
 scalp, or of both, is occupied with the inflammation. The lips swell enormously, 
 the cheeks enlarge, the eyes are sealed up by their oedematous and prominent Hds, 
 and all traces of the natural countenance are effaced. I know of no disease, except 
 perhaps the confluent small-pox, which so completely and speedily deforms and dis- 
 guises the visage of the patient. A stranger seeing a young female in the height of 
 the disorder, and revisiting her after her recovery, is astonished at the change. It 
 seems as if, by some magic process, such as we read of in our nursery tales, a hide- 
 ous monster has been metamorphosed into a comely damsel. 
 
 The inflammation frequently spreads from the face and forehead, or ears, to tlie 
 hairy scalp ; and from the head it travels backwards, in some cases, to the neck and 
 the shoulders. Sometimes — and in this it exactly resembles a scald — the inflamed 
 surface becomes covered with irregular bullae, or blisters ; but often there is no vesi- 
 cation. This circumstance, therefore, which has been mentioned by some as fui 
 nishing a point of distinction between erythema and erysipelas, fails of that purpose. 
 
 In many cases the inflammation is quite superficial : in others it dips, as it were, 
 through the skin, and affects the subcutaneous areolar tissue ; and then, and there
 
 1006 ERYSIPELAS. 
 
 suppuration, and even sloughing of that tissue, are apt to take place. We find this 
 to be the case often in the loose tissue of the eyelids ; and it is more common on the 
 scalp perhaps than on the face. 
 
 Afier the redness has lasted three or four days, it fades, the sv/ollen surface sub- 
 sides, and desquamation ensues ; and as the inflammation creeps, perhaps, gradually 
 from one part of the surface to another, you may find the face becoming pale, and 
 covered with patches of dead cuticle, while the scalp, or the upper part of the neck, 
 is becoming red. Sometimes those parts of the inflamed surface on Avhich bhsters 
 had formed are covered with crusts, rather than with merel}'' dead and dry cuticle. 
 In almost all these cases of erysipelas of the head and face there will be found to be 
 redness and soreness of the throat also; although this is not always inquired into, 
 or complained of. 
 
 There is considerable variety in the intensity and complication of the symptoms. 
 Sometimes the suff^erer lies patiently still, yet apparently conscious and rational, till 
 the tumefaction diminishes, and he is again able to open his eyes. Generally there 
 is some wandering of the mind, especially at night ; and in bad cases there is much 
 delirium, and at length complete coma, and the patient dies at the end of a few days. 
 In some of these cases the inflammation has extended to the encephalon ; in others 
 it is probable that the functions of the brain are disturbed through the febrile derange- 
 ment of the circulation. When death takes place, and the head is examined, serous 
 fluid is usually discovered beneath the arachnoid, and in the cerebral ventricles ; and 
 the veins of the pia mater are turgid. I have stated before that I doubt whether 
 such appearances are always to be attributed to inflammation. Sometimes there are 
 no morbid appearances at all within the skull. 
 
 It is said that the erysipelas does, now and then, suddenly desert the surface; and 
 that inflammation of some internal part, and particularly of the brain, is apt to follow 
 such rapid subsidence of the external malady. I presume that this metastasis is 
 rare. I do not recollect to have seen it. But the extension of the inflammation, the 
 supervention of delirium and coma, while the external inflammation continues, are 
 of common occurrence. 
 
 This, then, is one way in which erysipelas is accustomed to prove fatal ; by efTu- 
 sion within the head, and coma. 
 
 And there is another mode in which death is not unfrequently brought about, and 
 which has not been so much attended to ; I mean by the affection of the throat. 
 The patient dies sometimes almost suddenly; unexpectedly; you cannot account for 
 the unlooked-for dissolution. But if the throat be examined you may (sometimes at 
 least) there discover the solution of the mystery. The sub-mucous tissue of the 
 glottis and epiglottis is filled with serum, the chink of the larynx has been nearly or 
 completely closed, and the patient has died of apncea. This is just analogous to 
 what takes place externally : the enormous sAvelling of the eyelids, and lips, and 
 face, is owing, in a great degree, to serous fluid poured out into the swh-cutaneous 
 areolar membrane. 
 
 Another Avay in which erysipelas may kill, is by gradual asthenia. Without any 
 stupor or much wandering, without any marked affection of the breath, the pulse 
 becomes weaker and weaker, the surface cold, and the heart at length ceases to pul- 
 sate. This mode of dying is less common in this disorder than the other two. 
 
 The causes of erysipelas are various, and often obscure. I have stated that it is 
 tjommunicable, by contagion, from person to person : yet this contagious property is 
 so feebly marked, that it is denied by many. It is more active at certain times, at 
 certain seasons, at certain places, than at others ; which is the same thing as to say 
 that there are predisposing causes of the disease; that there are influences which 
 augment the susceptibility of the body to the agency of the poison. 
 
 I believe that on the continent they do not allow erysipelas to be contagious at all ; 
 but very satisfactory evidence of the fact has been collected by several of our own 
 practitioners. In the second volume of the Tratisactions of a Society for the Im- 
 provement of Medical and Chirurgical Knowledge, Dr. Wells has brought together 
 several examples in which the complaint appeared to be unequivocally propagated 
 'iy contagion. "I visited (says he), on the 8th of August, 1796, in Vine street,
 
 ERYSIPELAS. 1007 
 
 Clerkenwell, an elderly man, named Skelton, who had been attacked several days 
 before with erysipelas of the face. In about a week afterwards he died. On the 
 19th of the following month, I saw a Mrs. Dyke, of about seventy years of age, the 
 landlady of the house in which Skelton had been a lodger, and found her labouring 
 under an erj^sipelas of her face. I inquired whether any person in her house had 
 been ill of the same disease since the death of Skelton, and was told that his wife had 
 been seized with it a few days after his decease, and had died in about a week. 
 During my attendance upon Mrs. Dyke, an old woman, her nurse, was attacked with 
 the same disorder, and was sent to her parish-workhouse, where she died. Mrs 
 Dyke has since informed me that a young man, the nephew of Skelton, was taken 
 with the disease of which his uncle had died, shortly after visiting him, and survived 
 the attack only a kw days. That she herself had been several times with Skelton 
 and his wife during their sickness, and after their death had removed some furniture 
 from the room they had occupied to her own apartment." Dr. Wells relates other 
 histories of the same kind, all occurring when there was no particular epidemic of 
 erysipelas prevailing to account for them. Professor Arnott has given some other 
 examples, still more striking, of the propagation of erysipelas from one person to 
 another, not only under the same roof, and in the same locality, but also when the 
 parties lived at a distance from each other, and the intercourse between them had 
 been casual and temporary. These cases are stated, I think, in the fifty-seventh 
 volume of the London Medical and Physical Journal. The following incident has 
 been told me upon good authority. A man living somewhere in Westminster fell ill 
 of idiopathic erysipelas. In that state, for some reason or other, he was removed 
 thence ; and his brother, who was a servant in or near Portland Place, received him 
 clandestinely into his master's house, and allowed him (for two nights, I believe) to 
 share his bed. That brother was soon attacked with erysipelas; and in the course 
 of his illness was visited by his master. The master also was attacked ; and it is 
 worthy of remark, that in both master and servant the disease showed itself just 
 seven days after they had respectively come near another who was a&cted with it. 
 Dr. Elliotson gives an account of having suffered the disease in his own person. It 
 came on in him five days after the bseath from one of his patients, over whom he 
 was stooping to examine the skin, and who had erysipelas badly, and died of it, had 
 come upon his face. " I turned away (he says) disgusted, and said, I hope I have not 
 caught it ; but five days afterwards, having forgotten the circumstance, I was seized 
 with it." More than once I have had occasion to remark that successive tenants 
 of the same bed in a hospital have been seized with erysipelas after admission. 
 
 But allowing, as 1 think we cannot but allow, that contagion is one of the exciting 
 causes of erysipelas, there are others which more frequently excite it. At least there 
 are many instances of the disorder in which we can trace no exposure to contagion, 
 and in which we can perceive some other probable reason for its occurrence. Some- 
 times, no doubt, it comes on without any obvious cause. The application of cold 
 often gives rise to it. Irregularity of diet is said to do the same. Violent mental 
 emotions are also accused of being occasionally its cause : it is said to have been 
 brought on both by anger, which is an exciting, and by fear, which is a depressing, 
 passion. It is incidental to what I have called purulent infection of the blood. Many 
 cases, not to be distinguished in their appearances and eflects from idiopathic erysi- 
 pelas, result from local injury. I have already told you that there is no inconsistency 
 or absurdity in supposing that a disorder which originates in some common cause, 
 may be capable of spreading in the way of contagion. And the testimony of Mr. 
 Lawrence (who is not prone to admit of contagion on light grounds) goes to the effect 
 that such is the case with the disease in question. He mentions an instance m which 
 erysipelas of the head and face, which commenced after the insertion of a seton in 
 the neck, appeared to him to have affected two individuals by contagion. 
 
 I say that erysipelas further resembles the disorders of the group in which I have 
 placed it, that it sometimes prevails epidemically : and on those occasions, like tho 
 rest of the group, its occurrence is promoted by all circumstances that tend to debili- 
 tate the body : by intemperance ; by previous disease ; by low spirits and anxiety , 
 hy insufficient nourishment ; and by foul air. It used to be much more common
 
 1008 ERYSIPELAS. 
 
 formerly in hospitals than it is at present ; when less attention was paid to cleanliness 
 and ventilation. 
 
 Er3'sipelas is another of the diseases concerning the treatment of which there has 
 been, and there is, a most embarrassing difference of opinion. Some, prescribino- 
 according to a name, tell you that it is inflammation, and therefore that the remedies 
 of inflammation, and especially blood-letting, are to be vigorously emploj^ed. Others 
 declare that the safety of the patient hes in the early and hberal administration of 
 wine and bark. You will not think me a trimmer, I hope, or one who is content 
 with indecisive practice, when I state that neither of these plans, in my judgment, is 
 universally either proper or safe ; yet that each of them is the best, under certain cir- 
 cumstances. 
 
 I think the more you see of this disease the more convinced you will be that it ia 
 not to be cut short by any particular mode of treatment ; that it ivill run a certain 
 course ; and that it will generally terminate sooner or later, by resolution, whether 
 remedies be employed or not. It does not follow from this that i^medies are of no 
 use : but it does follow that we are to exhibit them, not with the view of curing the 
 disorder, but with the view of conducting it safely to its termination. 
 
 If you look at the history of erysipelas, and of the notions which have prevailed 
 respecting it, you will find that the opinions in favour of giving support, and of ab- 
 staining, as much as possible from the abstraction of blood, greatly preponderate. In 
 the outset of the complaint, if the pulse be hard as well as frequent, and there be 
 much headache, and active delirium, you must take blood either from the arm, or 
 from the neck by cupping, or by leeches from behind the ears. But (I speak of the 
 disease as it occurs in London) the time for this kind of practice soon passes by : and 
 when you do bleed from the arm, you must (in this town) bleed with caution, and in 
 the upright posture ; that the desired effect may be produced by the abstraction of 
 the smallest quantity of blood. 
 
 In all cases it will be right to purge the patient briskly at the commencement. 
 A full dose of neutral salts, or of rhubarb atid magnesia, will answer better, I think, 
 in these cases, than calomel and senna. If j-ou see the patient very early, and if 
 there be any nausea or oppression of the stomach, it will be proper to administer an 
 emetic. 
 
 In most instances you will soon perceive evidence of great debility : a feeble as 
 well as di frequent TpVihe ', tremors; a dry and brown tongue often. And these 
 symptoms increase, if you then persist in drawing blood. The carbonate of am- 
 monia does great good sometimes in such a condition : and this I am very much in 
 the habit of giving. The bad cases of erysipelas are apt to baffle us all. I am not 
 aware that I lose more of them than my neighbours. Speaking generally, a large 
 majority of my patients get well ; but I do not bleed one patient in a hundred, from 
 the arm. 
 
 I am bound, however, to set before you the kind of evidence which exists in favour 
 of the bark ; or rather of the sulphate of quina, which is what I mean when I speak 
 of the bark. 
 
 Dr. Fordyce, Dr. Wells, Dr. Heberden — all men of great sagacity and experience 
 -recommend the treatment by bark. Dr. Jackson, an American physician, advn 
 r^tes, I see, the same plan. He says that after a purge, and, if necessary, an emetic, 
 the sulphate of quina should be given in as large doses as the patient will bear; that, 
 from twelve to twenty-five grains in the twenty-four hours will generally suffice ; and 
 that we may know when the dose is sufficient by a buzzing which comes on in the 
 ears. Dr. EUiotson also — whom I here quote the more willingly because I think he 
 is rather of an antiphlogistic turn than otherAvise, in general — says, that he has never 
 seen quina do harm, even in active tonic erysipelas ; and that in doubtful cases, when 
 you hesitate whether to bleed and put the antiphlogistic plan in force, or to stimulate 
 and support, the quina is always a safe and eligible medicine. Dr. Williams, of St. 
 Thomas's Hospital, thinks better still of wine, which he gives in all cases from the 
 very beginning. 
 
 I have hitherto limited my observations to erysipelas of the face and head as it 
 occurs in London : and I have done so because I really believe that in the purer
 
 ERYSIPELAS. 1009 
 
 air of the country, and in young, strong, vigorous country persons, bleeding may be 
 proper and requisite. You will find country practitioners pretty well agreed on this 
 point. 
 
 But taking the disease as I see it here, I should say that many cases do well with 
 but little care or interference from medicine ; that many also, but a fewer number 
 than the former, prove fatal under whatever plan of treatment may be adopted ; and 
 that many patients are to be saved, by judicious management, who would otherwise 
 die. 
 
 The first requisite for rescuing these perilous, yet recoverable cases, is that they 
 should be perpetually watched and tended. The indications of treatment may alter 
 from one hour to another, and it is only by great vigilance on the part of the medical 
 attendant, and on the part of an intelligent and obedient nurse, that medicine obtains 
 its full chance of bringing the patient through. 
 
 After clearing out the alimentary canal, then, I would not be active in either way, 
 unless I saw some plain indication for activity. If the pulse became weaker, and I 
 did not feel sure about the propriety of stimulating, I would give five or six grains 
 of the carbonate of ammonia every four hours, and beef-tea. If the disease went on 
 smoothly under that treatment, well and good. If the powers still continued to sink, 
 I should have recourse to wine, or to both bark and wine ; but of the two, I am more 
 friendly to wine ; and as the patients like it better, you may be more sure of their 
 taking it. If, on the other hand, there were much headache, and the pulse were 
 hard, and the febrile distress great, I should apply a few leeches, and prescribe the 
 tartarized antimony in a saline draught. The bowels should not be allowed tq be- 
 come confined; but the mild aperients are better than the drastic in these cases. 
 
 Various external medicaments have been used and recommended for the inflamed 
 part. Putting leeches upon it ; puncturing it with needles, or lancets ; covering, or 
 surrounding it with blister, or with the lunar caustic in substance or in strong solu- 
 tion ; dusting the surface over with magnesia, or flour ; smearing it with various 
 unguents, and particularly with mercurial ointment; keeping it wet with some cold 
 lotion ; or fomeniing it with hot flannels. 
 
 Now of all these local appliances, that which, according to my own observation, 
 is the most useful, and which affords the greatest comfort to the patient, is the last 
 that I mentioned ; fomentation by flannels wrung out of a hot decoction of poppy- 
 heads. But in order to give this, also, fair play, it should be continual; not used 
 for half an hour, and then intermitted ; but it should be one person's business to 
 apply the fomentation assiduously, as long as it is soothing and grateful to the pa- 
 tient. In a few cases, and but a few, the warm appHcations have been disHked, and 
 cold lotions preferred ; and when such is the case, there is no risk incurred by usinw 
 them, so far as I know ; no hazard, I mean, such as you may read of, of the inflam- 
 mation being repelled from the surface, and driven in upon some vital organ. The 
 local treatment most in favour with our apothecary at the hospital is that of covering 
 the inflamed face and head with flour, by means of a dredging-box. The patients 
 declare that the flour cools, soothes, and comforts them. Now this is a more conve 
 nient, and, in some respects, a more eligible, application than that of hot flannels 
 It is less hkely to fail of its purpose through the negligence of the nurse. 
 
 [Keeping the inflamed surface constantly covered with perfectly fresh hof,"s lard, has 
 a very soothing effect, and tends to reduce the violence of the inflammation. We have 
 occasionally employed an ointment formed of acetate of lead fifteen grams, rubbed up with 
 one ounce of hog's lard, and have been pleased with its effects. — C] 
 
 So much for erysipelas, as it usually comes under the notice and the manao-ement 
 of the physician. You are aware that an affection of the skin very similar to thai 
 which I have been describing, and called also by the same name of erysipelas, is 
 very common in other parts of the body ; on the extremities especially, and occa- 
 sionally on the trunk : and it will travel sometimes from an extremity till it reaches 
 the head. These varieties of cutaneous inflammation are, in most instances, the 
 indirect consequences of some local injury ; of punctured wounds ; of the stings of 
 insects, or the bites of venomous reptiles : of mere scratches sometimes. Or th« 
 cutaneous inflammation will spread from old sores ; or supervene upon dropsica! 
 64 4 k
 
 1010 ERYSIPELAS. 
 
 limbs. It is curious that these complaints also are much more apt to occur, and 
 oven to multiply by a sort of contagion, or in virtue of some epidemic atmospheric 
 influence — at certain times and places than at others. You will find there are pe- 
 riods when the surgeons of hospitals dread to perform any operation, lest it should 
 be followed by this spreading inflammation of the skin. There are many points of 
 great interest connected with these diversified forms of what is called erysipelas ; 
 they are more liable to be attended with gangrene than erysipelas of the face and 
 scalp: on the other hand, they are more liable also to be complicated with inflam- 
 mation of the subcutaneous areolar tissue, and with suppuration ; and to require 
 incisions to relieve the great tension of the inflamed parts, and to facilitate the escape 
 of the pus, or of sloughy dead portions of areolar tissue; but all these r^:atters be- 
 long rather to surgery, and have been discussed, I make no doubt, by the Professor 
 of Surgery. 
 
 [Erysipelas is of frequent occurrence in the earlier period of infancy, and is among the 
 most fatal of the diseases which occur at that period. It very generally terminates in death 
 especially when it occurs during the first month. Its danger gradually diminishes as the 
 child advances in age, but even when it attacks after the fourth month, the greater portion 
 of the cases terminate fatally. • 
 
 The invasion of the disease is always extremely insidious. The child appears somewhat 
 morose ; his sleep is slightly diminished, and he sucks rather less than before ; with these 
 trifling symptoms, there is associated a small patch of redness upon the pubes, which is 
 painful upon pressure. The redness gradually spreads over the abdomen and thighs, and 
 is, occasionally, disseminated. When the redness extends to the hands and feet, these parts 
 acquire a degree of redness and swelling far greater than that of any other part. The geni- 
 tal organs, in some cases, sphacelate, in consequence of the local inflammation, and in many 
 acquire an emphysematous appearance. In place of appearing first upon the pubes, the 
 erysipelas has been known to extend from the areola of the vaccine vesicle, less frequently 
 from any accidental laceration of the skin or from the excoriations so common in the cuta- 
 neous folds of the groin and other parts. 
 
 The disease at first ajjpears perfectly local — it is not until several days have elapsed, that 
 general uneasiness and fretfulness present themselves. The colour of the skin, and the 
 expression of the countenance, often remain for some days without exhibiting any striking 
 change, when, suddenly, an ashy cadaverous paleness is observed ; the child cries inces- 
 santly, there is constant jactitation, and complete loss of sleep. These symptoms are suc- 
 ceeded by deep stupor and death. The pulse is at first frequent, and the heat of the skin 
 sinks only during the fatal stupor which precedes death. Convulsions, diarrhoea, and vomit- 
 ing are seldom observed. When the progress is such as we have described, peritonitis has 
 occurred — which is, according to M. Trousseau, a frequent disease in children, and one 
 which has not hitherto been accurately described. The duration of infantile erysipelas 
 varies considerably, sometimes being extremely short, in others, on the contrary, being pro 
 longed to the end of the week. 
 
 In post-mortem examinations, the cutaneous disease is occasionally the only morbid change 
 detected ; but when peritonitis (a frequent complication) has occurred, the umbilical vein 
 is often found inflamed, and filled with pus, as far as the transverse furrow of the liver 
 while inflammatory exudations are found on the peritoneal stirface of the abdominal viscera 
 
 According to IM. Trousseau, infantile erysipelas is principally observed when puerpera. 
 fever prevails in the wards of the lying-in hospitals of Paris. The infants appear to inherit 
 from their mother a purulent diathesis, and seem to be still, within certain limits, subject tc 
 the same maladies as the mother, whose constitution has so lately been theirs. The peri- 
 tonitis of the infant may be, therefore, as properly termed puerperal as that of the mother, 
 because its general cause is to be sought for in the circumstances which have accompanied 
 the last stage of child-bearing, and parturition. It is natural that the skin should be the seat 
 of disease, from its having been so recently called upon to the performance cf functions as 
 new as they are important. 
 
 In the infants predisposed to erysipelas, the umbilical cicatrix does not form readily, and 
 the ulceration which results is sometimes the occasional — the local cause — of the cutaneou.' 
 disease. 
 
 Dr. F/'ebe {Journal fur Kinderkrankheiten) describes a form of erysipelas which commence! 
 about the umbilicus, within a few weeks after birth, and is frequently accompanied with 
 ulceration of the navel, and infiltration of lymph or pus into the subcutaneous cellular tissue, 
 and deposus of a similar nature in the partially obliterated umbilical vessels. It is attended 
 with great and rapidly increasing exhaustion, and occasionally convulsive symptoms of more 
 or less severity. It is most generally fatal ; often within the course of forty-eight hours, and 
 M-ithout having extended more than three fingers' breadth around the navel. 
 
 Dr. Friebe is inclined to view this form of infantile erysipelas as a variety of partial indu-
 
 ERYSIPELAS. 1011 
 
 ration of the cellular substance, in consequence of the cachectic condition of the infants in 
 whom it usually occurs, and the peculiar character of the inflammation — while the circum- 
 stance of the umbilical vessels being, in fact, converted into fibrous cords, previously to the 
 commencement of the disease, leads him to believe that it cannot arise from the umbilical 
 phlebitis. 
 
 We have met very frequently with this form of infantile erysipelas among the children of 
 the poor, and our observations have convinced us that, in the majority of cases at least, it is 
 dependent upon phlebitis of the umbilical vessels ; the evidences of inflammation of the 
 latter were unquestionably present in almost every instance in which we have made an 
 examination. 
 
 In regard to the treatment of infantile erysipelas, although in those cases in which the 
 disease occurs soon after birth there is but little chance of saving the life of the child, yet 
 when the patient is a few months old, we may do much in arresting the progress of the dis- 
 ease, and conducting it to a favourable termination. 
 
 We may remark, however, that erysipelas is always to be considered a dangerous disease 
 during infancy, but more particularly when it occurs in infants of a weakly and unhealthy 
 Habit of body. 
 
 The bowels should be freely opened by a grain or two of calomel, followed in a few 
 hours by a teaspoonful of castor oil, or a simple laxative enema, and they should be kept in 
 a free condition subsequently, by the exhibition, every three hours, of divided doses of calo- 
 mel, combined with minute doses of ipecacuanha and extract of hyosciamus — the addition 
 of the latter is calculated to prevent or allay irritation, without interfering with the aperient 
 action of the calomel. When the skin is warm or dry, the liquor acetatis amoniae alone, or 
 combined with antimonial wine, will often prove beneficial, as will also the occasional use 
 of the warm or tepid bath. 
 
 If symptoms of cerebral disease should occur, a leech or two should be applied to the 
 temples, — cold applications to the scalp, — the bowels should be freely opened by calomel, 
 followed by castor oil, or purgative enemata, and warm sinapised pediluvia should be 
 resorted to. 
 
 In a few cases where the parts occupied by the disease are decidedly red and swollen, a 
 few leeches applied upon the sound skin, in the neighbourhood of the inflammation, will 
 often prove beneficial. Much judgment, however, is required, to discriminate the kind of 
 cases which are likely to be benefited by local depletion. As a general rule, a very mode- 
 rate abstraction of blood will be sufiicient. 
 
 When a tendency to gangrene is obvious, and the disease assumes a low typhoid charac- 
 ter, it will be necessary to resort at once to the use of the carbonate of ammonia, in doses 
 adapted to the age of the patient, and the urgency of the symptoms; and at the same time, 
 the child should be nourished at the breast of a healthy nurse, or if weaned, its diet should 
 consist of animal jellies dissolved in water, beef tea, chicken water, or sago. It is all im- 
 portant in these cases that the patient be removed to a healthy situation, where he can enjoy 
 the tonic influence of a pure, free atmosphere. When the symptoms of prostration are 
 more considerable, we may combine the use of the ammonia with the sulphate of quinia 
 and extract of hyosciamus. 
 
 Should diarrhcea ensue, particularly after suppuration has taken place, it should be imme 
 diately checked by the cretaceous mixture, with the addition of tincture of kino and lauda- 
 num. When the discharges from the bowels are of a vitiated character, or attended with 
 griping or colicy pains, a few drops of turpentine, three times a day, will be found a very 
 valuable remedy. The turpentine may be combined with the tincture of kino and 
 laudanum. 
 
 With respect to the local treatment — washing the inflamed parts frequently with tepid 
 water, or some mucilaginous fluid, will, in many cases, be productive of very great relief to 
 the patient, and occasionally will produce an abatement of the disease ; in the intervals, the 
 parts may be dusted with powdered starch, or covered with carded cotton. 
 
 When there is decided redness, swelling and tension of the skin, a lotion, composed of a 
 solution of equal parts of the acetate of lead and subcarbonate of ammonia, has been highly 
 recommended. Covering the parts with rags wet with the camphorated tincture, is said to 
 prove often very beneficial. Others recommend a wash composed of a solution of corrosive 
 sublimate, three grains to the ounce of water, or of nitrate of silver of the same strength. 
 It is said that the progress of the disease has been promptly arrested by applying once or 
 twice a very strong solution of the nitrate of silver, by means of a pencil, upon the sound 
 skin, for about an inch around the margin of the inflammation. One of the best applications 
 in cases which exhibit an early tendency to gangrene, is the chloride of lime in soiution. in 
 the proportion of half a drachm to a pint of water. Velpeau has employed with advantage 
 a solution of half an ounce of the sulphate of iron to eight ounces of water. 
 
 The local remedies just recited are to be employed in the early stages, previous to the rup- 
 ture of the vesications, and to the occurrence of suppuration or gangrene. 
 
 Among the local remedies which appear to be the most generally applicable to Infantilo
 
 1012 ERYTHEMA. 
 
 erysipelas, is a blister sufBciently large to extend over the inflamed skin, and for a short dis- 
 tance beyond it; after vesication has been produced, the serum should be evacuated, and the 
 vesicated surface dressed with fresh lard. When the erysipelas occurs upon the extremi- 
 ties, a blister applied around the limb, beyond the inflamed surface, will frequently arrest 
 the progress of the disease in that direction. When we have resorted to blisters, which are 
 only proper in the early stages of the disease, we have applied them along the edges of the 
 inflamed portion, partly upon it, and partly upon the sound skin, removing them at the end 
 of three hours, and immediately covering the parts with a soft emollient poultice, with the 
 addition of lard. The most important result which we have derived from the use of blis- 
 ters is to prevent the spread of the disease. 
 
 The mercurial ointment has been strongly recommended in the treatment of infantile ery- 
 sipelas. I* is to be spread on a piece of soft linen, with which the affected parts are to be 
 covered. 
 
 In cases attended with an intolerable sensation of burning, we have often derived benefit 
 from the local application of a watery solution of opium. 
 
 In a large number of instances, however, no benefit whatever will be derived from any 
 local application. M. Trousseau states that he has tried every imaginable one — ointments, 
 lotions, blisters, even the actual cautery — without suspending the progress of the disease. 
 Three cases only, occurring within the month, has he seen recover under the use of the 
 etherial solution of camphor, and baths containing corrosive sublimate. The disease is cer- 
 tainly a very unmanageable one when it occurs in very young infants ; we have nevertheless 
 seen it in children a few months old in many instances promptly arrested by the remedies 
 already detailed. 
 
 Whenever the cellular membrane is involved in the disease, free incisions should be early 
 made, as well to unload the vessels, and relieve the swelling and distension, as to give exit 
 »o the purulent fluid and dead portions of cellular structure. The pus, if allowed to remain, 
 will travel beneath the skin, and between the muscles and tendons, and thus increase the 
 danger and extent of the disease. After the incision, the part should be covered with soft; 
 emollient poultices, and kept as much as possible at rest, and in an elevated position. 
 
 When the erysipelas terminates in gangrene, washes of a solution of the chloride of lime, 
 of the chloride of soda, of a few drops of creasote diff"used in water, or of a strong decoc- 
 tion of black-oak bark, should be immediately employed, or the sphacelated surface may be 
 covered with the charcoal or yeast poultice. A wash of a very strong solution of the sul- 
 phate of copper will in some cases arrest the progress of the gangrene. 
 
 When convalescence has been established, some light mineral tonic or the mineral acids, 
 largely diluted, should be administered. The child should be allowed a nourishing diet; 
 he should be daily immersed in a warm or tepid bath, and enjoy a dry, fresh, wholesome 
 atmosphere. — C] 
 
 Very closely connected with erysipelas, and continually confounded with it, is ery- 
 thema. It also consists in superficial redness of some portion of the skin ; but is not 
 attended with inflammation of the areolar texture under the skin ; nor with vesica- 
 tion ; nor, in general, with fever ; nor is it peculiar to the face and head. 
 
 There are numerous varieties of erythema described by writers on cutaneous dis- 
 orders, to whom I must refer you for an account of them. Willan and Bateman ; 
 Wilson; Willis; Rayer; Ahbert ; and Biett, as his practice and lessons are re- 
 ported by two of his pupils. 
 
 The only variety on which I am disposed to say a word, is one which is attended 
 with more or less febrile disturbance. I mean what is called erythema nodosum. 
 
 This curious affection occurs much more often in young women than in any other 
 persons ; sometimes in feeble boys. The eruption is commonly preceded for a few 
 days by indisposition, and some slight degree of fever. Then red elevated spots 
 come out, on the fore part of the legs, and occasionally, but very rarely, on the arms. 
 The redness appears in oval patches, of which the long diameter is parallel to the 
 axis of the hmb. They are pretty large patches, an inch and half long, and an 
 inch broad perhaps, and they evidently project and form bumps upon the anterior 
 surface of the leg. From their look, you would suppose abscesses were about to 
 form ; but after lasting a few da5^s, the red colour fades, or rather changes to a blue, 
 and the protuberances gradually subside. This eruption seems sometimes connected 
 with disturbance of the menstrual functions. Rayer has seen it occur in connection 
 with acute rheumatism. So have I. A patient of mine in the hospital was attacked 
 with acute rheumatism of the joints immediately upon the cessation of erythema 
 nodosum. In another this order was reversed. 
 
 Now I am persuaded that, after an aperient, rest, the horizontal posture, and
 
 URTICARIA. 1013 
 
 qjiina, constitute the proper treatment of this affection. I had once a housemaid, in 
 whom the disorder appeared, and was attended with unusually high fever, and much 
 indisposition. I treated her, therefore, antiphlogistically ; i. e., I kept her on \o:v 
 diet, and gave purgatives ; bat the disease went on. Fresh knots came out as the 
 old ones faded. At length, T do not remember why, I prescribed some quina for 
 her ; and the improvement was immediate, and very striking. She relapsed, how- 
 ever, once or twice, upon leaving off' the bark ; but by persisting subsequently in 
 its use for some days after she appeared to be well, a permanent cure was effected. 
 Since that time — now ten or twelve years ago — I have seen a good many exam- 
 ples of erythema nodosum, and I have treated them all alike ; viz., first with an 
 aperient, and then with the sulphate of quina : and they have all rapidly got well. 
 Probably they would have recovered nearly as soon under some other tonic treat- 
 ment ; but I have been so well satisfied with this, since I began it, that I have felt 
 no temptation to try any other. 
 
 There is a rash which is well known, and very tormenting, and therefore not 
 without interest, although it is almost always without danger; I mean urticaria. It 
 is arranged by CuUen among the exanthemata ; but it does not properly belong to 
 the group to which I would restrict that name, for it is not contagious, and it may 
 happen to the same person a hundred times over. The eruption consists of what, 
 from analogy, are called wheals ; i. e., of httle solid eminences, of irregular outline, 
 but generally roundish or oblong, and either white or red, or (which is most common) 
 both red and white ; the whiteness occupying steadily the central and most project- 
 ing part of the spot, or becoming manifest there when the integuments are put upon 
 the stretch. The rash is accompanied with intense heat, a burning and tinghng iu 
 the affected spots, and great itching and irritation. 
 
 In truth, both the appearances upon the skin, and the sensations that attend them, 
 are very much like the appearances and feelings produced by the stinging of nettles. 
 Hence its trivial name, nettle-rash ; which is, indeed, the same in meaning with the 
 scientific appellation, urtica being the Latin for a nettle. Similar appearances follow 
 almost immediately upon a smart blow with a cane, or with the lash of a whip, on 
 the skin. Red stripes or wheals arise, and within the reddened surface one or more 
 elevated spots of a white colour are visible. 
 
 There are two varieties of urticaria : one in which the complaint runs a short 
 course, and soon subsides, and may be considered acute ; another in which it is 
 chronic, and either persistent or intermittent. The acute form is attended with fever- 
 ishness, which sometimes begins two or three daj^s, but commonly not more than a 
 few hours, before the eruption ; or the fever and the rash may commence together. 
 In most cases, perhaps in all, the disorder is intimately linked with some derange- 
 ment, manifest or latent, of the digestive organs ; and it may often be traced to the 
 use of particular articles of food. It is very curious that the contact of certain sub- 
 stances with the mucous membrane of the ahmentary canal should affect the external 
 tegument precisely in the same manner as the virus of the nettle, and some other 
 irritants, when these are applied to the skin itself. The offending articles of food do 
 not produce the cutaneous affection in all persons, nor even necessarily in the same 
 person at all times. But there are some edible substances which are much morf. 
 likely than others to be followed by nettle-rash. Certain vegetable matters are very 
 apt to excite the disorder in some persons : oatmeal ; almonds, especially the bitter 
 almonds ; any bitter kernels ; particular species of strawberries ; raw cucumbers ; 
 mushrooms. Some of the vegetable substances used in medicine are known to have 
 frequently the same effect; capivi, for example; the cubebs pepper; valerian 
 Urticaria has been brought on by drinking porter, or, most probably, by some of the 
 drugs with which our porter is sophisticated. These effects are not confined to vege- 
 table substances. Shell-fish is a common source of nettle-rash. I have known it to 
 be occasioned by prawns ; crabs, sometimes, have the same unpleasant consequence; 
 and, still more, muscles. An hour or two after some one of fhese substances has 
 been swallowed, and perhaps much sooner, nausea is fek, and oppression about thfl 
 
 4k2
 
 1014 URTICARIA. 
 
 epig-astrium ; the patient becomes gidd}-, his face and head sometimes swell, his skin 
 begins here and there to burn and tingle, and presently the eruption, as I have already 
 described it, breaks forth. It is attended with intolerable itching and pricking sensa- 
 tions, especially at night, when the patient is warm in bed, or when the affected sur- 
 face is exposed to the air. Vomiting and diarrhoea often supervene, and prove the 
 natural cure of the attack. 
 
 We read that this disorder has sometimes proved fatal; but this must be under 
 ■very unusual circumstances of weakness in the patient, or of some peculiar virulence 
 in the exciting cause. 
 
 The chronic form of the complaint is apt to be very obstinate and teasing. It 
 comes and goes, and comes again. The evening is one of its favourite periods. In 
 those who are subject to it, the itching and the wheals are readily brought on by 
 scratching or rubbing the surface. This is the urticaria evanida of Willan. Dr. 
 Heberden had known persons afflicted in this way for ten years together. I have 
 observed nettle-rash to occur in connection with sudden and violent paroxysms of 
 dyspncea, resernbhng asthma fits ; so that I could not help suspecting that the mucous 
 membrane of the respiratory passages was irritated after the same fashion with the 
 external skin. 
 
 Even the chronic variety of urticaria is, in some instances at least, produced by 
 certain ingesta : and the peccant substance may often be detected, and the tiresome 
 malady be cured, by following the simple and judicious plan recommended by Wil- 
 lan ; namely, that of instructing the patient to abstain, for a while, from all his cus- 
 tomary articles of diet, one by one, in their turn. This experiment does not, indeed, 
 always answer. The urticaria will sometimes abide, notwithstanding ; so that, 
 although it probably depends in all cases upon some disordered condition of the sto- 
 mach or bowels, we cannot say that such disorder is always the consequence of 
 something that has been swallowed. 
 
 The treatment to be adopted in the acute or febrile nettle-rash, when it depends 
 upon something recendy received into the stomach, is that which common sense 
 would suggest, and which nature often plainl}' indicates. We seek to expel the 
 offending material by an emetic, and by purgatives ; and, this being done, the cure 
 is completed. In the more chronic and recurring varieties, we endeavour, in the first 
 place, by making the experiment recommended by Dr. Willan, to detect, that we may 
 thenceforth interdict, any article of diet which may have caused the disorder. If 
 we fail in this attempt, our object must be to correct that faulty state of the digestive 
 organs, or to neutrahze that inbred poison, upon which the cutaneous affection 
 depends. Laxatives and antacids are found to be the most successful means of 
 attaining these ends. They may be given together, or separately. Rhubarb and 
 magnesia ; the carbonate and sulphate of magnesia ; castor oil. The snake-root has 
 obtained some repute as a remedy for urticaria. You may prescribe, therefore, if 
 you please, a scruple each of the carbonates of magnesia and of soda, in the infusion 
 of serpentaria. 
 
 External applications seem to be of but little avail in this disease ; and those 
 which do appear to be of service, act uncertainly, and produce different effects in 
 different persons. The warm bath sometimes gives ease in the severer cases. In 
 the more chronic form of the disorder, spirituous washes, vinegar, sea-bathing, are 
 things to be tried. And cases are related in which, when every other expedient 
 has "failed to give permanent relief, removal to a warmer chmate has been success- 
 fuL Dusting the itching surface with flour has, in my experience, afforded much 
 temporary comfort. Still more effectual, perhaps, is a lotion (first recommended by 
 Wilkinson, in a little work on skin diseases), composed of a drachm of the carbonate 
 of ammonia, a drachm of the acetate of lead, and eight ounces of rosewater. 
 
 I should add, that Dr. EUiotson has found bleeding verj' efficacious in relieving 
 patients affeeted with acute or febrile urticaria. And you may have recourse to the 
 lancet if the patient be strong and plethoric, and his pulse warrant it ; and if he be 
 so impatient of the irritation as not to be willing to wait the effect of other treatment, 
 which would probably be quite as effectual, though not quite so rapid.
 
 PRURIGO. 1015 
 
 Prurigo — Itching — is a cutaneous affection, bearing some analogy to urticaria, at 
 least in the sensations which accompany it. And a most terrible and melancholy 
 affection it often proves to be. Sometimes the parts of the skin which are the seat 
 of the itching do not present any perceptible deviation from the condition of health ; 
 but in the majority of instances you will find, upon close inspection, that they are 
 covered vi'ith papulre, which are nearly of the same colour with the skin itself. 
 Willan therefore places prurigo in the order of Papula3. He describes several 
 varieties of this troublesome complaint: prurigo mitis; prurigo formicans ; prurigo 
 senilis. The torment experienced by patients suffering under the severer forms of 
 the malady is scarcely describable ; they scratch and tear themselves incessantly till 
 the blood flows, their sleep is broken, and their lives are rendered perfectly misera- 
 ble. Sometimes this itching is diffused irregularly here and there over the surface ; 
 sometimes it affects the extremities only ; and frequently it has a still more limited 
 habitat, occurring round the anus, when it is called prurigo pofZicw; or on the scro- 
 tum, prurigo scroti; or, worst form of all, the prurigo pudendi muliebris. 
 
 All these forms of prurigo are apt to be aggravated by heat, and by exposure to 
 the air; they are, therefore, especially distressing when the patient undresses and 
 goes to bed. The scratching tears away the summits of the papulae, and some 
 watery fluid mixed with blood escapes, and concretes into small, thin, black scabs. 
 In the prurigo formicans, the itching is combined with other painful and disagreeable 
 sensations, which different patients describe in different terms : the feeling is like 
 the creeping of ants, or the stinging of insects, or as if hot needles were thrust into 
 the skin. The prurigo senilis, occurring, as that name implies, in old persons, is 
 usually very obstinate, and often effectually destroys all comfort for the rest of the 
 patient's life. 
 
 In such cases as I have now been mentioning, great care should be taken tho 
 roughly to cleanse the surface of the body : and the diet should be rigidly plain. All 
 kinds of rich sauces, hot condiments, pickles, and indigestible substances, should be 
 peremptorily forbidden. Various local applications have been praised ; but they are, 
 in most cases, used in vain : lime water, decoction of dulcamara, lotions composed 
 of prussic acid in an emulsion of bitter almonds, a dilute solution of creasote, decoc- 
 tion of stavesacre, and of digitals, ointments containing mercury, tar ointment, and a 
 hundred ot|;iers. In one instance lately, where the ingenuity of another practitioner 
 had been fruitlessly exhausted, I was fortunate enough to effect perfect relief by 
 smearing the itching surface with an ointment containing a small quantity of aconi- 
 tine. Of internal remedies, sarsapariUa, alkalies, arsenic, the iodide of potassium, 
 dulcamara, are the most hopeful. When these means fail, opium is our best, and 
 indeed our only resource. 
 
 The local forms of prurigo are frequently connected with local disease, and are 
 most likely to be relieved by measures directed against the primary disorder. Pru- 
 rigo podicis is sometimes dependent on the presence of ascarides in the rectum. The 
 same troublesome affection is not an uncommon symptom of intern"\l piles : and it 
 sometimes accompanies stone in the bladder. 
 
 The prurigo pudendi muliebris — itching of the genitals in females — is sometimes 
 so constant and tormenting, and the impulse to scratch the itching part so urgent, as 
 to drive the unhappy patient from society. It even gives rise, in some severe cases, 
 to nymphomania. It may proceed from leucorrhcea: it is frequently a sign of uterim. 
 disease. It most commonly affects women in whom the menstrual discharge has 
 ceased to appear. 
 
 [We have met with it just as frequently in the menstruating female as in thost m M'hom 
 the menses had ceased : some females are troubled with it during pregnancy and ai uo other 
 period. — C] 
 
 I have never had an opportunity of trying the aconitine in such cases. The local 
 application which has been found most serviceable is the yelloiu ^fJas/■^, which, as you 
 probably know, is a solution of corrosive sublimate in lime water, in the proportion 
 of a drachm to a pint. 
 
 [A saturated solution of borax will give, in many cases, very prompt relief; and by a poi 
 severance in its use a permanent cure may often be effected. — C]
 
 1016 SCABIES. 
 
 You will sometimes be consulted — at least I have been, on more than one occa- 
 sion — about itching of the pubes and scrotum, produced by the presence of the pe- 
 diculi that are vulgarly called crab-lice. The patients are sometimes quite unaware 
 of the cause of the itching-. You may relieve them by the wash I have just men- 
 tioned ; or, by a more elegant lotion, made by dissolving corrosive sublimate in a 
 little spirit, and adding rose water. A single washing with such a lotion will destroy 
 the whole colony : and the vermin become much more visible after this violent death, 
 turning black, and relaxing their hold upon the skin. 
 
 Prurigo is a convenient generic name for these cutaneous affections, of which the 
 prominent feature is the teasing sensation that accompanies them. But, besides all 
 these, there is a specific disorder, which, from the intensity of that sensation, is em- 
 phatically termed the itch, and which deserves a short notice ; for it is exceedingly 
 common, and exceedingly distressing, and (what is more interesting still) it is easy 
 of cure. It is one of the very few complaints for which we possess a specific or 
 infallible remedy. 
 
 Scabies, or the itch, is, as every body knows, contagious ; but it is contagious only 
 in that particular sense which implies contact. It is not producible by any effluvia 
 which the atmosphere can convey : it requires, for its propagation, that the healthy 
 person should touch the diseased person, or some substance which has been in con- 
 tact with his unhealthy skin. Certain parts of the skin are more liable to it than 
 others. It is most common at the roots of the fingers and thumbs, between them as 
 it were ; on the wrists ; between the toes ; in the flexures of the joints. It may 
 spread to almost every part of the trunk or of the extremities; but all observers 
 agree in stating that it is seldom or never seen upon the face and head ; a curious 
 but unaccountable exemption. 
 
 The eruption is at first papular, and then vesicular, presenting a number of pointed 
 watery heads. When ihe inflammation is aggravated by intemperate habits, or by 
 the scratching from w^hich the patient is unable to refrain, the vesicles are liable to 
 be converted into pustules : and this has needlessly been made a separate species of 
 itch, scabies puntlenta, pocky itch : you see large pustules, filled with a yellow viscid 
 matter, standing on an inflamed base. If you are not aware of these varieties and 
 changes, you may make unlucky errors of diagnosis ; affi'ont your patient by telling 
 him he has the itch when he has it not; or suffer him unconsciously to betray and 
 shame himself by communicating it to others, when he has. You will easily under- 
 stand how it has come to be considered a disgrace to have the itch : for it is fostered 
 and propagated in most unfashionable places, amidst poverty, vulgarity, and filth. 
 Yet the most delicate and high-bred lady may contract the distemper ; and when 
 once it is contracted, it will go on indefinitely, through life, unless proper means are 
 adopted for its cure. It never gets well if left to itself. 
 
 One very curious point in this discreditable malady, is its connection with a pecu- 
 liar insect, called accordingly the acurus scabiei. The existence of this ectozoon had 
 long been affirmed and denied ; but the vexed question has at length been set at rest 
 by the public demonstration of the acarus, by a M. Renucci, to a number of medical 
 practitioners in Paris. It has since been often detected and exhibited here. Dr. 
 Nevinsonhas lately assured me that he furnished Shaw, the naturalist. Dr. Wollaston, 
 and others, with living itch-mites, for examination, forty years ago. One reason, 
 probably, why it has often been searched for in vain, is, that the acari are not equally 
 numerous with the vesicles: there is not an insect for every vesicle. Another reason 
 is, that persons have not known exactly where to look for the insect. It is not in the 
 pustides or vesicles ; but 7iear them ; at the extremity of a short, small, superficial 
 tunnel or furrow which runs from them. A third reason why the inject had so long 
 and so often escaped detection, is to be found in its minuteness. It is barely visible 
 Oy the naked eye ; but under the microscope it is seen to be a most formidable 
 monster, in outline like a tortoise, and having eight legs. I show you here its por- 
 trait ; not a fittle, but enormously magnified. I hope to procure for you the privilege 
 of seeing the creature itself. The first that I can catch I will ask Professor Jones 
 show you by means of his microscope.
 
 HERPES. 1017 
 
 There is good reason for believing that this parasitic animal is, not merely a 
 casual companion, but the veritable cause, of scabies. Various attempts have been 
 made, and made in vain, to produce the disease by inoculation of the fluid from the 
 vesicles. On the other hand, transportation of the acarus has always excited the 
 eruption. 
 
 These facts explain how it is that the itch, though readily communicable by direct 
 contact, or by fomites, is not communicable through the medium of the air ; that 
 fomiles long retain the contagious property ; and that the disease is curable by what- 
 ever destroys the acari. I believe that the complaint called the mange, in dogs, 
 camels, and sheep, has the same, or a similar origin. 
 
 Now svlphur is as sure to cure the itch as quinia is to stop an ague. I presume 
 that it kills the acarus ; but whatever may be its modus operandi, I have never 
 known it fail to remove true scabies. It is applied externally ; and the only objec- 
 tions to its use are its disagreeable smell, and the dirtiness that belongs to ointments : 
 but these inconveniences are far outweighed by its certain efficacy. Although 
 many substitutes for this substance have been recommended, I pretermit them all, 
 and advise you to employ the sulphur ointment, of which you may disguise the 
 smell by the addition of a little bergamot, and the colour by intermixing a small 
 quantity of vermilion. 
 
 The ointment should be carefully rubbed all over the skin, at bed-time, and most 
 especially on parts visibly affected with the eruption. The patient should sleep 
 enveloped in a flannel dress. The rubbing should be repeated night and morning, 
 and in two or three days the complaint will be subdued. Then, thorough ablution 
 with soap and warm water, and the destruction of the contaminated clothes by fire, 
 will complete the purifying process. 
 
 LECTURE XC. 
 
 Herpes; Eczema; Pompholix ; Lepra; Psoriasis ; Im,petigo; Boils ; Carbuncle; 
 Purpura; Scurvy. Conclusion of the Course. 
 
 If you look at the lists of genera and species appended to the various works which 
 treat exclusively of cutaneous diseases, you will find that they are exceedingly 
 numerous. But these disorders differ widely in their relative importance ; and the 
 principles upon which their remedial management proceeds are not so greatly diversi- 
 fied as these " tables of contents" might lead you to suppose. I have spoken pretty 
 fully of the most serious and interesting of these maladies — I mean of the febrile ex- 
 anthemata ; but I have no time left for pursuing in detail the host of chronic affec- 
 tions to which the human skin is subject. Nor do I much regret this. To become 
 expert in the diagnosis of these blemishes, and in curing such as are curable by our 
 art, you must see them with your own eyes. Verbal descriptions of their changeful 
 characters are of comparatively little service or interest. They are among the things 
 that require to be "oculis subjecta fidelibus." Even pictured representations convey 
 but an inadequate notion of the morbid appearances they are designed to portray. 
 The lecturer on skin diseases should have actual patients before him, to whose bodies 
 he could point. 
 
 In this, the final lecture of the course, I can do no more than offer you some very 
 cursory remarks upon some of the genera into which nosologists have distributed this 
 class of disorders ; and I may premise, that the treatment of the genus mcludes, for 
 the most part, that of the species. 
 
 Ve-nclcs are, as you know, small transparent elevations formed by a drop of 
 aqueous fluid effused beneath the cuticle. Sometimes they are thinly scattered, 
 over the surface; sometimes collected into clusters: sometimes situated on a red 
 patch of skin ; sometimes quite free from redness. The whole crop comes out at 
 once in some cases ; in others the vesicles appear in irregular succession. They
 
 1018 HERPES. 
 
 terminate also in various \va3's : by llje reabsorption of the jiquid, and slight desqua- 
 mation ; by the giving way of the cuticle, and the formation of little scabs, under 
 which new cuticle is generated ; and sometimes, though rarely, by ulceration. 
 
 Of the vesicular class of cutaneous disorders I have already described the three 
 most important; namely, cow-pox, chicken-pox, and the itch. 
 
 Another not uninteresting genus of this class is herpes. This is a transient non- 
 contagious eruption, consisting of red patches of irregular form and variable size, 
 upon each of which stands a crop of vesicles. The eruption runs a definite course ; 
 and its several periods — its beginning, its increase, its acme, and its decline — are 
 completed, when its progress is not interfered with, in about ten days. These cha- 
 racters, once known, are easily recognized : and it is of importance that )'ou should 
 recognize them. Not that the disorder itself is of any great moment; nor that it is at 
 all under the influence of remedies ; but because it may be confounded with some 
 graver malady. For example, Herpes pracputlalis is a very common and a very 
 trifling species, affecting the foreskin ; but it might readily be mistaken for the result 
 of the poison of syphilis, and so cause much alarm and distress to the subject of it, 
 and entail upon him perhaps a needless course of mercury, and bring unmerited 
 suspicion upon the person with whom, whether lawfully or unlawfully, he might 
 have been connected. . It has nothing whatever to do with sexual intercourse ; and 
 it requires no treatment beyond cold ablution, and the interposition of a piece of lint 
 between the prepuce and the glans penis. In like manner another species. Herpes 
 cirdnaius, the vesicular ringworm, is liable, when it appears upon the hairy scalp, 
 to be mistaken for that pest of schools and of school-boys, the faiiis confertus, or 
 porrigo scutulata of Willan, the common scald-head; a complaint which is naturally 
 shunned as filthy, stubborn, and contagious. Herpes iris is a mere curiosity. la 
 this species each group of vesicles is surrounded by four concentric erythematous 
 rings, of different shades of colour. The rings form and fade in succession, one after 
 another, by a slight extension of the inflammation each time. The spots constituting 
 the eruption have been likened to small parti-coloured cockades. But the most 
 singular species of all is the Herpes zoster, in which the separate patches lie in the 
 direction of a band that encircles half the circumference of the body. Hence its 
 names, zoster, zona, zona ignea, and in our vernacular tongue, the shingles ; and 
 even this Dr. Johnson derives from the Latin, cinguhan, a girdle. 
 
 ]Most commonly the zone is confined to the trunk of the bod3% has a somewhat 
 oblique direction like a sword belt, and occupies exactly one-half of the circle, lying 
 between the linea alba and the spine on one side onl}'. Sometimes, however, it ex- 
 tends from the trunks to the limbs. Thus it may begin in the loins, pass obliquely 
 across the flank, and terminate at the inner part of the thigh. Or it may commence 
 from the upper part of the spine, cross the shoulder, and end on the arm or forearm. 
 In the year 1833 I saw a lady affected with this strange eruption, in whom the clus- 
 ters of vesicles began near the spine in the neck, passed over the scapula, then to 
 the shoulder and axilla, whence the main line ran along the outer side of the upper 
 arm till it reached the elbow, where it turned inwards, followed the inner side of the 
 forearm, went across the palm of the hand, and terminated by two or three patches 
 upon the palmar and inner side of the ring finger. Very rarely indeed it appears on 
 the limbs only. Once I have seen it limited to the thigh and leg, where it corre- 
 sponded to the course of the sciatic nerve. Once I have known it spread from the 
 neck, behind, up to the hairy scalp. The most common situation of the demi-cinc- 
 ture is across the base of the thorax. It is a curious feature of this curious disorder, 
 that, in nineteen cases out of twenty, according to Biett, it occupies the right half of 
 the body. Of this singular preference of the right side, if indeed it be a general fact, 
 I can give you no explanation. I have seen some fifteen cases of the complaint 
 since I began to attend to that circumstance, and in ten of these the eruption was on 
 the right side. Raj-er, in the first edition of his book, said that eight cases in ten 
 v.-ould be found to be on that side ; but a longer experience has reduced that propor- 
 tion. Of fifty-three examples seen by himself, thirty-seven only were on the right, 
 and sixteen on the left. Reil states that he has always observed it on the left half 
 of the body; and Mehlis, among twenty-five patients, counted sixteen in whom the
 
 ECZEMA. 1019 
 
 left side was affected. This statistical point remains, therefore, to be settled, if it be 
 worth settling, by a larger induction of particular cases. The zone seldom trans- 
 gresses the median line at either extremity, unless perhaps the redness of the 
 extreme patches may extend a few lines further. It is said, however, in some ex- 
 ceedingly rare instances, to complete the circuit of the body. There is a vulgar but 
 erroneous notion, that the eruption proves fatal when it thus surrounds the whole of 
 the trunk ; and this notion is as old as the time of Pliny, who says, " Zoster appella- 
 tur, et enecat si cinxerit." 
 
 The most important, because the most distressful, of the symptoms, is an intense 
 darting pain, described by the patients as being deep-seated, very acute, and shooting 
 through the chest. Fortunately, however, this is by no means a common incident. 
 I have met with it in two or three cases only. Sometimes the pain precedes the 
 eruption ; more often it accompanies it ; and it is apt to last, in spite of remedies, for 
 some time after the eruption has disappeared. Mr. North tells me that, in a female 
 patient of his, this pain continued to be severe and intractable for eighteen weeks. 
 That this is a rare complication of the disorder we gather from the experience of 
 M. Biett, who never once witnessed this symptom in more than 500 cases of shingles. 
 The severe and intermitting character of the pain, and the peculiar direction of the 
 row of herpetic patches, lead to the belief that the whole malady may arise from some 
 fault in the nervous system. Of its causes we have no certain knowledge. It is 
 said to attack young persons more especially, and those who have fine and delicate 
 skins, and the male more frequently than the female sex. But I suspect that 
 these assertions rest on a very loose foundation. Of the fifteen cases already men- 
 tioned, ten occurred in females. One of the patients was a child two years and seven 
 months old ; another was an aged man of about seventy-five. In several instances I 
 have found, upon inquiry, that the patients, being children, were in the nightly habit 
 of wetting their beds. Whether this has been anything more than a casual coinci- 
 dence, I do not know ; but my attention was first directed that way, some years ago, 
 by Mr. Wheeler, the apothecary at St. Bartholomew's Hospital, who told me that he 
 had often noticed the same circumstance. According to Bateman, the disorder 
 "seems occasionally to arise from exposure to cold after violent exercise. Sometimes 
 it has appeared critical, when supervening on bowel complaints. Like erysipelas, it 
 has been ascribed by some authors to paroxysms of anger." Schwartz saw three 
 cases which followed violent fits of passion ; and Plenck affirms that he had known 
 it occur twice after furious anger — and a copious potation of beer. 
 
 The duration of the eruption is from ten days to a fortnight; but it is liable to be 
 considerably prolonged by troublesome ulceration, whenever the vesicles and crusts 
 are prematurely chafed off by friction or pressure. 
 
 Very little, as you must perceive, can be done, or is requisite in the way of treat- 
 ment. The patient is to be cautioned against rubbing off the heads of the vesicles. 
 Attention should of course be paid to the state of the stomach and bowels ; and the 
 diet should be regulated. Our main business is to look on, and to endeavour to set 
 right whatever may be manifestly wrong. 
 
 Should the eruption be attended or followed by the intense shooting pain which 
 sometimes, but not often, harasses the patient, it will be right to apply opiates, by 
 friction, over the afftcted region. I would use the aconitine ointment in such a case. 
 Warm baths will also be proper : and as the pain is probably neuralgic, the carbonate 
 of iron is a remedy which ought to be tried. 
 
 Eczema is another genus of the vesicular class of diseases. It is characterized, 
 in its commencement, by an eruption of very minute vesicles, scarcely prominent, 
 closely crowded together, and requiring a microscope sometimes to render them 
 distinctly visible. They terminate either by the re-absorption of the fluid they 
 contained, or by the formation of superficial moist excoriations. Eczema is not 
 contagious. 
 
 There are several species or varieties of this form of cutaneous disorder also. It 
 is sometimes produced by great heat, and particularly by the heat of the sun ; and 
 this is named eczema solan; heat-sjjot : sometimes by the contact of irritating sub-
 
 1020 ECZEMA. 
 
 Stances with the skin, as in what is vulgarly called the grocer's itch, afll-cting the 
 hands of those who are much conversant with sugar. Eczema often occurs upon the 
 scalp, and constitutes, I believe, the most frequent form of what is commonly named 
 scald-head, porrigo, or tinea capitis. But the most severe of all its species is that 
 which has received the name o{ Hydrargyrum., Erythema mercuriale, and Eczema 
 riibrum mercuriale. This, as these names imply, is an occasional consequence of 
 mercury; an unusual consequence, no doubt, and one that happens only in a few 
 peculiar constitutions ; but you ought to know it, in case it should follow the use of 
 mercury prescribed by j'ourselves. 
 
 The eruption begins usually in the groins and upon the thighs. It is at first red, 
 and is accompanied by much heat and itching. It soon extends, in the severer cases, 
 over the whole body ; and an innumerable multitude of very minute glittering vesi- 
 cles may be seen, with the aid of a magnifying glass, from the beginning. Like that 
 of erysipelas, the eruption is attended with a good deal of swelling. The intumes- 
 cence of the face is such as to close up the eyes : and the disorder becomes febrile, 
 in its course ; for there is seldom much fever at the onset. The vesicles increase in 
 size, turn milky, burst, and pour forth an acrid exudation, that irritates and inflames 
 the skin with which it comes in contact, and thus increases the local complaint. The 
 distress and worry occasioned to the patient by the fetid smell of the discharge, by 
 the stiffening which it causes of his bodj'-linen, and by the heat and itching, are, I 
 conceive, the main causes of the febrile disturbance. The discharged matter is apt 
 to become thick and hard, and to present the appearance of large scabs : and in this 
 state the nature of the disease may very easily be understood, it being impossible to 
 say, when it is seen for the first time under these circumstances, whether it was 
 originally vesicular or not. 
 
 The duration of this harassing distemper is variable. It may be over in a fort- 
 night, or it majj^ last several weeks. It terminates by the cessation of the discharge, 
 and then the cuticle detaches itself in large flakes. Sometimes in this disease also 
 the epidermis falls entire from the hand, like a glove. 
 
 Without being dangerous to life, this disorder is apt to be obstinate. It is not 
 much within the control of remedies. What little can be done is chiefly palhative. 
 The mildest local applications must be used : tepid water, barley-water, strained 
 gruel. The warm bath, when circumstances permit. Poultices are sometimes of 
 much service, in preventing the hardening of the matter that exudes, and so obvi- 
 ating one source of irritation. Flour, or powdered charcoal, may be sprinkled over 
 the eruption in the slighter and early cases, for the purpose of absorbing the dis- 
 charge. Equal parts of olive-oil and lime-water make a soothing liniment, which 
 may be applied by means of a feather. The local remedies may fairly be varied, 
 for sometimes one, and sometimes another, is found to give rehef. The patient's 
 linen must be frequently changed, especially whenever it becomes stiffand hard with 
 the exudation. 
 
 With respect to the general treatment, opiates to procure rest, and to allay irrita- 
 tion, are probably indispensable. The bowels must be kept moderately open, but 
 no severe purging should be employed, for the patient must at all events undergo a 
 long and weakening process, and therefore it must be our care that the treatment be 
 as little weakening as possible. In protracted cases, where there is much exhaustion, 
 wine may with propriety be given ; and, almost always, good strong broths. As the 
 disorder declines, some of the reputed tonics may be prescribed ; the mineral acids, 
 quina, sarsaparilla. 
 
 I need not say that, in such cases, you must be scrupulous in seeing that no more 
 mercury is administered or apphed. 
 
 A separate class of cutaneous diseases, very analogous, however, to that which we 
 nave been describing, is the class of bullae, or blebs. Anatomically speaking, there 
 IS but little difference between the two : bullse are large vehicles. When the erup- 
 tion is at its height, it is composed of hemispherical prominences of various sizes, 
 iVom that of a pea to that of a hen's egg, and having the shape and appearance of 
 ihe bubbles raised in a pool of water by a hard shower of rain. They are formed
 
 POMPHOLIX. 1021 
 
 Dy the efTusion of a serous, or a sero-puriform fluid, between the true skin and the 
 cuticle. You can oiily be sure of the diagnosis when you see the eruption in this 
 stage of its progress. 
 
 The best example of this class is that which is called by some writers Pemphigus^ 
 by others Pompholix. 
 
 It is characterized by the presence of bullse, varying in their magnitude, commonly 
 distinct, but numerous, springing up in successive crops, on one or more parts of the 
 surface. At first these bullfe are nearly transparent, and contain a thin limpid serum ; 
 but they become gradually opaque, pearl-coloured, and ultimately many of them 
 acquire a reddish tinge. 
 
 Pemphigus has been described as being sometimes acute, sometimes chronic. 
 The acute form is attended with smart fever, the bullse rise spontaneously or in 
 quick succession, run their course, and disappear; and then the disease is over. 
 This is a very rare form. In general the bullse continue to come out ; the complaint 
 is spread over weeks, or months, or years ; and it is accompanied by httle or no 
 febrile reaction. This, on the other hand, is a common form of disease. It is the 
 Pompliolix diutinus of Willan andBateman. The eruption often occupies all parts 
 of the body at the same time, or in succession ; in other cases it is confined to a 
 limited space. I have most frequently seen it on the forearms and legs. When the 
 bullee are very numerous, they may give rise to some febrile symptoms, but not else. 
 The complaint may be indefinitely prolonged by successive crops. 
 
 The eruption begins in small red points, the formation of which is attended with 
 a slight pricking sensation. Some patients have likened this sensation to that which 
 accompanies the passage of the electric spark. In the centre of each of these spots, 
 the cuticle becomes hfted, Avhile the circumference of the spot enlarges, so that bullsB 
 are rapidly formed, often in the space of a few hours only, as big as a hazelnut, or a 
 walnut: or the blebs may even be much greater than that. Either in consequence 
 of their distension, or of the pressure made upon them by the movements of the 
 patient, some of these bullse burst, and a straw-coloured serum exudes. Then the 
 epidermis collapses into folds and wrinkles ; or if it be detached at a part of the 
 margin of the bulla, it is rolled back, so as to expose a portion of the red, painful, 
 and smarting surface beneath it. Towards the third or fourth day, when the buUas 
 lose their transparency, and the liquid they contain becomes reddish, those bullse 
 which have not been broken sink down and wither ; the cuticle is no longer stretched ; 
 but, sodden by the serous fluid, it assumes a whitish hue, becomes opaque, and forms 
 at length small brownish flat crusts, of no great thickness. 
 
 In the meantime fresh bullse appear by the side of the former ones, and pursue 
 the same course ; so that generally you may see, in the same person, tense bullae con- 
 taining a transparent and yellowish serum ; thin crusts ; and irregular patches of 
 various size, slightly excoriated. 
 
 This is the ordinary course of chronic pemphigus : and I say it may thus go on 
 for months or years. 
 
 The disease is most frequently observed in persons of debilitated habits. It is 
 sometimes apparently the result of intemperance ; or of the use of bad or insufficient 
 food. In Biett's experience it has often been coincident with the fatty liver. When 
 the disorder is chronic and uncomplicated, the treatment found useful is such as we 
 might expect benefit from, knowing the constitutions in which the disease is most 
 apt to occur, and the causes which seem at least to favour its occurrence, if they do 
 not produce it: regulation of the bowels; good nourishing food; tonic medicines, 
 bitters, and especially quina and the mineral acids. Biett describes this kind of 
 treatment to have been very successful in St. Louis ; and that not only in old and 
 worn-out subjects, but also in the young, especially when the complaint has been 
 chronic. Bateman recommends the same general plan. 
 
 Local applications have seldom been much employed, except some mild ointment 
 to the excoriated parts. Biett advises emollient lotions, or even opiate washes when 
 much irritation exists ; but a case recorded in the Medical Gazette, by Dr. Graves, 
 of Dublin, affords a remarkable instance of a cure by local applications alone : an*! 
 
 4l
 
 1022 LEPRA. 
 
 it is a case worth recollecting, although, as he justly remarks, we ought not to gene- 
 ralize from a single instance. 
 
 His patient was a boy, fourteen years old, of slender frame and delicate consti- 
 tution, yet enjoying uninterrupted health, except the cutaneous disease, which had 
 lasted five years. During that time the succession of bullae had seldom ceased. The 
 bullfe were very numerous, occupying not merely the face and extremities, but the 
 trunk also ; and they were in various stages of their progress, some healing after 
 having burst, some of a larger size and unbroken, others small, and recent. 
 
 Dr. Graves observes, that from the descriptions of Bateman, and of Biett, although 
 both authors describe it correctly, we should scarcely form a notion of the occasional 
 severity of this disorder. He had seen two examples of it in young men, where the 
 irritation and suffering produced by the constant exposure of large portions of skin 
 denuded of epidermis, had operated most unfavourably on the general health, almost 
 banishing sleep, and reducing the patients to a state of great debility. These cases 
 did not yield to the method of treatment recommended by authors ; and, therefore, 
 Dr. Graves determined, whenever another opportunity should occur, to have recourse 
 to a new plan. 
 
 In the boy in question, therefore, he had all the bullae opened with a lancet, and 
 the denuded surface of the corium was then touched with a stick of lunar caustic. 
 The nitrate of silver was also apphed to the skin around each buUas, for the breadth 
 of a line ; and the recent pimples, which indicated the formation of a future bulla, 
 were all treated in the same way. The boy was then washed, and supplied with 
 clean linen. 
 
 This single application of the nitrate of silver had not merely the effect of entirely 
 destroying the morbid action in the portions of the skin which were at the time 
 affected, but (what was very remarkable) no fresh bull;E made their appearance after- 
 wards : none at least had appeared for four months, when he wrote his account. The 
 only part where a repetition of the process was required, was the palm of the hand, 
 where the thickness of the cuticle rendered it more difficult to expose the diseased 
 surface of the cutis to the full action of the caustic. 
 
 It might strike you from this cure of a long standing disorder, so readily, by mere 
 local means, that the disease propagated itself from one part of the surface to another, 
 by a sort of re-inoculation. But it has been fully proved that the disease is not con- 
 tagious. A Mr. Gaitskill engrafted himself, with impunity, with the fluid ; and 
 analyzed it, and found it apparently Uke the thin serum of hydrocephalus. Dr. 
 Graves, therefore, supposes that the cure was owing to the simultaneous destruction 
 of all the parts of the skin that were in a state of morbid action : a morbid action 
 which would have been olherwnse propagated to other portions of the surface, by 
 what is called the sympathy of continuity. 
 
 The class of scaly eruptions — the squamas — is distinguished by the occurrence of 
 red spots or blotches, upon which lamina of altered cuticle form, and are thrown off, 
 and constantly renewed. You wnll perceive that, anatomically, this class of cutaneous 
 disorders has a close analogy with the rashes ; and yet it is separated from them by 
 very obvious particulars. In the exanthemata of Willan and Bateman, the redness 
 is followed by desquamation ; in the squamce these two appearances co-exist : in the 
 exanthemata the sequence of redness and desquamation takes place, in general, once 
 only : in the squamae the morbid cuticle continues for an indefinite time to scale oft 
 again and again, in successive fragments, from the abiding red patch of skin. 
 
 Lepra, psoriasis, and ptyriasis, and some sj^phihtic eruptions, constitute the prin- 
 cipal of the squamous affections. 
 
 Lepra is a very common disorder of this class ; hence its name, lepra viJgaris. 
 It consists in red scaly patches, of various dimensions, but always affecting a circular 
 or e^'iptical shape, and scattered over different parts of the body. It commoniy 
 begins on the limos, most usually near the joints ; just below the knees, or the 
 elbows ; and Dr. William Budd has pointed out the curious fact that these patches, 
 especially when they are few, and the disease is recent, are distributed symmetrically, 
 each spot on the one limb answering in situation to a similar spot on the fellow Hmb.
 
 PSORIASIS. 1023 
 
 This shows that the disease is a blood disease ; that it depends upon some poison, 
 introduced from without, or, more probably, bled within the body. By degrees the 
 patches both enlarge in size, and multiply in number, and extend along the extre 
 mities to the trunk. The eruption is seldom seen upon the hairy scalp, or upon the 
 hands. As the patches enlarge they sometimes become confluent ; but even then, 
 the outhne of the confluent scaly space is defined by arcs of circles, and the disorder 
 is sufficiently distinguishable from psoriasis. It is not easy to set these things 
 before you in mere verbal description. To have seen lepra once, is to know it for 
 ever. 
 
 When the patches begin to get well, the restoration of the altered surface to its 
 natural condition and appearance commences in the centre — i. e., in the spot first 
 affected — and proceeds outwardly towards the circumference : so that the scaly 
 redness assumes a ring-like arrangement. This ring becomes gradually narrower and 
 narrower ; at length its continuity is here and there broken ; and at last it vanishes 
 entirely. 
 
 The eruption does not, however, run any definite course. Sometimes it goes 
 rapidly through its phases ; in other cases it persists for a very long period. It is 
 not at all contagious. 
 
 Neither is lepra attended, in general, with much local inconvenience, nor with 
 much constitutional disturbance. When the eruption is very copious and extensive, 
 and especially when it is plentiful or almost continuous around the larger joints, it 
 renders the movements of the limbs stiff and difficult; and even sometimes painful, 
 from the cracking of the inflamed surface as it is stretched in the bending of the 
 joint. 
 
 But I have seldom found the lepra to exist unconnected with some disorder of the 
 digestive organs. Usually the connection is that of alternation, and not of co-existence. 
 The patient is dyspeptic till the eruption comes out, and then the dyspepsia is re- 
 lieved : and it often returns as the leprous patches disappear. The eruption is the 
 more unsightly : the dyspepsia is the more troublesome. This alternation would 
 seem to mark the shifting location of the matereis niorbi. 
 
 When the patches are small, and chronic, and white, that variety is no longer 
 called lepro vulgaris, but lepro alpho'ides ; and there certainly is another distinct 
 variety, of a more blue, or livid, or copper colour than the ordinary ; and a result of 
 the poison of syphilis. It is named accordingly syphilitic lepra. This species will 
 get well under the influence of mercury ; which, so far as my observations go, does 
 not cure the others. 
 
 Psoriasis is closely allied to lepra. When it occurs in distinct patches it is often 
 difficult to say to which genus the eruption belongs. In general the patches of 
 psoriasis are not so broad as those of lepra ; their edges are less raised, and their 
 centres less depressed ; the scales adhere more firmly ; and the patches are less uni- 
 form and less circular. 
 
 But psoriasis frequently spreads itself over large portions of the skin, and it may 
 come to occupy nearly the whole surface of the body. It is then called psoriasis 
 diffusa. It often renders the patient hideous to look at. The scaly incrustation is 
 interspersed with chaps, furrowing the skin in aU directions, and following parti- 
 cularly its natural folds and angles. These cracks, when the skin is put upon the 
 stretch by the movements of the patient, are apt to bleed. In these severer cases 
 (which are said to be examples of psoriasis inveterata), the laminse of altered cuticle 
 are thick, and very abundant. They fall off perpetually, or are rubbed off, and may 
 be shaken from the patient's clothes, or collected in handfuls from his bed. 
 
 Both these scaly disorders, lepra and psoriasis, require the same kind of treatmcni. 
 
 I believe that external applications are of but little use. I have tried a good many 
 and have lost all confidence in them, with the exception of the warm bath. What 
 ever tends to improve the general health, will hasten the departure of these eruptions. 
 I believe that they sometimes depend upon the presence, or the generation, of an 
 excess of acid in the system ; and that they are often to be cured by alkaline reme- 
 dies I am sure. I have seen many cases of psoriasis rapidly improve, and get ulti- 
 mately well, under full doses of the liquor pot ass se ; from half a drachm to a drachm,
 
 1024 IMPETIGO — BOILS. 
 
 three or four times daily, in a glass of milk, or of water, or of beer. Another inter- 
 nal remedy from which 1 have seen manifest improvement result, is arsenic ; orjven 
 with the cautions, and in the doses, which I have more than once spoken of. These 
 are the two remedies of which I have the most experience ; but neither of them is 
 intallible ; and you will have to try many things in succession, for patients are very 
 desirous of getting rid of the disfiguring eruption, even when it does not interfere 
 with their health or comfort. Now the Harrowgate waters, a strong decoction of 
 dulcamara, pitch-pills (and if pitch-pills, I should suppose a fortiori creasote), 
 tincture of cantharides, and the iodide of potassium, are remedies of some renown for 
 tnese scaly diseases. Of the syphilitic lepra I repeat that mercury will prove a cure. 
 In all cases the diet must be regulated, and all kinds of stimulating food abstained 
 from. Dr. Bateman knew a man who was always attacked with lepra if he took 
 spices with his food, or drank ardent spirits : and a patient of my own got rid of long 
 standing and very troublesome psoriasis of the scrotum, upon adopting, for other 
 reasons, a very abstemious and simple mode of living. 
 
 Among the pustular diseases of the skin there is one which assumes many forms, 
 and is termed impetigo. Whatever may be the minuter peculiarities of this erup- 
 tion, its general characters are the following. It consists of crops of pustules, some- 
 times scattered irregularly, sometimes collected into groups. The pustules burst, or 
 are broken, dry up, and scab over. The crusts are yellowish, and very friable, and 
 resemble in appearance little masses of candied honey ; or sometimes they look like 
 small pieces of dirty plaster. From beneath these crusts a considerable discharge 
 continues to take place ; the crusts become thicker and larger, and around the mar- 
 gins the skin is red and raw, as it is also beneath them. 
 
 We have, I say, various forms of this complaint ; impetigo Jigiirata, impetigo 
 sparsa, &c. It often borders closely on eczema, so that authors describe an eczema 
 impetiginodes, or an impetigo eczeniatodes. These varieties are delineated by 
 Rayer, by Willan, and Bateman, and by others ; and knowing their character, you 
 can examine and study their appearances for yourselves. Impetigo is a non-conta- 
 gious disorder. 
 
 Sometimes this complaint occurs in an acute form, and is attended with fever. In 
 such cases its removal will be accelerated by bleeding the patient ; and the blood 
 drawn will be found to present the buffy coat. Whatever local apphcations' are 
 made should not be unctious. It is seldom that impetigo will bear, or be the bettei 
 for, ointments. Purgatives and alkalies internally, and a very weak spirit or alka 
 line lotions externally, with a scrupulous diet, constitute, I beheve, its best treatment 
 When the complaint is chronic, and the discharge copious, the oxide of zinc ha» 
 often a very beneficial effect. It may be dusted over the affected surface, from a 
 thin muslin bag; or it may be applied in the shape of a lotion — fifteen grains to an 
 ounce of rose-water. You will find this a most useful lotion for that disfiguring im- 
 petiginous eruption which sometimes covers the faces of children like a mask, and 
 is called cnista laclea. The phrase crusta lactea is, however, very loosely employed 
 by medical men. 
 
 There is a very common, and a very teasing pustular disease of the skin, usually 
 called a boil, in some parts of England a push, and by the learned furunculus. 
 
 First, there is a slight degree and extent of hardness to be felt, a tender knot, just 
 beneath the surface, which soon begins to look red, and a small swelling arises, which 
 gradually increases up to a certain size, that of a large pea, or of a hazelnut, or of a 
 walnut. The tumour is painful, and undergoes a process of slow suppuration. 
 Some time from the fourth to the eighth day it acquires a conical or pointed form, 
 and its apex becomes of a white or yellow colour. At last the cuticle gives w-ay, 
 and the patient begins to congratulate himself that the little abscess is ripe, and that 
 his troubles are nearly over. But he is disappointed ; an insignificant quantity of 
 pus mixed with blood escapes, and leaves visible a mass of dead areolar tissue — a 
 core as it is called — of greater diameter than the opening, which is commonly small. 
 \t last, two or three days perhaps after this, the slough is expelled, in company \iitb 
 
 1
 
 CARBUNCLE — PURPURA. 1025 
 
 more pus, and a deep cup-like cavity remains, which soon, however, fills up, and 
 the boil is really over. 
 
 These litile phlegmons frequent the buttocks, the thighs, the arm-pits, the nape of 
 the neck, the abdomen. They may occur almost anywhere. They are apt to come 
 in crops, or in a series : and any kind of irritation suffices to cause them when a 
 constitutional tendency to their formation exists. I have known a piece of soap- 
 plaster applied to the skin give occasion to a long succession of boils. Poultices, 
 apphed to promote the suppuration of any existing furunculus. are believed to en- 
 courage, by their warmth, the growth of others around it. In truth, these phlegmons 
 belong primarily and essentially to the subcutaneous areolar tissue rather than to the 
 skin. Dr. Prout corroborates the statement of Cheselden that they are often accom- 
 panied by a saccharine condition of the urine. You know probably that, in Dr. 
 Prout's theory of assimilation, the areolar tissue represents the saccharine aliment. 
 
 The individual boils are intractable ; the state of the system which engenders them 
 may perhaps be corrected. Some dab them, when nascent, with a solution of cor- 
 rosive sublimate in spirit; some support them with sticking plaster ; others apply 
 poukices ; and others again cut the hard tumour through while it is yet crude. Do 
 what you will, you can seldom prevent or accelerate their dehberate course ; but I 
 believe that by applying leeches, or cold, you may prolong, though you cannot ar- 
 rest, that course. 
 
 Sarsaparilla, and the liquor potassae, and where the system is below par, the sul- 
 phate of quina and a generous diet, are found useful. Sugar, and saccharine food 
 of all kinds, should be scrupulously avoided. 
 
 Carbuncle, alias anthrax, is a gigantic boil ; but it is far more serious than the 
 common furuncle, not only in respect to its magnitude, and to the amount of suffer- 
 ing which it occasions, but also on account of the constitutional vice that it betokens. 
 A carbuncle is a large, flat, circumscribed, very hard, and very painful tumour, of a 
 purplish red colour, and attended with a sensation of burning heat. Its ultimate 
 diameter may be three or four inches, or more. It ends in the formation of a deep 
 slough, of more than corresponding dimensions, and the destruction of the skin above 
 it. A number of pinhole openings at length present themselves on the dark red 
 surface, and disclose the immense core beneath. 
 
 This serious complaint occurs chiefly in advanced life, in corpulent males, and in 
 persons who have lived fully. It is frequently attended with diabetes. The tumour 
 is more often situated upon the nape of the neck, or between the shoulders, than 
 elsewhere. It produces high constitutional disturbance and irritation. Surgeons 
 are in the habit of dividing the firm mass into quarters, by deep crucial incisions. 
 This is a sharp remedy, but it purchases speedy ease by removing that tension of 
 the inflamed parts whereupon the pain chiefly depends. I am persuaded, however, 
 that this severe operation is done too indiscriminately. If the tension be not mani- 
 fest, and there is not much complaint of pain, you had better, in my opinion, leave 
 these tumours to the care of nature, and address your remedies to the system at large. 
 Support is often needed ; and opiates are sometimes indispensable ; and the bowels 
 must be kept clear by purgatives. 
 
 I shall not attempt to discuss, even in this cursory and disjointed manner, any 
 more of the inflammatory affections of the skin, whether acute or chronic : but I 
 wish, before I conclude, to direct your attention to a peculiar morbid condition, of 
 much greater interest and consequence than most of those which I have just been 
 describing. I mean the malady which is best known by the appellation o^ purpura, 
 or the purples, and which usually, though it must be confessed very incorrectly, 
 is ranked among cutaneous disorders. It is strictly a hemorrhage. Its external 
 phenomena are so obvious, and so well known, that I need not dwell upon them. . 
 Small round spots appear on various parts of the surface, generally upon the legs 
 first and most plentifully, of a dull red, or of a deep purple colour. They are accom- 
 panied by no local pain, by no sensation of any kind. Pressure upon them docs 
 not efface the colour, nor render it fainter, as it does that of inflammatory spots of the 
 skin. There is scarcely ever any prominence of the purple stigmata ; but they are 
 sometimes intermixed with livid blotches, with appearances exactly resemblinjj 
 65 , 4La
 
 1026 SCURVY. 
 
 bruises ; and both the circular spots and the ill-defined vibices undergo, before they 
 disappear, the same changes of colour, from red to a greenish yellow, which a bruise 
 undergoes. In fact the anatomical condition of a bruise is exactly the same with the 
 condition of the diffused livid blotches of purpura. In each case the colour is the 
 result of ecchymosis. With all this, passive hemorrhages from various parts, and 
 particularly from the mucous membranes, are common. 
 
 It is clear, therefore, that this complaint cannot be regarded as a cutaneous com- 
 plaint, even in the loose sense in which that epithet is sometimes applied to affec- 
 tions that are really beneath the skin, but visible through it. The hemorrhage 
 takes the form of red or purple spots when the quantity of blood extravasated in 
 the same place is only a drop. And the spots are not peculiar to the skin, nor to 
 the subcutaneous tissues, but are found, occasionally, upon all the internal surfaces 
 also, and within the substance of the several viscera. I have seen these purple 
 spots on the mucous surface of the mouth, the throat, the stomach, and the intes- 
 tines, on the pleurae and pericardium in the chest, on the peritoneal investment of the 
 abdominal organs, in the substance of the muscles, and even upon the membranes 
 of the brain, and in the sheaths of the larger nerves ; and I have known them to 
 be accompanied with large extravasations of blood in most of the vital organs of 
 the body. 
 
 The superficial markings of purpura, the red and purple spots and livid blotches, 
 exactly resemble the spots and bruise-like stains which characterize sea-scurvy ; 
 and I confess that I formerly regarded the two affections as being identical, or as 
 mere varieties of the same disorder. But it is not so. For a very full and inte- 
 resting account of scurvy, I must refer you to an essay, by Dr. Budd, in the 
 Librurij of Practical Medicine. He has there collected from various sources, and 
 exhibited in a clear light, convincing evidence that scurvy is caused — neithei; by con- 
 tagion, nor by cold weather, nor by impurity of the air, nor by the continued use of 
 salt provisions, all of which have been alleged as sources of the disease, but — by the 
 privation, for a considerable length of time, of fresh succulent vegetables. Now 
 purpura often makes its appearance when there has been no deficiency of such food, 
 and no remarkable abstinence from it. Scurvy is most common in winter, or the 
 beginning of spring; purpura in the fruit seasons, in summer and autumn. In 
 scurvy the gums are uniformly soft, and swelled, and spongy, and bleed readily ; 
 this is no necessary feature in purpura. Scurvy is marked by extreme debility and 
 dejection of spirits ; it is always rendered worse by blood-letting and by mercury ; 
 and it is infallibly and rapidly cured by the administration of lemon-juice, or of 
 other fresh fruits and vegetables. Purpura, on the other hand, often requires vene- 
 section for its cure ; is not constantly nor surely, if ever, benefited by the anti-scor- 
 butic juices ; is not alwa3^s attended by sponginess of the gums, nor by feeblenesr 
 of the mind and body ; and I have seen it clear speedily away upon the superven- 
 tion of mercurial salivation and hypercatharsis. 
 
 Lemon-juice is really a specific against scurvy, whether it be employed as a pre- 
 ventive or as a remedy. It supphes something to the blood which is essential to its 
 healthy properties. Its virtues were known in this country full two hundred years 
 ago, as appears by the work entitled The Surgeon'' s Mate, or Military and Domes- 
 tic Medicine, by John Woodall, Master in Surger}' : London, 1636. But the merit 
 of making the fact generally known, and of procuring the S3'stematic introduction of 
 lemon-juice into nautical diet, by an order from the Admiralty, is due to Dr. Blair 
 and Sir Gilbert Blane, in their capacity of Commissioners of the Board for sick and 
 wounded seamen, in 1795. "The effect (says Sir John Herschel) of this wise mea- 
 .-sure may be estimated from the following facts. In 17&0 the number of cases of 
 scurvy received into Haslar Hospital was 14.57 : in 1806 one only, and in 1807 one.''^ 
 He adds, " there are now many surgeons in the navy who have never seen the 
 .lisease." 
 
 Dr. Budd, however, has assured me that the Dreadnought hospital-ship, at Green- 
 ■vich, is often full of cases of scurvy; most of the patients so affected having just 
 <\rrived in imrchant-sliips, from a long voyage. This surely ought not to be.
 
 SCURVY. 1027 
 
 It could not be if the owners of those vessels knew how easily, surely, and cheaply, 
 this truly dreadful scourge may be averted. 
 
 Scarcely less — if indeed less at all — of anti-scorbutic virtue, belongs, fortunately, 
 to that common esculent root,, the potato. Jiaw potatoes have long been in good 
 repute, both for the cure and for the prevention of scurvy : but raw potatoes are 
 neither palatable nor easy of digestion ; and it is a great discovery, which we owe to 
 the sagacity of Dr. William Baly, that this vegetable is equally effective for these 
 purposes, when cooked. During some months of continued observation of the pri- 
 soners confined in the Penitentiary at Milbank, I had remarked, without being able 
 to account for it, that among the small number of soldiers, committed for compara- 
 tively short periods, for offences against military discipline, scurvy was not uncom- 
 mon ; whereas I noticed it in one instance only among the much more numerous 
 class of convicts, whose term of imprisonment was considerably longer. Dr. Baly 
 was afterwards appointed Physician to the Penitentiary, and the same curious fact 
 soon caught his attention : and he has traced the cause. By the examination and 
 comparison of various dietaries — those, namely, which have been adopted at different 
 periods in the Penitentiary itself, those which, at the same period, were prescribed 
 respectively for the military offenders, and for the ordinary convicts, and those in use 
 in sundry other gaols in which scurvy has occurred with different degrees of fre- 
 quency — he has shown, most satisfactorily, that the liability to the malady has a strict 
 relation to the amount of succulent vegetables consumed by the prisoners, and espe 
 cially of potatoes. " Wherever this disease has prevailed, there the diet of the 
 prisoners, though often abundant in other respects, has contained no potatoes, or only 
 a very small quantity. In several prisons, the occurrence of scurvy has wholly 
 ceased on the addition of a few pounds of potatoes being made to the weekly dietary. 
 There are many prisons in which the diet, from its unvaried character, and the 
 absence of animal food, as well as green vegetables, is apparently most inadequate 
 to the maintenance of heakh ; and where, nevertheless, from its containing abundance 
 of potatoes, scurvy is not produced." * 
 
 Now potatoes are food as well as medicine, and they are a cheap kind of food, 
 and it may be hoped that a more general knowledge of their anti-scorbutic properties, 
 even when cooked, will abolish this wretched complaint, whenever a good supply 
 of them is obtainable. Dr. Baly believes that from three to six pounds, weekly, for 
 each person, would suffice. He thus accounts for their salutary influence. 
 
 "A glance at the chemical analysis of the potato at once explains its anti-scorbutic 
 virtue. The various fruits, succulent roots, and herbs, which have the property of 
 preventing and curing scurvy, all contain, dissolved in their juices, one or more 
 organic acids — such as the citric, tartaric, and malic acids. Sometimes these acids 
 exist in the free state, but more generally they are combined with potash, or lime, 
 or with both these bases. Now potatoes have been submitted to most elaborate 
 chemical examination by Einhoffand Vauquelin; and by both these chemists they 
 have been found to contain a vegetable acid in considerable quantity. According to 
 Einhoff, this acid is the tartaric combined with potash and lime. According to 
 Vauquelin it is the citric partly in combination with those bases, and partly in the 
 free state. The farinaceous seeds, as wheat, barley, oats and rye, which are destitute 
 of anti-scorbutic property, contain no organic or vegetable acids." 
 
 The same causes which give rise to sea scurvy will produce precisely the same 
 effect on land. Of this I must give you one illustration from my own case-book. In 
 August, 1830,1 admitted into the Middlesex Hospital a blacksmith, thirty-five years 
 old, covered \vith round purple spots of various sizes, and with irregular blotches of 
 ecchymosis. He had vomited blood on the preceding day. He was continually 
 coughing up blood at the time of his admission, and his wife estimated the whole 
 quantity that he had then lost to be more than half a pailful. The interior of his 
 mouth and palate was pouring forth blood from a number of livid fungous tumours 
 formed by the extravasation of blood into the areolar tissue beneath the membrane, 
 and the subsequent rupture of that membrane. He was passing, blood by the bowels 
 also ; and his urine was loaded with blood. 
 
 Here were the symptoms of scurvy strongly marked. In the man's history \\f.
 
 1028 SCURVY. 
 
 could trace its peculiar cause. He had long been subsisting on very poor and 
 insufficient nutriment, seldom eating any meat, but living almost entirely on tea, 
 coffee, and bread and butter. He had been too ill and weak to work regularly, yet 
 he had been obliged occasionally to over-exert himself to obtain a scanty supply 
 of food for himself, his wife, and a large family of children. He had been a 
 settled dram-drinker, but for some time had taken much less of that stimulus ; 
 merely because he had not the means of procuring it. His pulse was frequent and 
 feeble. 
 
 1 had not much hope that this patient could be saved by any treatment. He was 
 immediately put upon a diet of roast meat, and began to take daily half a pint of 
 fresh lemon-juice diluted with a pint and a half of water. This plan, with some tonic 
 medicine, was commenced on the 3d of August. He improved at once. On the 
 8th all the hemorrhage had ceased ; the fungous tumours in the mouth had disap- 
 peared, leaving small scars in the places they had occupied: and the discoloration 
 of the skin was almost gone. The amendment was so striking and rapid, and so 
 immediately consequent upon the institution of the treatment, that no room was left 
 for mistaking recovery for cure. 
 
 It is chiefly by investigating the previous history of the patient, and by noting the 
 degree of strength that he possesses, and the condition of his pulse, that we are 
 guided in our diagnosis of ambiguous cases. The late Dr. Parry, of Bath, was one 
 of the first to point out the efficacy of abstinence, venesection, and purgatives, in 
 some instances, at least, of purpura. I may refer you to an example of this kind 
 detailed in the Medical Gazette for the 5th of April, 182S. It occurred in one of 
 Dr. Latham's hospital patients ; and several of the symptoms were very like those 
 I have just been relating. In particular the whole tongue was livid, one half of it 
 presenting the appearance of a large, black, bleeding fungus ; and on the inner 
 surface of each cheek were several black fungoid patches. The patient was void- 
 ing also unmixed blood from the bowels. In this case there was no evidence of the 
 operation of any debilitating cause, and the pulse, though frequent, was hard. 
 Bleeding from the arm always gave relief to his uneasy sensations : he was purged 
 also, and put upon low diet. Under this plan he steadily improved, and in four or 
 five days no vestige of the complaint remained except the fading spots. For some 
 time afterwards, however, " the frequent use of active purgatives, and a rigid re- 
 striction to a low diet, were necessary to obviate costiveness, and to keep down the 
 circulation, which had a tendency to become over-active." 
 
 You are not to suppose that all cases of purpura bear this sthenic character, or 
 require these heroic remedies. Your treatment must be guided by the previous 
 circumstances and habits of the patient, by the state of his pulse, and by the other 
 symptoms which accompany the purple spots. And when you are in doubt what 
 plan to pursue, make a cautious tentative bleeding. Take away a couple of ounces 
 at a time, into a wineglass, note carefully the appearance of the blood itself, and the 
 effect of the blood-letting upon the patient ; and then go on more boldly, or abstain 
 thenceforth altogether from the lancet, according to circumstances. In many case? 
 your chief reliance will be placed in the watchful employment of purgatives. Thesft 
 have been highly recommended by Dr. Harty, of Dublin, as having proved eminently 
 successful in his practice. The late Dr. Whitlock Nicholl, and others, have spoken 
 in terms of strong praise of the oil of turpentine, administered in moderate and re- 
 peated doses, as a remedy in purpura. 
 
 I have adverted to one pecuhar source of danger in purpura, the hazard that blood 
 maybe effused in some vital organ Avhere even a slight amount of hemorrhage suffices 
 to extinguish life. Dr. Bateman states that he had seen three instances in which 
 persons were carried off, while affected with purpura, by hemorrhage into the lungs. 
 During the course of one week, in the year 1825, I was present at two inspections 
 in the dead house of St. Bartholomew's Hospital, illustrative of the same point in 
 respect to another vital organ, and involving a question in forensic medicine. The 
 subjects of examination were both of them women of middle age, who had been 
 brought into the hospital covered with purple spots and bruise-like discolorations, 
 and suffering hemorrhage from the mucous membranes. Each of these women de-
 
 CONCLUSION. 1029 
 
 clared that the apparent bruises were marks of beatings received from her husband 
 One of them became suddenly hemiplegic a httle while before she died. Of the 
 manner of dissolution in the other case I am not sure. In both instances a consider- 
 able quantity of blood was spread over the surface of the brain, between its mem- 
 branes ; and in one of them blood had been shed also into the cerebral substance, 
 which it had extensively lacerated. 
 
 It may be worth mentioning that in one of these corpses there Avere indications, 
 either of unusually rapid putrefaction after death, or (what I think more probable) 
 of some degree of decomposition even before life was extinct. This woman died 
 in the evening, and the body was examined the next day, twelve or fourteen hours 
 afterwards. A quantity of fetid gas escaped from the cavity of the abdomen as 
 soon as it was opened, and small bubbles of air were seen to ooze from the areolar 
 tissue of various parts of the body. Even when incisions were made into the liver, 
 air frothed up, as it might do, under ordinary circumstances, from a section of the 
 lungs. 
 
 I have no time left for discussing the pathology of these complaints. They are 
 eminently blood-diseases. In scurvy the blood is starved of some essential ingre- 
 dient, which the juice of lemons, and other fresh succulent vegetables, readily sup- 
 plies and renews. When drawn from a vein the blood is often visibly unnatural. 
 A very small quantity was taken before I saw him, from the arm of the blacksmith 
 whose case I just now mentioned. After standing for some time, it continued to fill 
 the whole area of the vessel in which it had been received, without any apparent 
 contraction, or separation of serum. On its flat upper surface was a thick, gray, 
 semi-transparent jelly, and beneath this there was, strictly speaking, no coagulum, 
 but a black semi-fluid substance of the consistence of syrup. Huxham describes 
 similar appearances. " The blood of such persons (says he), when it hath been 
 drawn off", always appears a mere gore, as it were, not separating into crassamentum 
 and serum as usual, but remaining in a uniform half coagulated mass, generally of 
 a livid or darker colour than usual, though sometimes it continues long very florid ; 
 Out it alwaj'^s putrefies very soon." In another place, when describing a particular 
 case, he says, " I found that neither of the portions of the blood that had been drawn 
 had separated into serum and crassamentum as usual, though it had stood many 
 hours ; but continued, as it were, half coagulated, and of a bluish hvid colour on 
 the top. It was most easily divided on the slightest touch, and seemed a purulent 
 sanies rather than blood, with a kind of sooty powder at bottom." 
 
 Dr. Budd, however, states that in some cases of scurvy the separation of blood into 
 serum and clot is as perfect, and takes place as readily, as in healthy blood. 
 
 When you recognize the disease as genuine scurvy, and trace a previous absti- 
 nence, whether forced or voluntary, from fresh vegetables, the treatment is plain ; 
 you must supply the kind of nutriment which has been defective, and support 
 your patient's strength in such other ways as the circumstances of the case may 
 dictate. 
 
 And now, gentlemen, I must needs stop. Here ends my course. And if this 
 were all I had to say, I should say it with something like glee, and you, no less than 
 myself, would rejoice that at length a breathing-place and holiday had arrived. But 
 I cannot feel so when I add that this is the last lecture, not of this course merely, but 
 the last of any kind, that I am ever hkely to dehver in King's College. I cannot 
 say this without concern and regret. 
 
 I am quite aware that my lectures have been in many respects imperfect. They 
 have been very unequal to my own wishes. But they have been as full, and as 
 carefully weighed, as my broken leisure, and irregular opportunities, and slender 
 ability, would permit. I can only hope that at any rate I have not misled you. If 
 I have been intelligible, if I have drawn such a sketch of a great and difficult subject 
 as may help you in studying it for yourselves, I have achieved my task. I told you, 
 in the outset, that I could not here teach you the practice of physic, but only its 
 principles. It would be idle for me to speculate further upon the success of my 
 endeavours. You are to be the judges of that matter. Whatever rules and precepts
 
 J 030 CONCLUSION. 
 
 I have laid down, you will soon test by your own experience, and adopt or reject 
 them accordingly. The well-known maxims of Bacon apply with especial truth to 
 medical instructors and their pupils. " Etsi non displiceat regula, oportet discentem 
 credere ; h«iic tamen conjungendum est, oportet jam edodum judicio suo idi ; dis- 
 cipuli enim debent magistris temporariam solum fidem, judiciique suspensionem, 
 donee penitus imbiberint artes : non autem plenam libertatis ejurationem, perpe- 
 tuamque ingenii servitutem." 
 
 Retiring reluctantly from this place, in obedience to the force of circumstances, 
 there are yet many things to comfort and console me. It is a great satisfaction to 
 reflect that I have never had any serious disagreement with yourselves ; have never 
 received any but the most respectful and kind treatment either from my present or 
 from any preceding class. I have reason to thank you — and I do thank you — for 
 the courtesy and attention you have at all times shown me. It is a source of gratifi- 
 cation also that I carry with me the good will, as I believe, of my excellent colleagues ; 
 and that I go without having forfeited any of that confidence which the Council first 
 reposed in me as their servant, when they offered me, without solicitation, the chair 
 I now resign. 
 
 Had I been a few years younger, unembarrassed by previous official engagements, 
 and somewhat more at leisure than I am, I should have been glad and proud to have 
 attached myself to the new hospital, and to have laboured still in the cause of King's 
 Collefre, and of its Medical School. But it is otherwise ordered : and I will men- 
 tion, as the last source of consolation in taking leave of you, my conviction that to 
 you my loss (if, without presumption, I may so venture to speak of my resignation,) 
 "will be more than supplied by my successor. I know that gentleman well. I know 
 indeed the world knows, his talents. He was highly distinguished in the Senate 
 House at Cambridge. He has since devoted, and Avill continue to devote, the powers 
 of a very strong intellect, in the investigation of disease. Dr. Budd is one of the most 
 strenuous cultivators of our science that I am acquainted with : and I am confident — 
 without any affectation of modesty — that he will soon give a much better course of 
 lectures than you have heard from me. That you may prosper in his instruction, 
 and afterwards ; that by the humane exercise of our noble calling you may do good 
 in 3'our generation, to others, and so to yourselves ; is my earnest desire and prayer. 
 I hope it is unnecessary for me to assure you that I shall always continue to take a 
 lively interest in your welfare individually; and that it uill give me sincere pleasure 
 if I shall find any future opportunity of rendering you any service. Gentlemen, I 
 do not like this sort of parting, and I will not further protract the pain that belongs 
 U) it ; but bid you finally, and most cordially — Farewell.
 
 INDEX. 
 
 Abdomen, diseases of the, 727. 
 
 dropsy of the, 741. 
 
 mode jf examining, 728. 
 
 paracentesis of the, 751. 
 
 regions of, 728. 
 
 tumours of the, 749. 
 Abdominal dropsy, 740. 
 
 palpitation, 729. 
 
 percussion, 729, 742. 
 
 respiration, 521. 
 
 tumours, 749, 904. 
 Abscess, 110. 
 
 of the brain, 256. 
 liver, 842. 
 lungs, 561. 
 Abscesses, disseminated, 710. 
 Acute inflammation, 124. 
 Adhesive inflammation, 108. 
 .iEgophony, 527. 
 Ague, 435. 
 
 cake, 856. 
 Air, impurity of a cause of disease, 75, and 
 
 [note'\, 76. 
 Air passages, foreign bodies in the, 656. 
 Albuminous urine, 877. 
 
 nephritis, 886. 
 Alveolar cancer, 138. 
 Amaurosis, 213. 
 Amygdalitis, 485. 
 Ansemia, 42, 50. 
 
 accidents and diseases attended by, 51. 
 
 anatomical characters, 50. 
 
 death by, 50. 
 
 phenomena, 51. 
 Anaesthesia, facial, 336, 343. 
 
 of other parts, 344. 
 Anasarca, 169, 887, 999. 
 
 cardiac, 174, 888. 
 
 with pulmonary disease, 173, 890. 
 
 renal, 174, 891. 
 
 treatment, 178, 892. 
 Aneurism, 'thoracic, 700. 
 
 of the heart, 661—674. 
 Angina maligna, 995. 
 
 parotidoea, 479. 
 
 pectoris, 679. 
 Anthrax, 1025. 
 Anorexia, 776. 
 
 Antimony in inflammation, 155. 
 Antiphlogistic regimen, 142. 
 Anus, artificial, 791. 
 Aorta, diseases of the, 662, 675, 700. 
 
 Aphtha, 482. 
 
 pathology of [no^e], 483. 
 Apnoea, anatomical characters, 53. 
 
 causes of, 52. 
 
 death by, 51. 
 
 diseases in which it occurs as a mode <rf 
 death, 54. 
 
 general pathology of, 53. 
 
 phenomena, 52. 
 Apoplexy, 298. 
 
 diagnosis, 299, 327. 
 
 phenomena, 304, 308. 
 
 morbid anatomy, 313. 
 
 treatment, 328. 
 
 pulmonary, 611. 
 Arachnitis, 237. 
 
 Arachnoid membrane, inflammation of, 237. 
 Areolar tissue, inflammation of, 119. 
 
 induration of, 120. 
 
 dropsy of, 169. 
 Arterial tissue, eflects of inflammation on, 123, 
 Arthritic ophthalmia, 209. 
 Artificial anus, 791. 
 Ascaris lumbricoides, 826 — 837. 
 
 vermicularis, 826—837. 
 Asiatic cholera, 805. 
 Ascites, 740. 
 
 causes, 744. 
 
 diagnosis, 741. 
 
 treatment, 748. 
 Asphyxia, death from, 52. 
 Asthenia, anatomical characters, 50. 
 
 death by, 51. 
 
 diseases in which it occurs as a mode oi 
 dying, 51. 
 
 phenomena, 51. 
 Asthma, 621. 
 
 associated organic changes, 719. 
 
 grinders, 647. 
 
 hay, 545. 
 
 spasmodic, 621, 623, 716. 
 
 thymic, 512. 
 Atmospherical temperature a cause of disease, 
 
 60. 
 Atrophy, 30—31. 
 
 of the brain, 260. 
 Auscultation, general account of, 52 1. 
 
 Bastard croup, 512. 
 Bajle, granulations of, 626. 
 Belladonna as a preventive of scarlet fever 
 no/e], 1003. 
 
 0031J
 
 1032 
 
 INDEX. 
 
 Bellows sound of the heart, 665. 
 Belly, dropsy of the, 740. 
 Bihary concretions, 850. 
 Bilious remittent fever [no/e], 964. 
 Bleeding from lungs, 608, 638. 
 
 stomach, 766. 
 Blisters, as a remedy in inflammsition, 159. 
 Blood, buffy coat of, 95—103. 
 
 diseases of, 39. 
 
 spitting of, 638. 
 
 state of in inflammation [no/e], 104. 
 
 urination of, 899. 
 
 vomiting of, 766. 
 Blood-letting, as a remedy in inflammation, 143. 
 Blood-vessels, state of in inflammation, 99. 
 Bloody urine, 899. 
 
 flux, 816. 
 Boils, 1024. 
 Bowels, inflammation of, 784. 
 
 mechanical obstruction of, 786, 787, 788. 
 
 perforation of, 734. 
 3rain and nervous system, diseases of the, 220. 
 
 abscess of, 257. 
 
 atrophy of the, 261. 
 
 cancer of the, 258. 
 
 dropsy of the, 278. 
 
 effects of pressure on the, 225, 309. 
 
 hemorrhage in the, 299, 300, 316. 
 
 hypertrophy of the, 259 [note], 
 
 induration of the, 258. 
 
 inflammation of the, 123, 239. 
 
 meningitis of the, 237. 
 
 mortification of the, 124. 
 
 softening of the, 255. 
 
 suppuration of the, 256. 
 
 tubercles of the, 258, 269, and [note], 
 
 tumours in the, 258. 
 
 tapping, 285. 
 Branks, 480. 
 Breathing, abdominal, 521. 
 
 bronchial, 527, 563. 
 
 cavernous, 634. 
 
 puerile, 526, 565. 
 
 thoracic, 519. 
 
 vesicular, 527, 530. 
 Bright's kidney, 878. 
 
 anatomical characters, 878. 
 
 signs of, 879. 
 
 changes in the urine, 879. 
 in the blood, 881. 
 
 course of the disease, 882. 
 
 secondary affections, 882. 
 
 causes, 883. 
 
 nature, 884, 
 Bronchi, dilated, 551. 
 Bronchial respiration, 527, 563. 
 
 polypi, 121, 549. 
 Bronchitis, acute, 529 — 537. 
 
 morbid anatomy, 639, 551. 
 
 treatment, 535. 
 
 chronic, 537 — 547. 
 
 varieties of, 548. 
 
 prevention, 534. 
 Bronchocele, 469, 
 Bronchophony, 527. 565. 
 
 Buffy coat of blood, 95 — 102. 
 Bullae, 925, 1021. 
 
 Calculi, renal, 858. 
 Cancer, 135. 
 
 alveolar, 138. 
 
 colloid, 138. 
 
 «atephaloid, 138. 
 
 intimate structure, 139, and 137 [note]. 
 
 origin, 139. 
 
 propagation, 140. 
 
 treatment, 141. 
 
 varieties, 137, and [note'\. 
 
 of the brain, 258. 
 lungs, 656, 
 stomach, 762. 
 Canine madness, 368. 
 Capillaries, state of in inflammation, 99. 
 Carbuncle, 1026. 
 Carcinoma of the stomach, 762. 
 Cardiac dropsy, 170, 174, 889. 
 Cardialgia, 778. 
 Carditis, rheumatic, 683. 
 Carnification of the lungs, 583. 
 Catalepsy, 424. 
 Causes of disease, 57. 
 
 cold, 65. 
 
 exciting, 58. 
 
 heat, 61. 
 
 hereditary predisposition, 77. 
 
 impurity of the air, 75. 
 
 predisposing, 58. 
 
 seasons, 73. 
 Catarrh, 528. 
 
 chronic, 547, 548. 
 
 dry, 622. 
 
 epidemic, 539, 
 
 senile, 537. 
 
 summer, 545. 
 Catarrhal ophthalmia, 181. 
 Catarrhus aestivus, 545. 
 Cavernous respiration, 633. 
 Cellular tissue, dropsy of, 169. 
 
 induration of, 120. 
 Cerebral diseases, 229. 
 
 hemorrhage, 299, 301, 316. 
 Cerebro-Spinal Meningitis, 292 [no/e]. 
 Chemosis, 185. 
 Chicken-pox, 991. 
 Child-bed fever, 731. 
 Child-crowing, 512. 
 Cholera, sporadic, 798. 
 
 epidemic, 805. 
 
 morbid anatomy, 806. 
 mode of propagation, 807. 
 modes of attack, 809. 
 treatment, 811. 
 
 infantum, 811 [note'j^. 
 Chorea, 399. 
 
 Chronic inflammation, 124. 
 Chylous urine, 897. 
 Circulation, disturbance of as a symptom of dis 
 
 ease, 90. 
 Cirrhose liver, 120, 744 — 845. 
 Coagulable lymph, 107.
 
 INDEX. 
 
 1033 
 
 Cold, a cause of disease, 65. 
 
 as a remedy in inflammation, 158. 
 
 in the head, 530. 
 chest, 529. 
 Colic, 784 — 792. 
 
 from lead, 792. 
 
 symptoms, 795 [no^e]. 
 treatment, 796. 
 Colloid cancer, 138. 
 Coma, death by, 52, 55, 300. 
 
 phenomena, 55. 
 
 diseases in which it occurs as a mode of 
 dying, 56. 
 Concretions, biliary, 850. 
 
 intestinal, 823. 
 
 renal, 858. 
 Congestion, 41. 
 
 active, 45. 
 
 local, 43. 
 
 mechanical, 45. 
 
 passive, 47. 
 Conjunctiva, inflammation of, 181,185,191, 196. 
 Consumption, 626. 
 
 curability of [no^e], 644. 
 Contagion, 928, 949. 
 Continued fever, 935. 
 Convulsions, Salaam, 414 [note"]. 
 Cord, spinal, general pathology of, 288. 
 
 inflammation of, 290. 
 Coryza, 530. 
 Cough, a symptom of disease, 89, 520. 
 
 hysterical, 418. 
 
 nocturnal, periodic, 516 [note"]. 
 Coup de soleil, 64. 
 Crepitation, a sign of disease, 631, 
 Cretinism, 475. 
 Croup, 502. 
 
 bastard, 512. 
 
 false, 515 [no/e], 
 
 spasmodic, 512, and [noiej, 515. 
 
 causes of, 515. 
 
 diagnosis, 512 [woie]. 
 
 prognosis, 507. 
 
 symptoms, 503. 
 
 treatment, 507. 
 
 tracheotomy in, 510 [note]. 
 Cutaneous diseases, 924. 
 Cutaneous tissue, inflammation of, 121. 
 Cynanche laryngitis, 491. 
 
 maligna, 994. 
 
 parotidea, 479. 
 
 tonsillaris, 485. 
 
 trachealis, 502. 
 t?ysticercus cellulosus, 829. 
 
 Dance of St. V^tus, 405. 
 Death, sudden, pathology of, 48. 
 by anaemia, 50. 
 
 apnoca, 52. 
 
 asthenia, 50. 
 
 coma, 55, 300. 
 
 inanition, 51. 
 
 syncope, 61. 
 Debility, a symptom, 88. 
 Delirium of drunkards, 245. 
 
 4h 
 
 Delirium tremens, 245. 
 
 treatment, 250, 254 [note]. 
 
 in continued fever, 938. 
 Devonshire colic, 793. 
 Diabetes, 868. 
 Diagnostic signs, 80, 83. 
 Diarrhcea, 798. 
 
 adiposa, 822. 
 
 chronic, 800 [noiej. 
 
 crapuiosa, 798. 
 Diathesis, lithic, 862. 
 
 oxalic, 865. 
 
 phosphatic, 862. 
 
 scrofulous, 126, 134. 
 Dietetic rules for dyspeptics, 782. 
 Digitalis, as a remedy in inflammation, 156. 
 Disease defined, 18. 
 Digestion, physiology of, 774. 
 Dilatation of bronchi, 551. 
 
 heart, 674. 
 
 oesophagus, 725. 
 Diuresis, chronic, 876. 
 Disease, causes of, 57. 
 
 hereditary tendency to, 59, 77, 
 Diseases of the abdomen, 727. 
 
 aorta, 652, 675, 700. 
 
 blood, 39. 
 
 brain and nervous system, 220. 
 
 Bright's, 878. 
 
 cerebral, 229. 
 
 cutaneous, 896. 
 
 eye, 180. 
 
 fluids, 39. 
 
 gall bladder, 855. 
 
 heart, 660. 
 
 intestines, 784. 
 
 kidneys, 856. 
 
 liver, 841. 
 
 lungs, 528. 
 
 (Esophagus, 722. 
 
 pancreas, 856. 
 
 skin, 924. 
 
 spleen, 856. 
 
 stomach, 753. 
 
 thorax, 518. 
 
 veins, 707. 
 Displacement of parts, 38. 
 Dizziness, a symptom, 85. 
 Dracunculus, 831. 
 
 Dropsy, general pathology of, 168 — 170, 888. 
 Dropsy, varieties, 171. 
 
 phenomena, 174. 
 
 prognosis, 178. 
 
 treatment, 178. 
 
 of the areolar tissue, 169, 887. 
 
 of the belly, 741. 
 
 of the brain, 277. 
 
 cardiac, 174, 889, 
 
 chest, 582. 
 
 ovarian, 741—746, 749. 
 
 renal, 173. 
 
 after scarlet fever, 997. 
 Drunkards, delirium of, 245. 
 Dura mater, inflammation of, 231. 
 Dying, modes of, 48.
 
 1034 
 
 INDEX. 
 
 Dysenter}', 814. • 
 
 causes, 81i. 
 
 phenomena, 815. 
 
 morbid anatomy, 817 [7?o/e]. 
 
 treatment, 818 [no/e]. 
 
 chronic, 821 [Ho^el. 
 Dyspepsia, 757, 774. 
 Dyspeptics, dietetic rules for, 782. 
 Dyspnoea, a symptom, 90, 519. 
 
 general pathology, 519. 
 
 Ecstacy, 425. 
 Eczema solare, 1020. 
 
 rubrum mercuriale, 1020. 
 Effusion of serum from inflammation, 106. 
 
 coagulable lymph, 107. 
 
 pus, 109. 
 Egyptian ophthalmia, 184, 186. 
 Exhalation, hemorrhage from, 160. 
 Emaciation, a symptom, 91. 
 Emphysema of the lungs, 553, 618. 
 
 interlobular, 618, 624. 
 
 sub-p!eural, 624. 
 
 vesicular, 618. 
 Empyema, 110. 
 Encephalitis, 239. 
 
 phenomena, 240. 
 
 morbid anatomy, 241. 
 
 treatment, 242. 
 Encephalon, inflammation of, 240. 
 Encephaloid cancer, 138. 
 Endocarditis, rheumatic, 683. 
 Endocardium, morbid states of, 676. 
 Engorgement of the lungs, 559. 
 Enteritis, 784. 
 
 diagnosis, 785. 
 Entozoa, 825. 
 
 mode of production, 832, 
 Epidemic catarrh, 539. 
 
 cholera, 805. 
 Epilepsy, 379. 
 
 phenomena, 380. 
 
 varieties, 381. 
 
 pathology, 386. 
 
 morbid anatomy, 387. 
 
 treatment, 393. 
 
 feigned, 391. 
 Epistaxis, 468. 
 
 Erysipelas, phlegmonoides, 199. 
 Erysipelas, 1004. 
 
 in young infants, 1010 ^note]. 
 Erythema, 121, 1014. 
 
 nodosum, 1014. 
 Events of inflammation, 100. 
 Examination of abdomen, 728. 
 Exanthemata, 925. 
 Exciting causes of disease, 58. 
 Eye, diseases of the, 180. 
 
 r'ace-ache, 433. 
 
 Facial anaesthesia, 336, 342. 
 
 neuralgia, 429. 
 
 paralysis, 337. 
 Falling sicknesa, 379. 
 False membranes of the pleura, 580. 
 
 False membranes of the trachea, 516. 
 Fatty transformation of tissues, 36. 
 
 liver, 632, 845, 
 Fever, inflammatory, 93, 115. 
 
 continued, 934. 
 
 hay, 545. 
 
 hectic, 94, 116, 610. 
 
 intermittent, 435. 
 
 puerperal, 730. 
 
 remittent, 964 [riotej. 
 
 scarlet, 994. 
 
 typhoid, 95, 934. 
 Filaria medinensis, 831. 
 Flatulence, 777. 
 Fluids, diseases of, 39. 
 Fluxes, 796. 
 Fungus hsematodes, 141. 
 Furunculus, 1025. 
 
 Gall-bladder, diseases of, 855. 
 
 Gall-stones, 850. 
 
 Gangrena Senilis, 114. 
 
 Gangrene, from inflammation, 112 — 119. 
 
 of the lungs, 562. 
 Gastric hemorrhage, 766. 
 Gastritis, acute, 753. 
 
 phenomena, 754. 
 
 morbid anatomy, 755. 
 
 treatment, 757. 
 
 chronic, 757. 
 
 acute, of infants, 760 [no/el. 
 Gastrodynia, 779. 
 Generation, spontaneous, 833. 
 Giddiness, a symptom, 85. 
 Glottis, oedema of, 500. 
 Goitre, 469. 
 
 Gonorrhoea! ophthalmia, 191. 
 Gout, 922. 
 
 Granulations of Bayle, 626. 
 Gravel, fit of the, 859. 
 
 different kinds of, 860. 
 Gravedo, 529. 
 
 Gray and red softening of the lungs, 561. 
 Grinder's asthma, 647. 
 Grippe, 539. 
 Guinea worm, 831. 
 Gulta serena, 213. 
 
 Haematemesis, 706. 
 
 hysterical, 419. 
 
 vicarious, 767. 
 Hsematuria, 899. 
 Haemoptysis, 638. 
 
 hysterical, 419. 
 Hemorrhages, general pathology, 159. 
 
 active and passive, 162. 
 
 diagnosis, 166. 
 
 habitual, 161. 
 
 treatment, 166. 
 
 vicarious, 162. 
 Hemorrhage, a result of inflammation, 107 
 
 of the brain, 298, 300, 316. 
 
 cerebral, 298, 300, 316 
 
 gastric, 766. 
 
 nasal, 467.
 
 INDEX. 
 
 1035 
 
 Hemorrhage, pulmonary, 608. 
 
 spinal, 332. 
 
 vesical, 899. 
 
 vicarious, 161, 768. 
 Hay-asthma, 545. 
 Headache, sick, 780. 
 Health, what is, 18. 
 Heart, diseases of, 660. 
 
 aneurisms of, 661, 674. 
 
 bellows sound of, 666. 
 
 dilatation of the, 674. 
 
 dropsy from, 172. 
 
 hypertrophy of, 660, 671. 
 
 morbid sounds of, 666. 
 
 natural sounds of, 663. 
 
 palpitation of, 668. 
 
 rupture of, 674. 
 
 valvular disease of, 675. 
 Heart-burn, 778. 
 Heat a cause of disease, 61 — 63. 
 
 a symptom of inflammation, 96, 
 Hectic fever, 94, 117,638. 
 Hemicrania, 434. 
 Hemiplegia, 310, 333. 
 Hepatic abscess, 842. 
 Hepatization of the lungs, 33, 560. 
 Hepatitis, acute, 841. 
 
 treatment, 843, and [note] 852. 
 
 chronic, 845. 
 Hereditary disposition to disease, 59, 77. 
 Herpes, 1017, 1018. 
 
 cjrcinatus, 1018. 
 
 iris, 1018, 
 
 praeputialis, 1018. 
 
 zoster, 1018. 
 Hobnail liver, 120, 745, 845. 
 Hooping cough, 552. 
 
 pathology of, 555 [note]. 
 Hydatids, 829. 
 Hydrargyrum, 1020. 
 Hydrocephalus, acute, 263. 
 
 chronic, 278. 
 
 spurious, 278. 
 Hydrophobia, 360. 
 
 phenomena, 361. 
 
 causes, 366. 
 
 morbid anatomy, 374. 
 
 in the dog, 372. 
 
 pathology, 374. 
 
 treatment, 374. 
 
 prevention, 377. 
 Hydrothorax, 582. 
 Hypersemia, 41. 
 Hypertrophy, 26 — 30. 
 
 of the brain, 259. 
 
 heart, 660, 671. 
 thyreoid gland, 469. 
 Hypochondriasis, 781. 
 Hysteria, 413. 
 
 phenomena, 414. 
 
 diagnosis, 414. 
 
 pathology, 415. 
 
 treatment of, 421. 
 
 Hysterical affection of joints, 419 
 cough, 417. 
 hfematemesis, 418. 
 laryngitis, 417. 
 palsy, 417. 
 peritonitis, 417. 
 
 Icterus, 847. 
 
 Ileus, 784. 
 
 Impetigo, 1024. 
 
 Impure air, a cause of disease, 75 
 
 Inanition a cause of death, 51. 
 
 Indigestion, 757, 774. 
 
 Induration, 32. 
 
 of the areolar tissue, 120. 
 
 of the brain, 258. 
 
 of the cellular tissue, 120. 
 Infants, purulent ophthalmia of, 196. 
 Infiltration of the lungs, purulent, 561 . 
 
 tubercular, 629. 
 Inflammation, general account of, 92 
 
 acute, 124. 
 
 adhesive, 108. 
 
 arachnoid, 237. 
 
 areolar tissue, 119. 
 
 arteries, 122. 
 
 bowels, 784. 
 
 brain, 123, 241. 
 
 chronic, 124. 
 
 conjunctiva, 181, 195. 
 
 cutaneous tissues, 121. 
 
 dura mater, 231. 
 
 encephalon, 240. 
 
 events of, 105. 
 
 eye, 181. 
 
 fibrous tissue, 906. 
 
 hectic fever from, 117. 
 
 intestines, 784. 
 
 iris, 202. 
 
 kidneys, 856. 
 
 larynx, 491. 
 
 liver, 842. 
 
 lungs, 559. 
 
 mucous membrane, 121. 
 
 oesophagus, 726 [no/e]. 
 
 of the several tissues, 119. 
 
 parotid, 479. 
 
 pericardium, 683. 
 
 peritoneum, 729. 
 
 phenomena, 93. 
 
 pia mater, 237 
 
 pleura, 579. 
 
 pyrexia, 115. 
 
 retina, 213. 
 
 serous tissue, 120. 
 
 skin, 120. 
 
 spinal cord, 290—295. 
 
 state of minute blood-vessels in, 100 ' note\ 
 
 stomach, 753. 
 
 synovial membrane, 120. 
 
 thorax, 518. 
 
 tonsils, 485. 
 
 trachea, 502.
 
 1036 
 
 INDEX. 
 
 [nflammation, treatment, 142. 
 
 typhoid fever, 117. 
 
 varieties of, 124. 
 
 veins, 122, 707. 
 Inflammatory fever, 94, 115. 
 Influenza, 539. 
 
 Inoculation of small-pox, 981. 
 Intellect, affections of, symptom of disease, 87. 
 Intermittent fever, 435. 
 
 exciting cause, 440. 
 
 pathology, 448. 
 
 phenomena, 435. 
 
 prophylaxis, 465. 
 
 species, 437. 
 
 treatment, 456. 
 Interlobular emphysema, 620, 624. 
 Intestinal concretions, 823. 
 
 worms, 825. 
 Intestines, diseases of the, 784. 
 
 inflammation of, 784. 
 
 perforation of, 734. 
 Iritis, 202. 
 
 syphilitic, 209. 
 Ischuria renalis, 866. 
 Itch, 1016. 
 Itching, a symptom, 84. 
 
 Jaundice, 847. 
 
 phenomena, 847. 
 
 pathology, 848 — 852 [note]. 
 
 prognosis, 852. 
 
 treatment, 852 [rao/e], 854 text. 
 
 Kidney, diseases of, 856. 
 Bright's, 859. 
 inflammation of, 856. 
 suppuration of, 858. 
 
 Laryngismus stridulis, 512. 
 Laryngitis, 491—500. 
 
 hysterical, 417. 
 
 spasmodic, 515 ^note]. 
 Larynx, acute inflammation of, 491. 
 
 chronic " 500. 
 
 syphilitic ulceration of, 500. 
 
 warty growths of, 501. 
 Larjngeal oedema, 499. 
 
 phthisis, 614—632. 
 
 ulceration, 500, 614, 632. 
 Laryngeo-tracheitis, 502 [nofe]. 
 Lead colic, 792. 
 
 palsy, 793. 
 Lecturer on medicine, duties of a, 24. 
 Lepra, 1022. 
 Jjife, conditioris of, 48. 
 Lithic diathesis, 852. 
 Iiiver, diseases of, 841. 
 
 abscess of, 842. 
 
 cirrhose, 120, 745, 845. 
 
 fatty, 632, 845. 
 
 hobnail, 120, 745, 845. 
 
 inflammation of, 842- 
 
 Liver, suppuration of, 842. 
 Lobular pneumonia, 560. 
 Locked jaw, 352. 
 Lumbricoid worms, 826 — 838 
 Lungs, diseases of the, 528. 
 
 abscess of, 561. 
 
 cancer of, 656. 
 
 carnification of, 583. 
 
 consumption of, 626. 
 
 emphysema of, 553, 618 
 
 engorgement of, 559. 
 
 gangrene of, 561. 
 
 hemorrhage from, 504. 
 
 hepatization of, 32, 560. 
 
 inflammation of, 559. 
 
 melanosis of, 652. 
 
 oedema of, 625. 
 
 purulent infiltration of, 561. 
 
 red and gray, softening of, 5b 
 
 sounds of, 521. 
 
 splenization of, 559. 
 
 tubercles of, 675. 
 
 tubercular, infiltration, 629. 
 Lymph, coagulable, 107. 
 
 MaculiB, 924. 
 
 Malaria, 441. • 
 
 circumstances which influence, 450. 
 
 condition, necessary to produce, 443. 
 
 eflTects of, on human body, 446. 
 
 influence of soils in evolving, 447. 
 
 ultimate effects of, 454. 
 Malignant cholera, 805. 
 Measles, 993. 
 Medicine, principles of, 22. 
 
 duties of a lecturer on, 23. 
 Melsena, 769. 
 Melanosis, true, 652. 
 
 spurious, 654. 
 Meningitis of the brain, 237. 
 
 cerebro-spinal, 292 [note], 
 
 encephalica, 287 [/?o/e]. 
 
 spine, 290. 
 
 tubercular, 264. 
 Mercury, a remedy in inflammation, 153. 
 Metastasis, 105. 
 Mercurial eczema, 1020. 
 
 tremor, 412. 
 Miliary tubercles, 626. 
 Modes of dying, 48. 
 Morbilli, 993. 
 Mortification, 95, 112, 119. 
 
 of the brain, 123. 
 Mucous membrane, inflammation of, 121. 
 
 morbid anatomy of, 551. 
 Mucous rattle, 532. 
 Mumps, 480. 
 Murmur, respiratory, 526, 530. 
 
 bellows, 666. 
 MuscsB volitantes, a symptom, 86, 238. 
 Muscular tissue, inflammation of, 123. 
 
 Nasal hemorrhage, 467.
 
 INDEX. 
 
 1037 
 
 Nausea, a" symptom, 85. 
 Nephralgia, 856. 
 Nephritis, 856. 
 
 albuminous, 886. 
 Nervous system, diseases of, 220, 
 
 physiology of, 220. 
 
 pathology of, 224. 
 Nervous tissue, inflammation of, 123. 
 Nettle rash, 1013. 
 Neuralgia, 426. 
 
 facial, 429. 
 Nutrition, lesions of, 38. 
 
 Obliteration of veins, 712. 
 
 Obstruction of bowels, mechanical, 785, 786, 788. 
 
 CEdema, 171. 
 
 of the glottis, 500. 
 
 lungs, 625, 
 
 laryngeal, 499. 
 (Esophagus, diseases of, 722. 
 
 dilatation of, 725. 
 
 inflammation of, 726 [no/e]. 
 
 stricture of, 722. 
 Old persons, catarrh of, 537. 
 Opium, a remedy in inflammation, 157. 
 Ophthalmia, arthritic, 210. 
 
 catarrhal, 181. 
 
 Egyptian, 185, 186. 
 
 gonorrhoeal, 190. 
 
 purulent, 184. 
 
 purulent in infantSj 196. 
 
 pustular, 198. 
 
 rheumatic, 210. 
 
 strumous, 198. 
 Orthopncea, a symptom, 88. 
 Ovarian dropsy, 741, 745, 749. 
 Ovaries, extirpation of, 749. 
 Oxalic diathesis, 864. 
 
 Pain, a symptom, 84, 95. 
 Painter's colic, 792. 
 Palpation of the abdomen, 729. 
 Palpitation, 669. 
 Palsy, 310, 332. 
 
 facial, 337. 
 
 from lead, 793. 
 
 hysterica], 417. 
 
 local, 336. 
 
 shaking, 410. 
 Pancreas, diseases of the, 856. 
 Papula, 924. 
 Paracentesis thoracis, 597. 
 
 abdominis, 751. 
 Paralysis agitans, 410. 
 
 facial, 337. 
 
 from lead, 793. 
 
 of one side, 310, 333. 
 
 partial, 336. 
 Paraplegia, 310, 333. 
 Parotitis, 479. 
 Pathology, 26. 
 
 of sudden death, 49. 
 
 Pectoriloquy, 527 — 635. 
 Pemphigus, 1021. 
 Percussion of thorax, 522. 
 of abdomen, 729, 742. 
 Pericarditis, 683. 
 
 Pericardium, diseased conditions of, 537. 
 Periodicity, 448. 
 Peripneumonia notha, 537. 
 Peritonitis, acute, 729. 
 treatment, 736. 
 chronic, 740. 
 hysterical, 416. 
 tubercular, 739. 
 Pertussis, 552. 
 Petechia, 649. 
 
 Phlegmasia dolens, 122, 171, 708. 
 Phlebitis, 123, 707. 
 Phosphatic diathesis, 864. 
 Phrenitis, 239. 
 Phthisis, 626. 
 
 auscultatory signs, 633. 
 its connection with tubercles, 626. 
 diagnosis, 641. 
 general symptoms, 635. 
 granulations of Bayle, 643. 
 intercurrent pleurisy, 631. 
 laryngeal, 500, 615, 632. 
 statistics, 646. 
 treatment, 648. 
 varieties, 642. 
 vomicae, 630. 
 Physician, duties and responsibilities of a, 25. 
 Pia mater, inflammation of, 237. 
 Pictonum, colica, 792. 
 Pimples, 924. 
 Plague, 1004. 
 Plethora, 41, 43. 
 Pleura, inflammation of, 580. 
 morbid anatomy, 580. 
 false membranes of, 580. 
 Pleurisy, 580. 
 
 Pleuro-pneumonia, 559, 580. 
 Pneumonia, 559. 
 
 in children, 574 [note]. 
 lobular, 561, 84;j. 
 morbid anatomy, 562. 
 prognosis, 570. / 
 
 treatment, 571, 
 Pneumonia notha, 537. 
 
 typhoid, 602 [note]. 
 Pneumo-thorax, 593. 
 Podagra, 912. 
 
 Polypi, bronchial, 121, 548. 
 Polysarcia, 28. 
 Pompholix, 1021. 
 Predisposing causes of disease, 58. 
 Predisposition, hereditary, 77. 
 Pressure on the brain, effects of, 225, 309. 
 Principles of medicine, 22. 
 Prognostic signs, 81, 83. 
 Proximate causes, 57. 
 Prurigo, 1014. 
 Psoriasis, 1013. 
 
 4M3
 
 1038 
 
 INDEX. 
 
 Ptj'alisni, spontaneous, 481. 
 
 Puerile respiration, 526, 565. 
 
 Puerperal iever, 731. 
 
 Pulmonary tissue, inflammation of, 559. 
 
 Pulmonary apoplexy, 612. 
 
 consumption, 626. 
 
 emphysema, 618. 
 
 hemorrhage, 608. 
 
 vesicles, dilatation of, 621. 
 Pulse, indications of, in disease, 90. 
 Purging:, as a remedy in inflammation, 151. 
 Purpura, 1026. 
 Purulent ophthalmia, 184. 
 
 of infants, 195. 
 
 infiltration of the lungs, 561. 
 Pus, 109. 
 Pustulae, 924. 
 Pustular ophthalmia, 193. 
 Pyrexia, with inflammation, 94, 115. 
 Pyrosis, 779. 
 
 Quinsy, 485. 
 
 RaUies canina, 368, 372. 
 Eamollissement of the brain, 255. 
 Red and gray softening of the lungs, 561. 
 Redness, a symptom of inflammation, 98. 
 Regimen, antiphlogistic, 142. 
 Regions of the thorax, 524. 
 
 abdomen, 728. 
 Remittent fever, 964 [no^e]. 
 Renal dropsy, 173. 
 
 calculi, 859. 
 
 Resolution, an event of inflammation, 94 106, 
 
 Respiration, abdominal, 531. 
 
 bronchial, 527, 
 
 cavernous, 634. 
 
 natural sounds of, 531. 
 
 puerile, 526. 
 
 thoracic, 519, 730. 
 
 vesicular, 530. 
 Respiratory murmur, 526, 531. 
 Retinitis, 214. 
 Revaccination, 989. 
 Rheumatic ophthalmia, 185 — 210. 
 
 carditis, 683. 
 Rheumatism, acute, 906. 
 
 varieties, 907. 
 
 connection with disease of heart, 683. 
 
 chronic, 911. 
 Rhonchus, 531 — 563. 
 Round worms, 826. 
 Rubeola, 993. 
 
 St. Vitus' dance, 405. 
 Salaam convulsions, 414 [no/e]. 
 Salivation, spontaneous, 481. 
 Scabies, 1016. 
 Scarlet fever, 996. 
 
 species, 996. 
 
 diagnosis, 997. 
 
 symptoms, 997. 
 
 Scarlet fever, sequela; of, 999. 
 treatment, 1000. 
 prophylaxis, 1003. 
 Sciatica, 434. 
 Scirrhus, 138. 
 Scrofula, agency of impure air in production of, 
 
 76 [no/el. 
 Scrofulous diathesis, 126 — 134. ^ 
 inflammation, 126. 
 ophthalmia, 198. 
 Scurvy, 1026. 
 
 Seasons, influence of the, 73. 
 Senile catarrh, 537. 
 Sensations, morbid, as symptoms, 86. 
 Serous tissues, inflammation of, 120. 
 Serum, efTusion of, 106. 
 Shaking palsy, 410. 
 Sibilus, 530. 
 Sick headache, 780. 
 Signs of disease, 82. 
 Scirrhus, a symptom, 85. 
 Skin, inflammation of, 121. 
 Sloughing, 95. 
 Small-pox, 975. 
 
 complications, 977. 
 diagnosis, 976. 
 species, 977. 
 symptoms, 976. 
 treatment, 988. 
 Sneezing, a symptom, 89. 
 Softening, 34. 
 
 of the brain, 255. 
 of the heart, 674 — 681. 
 red and gray of the lungs, 561. 
 spine, 298. 
 
 of the stomach, 756, 760 [no/e]. 
 Solids, alterations of the, in disease, 26 
 
 change of situation in the, 38. 
 Sore-throat, inflammatory, 485. 
 
 malignant, 995. 
 Sounds of the lungs, 521. 
 
 heart, 663, 666. 
 Spasm, a symptom, 88. 
 Spasmodic asthma, 621, 023, 716. 
 cholera, 805. 
 croup, 512 [?2o/e]. 
 diseases, 345. 
 laryngitis, 515 [note]. 
 stricture of oesophagus, 724. 
 Sphacelus, 113, 119. 
 Specific inflammation, 125. 
 Spinal cord, pathology of, 288. 
 physiology of the, 288. 
 inflammation of, 290, 292. 
 Spinal hemorrhage, 332. 
 
 meningitis, 291. 
 Spleen, diseases of, 856. 
 Splenization of the lungs, 560. 
 Spontaneous generation, 834. 
 
 salivation, 481. 
 Spotted fever, 940. 
 Spitting of blood, 638. 
 Spurious croup, 512.
 
 INDEX. 
 
 1039 
 
 Spurious hydrocephalus, 276. 
 SquamjB, 924, 1022. 
 Starvation, death by, 52. 
 » Stomach, diseases of the, 753. 
 cancer of the, 762. 
 hemorrhage from the, 766. 
 inflammation of the, 753. 
 perforation of the, 735. 
 softening of the, 756 — 760 [notej. 
 ulceration of the, 735, 758. 
 Strictures of the oesophagus, 723. 
 Strongulas gigas, 832. 
 Strumous diathesis, 133. 
 
 ophthalmia, 198. 
 Sub-pleural emphysema, 624. 
 Succussion, 528. 
 Sudamia, 649. 
 
 Sudden death, pathology of, 49. 
 Suffocation, death by, 52. 
 Summer catarrh, 545. 
 Summer complaint of infants, 811 [note]. 
 Suppression of urine, 866. 
 Suppuration, 94^ 109. 
 of the brain, 256. . 
 diffuse of the lungs, 561. 
 of the kidney, 858. 
 of the liver, 842. 
 of the spine, 298. 
 Swelling, a symptom of inflammation, 99. 
 Symptoms, general account of, 79. 
 diagnostic, 80. 
 prognostic, 81. 
 pathognomonic, 83. 
 Syncope, death by, 51. 
 
 anginosa, 680. 
 Synovial membrane, inflammation of, 120. 
 Syphilitic ulceration of the larynx, 500. 
 iritis, 209. 
 
 Tabes mesenterica, 129 
 
 Tffinia, 827. 
 
 Tape worm, 827 — 838. 
 
 Tapping the brain, 284. 
 
 Tegumentary membranes, inflammation of, 121. 
 
 Temperature, vicissitudes of, a cause of disease, 
 
 69. 
 Tetanus, 345. 
 Thorax, diseases of, 517. 
 
 auscultation of, 521. 
 
 inflammation ofj 517. 
 
 paracentesis of, 597. 
 
 percussion of, 522. 
 
 regions of, 524. 
 Thoracic respiration, 521, 730. 
 
 aneurisms, 700. 
 Thrush, 482. 
 Thymic asthma, 512. 
 Thyreoid glands, hypertrophy of, 469 
 'i'ic douloureux, 429. 
 Tinnitus aurium, a symptom, 87. 
 Tissues, effects of inflammation in the, 119. 
 
 atrophy of, 30. 
 
 hypertrophy of, 26. 
 
 Tissues, induration of, 32. 
 softening of, 33. 
 transformation of, 35. 
 To and fro sound of heart, 687. 
 Tonsillitis, 485. 
 Tonsils, inflammation of, 485. 
 Tonsils, enlarged, 491, and [note]. 
 Tormina, 784. 
 
 Trachea, false membranes of, 506. 
 foreign bodies in, 656. 
 inflamed, 502. 
 Tracheitis, 502. 
 Tracheotomy in croup, 510, and \nott\ 
 
 laryngitis, 494. 
 Transformation of tissues, 35. 
 Traumatic tetanus, 347. 
 Tremor, a symptom, 88. 
 
 mercurial, 412. 
 Trembles, 412. 
 Trichina spiralis, 830. 
 Tricocephalus dispar, 827. 
 Trismus, 346. 
 Tubercle, 126. 
 
 forms of, 129 \notb\. 
 diffusion of in children, 131 \tiote\. 
 of the brain, 258—269, and [note] 
 iungs, 626. 
 peritoneum, 739. 
 Tuberculffi, 925. 
 
 Tubercular infiltration of lungs, 629. 
 meningitis, 264. 
 
 morbid anatomy, 268, and [no/e]. 
 peritonitis, 739. 
 phthisis, 626. 
 Tumours of abdomen, 749, 904. 
 
 in brain, 258. 
 Typhoid fever, 95, 935. 
 Twulioul pneumonia, 602 \note\. 
 
 I Ulceration, 95, 111. 
 
 /aryngeal, 501, 615, 632. 
 of the stomach, 735, 757. 
 syphilitic, of the larynx, 501. 
 tubercular " « 631. 
 
 Urine, albuminous, 877. 
 bloody, 898. 
 chylous, 897. 
 diabetic, 868. 
 
 morbid conditions of, 862 — 868, 877, 
 retention of, hysterical, 420. 
 saccharine, 868. 
 suppression of, 866. 
 Urticaria, 1013. 
 
 varieties, 1013. 
 treatment, 1014. 
 
 Vaccination, 982. 
 
 Valves of the heart, diseases of, 675, 
 
 Varicella, 991. 
 
 Variola, 975. 
 
 Veins, diseases of, 707. 
 
 inflammation of, 122, 707. 
 
 obliteration of, 712.
 
 1040 
 
 INDEX. 
 
 Venesection, 143. 
 
 Venous tissue, under inflammation, 122. 
 
 Vertigo, a symptom, 85. 
 
 Vesiculae, 925, 1017. 
 
 Vesicles of the lungs, dilated, 621. 
 
 Vesicular emphysema, 619. 
 
 respiration, 527, 531, 564. 
 Vicarious hemorrhage, 162, 767. 
 Vicissitudes of temperament a cause of disease, 68. 
 Viscera, inflammation of the, 120. 
 Vomicae, 628 — 630. 
 Vomiting, 776. 
 Vomiting of blood, 766. 
 
 hjsterical, 418. 
 
 Warmth, external, a remedy in inflammation, 
 
 158. 
 Warty growth of larynx, 501. 
 Wasting, a symptom, 91. 
 Water brash, 779. 
 
 stroke, 266. 
 Worms, 825. 
 
 varieties, 825. 
 
 round, 826. 
 
 flat, 827. 
 
 mode of production, 833. 
 
 symptoms of, 837. 
 
 treatment, 838. 
 Zona ignea, 1018. 
 
 THE END.
 
 BLANCHARD & LEA'S 
 MEDICAL Am SURGICAL PUBLICATION'S. 
 
 TO THE MEDICAL PROFESSION. 
 
 In the present catalogue we have affixed prices to our publications, in obedience 
 to the repeated requests of numerous members of the profession. While books, 
 like all other articles, must necessarily vary somewhat in cost throughout the ex- 
 tended territories of this country, yet our publications will generally be furnished 
 at these rates by booksellers throughout the Union, who can readily and speedily 
 procure any which they may not have on hand. 
 
 To accommodate those physicians who have not convenient access to bookstores, 
 or who cannot order through merchants visiting the larger cities, we will forward 
 our works by mail, //re o/pvsta[/e, on receipt of the printed prices in current funds 
 or postage stamps. As our business is wholesale, and we open accounts with book- 
 sellers only, the amount must in every case, without exception, accompany the 
 order, and we can assume no risks of the mail, either on the money or the books ; 
 and as we only sell our own publications, we can supply no others. Physicians 
 will, therefore, see the convenience and advantage of making their purchases, when- 
 ever practicable, from the nearest bookseller. 
 
 We can only add that no exertions are spared to merit a continuance of the 
 gratifying confidence hitherto manifested by the profession in all works bearintT our 
 imprint. 
 
 BLANCHARD & LEA. 
 
 Philadelphia, Augu.<t, 1856. 
 
 ^■'^* A copy of our Illustrated Catalogue, 64 pages, octavo, will be sent free to 
 any address on receipt of six cents in postage stamps. Catalogues of our numerous 
 publications in miscellaneous and educational literature forwarded on application. 
 
 T^VO MEDICAL PERIODICALS, FREE OF POSTAGE, 
 
 FOK FIVE ©©L.I.AMS PER A]¥I¥UM. 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, subject to 
 
 postage, when not paid for in advance, - - - - - - - $5 00 
 
 THE MEDICAL NEWS AND LIBRARY, invariably in advance, - - 1 00 
 or, BOTH PERIODICALS fumished, free of postage, for Five Dollars remitted 
 in advance. 
 
 THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
 
 Edited by ISAAC HAYS, M. D., 
 
 is pviblished Quarterly, on the first of Januajy, April, July, and October. Each number contains 
 at least two hundred and eighty large octavo pages, handsomely and appropriately illustrated, 
 wlierever necessary. It has now been issued regularly for more than thirty-five years, and it has 
 tx;en under the control of the present editor for more than a quarter of a century. Throughout 
 this long period, it has maintained its position in the highest rank of medical periodicals both at home 
 and abroad, and has received the cordial support of the entire proiession in this countiy. Its list o! 
 Collaborators will be found to contam a large number of the most distinguished names of the pro- 
 tessiou iu every section of the United States, rendering the department devoted to 
 
 ORIGINAL COMMUNICATIONS 
 
 lul: of varied and important matter, of great interest to all practitioners. 
 
 As the aim of the Journal, however, is to combine the advantages presented by all the difleren; 
 varieties of periodicals, in its 
 
 REVIEW DEPARTMENT 
 
 will be found extended and impartial reviews of all important new works, presenting subjects of 
 novelty and interest, together with very numerous 
 
 BIBLIOGRAPHICAL NOTICES, 
 
 including nearly all the medical publications ot the day, both in this country and Great Britain, with 
 a choice selection of the more important continental works. This is followed by the
 
 BLANCHARD & LEA'S MEDICAL 
 
 QUARTERLY SUMMARY, 
 
 being a very full and complete abstract, methodically arranged, of the 
 
 IMPROYEMENTS AM) DISCOVERIES IN THE MEDICAL SCIENCES. 
 
 This department of the Journal, so important to the practising physician, is the object of especial 
 care on the part of the editor. It is classified and arranged under difTereni heads, thus facilitating 
 the researches of the reader in pursuit of particular subjects, and will 1^ found to present a very 
 full and accurate digest of all observations, discoveries, and inventions recorded in every branch oi 
 medical science. The very extensive arrangements of the publishers are such as to aflord to the 
 editor complete materials for this purpose, as he not only regularly receives 
 
 ALL THE AMERICAN MEDICAL AND SCIENTIFIC PERIODICALS, 
 
 but also twenty or thirty of the more important Journals issued in Great Britain and on the Conti- 
 nent, thus enabling him to present in a convenient compass a thorough and complete abstract ol 
 everything inleresting or important to the physician occurring in any part of the civilized world. 
 
 An evidence of the success which has attended these efforts may be found in the constant and 
 steady increase in the subscription list, which renders it advisable for gentlemen desiring the 
 Journal, to make known their wishes at an early day, in order to secure a year's set with certainty, 
 the publishers having frequently been unable to supply copies when ordered late in the year. To 
 their old subscribers, many of whom have been on their list for twenty or thirty years, the publish- 
 ers feel that no promises are necessary; but tho?e who may desire for the first time to subscribe, 
 can rest assured that no exertion will be spared to maintain the Journal in the high position M'hicij 
 it has occupied for so long a period. 
 
 Bv reference to the terms it will be seen that, in addition to this large amount of valuable and 
 practical information on every branch of medical science, the subscriber, by paying in advance, 
 tecomes entitled, without further charge, to 
 
 THE MEDICAL NEWS AND LIBRARY, 
 
 a monthly periodical of thirty-two large octavo pages. Its "News Department" presents the 
 current information of the day, while the " Library Department" is devoted to presenting stand- 
 ard works on various branches of medicine. Within a few years, subscribers have thus received, 
 without expense, the following works which have passed through its columns: — 
 WATSON'S LECTURES ON THE PRACTICE OF PHYSIC. 
 BRODIE'S CLINICAL LECTURES ON SURGERY. 
 TODD AND BOWMAN'S PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAJJ. 
 
 724 paares, with numerous wood-cuts, being all that has vet appeared in England. 
 WEST'S LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. 
 MALGAIGNE'S OPERATIVE SURGERY, with wood-cuts. 
 SIMON'S LECTUKES ON GENERAL PATHOLOGY. 
 BENNETT ON PULMONARY TUBERCULOSIS, with wood-cuts, 
 WEST ON ULCERATION OF THE OS UTERI, and 
 BROWN ON THE SURGICAL DISEASES OF FEMALES, with wood-cuts. 
 
 While the number for July, 1856, will commence a new and highly important work, 
 
 WEST'S LECTURES ON THE DISEASES OF WOMEN. 
 
 Part I. — Diseases of the Uterus. 
 
 The very favorable reception accorded by the profession to the valuable "Lectures on the 
 Diseases of Children," by the same author, which likewise appeared in this periodical, has in- 
 duced the publishers to secure the present work for their subscribers, from advance sheets, supplied 
 bv the author. The very high reputation of Dr. West, and the unutual clinical advantages which 
 he has enjoyed, sufliciently indicate the practical value of a systematic work from his pen on so 
 important a subject. The publishers, therefore, trust that its appearance in the " News" will aflbrd 
 entire satisfaction to their numerous subscribers, who will thus receive it hee of all expense. 
 
 |^° For a more extended advertisement, see p. 32. 
 
 It will thus be seen that for the small sum of FIVE DOLLARS, paid in advance, the subscriber 
 will obtain a Quarterly and a Monthly periodical, 
 
 EMBRACING ABOUT FIFTEEN HUNDRED LARGE OCTAVO PAGES, 
 
 mailed to any part of the United States, free of postage. 
 
 These very favorable terms are now presented by the publishers with the view of removing all 
 ditriculties and objections to a full and extended circulation of the Medical Journal to the olfice of 
 -.ivery member of the profession throughout the United States. The rapid extension of mail facili- 
 ties will now place the numbers before subscribers with a certainty and dispatch not heretofore 
 attainable; while by the system now proposed, every subscriber throughout the Union is placed 
 '.ipon an equal footing, at the very reasonable price of Five Dollars for two periodicals, without 
 f.;rther expense. 
 
 Those subscribers who do not pay in advance will bear in mind that their subscription of Five 
 j.)ollars will entitle them to the Journal only, without the News, and that they will be at the expense 
 'a' their own postage on the receipt of each number. The advantage of a remittance when order- 
 i'£ the Journal will thus be apparent. 
 
 As the Medical News and Library is in no case sent without advance payment, its subscribers 
 'i;! always receive it free of postage. 
 
 x^emittances of subscriptions can be mailed at our risk, when a certificate is taken from the Post- 
 master that the money is duly inclosed and forwarded. 
 
 Address BLANCHARD & LEA, PHiUkJ)ELPHU.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 ALLEN (J. M.), M. D., 
 
 Profesfior of Anatomy in the Penasylvaaiu Medical Coilege, &c. 
 
 THE PRACTICAL ANATOMIST; or, The Student's Guide iu the Dissecting. 
 
 ROOM. With over 200 illiis;tratioiis. Iji one handsome royal 12nio. volume, of over 500 pages. 
 
 {To be ready for tlte- fall sessions.) 
 
 In the arrangement of this work, the atUhor has endeavored to present a complete and thorough 
 course of dissections in a clearer and more available form for practical use, than has as yet been 
 acconiplished. The chapters follow each other in the order in which dissections are usually con- 
 ducted in this country, and as each region is taken up, every detail regarding it is fully descril:>ed 
 and illusiraled, so that the student is not iuJerrupted ia his labors, by the necessity of referring froui 
 oae portion q( tiie volume to another. 
 
 ANALYTJCAL COMPENDtUM 
 
 OF MEDICAL SCIENCE, containiag Anatomy, Physiology, Surgery, Midwifery, 
 
 Chemistry, Materia Medica, Tlierapeutics, and Practice of Medicine. By John Neill, M. D., 
 &ud F. G. S.MiTH, M. D. New and enlarged edition, one thick volume royal 12mo. o[ over 
 1000 pag^s, with 374 illustrations. I^^ See Neill, p. 24. 
 
 ABEL (F. AJ, F. C. S. AND C. L. BLOXAM. 
 HANDBOOK OF CHEMISTRY, Theoretical, Practical, and Technical ; with a 
 
 Recommendatory Preface by Dr. Hofmann. In o«e large octavo volume, extra cloth, of 662 
 pages, v/ith illustrations. $3 25. 
 
 It must be understood that this is a work fitted for 
 tiie earnest studeat, who resolves to pursue for lum- 
 eell' a steady searcli into the clieniieal mysteries of 
 creation. For such a student tlie ' Handbook' will 
 prove an excellent guide, since he will find ia it, 
 cot merely the approved modes of analytical investi- 
 gration, b«t laost descriptions of the apparatus ne- 
 
 eesBary, with such manipulatory details as rendered 
 Faraday's ' Cliemical Manipulations' so valuable at 
 tlie time of its publication. Beyond this, the im- 
 portauce of the work is increased by tlie introduc- 
 tiim of much of the technical chemistry of the manu- 
 factory. — Df. Hofnianx,'' s Fveface. 
 
 ASHWELL (SAMUEL), M. D., 
 
 Obstetric Physiciaa acd Lecturer to Guv's Hospital, London. 
 
 A PRACTICAL TKEATISE ON THE DISEASES PECULIAR TO WOMEN. 
 
 illustrated by Cases derived from Hospital and Private Practice. Tliird American, from the Third 
 and revised London edtlioJi. I« one octavo v^olume, extra cloth, of 52S pages. (Lately Piib- 
 U-sked.) $3 00. 
 
 The most useful practical work oa the subject in 
 Che English language. — Boston Med. and Surg. 
 Journal. 
 
 The most able, and certainly] the most etatidard 
 and practical, work on female diseases that we have 
 yet seea. — Medico-C hirurgical Review. 
 
 The young practitioner will find it invaluable, 
 while tiioee who have had most experience will yet 
 
 find Boraething to learn, and much to commend, in a 
 l)ook which shows so much patient observaticm, 
 practical skill, and sound sense. — British and Fo- 
 reign Med. Review. 
 
 We commend it to our readers as the best practi- 
 cal treatise on the subject which has yet appeared. 
 — London Lancet. 
 
 ARNOTT (NEILL), M. D. 
 
 ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. 
 
 Written lor universal use, in plain or non-technical language. A new edition, by Isaac Hays, 
 M. D. Complete in otje octavo volume, leather, ol' 484 pages, with about two hundred illustra- 
 tions. ^2 6U. 
 
 BENNETT (HENRY), M. D. 
 A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, 
 
 ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Fourth 
 American, from the third and revised London edition. To which is added {July, 1856), a K kview 
 OF THE PiiESENT State OF Uterine Pathology. In cuie neat octavo volume, extra cloth, of 
 r)00 pages, with wood-cuts. $2 00. 
 
 The addition of the "Review" presents the most recent aspects of the questions discussed in 
 tids well-known work, bringing it down to the latest moment. 
 
 This edition has beea carefully revised and altered, | When, a (e\v years back, the first edition of the 
 and various additions have been made, which render present work was published, the subject was one al- 
 it more complete, and, if possible, more worthy of most entirely unknown to the obstetrical celebrities 
 the high appreciaticxi in wliicli it is held by the i of the day ; and even now we have reason to know 
 medical profession throughout the world. A copy that the bulk of the profession are not fully alive to 
 should be in the possession of every phyatciaa. — the importance and frequency of the dfsease of which 
 
 it takes cognizance. The present edition is so much 
 enlarged, altered, and improved, that it can scarcely 
 be considered tlie same work.— iJr. lianlcing's Ab- 
 stract. 
 
 Charleston Med. Journal and Review 
 
 We are firmly of opinion that in proportion as a. 
 knowledge of uterine diseases becomes more appre- 
 ciated, this work will be proportionably established 
 as a text-book in tke profession. — The Lancet. | 
 
 Also, just ready, by the same author, and for sale separate, 
 
 A REVIEW OF THE PRESENT STATE OF UTERINE PATHOLOGY. 
 
 1 small vol. Svo. 50 cents, in flexible cloth. 
 
 In this little work, which can be had either in connection with the "Practical Treatise," or 
 separate, the author presents his latest views with regard to the various doctrines which have re- 
 cently been brought forward on this interesting question, under the following heads : — 
 Chap. .Preliminary. II. Sketch of Uterine Pathology. III. Objections. IV. The Leucorrhoea 
 
 Theory — the Syphilis Theory — the Ovarian Theory. V. The Displacement Theory. VI. 
 
 Summary.
 
 BLANCHARD & LEA'S MEDICAL 
 
 BROWN (ISAAC BAKER), 
 
 Surgeon-Accoucheur to St. Mary's Hospital, &c. 
 
 ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- 
 
 MENT. With handsome illustrations. One vol. 8vo., extra cloth. {Now Ready.) $L 60. 
 
 Mr. Brown has earneil for himself a high reputa- anil merit the careful attention of every surgeon- 
 tion in the operative treatment of sundry diseases 1 accoucheur. — Association Journal. 
 and injuries to which females are peculiarly subject, i ,,^ , i -^ ,■ • „ i- ^u- v u 
 
 , '. '".1""^ ^ ,„„,.i, ,u.'i if ,c or, irr,,„„.t.,v,t Wb lavB HO hesitatioH in recommending this book 
 
 ^^' e can trulv say ot his worK that it is an important I . .^i <• i ii •■ /• n i i 
 
 addition to obstetrical literature. The operative : '" ^'f c^^^'^f"' ""/"tion of a 1 surgeons who make 
 suggestions and contrivanoes which Mr. Brown d.- , fe.rtile complaints a part of heirstudyandpract.ee. 
 scnbes, exhibit much practical sagacity and ^i,ni, -Dublin Quarterly .Journal. 
 
 BENNETT (J. HUGHES), M.D., F. R. S. E., 
 
 Professor of Clinical Medicine in the University of Edinburgh, <fcc. 
 
 THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- 
 
 LOSIS, and on tiie Local Medication of Pharyngeal and Larj'ng-eal Diseases frequently mistaken 
 for or associated with, Phthisis. In one handsome octavo volume, extra cloth, with beautiful 
 wood-cuts. pp. 130. {Latelij Issued.) $1 25. 
 
 SUDD (GEORGE), M. D., F. R. S., 
 
 Professor of Medicine in King's College, London. 
 
 ON DISEASES OP THE LIVER. Second American, from the second and 
 
 enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- 
 fully colored plates, and numerous wood-cuts. pp. 40S. $3 00. 
 For many years, Dr. Budd's work must be the I the subject has been taken up by so able and experi- 
 
 aulhority of the i;reat mass ol British practitioners enced a physician — British and Foreign Medico- 
 
 on the hepatic diseases ; and it is satisfactory that I Chirurgical Review. 
 
 BY THE SAME AUTHOR. [NoiV HeadlJ.) 
 
 ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OP 
 
 THE STOJMACH. In one neat octavo volume, extra cloth. $150. A new work, 1856. 
 
 While special treatises havebeen multiplying upon almost all the different classes of diseases, there 
 has long- been fijlt the want of an authoritative work on the disorders of the stomach, which con- 
 stitute, perhaps, a larger proportion of the daily practice of the physician than any other class of 
 maladies. To supply this want has been the object of the author, and his reputation is an ample 
 g-uarantee of the value of his labors. 
 
 From the high position occupied by Dr. Budd as | style, the .subjects are well arranged, and the practi- 
 a teacher, a writer, and a practitioner, it is uliuost I cal precepts, both of diagnosis and treatment, denote 
 needless to state tliat the present book may be con- I llie character of a thouglitful and experienced phy- 
 sulted with great advantage. It is written in an easy I sician. — London Med. times and Gazette, Dec. 1S55. 
 
 BIRD (GOLDING), A. M., M. D., Sic. 
 URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND 
 
 THERAPEUTICAL INDICATIONS. A new and enlarged American, from the last improved 
 London edition. With over sixty illustrations. In one royalT2mo. vol, extra cloth, pp.372. §130. 
 
 It can scarcely be necessary for us to say anything i extension and satisfactory employment of our thera- 
 of the merits of this well-known Treatise, which so peutic resources. In the preparation of this new 
 admirably brings into practical application the re- edition of his work, it is obvious that Dr. Golding 
 suits of ttiose microscopical and chemical researches Bird lias spared no pains to render it a faithful repre- 
 regarding the physiology and pathology of the uri- sentation of the present state of scientific knowledge 
 na7y secretion, which have contributed so much to \ on the suhiect it emhrnces.— The British and Foreign 
 the increase of our diagnostic powers, and to the I Medico-C hirurgical Review. 
 
 BY THE SAME At'THOR. 
 
 ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro- 
 duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the 
 third London edition. In one neat volume, royal 12mo, extra cloth, pp.402. §125. 
 
 BILLING'S PRINCIPLES OF MEDICINE.— 
 Second American, from tlie Fifth and Improved 
 I.ondon edition. In one handsome octavo volume, 
 extra cloth. 250 pages. Sfl 25. 
 
 BLAIflSTON'S PRACTICAL OBSERVATIONS 
 ON CERTAIN DISEASES OF THE CHEST, 
 and . n tlie Princiiiles of Auscultation. In one vol., 
 cloth, 8vo pp.384. ®1 "25. 
 
 BTRROWS ON DISORDERS OF TIIE CERE- 
 URAli CIRCULATION, and on the Connection 
 between the Affections lU' the Brain and Diseases 
 of tlie Heart. In one 8vo. vol., extra clolh, with 
 c-..l.irtd pbites. pp. -210. SI 25. 
 
 BEM.E ON THE LAWS OF HEALTH IN RE- 
 LATION TO ?<II\D AND BODY. A Series of 
 Lettfrs from an old Practitioner to a Patient. In 
 •lie volume, royal 12mo., extra cloth, pp. 296. 
 80 cents. 
 
 BUSHNAN'S PHYSIOLOGY OF ANIMAL AND 
 VEGETABLE LIFE; a Popular Treatise on the 
 Functions and Phenomena of Organic Life. In 
 one handsome royal ]2mo. volume, extra cloth, 
 with over 100 illustrations, pp.231. 80 cents. 
 
 BUCKLER ON TIIE ETIOLOGY. PATHOLOGY, 
 AND TREATMENT OF FIBRO-BRONCHI- 
 TIS AND RHEUMATIC PNEUMONIA. In 
 
 one Svo. volume, extra clolh. pp.150. §125. 
 
 BLOOD AND URINE (MANUALS ON). BY 
 JOHN WILLIAM GRIFFITH. G. OWEN 
 REESE, AND ALFRED MARKWICK. One 
 
 thick volume, royal 12ino., extra cloth, with 
 plates, pp. 460. $1 25. 
 
 BRODIE'S CLINICAL LECTURES ON SUR- 
 GERY. 1 vol. 8vo., cloth. 350 pp. $125.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 BARLOW (GEORGE H.), M . D. 
 
 Physician to Gay's Hospital, London, &c. 
 
 A MANUAL OF THE PRACTICE OF iMEDICINE. With Additions by D, 
 
 F. CoNDiE, M. D., author of'' A Praclieal Treatise on Diseases of Children," &c. In one hand- 
 some oclavo voliuue, leather, of over bOO pages. (A new work., just ready, 1856.) $2 75. 
 The position of the author as physician to Guy's Hospital and other large public institutions, is 
 a sufficient guarantee of the extent and value of the experience which is here systematically re- 
 corded and condensed. His aim throughout has been to produce a practical work, on which the 
 student can rely as a guide, and to which the practitioner can refer with confidence. The additions 
 by the editor comprise chapters on Cerebro-spinal PJeningitis, Cholera Infantum, and Yellow Fever, 
 besides numerous notes wherever the diseases or practice of this country seemed to render them 
 necessary or desirable. 
 
 We most empliatically commend it to the attention 
 of the profession, as deserving rheir confidence — a 
 depository of practical knowledpie, from which they 
 may draw with great benefit. — Cincinnati Med. Ub- 
 teri-er, Mar. 1656. 
 
 The student has long been in want of a gocd ele- 
 mentary work on tlie Practice of Medicine. In Dr. 
 Bailow's Manual that want is supplied; and we 
 have no question that it will at once be installed 
 as tlie favorite text-book in ail Medical Schools. — 
 Medical Times and Gazette. 
 
 We recommend Dr. Barlow'sManual in the warm- 
 est manner as a most valuable vade-mccutn. We 
 have had frequent occasion to consult it, and have 
 found it clear, concise, practical, and sound. It is 
 eminently a practical work, containing all that is 
 essential, and avoiding useless theoretical discus- 
 sion. The work supplies what has been for some 
 time wantiig, a manual of practice based upon mo- 
 dern discoveries in pathology and rational views of 
 treatment of disease. It is especially intended for 
 the use of students and junior practitioners, but it 
 
 will be found hardly less useful to the experienced 
 physician. The American editor has added to tlie 
 work three ehajiters — <m Cholera Infantum, Yellow 
 Fever, and Cerebro-spinal Meningitis. These addi- 
 tions, the two first of which are indispensable to a 
 work on practice destined for the profession in this 
 country, are executed with great judgment and fi- 
 delity, by Dr. Condie, who has also succeeded hap- 
 pily in imitating the conciseness and clearness of 
 style which are such agreeable characteristics of 
 the original book. — Boston Med. and Surg. Journal, 
 Feb. 1&3G. 
 
 We have looked through this volume with very 
 great satisfaction ; it is written in an easy and plea- 
 sant style, and the short though lacid expositions of 
 disease, clearness of description, and soundness of 
 precept will make it a welcome visitor in the library 
 of every practitioner. It combines the simplicity of 
 old CuLLEN, Willi the elegance of Watson, and al- 
 though not so copious as other works we might men- 
 tion, it will, nevertheless, become a standard autho- 
 rity. — American Lancet, Mar. 1856. 
 
 BARTLETT (ELISHA), M. D. 
 THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS 
 
 OF THE UNITED STATES. A new and revised edition. By Alonzo Clahic, M. D., Prof. 
 
 of Physiology and Pathology in the N. Y. Coll of Physicians and Surgeons, &c. In one octavo 
 
 volume, of six hundred pages, extra cloth. {Nearly Ready.) 
 
 The masterly and elegant treatise by Dr. Bartlett 
 is invaluable to the American student and practi- 
 tioner. — Dr. Holmes's Report to the JSat. Med. Asso- 
 
 etation. 
 
 We regard it, from the examination we have made 
 of it, the best work ou fevers extant in our language. 
 
 and as such cordially recommend it to the medical 
 public. — St.Lo-uis Medical and Surgical Journal. 
 
 Take it altogether, it is the most complete history 
 of our fevers which has yet been published, and 
 every practitioner should avail himself of its con- 
 tents. — Tke Western Lancet. 
 
 BOWMAN (JOHN E.), M.D. 
 PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- 
 
 rican, from the third and revised Engli.^h Edition. In one neat volume, royal 12mo., extra cloth, 
 
 with numerous illustrations, pp. 2S8. [Now Ready, 1856.) $1 25. 
 
 Presenting, in a condensed and convenient form, at a very low price, the applications of Chemistry 
 to the practical purposes of Clinical Medicine, this work supplies a want which has long been 
 felt by the physician. The numerous editions which have been called for both in England and this 
 country, suliiciently attest the success with which the author has carried out his plan. 
 
 BY THE SAME AUTHOR. 
 
 INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- 
 
 LYSIS. With numerous illustrations. In one neat vol., royal 12mo., extra cloth, pp.350. $125. 
 
 CURLING (T. B.), F. R.S., 
 Surgeon to the Londim Hospital, President of the Hunterian Society, &c. 
 
 A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- 
 TIC CORD, AND SCROTUM. Second American, from the second and enlarged English edj- 
 tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. (Now 
 Ready, 1856.) $2 00. 
 
 In the revised English edition, of which this is a reprint, the author, for want of space, omitted 
 the Anatomical Introduction. By a more condensed style of printing, room has been found in the 
 present volume to retain this important portion without rendering the work inconveniently lur"-e. 
 Some of the notef; of the former American editor have also been incorporated, and a number of new 
 illustrations introduced. With these improvements, and the thorough revision which it has enjoyed 
 at the hands of the author, it will be found fully worthy to retain the authoritative position which 
 it has acquired with regard to this class of atiections. 
 
 We now take farewell, for the present, o{ this ex- 
 cellent treatise, placing it on our book shelves by 
 the side of Cooper on Fractures and Dislocations, 
 and other similar standard and valuable works — 
 ^550. Med. Jojtrnnl, Jan. 1856. 
 
 We shall not devote any further space to the work 
 under netice, as it is so well known to the profession 
 
 already. We can only say that it should be in the 
 library of every practical surgeon. The present edi- 
 tion is much improved, contains numerous wood- 
 cuts, and several accounts of cases illustrating the 
 various diseases of the testicles.— ilfed. Tinus and 
 Gazette, Feb. 1S56.
 
 BLANCHARD & LEA'S MEDICAL 
 
 CARPENTER (WILLIAM B.), M. D., F. R. S., &.C., 
 
 Examiner in Piiysiology and Comparutive Anatomy in the University of London. 
 
 PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to 
 
 Psychology, Palholog^', Therajieutics, Hygiene, and Forensic Meilicine. A new American, from 
 the' last and revised London edition. With nearly three hundred illustrations. Edited, with addi- 
 tions, by Francis Gurney SiMiTH, M. D., Professor of the Institutes of Medicine in the Pennsyl- 
 vania Medical College, Arc. In one very large and beautiful octavo volume, of about nine hundred 
 large puges, handsomely printed and strongly bound in leather, with raised bands. {Just Issued, 
 1856.) §4 Z^. 
 
 In the preparation of this new edition, the author has spared no labor to render it, as heretofore, 
 a complete and lucid exposition of the most advanced condition of its important subject. The 
 amouiit of the additions required to efl'ect this object thoroiiglily, joined to the former laige size of 
 the volume, presenting objections arising from Ilie unwieldy bulk of the work, he has omitted all 
 those portions not bearing directly upon Hujhan Physioi^ogy, designing to incorporate them in 
 his forthcoming Treatise on General Physiology. As a full and accurate text-book on the Phy- 
 siology of Man, the work in its present condition therefore presents even greater claims upon 
 the student and physician than those which have beretoiore won for it the very wide and distin- 
 guished favor which it has so long enjoyed. The additions of Prof. Smith will be found to supply 
 whatever may have been wanting to the American student, while the introduction of many new 
 illustrations, and the most careful mechanical execution, render the volume one of the most at- 
 tractive as yet issued. 
 
 For upwards of thirteen years Dr. Carpenter's] To eulogize tliis great work would be superflaous. 
 ■work has been considered by tlie i)rofession gene- We should observe, liowever, that in tliis edition 
 rally, both in this country and England, as the most tlie authtir has remodelled a large portit)n of the 
 valuable compendium on tlie sul)ject of physiology i former, and the editor has added much matter of in- 
 in our language. 7'his distinction it owes to the high i terest, especially in the form of illustrations. We 
 attainments and unwearied industry of its aecom- j may confidently recommend it as the most complete 
 
 plishod author. The present edition (which, like the 
 last American one, was prepared by the author him- 
 selt"), is the result of such extensive revisii n, that it 
 may almost be considered a new work. We need 
 hardly say, in concluding this brief notice, that while 
 the work is indispensable to every stuilent of medi- 
 cine in this country, it will amply repay the practi- 
 tioner for its perusal by the interest and value of its 
 contents. — Boston Med. and Surg. Journal. 
 
 This is a standard work — the text-book used by all 
 medical students who read the English language. 
 It has passed through several editions in order to 
 keep pace with the rapidly growing science of Phy- 
 siology. Nothing need be said in its praise, for its 
 merits arfe universally known; we have nothing to 
 fay of its defects, for they only appear where the 
 science of which it treats is incomplete. — Western 
 Lancet. 
 
 The most complete exposition of physiology which 
 any language can at present give. — Brit, and For. 
 Mtd.-Chirurg. KevietB. 
 
 The greatest, the most reliable, and the best book 
 on the subject which we know of in the English 
 language. — Stethoscojte. 
 
 work on Human Physiology in our language. — 
 Houthern Med. and Surg. Journal, December, 1855. 
 
 The most complete w^ork on the science in out 
 language. — Am. Med. Journal. 
 
 The most complete work now extant in our la»- 
 gviage. — N. O. Med. Register. 
 
 The best text-book in the )at\guage on this ea- 
 tensive subject. — LoTidon Med. Times. 
 
 A complete cyclopcedia of this branch of science. 
 —N. Y. Med. Times. 
 
 The profession of this country, and perhaps also 
 of Europe, have anxiously and for some time awaited 
 the announcement of this new edition of Carpenter's 
 Human Physiology. His former editions have for 
 many years been almost the only text-book on Phy- 
 sioU)gy in all our medical schools, and its circula- 
 tion among the profession has been unsurpassed by 
 any work in any department of medical science. 
 
 It is quite unnecessary for us to speak of thi» 
 work as its merits would justify. The mere an- 
 nouncement of its appearance will afTord the highest 
 pleasure to every student of Physiology, while its 
 perusal will be of infinite service in advancing 
 physiological science. — Ohio Med. and Surg. Jonm. 
 
 BY THE SAME AUTHOR. {Lately Issued.) 
 
 PRINCIPLES OF COMPARATIVE PHYSIOLOGY. New Araeriean, from 
 
 the Fourth and Revised London edition. In one large and handsome octavo volume, with over 
 three hundred beaulilul illustrations, pp. 752. Extra cloth, $4 80 ; leather, raised bands, $5 25. 
 The delay which has existed in the appearance of this work has been caused by the very thorough 
 revision and remodelling which it has undergone at the hands of the author, and the large number 
 of new illustrations which have been prepared for it. It will, therefore, be found almost a new 
 work, nnd fully up to the day in every department of the subject, rendering it a reliable text-book 
 for all students engaged in this branch of science. Every effort has been made to render its typo- 
 graphical finish and mechanical execution worthy of its exalted reputation, and creditable to the 
 nsechanical arts of this country. 
 
 This book should not only be read bat thoroughly 
 studied by every member of the profession. None 
 are too wise or old, to be benefited thereby. But 
 especially to the younger class would we cordially 
 commend it as best fitted of any work in the English 
 language to qualify them for the reception and com- 
 prehension of those truths which are daily being de- 
 veloped in physiology. — Medical Counsellor. 
 
 Without pretending to it, it is an encycloppdia of 
 the subject, accurate and complete in all respects — 
 a truthful reflection of the advanced state at which 
 the science has now arrived. — Dublin Quarterly 
 Jottrnnl of Medical Science. 
 
 A truly magnificent v/ork — in itself a perfect phy- 
 siological study. — Ranking'' s Abstract. 
 
 This work stands without its fellow. It is one 
 few men in Europe could have undertaken ; t is one 
 
 no man, we believe, could have brought to so suc- 
 cessful an issue as Dr. Carpenter. It required for 
 its production a physiologist at once deeply read in 
 the labors of others, capable of taking a general, 
 critical, and unprejudiced view of tht)8e labors, and 
 of combining the varied, heterogeneous materials al 
 his disposal, so as to form an harmonious whole. 
 We feel that this abstract can give the reader a very 
 imperfect idea of the fulness of this work, and no 
 idea of its unity, of the admirable manner in which 
 material has l>een brought, from the most various 
 sources, to conduce to its completeness, of the lucid- 
 ity of the reasoning it contains, or of the clearness 
 of language in which the whole is clothed. Not the 
 profession only, but the scientific world at large, 
 must feel deeply indebted to Dr. Carpenter for this 
 great work. It must, indeed, add largely evem to 
 his high reputation. — Medital Times.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 CARPENTER (WILLIAM B.), M . D., F. R. S., 
 
 Examiner in Physiology and Comparative Anatomy in the University of London. 
 {Now Ready, June, 1S56.) 
 
 THE MICROSCOPE AND ITS REVELATIONS. With an Appendix con- 
 
 taining the Applications of the Microscope to Clinical Medicine, fcc. By F. G. Smith, M. D 
 Illustrated by four hundred and thirty-lour beautiful engravings on wood. In one large and ver- 
 handsome octavo volume, of 724 pages, extra cloth, $4 00 ; leather, $4 50. 
 Dr. Carpenter's position as a microscopist and physiologist, and his great experience as a teacher, 
 emuiently qualify him to produce what has long been wanted — a good text-book on the practical 
 use of the microscope. In the present volume his object has been, as stated in his Preface, " to 
 combine, within a moderate compass, that information with regard to the use of his ' tools,' which 
 is most essential to the working microscopist, with such an account of the objects best fitted for 
 his study, as might qualify him to comprehend what he observes, and might thus prepare him to 
 benefit science, whilst expanding and refreshing his ownmind " That he has succeeded in accom- 
 plishing this, no one acquainted with his previous labors can doubt. 
 
 The great importance of the microscope as a means of diagnosis, and the number of microsco- 
 pists who are also phy.-^icians, have induced the American publishers, with the author's approval, to 
 add an Appendix, carefully prepared by Professor Smith, on the applications of the instrument to 
 clinical medicine, together with an account of American Microscopes, their modifications and 
 accessories. This portion of the work is illustrated wilh nearly one hundred wood-cuts, and, it is 
 hoped, will adapt the volume more particularly to the use of the American student. 
 
 Every care has been taken in the mechanical execution of the work, which is confidently pre- 
 sented as in no respect inferior to the choicest productions of the London press. 
 
 The mode in which the author has executed his ikitentions may be gathered from the following 
 condensed synopsis of the 
 
 CONTENTS. 
 Introduction — History of the Microscope. Chap. I. Optical Principles of the Microscope. 
 Chap. II. Construclion of the Microscope. Chap. III. Accessory Apparatus. Chap. IV. 
 Management of the Microscope Chap. V. Preparation, Moimting, and Collection of Objects. 
 Chap. VI. Microscopic Forms of Vegetable Life — Protophytes. Chap. VII. Higher Cryptoga- 
 mia. Chap. VIII. Piianerogamic Plants. Chap. IX. Microscopic Forms of Animal Life — Pro- 
 tozoa — Animalcules. Chap. X. Foraminifera, Polycystina, and Sponges. Chap. XI. Zoophytes. 
 Chap. XII. Echinodermala. Chap. XIII. Polyzoa and Compound Tunicata. Chap. XIV. 
 Molluscous Animals Generally. Chap. XV. Annulosa. Chap. XVI. Crustacea. Chap. XVII. 
 Insects and Arachnida. Chap. XVIII. Vertebrated Animals. Chap. XIX. Applications of the 
 Microscope to Geology. Chap. XX. Inorganic or Mineral Kingdom — Polarization. Appendix. 
 Microscope as a means of Diagnosis — Injections — Microscopes of American Manufacture. 
 Those who are acquainted with Dr. Carpenter's 
 previous writings on Animal and Vegetable Physio- 
 logy, will fully understand how vast a store of know- 
 ledge he is able to bring to bear ujion so comprehen 
 
 and even those who have no previous acquaintance 
 with the construction or uses of this instrument, 
 will find abundance of information conveyed in clear 
 and simple language. — Med. Times and Gazette. 
 May, lb56. 
 
 sive a subject as the revelations of the microscope ; 
 
 BY THE SAME AUTHOR. 
 
 ELEMENTS (OR MANUAL) OF PHYSIOLOGY, INCLUDING PHYSIO- 
 
 LOGICAL ANATOMY". Second American, from a new and revised London edition. With 
 one hundred and ninety illustrations. In one very handsome octavo volume, leather, pp. 566 
 
 $3 00. 
 
 In publishing the first edition of this work, its title was altered from that of the London volume, 
 by the substitution of the word " Elements" for that of " Manual," and with the author's sanction 
 tne title of "Elements" is still retained as being more expressive of the scope of the treatise. 
 
 To say that it is the best manual of Physiology i Those who have occasion for an elementary trea- 
 now before the public, would not do sufficient justice tise on Physiology, cannot do better than to possess 
 to the author. — Buffalo Medical Journal. themselvesof the manual of Dr. Carpenter. Medical 
 
 In his former works it would seem that he had Examiner. 
 exhausted the suliject of Physiology. In the present. The best and most complete expose of modern 
 hegivestheessence,a8itwere, of the whole. — N. Y.\ Physiology, in one volume, extant in the English 
 Journal of Medicine. | language. — St. Louis Medical Journal. 
 
 BY THE SAME AUTHOR. {Preparing.) 
 
 PRINCIPLES OF GENERAL PHYSIOLOGY, INCLUDING ORGANIC 
 
 CHEMISTRY AND HISTOLOGY. Wilh a General Sketch of the Vegetable and Animal 
 
 Kingdom. In one large and very handsome octavo volume, with several hundred illustrations. 
 
 The subject of general physiology having been omitted in the last editions of the author's " Comr 
 
 parative Physiology" and " Human Physiology," he has undertaken to prepare a volume which 
 
 shall present it more thoroughly and fully than has yet been attempted, aiid which may be regarded 
 
 as an introduction to his other works. 
 
 BY THE SAME AUTHOR. 
 
 A PRIZE ESSAY ON THE USE OF ALCOHOLIC LIQUORS IN HEALTH 
 
 AND DISEASE. New edition, with a Preface by D. F. Condie, M. D., and explanations of 
 scientific words. In one neat I2mo. volume, extra cloth, pp. 178. [Just Issued.) 50 cents. 
 
 CHELIUS (J. M.), M. D., 
 
 Professor of Surgery in the University of Heidelberg, &c. 
 
 A SYSTEM OF SURGERY. Translated from the German, and accompanied 
 
 with additional Notes and References, by John F. South. Complete in three very large octavo 
 volumes, of nearly 2200 pages, strongly bound, with raised bands and double titles. $10 00.
 
 BLANCHARD & LEA'S MEDICAL 
 
 CONDIE (D. F.), M. D., &.c. 
 A PRACTICAL TREATISE ON THE DISEASES OF CHiIdREN. Fourth 
 
 edition, revised and augmented. In one large volume, 8vo., leather, of nearly 750 pages. $3 00. 
 From the Author's Preface. 
 
 The demand for another edition has afflirded the author an opportunity of again subjecting the 
 entire treatise to a careful revision, and of incorporating in it every important observation recorded 
 since the appearance of the last edition, in reference to the pathology and therapeutics of the several 
 diseases oi which it treats. 
 
 In the preparation of the present edition, as in those which have preceded, while the author has 
 aj^proprialed to his use every important fact that he has found recorded in the works of others, 
 having a direct bearing upon either of the subjects of which he treats, and the numerous valuable 
 observations — pathological as well as practical — dispersed throughout the pages of the medical 
 journals of Europe and America, he has, nevertheless, relied chiefly upon his own observations and 
 experience, acquired during a long and somewhat extensive practice, and under circumstances pe- 
 culiarly well adapted for the clinical stud}' of the diseases of early life. 
 
 Every species ol hypothetical reasoning has, as much as possible, l>een avoided. The author lias 
 endeavored throughout the work to conline himself to a simple statement of well-ascertained patho- 
 logical facts, and plain therapeutical directions — his chief desire being to render it what its title 
 imports it to be, a practical treatise on the diseases of children. 
 
 Dr. Condie's scliolarship, acumen, industry, and : We feel assured from actual experience that no 
 practical sense are manifested in this, as in all his ! physician's library can be complete without a copy- 
 numerous contributions to science. — Dr. Holmes''s \ of this work. — N. Y. Journal of Medicine. 
 Report to the American Medical Association. I . .. , , ... , ,. , , 
 
 . T-v ^ J- ^ A veritable paediatric encyclopaedia, and an honor 
 
 Taken as a whole, in our judgment. Dr. Condie s j^ American medical literature.— OAio Medical and 
 
 Treatise is the one from the perusal of which the 
 practitioner in this country will rise with the great- 
 est satisfaction. — Western Journal of Medicine and 
 Surgery. 
 
 One of the best works upon the Diseases of Chil- 
 dren in the English language. — Western Lancet. 
 
 Perhaps the most full and complete work no^v be- 
 
 Surgical Journal. 
 
 We feel persuaded that the American medical pro- 
 fession wiU soon regard it not only as a very good, 
 but as the veky best " Practical Treatise on the 
 Diseases of Children." — American Medical Journal. 
 
 We pronounced the first edition to be the best 
 fore the profession of tlie United States; indeed, we j work on the diseases of children in the English 
 may say in the English language. It is vastly supe- i language, and, notwithstanding all that has been 
 rior to most of its predecessors. — Transylvania Med. I published, we still regard it iu that light. — Medical 
 Journal. I Examiner. 
 
 CHRISTISON (ROBERT), M. D., V. P. R. S. E., &c. 
 
 A DISPENSATORY; or, Commentary on the Pharmacopoeias of Great Britain 
 
 and the United States; comprising the Natural History, Description, Chemistry, Pharmacy, Ac- 
 tions, Uses, and Doses of the Articles of the Materia Medica. Second edition, revised and im- 
 proved, with a Supplement containing the most important New Remedies. With copious Addi- 
 tions, and two hundred and thirteen large wood-engravings. By R. Eglesfeld Griffith, M. D. 
 In one very large and handsome octavo volume, leather, raised bands, of over 1000 pages. $3 50. 
 It is not needful that wt should compare it with this branch of knowledge which the student has a 
 the other pharmucopceias extant, which enjoy and right to expect in such a work, we confess the omis- 
 inerit the confidence of the profession : it is enough sion has escaped our scrutiny. We cordially recoin- 
 to say that it appears to us as perfect as a Dispensa- mend this work to such of our readers as are in need 
 tory, in the present state of pharmaceutical science, of a Dispensatory. They cannot make choice of a 
 could be made. If it omits any details pertaining to , better. — Western Journ. of Medicine and Surgery. 
 
 COOPER (BRANSBY B.), F. R. S. 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF SURGERY. 
 
 In one very large octavo volume, extra cloth, of 750 pages. S3 00. 
 
 COOPER ON DISLOCATIONS AND FRAC- 
 TURKS OF THE JOINTS —Edited by Bkansby 
 D. Cooper, F. R. S., &c. With additional Ob- 
 servations by Prof. J. C. Warren. A new Ame- 
 rican edition. In one handsome octavo volume, 
 extra cloth, of about 500 iiages, with numerous 
 illustrations on wood. $3 '25. 
 
 COOPER ON THE ANATOMY AND TREAT- 
 MENT OF ABDOMINAL HERNIA. One large 
 volume, imperial Svo., extra cloth, with over 130 
 lithographic figures. $2 50. 
 
 COOPER ON THE ANATOMY AND DISEASES 
 OF THE BREAST, with twenty-five Miscellane- 
 ous and Surgical Papers. One large volume, im- 
 perial 8vo., extra cloth, with 252 figures, on 36 
 plates. S2 50. 
 
 COOPER ON THE STRUCTURE AND DIS- 
 
 EASES OF THE TESTIS, AND ON THE 
 THYMUS GLAND. One vol. imperial Svo., ex- 
 tra cloth, with 177 figures on 29 plates. $.2 00. 
 
 COPLAND ON THE CAUSES, NATURE, AND 
 TREATxMENT OF PALSY AND APOPLEXY. 
 In one volume, royal 12mo., extra cloth, pp. 32G. 
 60 cents. 
 
 CLYMER ON FEVERS: THEIR DIAGNOSIS, 
 PATHOLOGY, AND TREATMENT In one 
 octavo volume, leather, of GOO pages. $1 50. 
 
 COLOiVIBAT DE L'lSERE ON THE DISEASES 
 OF FE.MALES, and on the special Hygiene of 
 their Sex. Translated, with many Notes and Ad- 
 ditions, by C. D. Meigs, M. D. Second edition, 
 revised and improved In one large volume, oc- 
 tavo, leatlier, with numerous wood-cuts. pp. 720. 
 S3 50. 
 
 CARSON (JOSEPH), M. D., 
 
 Professor of Materia Medica and Pharmacy in the University of Pennsylvania. 
 
 SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA 
 
 AND PHARMACY, delivered in the University of Pennsylvania. Second and revised edi- 
 tion. In one very neat octavo volume, extra cloth, of 208 pages. (Now Ready.) $1 50.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 CHURCHILL (FLEETWOOD), M. D., M. R. r. A. 
 ON THE THEORY AND PRACTICE OF MIDWIFERY. A new American, 
 
 from the last and improved English edition. Edited, witli Notes and Additions, by D. Francis 
 CoNDiE, M. D., author of a "Practical Treatise on the Diseases of Children," &c. With 139 
 illustrations. In one very handsome octavo volume, leather, pp.510. $3 00. 
 
 No work holds a higher position, or is more de- 
 servinn;' of being placed in the hands of the tyro, 
 the advanced student, or the practitioner. — Medical 
 Exaviiner . 
 
 To bestow praise on a book that has received such 
 marked approbation would be superfluous. We need 
 only say, therefore, that if the first edition was 
 thought worthy of a favorable reception by the 
 medical public, w^e can confidently aflirm that this 
 will be found nuieh more so. The lecturer, the 
 practitioner, and the student, may all have recourse 
 to its pages, and derive from their perusal much in- 
 terest and instruction in everything relating to theo- 
 retical and practical midwifery. — Dublin Quarterly 
 Journal of Medical Science. 
 
 A work of very great merit, and such as we can 
 confidently recommend to the study of every obste- 
 tric practitioner. — London Medical Gazette. 
 
 This is certainly the most perfect system extant. 
 It is the best adapted for the purposes of a text- 
 book, and that which he whose necessities confine 
 him to one book, should select in preference to all 
 others. — Southern Medical and Surgical Journal. 
 
 The most popular work on midwifery ever issued 
 from the American press. — Charleston Med. Journal. 
 
 Were we reduced to the necessity of having but 
 
 one work on midwifery, and permitted to choose, 
 
 •ve would unhesitatingly take Churchill. — Western 
 
 Med. and Surg. Journal. 
 
 It is impossible to conceive a more useful and 
 
 ■"gant manual than Dr. Chnrehill's Practice of 
 
 Iidwifery. — Provincial Medical Journal. 
 
 Certainly, in our opinion, the very best work on 
 the subject which exists. — N. Y. Annalist. 
 
 Previous editions, under the editorial supervision 
 of Prof R. M. Huston, have been received with 
 marked favor, and they deserved it ; but this, re- 
 printed from a very late Dublin edition, carefully 
 revised and brought up by the author to the present; 
 time, does present an unusually accurate and able 
 exposition of ever)' important particular embraced 
 in the department of midwifery. * * The clearness, 
 directness, and precision of its teachings, together 
 with the great amount of statistical research which 
 its text exhibits, have served to place it already in 
 the foremost rank of works in this department of re- 
 medial science. — N. O. Med. and Surg. Journal. 
 
 In our opinion, it forms one of the best if not the 
 very best text-book and epitome of obstetric science 
 which we at present possess in the English lan- 
 guage. — Montlily Journal of Medical Science. 
 
 The clearness and precision of style in which it is 
 written, and the greatamount of statistical research 
 which it contains, have served to place it in the first 
 rank of works in tliis departmentof medical science. 
 — N. Y. Journal of Medicine. 
 
 Few treatises will be found better adapted as a 
 text-book for the student, or as a manual for the 
 frequent consultation of the young practitioner. — 
 American Medical Journal. 
 
 BY THE SAME AUTHOR. (Now Readi/, 1856.) 
 
 ON THE DISEASES OF INFANTS AND CHILDREN. Second American 
 
 Edition, revised and enlarged by the author. Edited, with Notes, by W. V. Keating, M. D. In 
 
 one large and handsome volume, extra cloth, of over 700 pages. $3 00, or in leather, $3 2-5. 
 
 In preparing this work a second time for the American profession, the author has spared no 
 labor in giving it a very thorough revision, introducing several new chapters, and rewriting others, 
 while every portion of the volume has been subjected to a severe scrutiny. The efforts of the 
 American editor have been directed to supplying such information relative to matters peculiar 
 to this country as might have escaped the attention of the author, and the whole may, there- 
 fore, be safely pronounced one of the most complete works on the subject accessible to the Ame- 
 rican Profession. By an alteration in the size of the page, these very extensive additions have 
 been accommodated without unduly increasing the size of the work. 
 
 A few notices of the Ibrmer edition are subjoined : — 
 
 We regard this volume as possessing more claims 
 to completeness than any other of the kind with 
 which we are acquainted. Most cordially and ear- 
 nestly, therefore, do we commend it to our profession- 
 al brethren, and we feel assured that the stamp of 
 their approbation will indue time be impressed upon 
 it. After an attentive perusal of its contents, we 
 hesitate not to say, that it is one of the most com- 
 prehensive ever written upon the diseases of chil- 
 dren, and that, for coi)iousnessof reference, extent of 
 research, and perspicuity of detail, it is scarcely to 
 be equalled, and not to be excelled, in any lan- 
 guage. — Dublin Quarterly Journal. 
 
 After this meagre, and we know, very imperfect 
 notice of Dr. Churchill's work, we shall conclude 
 by saying, that it is one that cannot fail from its co- 
 piousness, extensive research, and general accuracy, 
 to exalt still higher the reputation of the author in 
 this country. The American reader will be particu- 
 larly pleased to find that Dr. Churchill has done full 
 justice tliroughout his w^ork to the various American 
 authors on tliis subject. The names of Dewees, 
 Eberle, Condie, and Stewart, occur on nearly every 
 page, and these authors are constantly referred to by 
 the author in terms of the highest praise, and with 
 the most liberal courtesy. — The Medical Examiner. 
 
 The present volume will sustain the reputation 
 acquired by the author from his previous works. 
 The reader will find in it full and judicious direc- 
 tions for the management of infants at birth, and a 
 compendious, but cle^r account of the diseases to 
 which children are liable, and the most successful 
 mode of treating them. VVe must not close this no- 
 tice without calling attention to the author's style, 
 which is perspicuous and polished to a degree, we 
 regret to say, not generally characteristic of medical 
 works. We recommend the work of Dr. Churchill 
 most cordially, both to students and practitioners, 
 as a valuable and reliable guide in the treatment of 
 the diseases of children. — Am. Journ. of the Med. 
 Sciences. 
 
 We know of no work on this department of Prac 
 tical Medicine which presents so candid and unpre- 
 judiced a statement or posting up of our actual 
 knowledge as this. — N. Y. Journal of Medicine. 
 
 Its claims to merit both as a scientific and practi- 
 cal work, are of the highest order. Whilst we 
 would not elevate it above every other treatise on 
 the same subject, we certainly believe that very few 
 are equal to it, and none superior. — Southern Med. 
 and Surgical Journal. 
 
 BY THE SAME AUTHOR. 
 
 ESSAYS ON THE PUERPERAL FEVER, AND OTHER DISEASES PE- 
 CULIAR TO WOMEN. Selected from the writings of British Authors previous to the close of 
 the Eighteenth Century. In one neat octavo volume, extra cloth, of about 450 pages. $2 50.
 
 10 
 
 BLANGHAKD & LEA'S MEDICAL 
 
 CHURCHILL (FLEETWOOD), M. D., M. R. I , A,, &.c. 
 OX THE DISEASES OF WOMEN; including those of Pregnancy and Child- 
 
 bed. A new American edition, revised by the Author. With Notes and Additions, by D Fran- 
 cis CoNDiE, M. D., author of "A Practical Treatise on the Diseases of Children." Li one large 
 and handsome octavo volunme, with wood-cuts, leather, pp. 684. S3 00. 
 
 ■\Venow reg;retfully take leave of Dr. ChurcliiirB 
 book. Had our typographical limits permitted, we 
 should gladly have borrowed more from its riolily 
 st<irpd pages. In conclusion, we heartily recom- 
 mend it to the profession, and would at the same 
 time express our firm conviction that it will not only 
 add to the reputation of its author, but will prove a 
 work of great and extensive utility to obstetric 
 practitioners. — Dublin Medical Press. 
 
 Former editions of this work have been noticed in 
 previous numbers of the Journal. The sentiments of 
 high conmiendation expressed in those notices, have 
 only to be repeated in this; not from the fact that 
 the profession at large are not aware of the high 
 merits which this work really possesses, but from a 
 desire to see the principles and dt>ctrines therein 
 contained more generally recognized, and mijre uni- 
 versally earned out in practice. — N. Y. Journal of 
 Medicine. 
 
 We know of no author who deserves that appro- 
 bation, on " the diseases of females," to the same 
 extent that Dr. Churchill does. His, indeed, is the 
 only thorough treatise we knnw of on the subject; 
 and it may be commended to practitioners and stu- 
 dents as a masterpiece in its particular department. 
 The former editions of this work have been com- 
 mended strongly in this journal, and they have \von 
 their way to an extended, and a well-deserved popu- 
 
 larity. This fifth edition, before us, is well calcu- 
 lated to maintain Dr. Churchill's high reputation. 
 It was revised and enlarged by the author, for his 
 American publishers, and it seems to us that there ig 
 scarcely any species of desirable information on ite 
 subjects that may not be found in this work. — Tin 
 Western Journal of Medicine and Surgery. 
 
 We are gratified to announce a new and revised 
 edition of Dr. Churchill's valuable work on the dis- 
 eases of females We have ever regarded it as one 
 of the very best works on the subjects embraced 
 within its scope, in the English language; and the 
 present edition, enlarged and revisetl by the author, 
 renders it still more entitled to the confidence of the 
 profession. The valuable notes of Prof. Huston 
 have been retained, and contribute, in no small de- 
 gree, to enhance the value of the work. It is a 
 source of congratulation that the publishers have 
 permitied the author to be, in this instance, his 
 own editor, thus securing all the revision which 
 an author alone is capable of making. — The Western 
 Lancet. 
 
 Asa comprehensive manual for students, or a 
 work of reference for practitioners, vee only speak 
 with common justice when we say that it surpasses 
 any other that has ever issued on the same sub- 
 ject from the British press. — The Dublin Quarterlp 
 Journal. 
 
 DICKSON (S. H.>, M. D., 
 
 Professor of Institutes and Practice of Medicine in the Medical College of South Carolina. 
 
 ELEMENTS OF MEDICINE; a Compendious View of Pathology and Thera- 
 
 pentics, or the History »nd Treatment of Diseases. In one large and handsome octavo volume, 
 
 of 7-50 pages, leather (No^v Ready.) $-3 75. 
 
 As an American text-book on the Practice of Medicine for the student, and as a condensed work 
 of reference for the practitioner, this volume will have strong claims on the attention of the prolession. 
 Few physicians have had wider opportunities than the author for obsen'ation and experience, and 
 few perhaps have used them belter. As the result of a life of study and practice, therefore, the 
 present volume will doubtless be received with the welcome it deserves. 
 
 This book is eminently what it professes to be; a I clear and accurate descriptions, purity, and simpli- 
 distmguishcd merit in these days. Designed for city of style, and soundness of precept, the reader 
 " Teachers and Students of Medicine," anil admira- will find much to admire and adopt, and lot a little 
 bly suited totheir wants, \\'e think it will be received, \ that calls for deep reflection. We cordially recom- 
 on its own merits, with a hearty welcome. — Boston mend this volume to our readers, vrhether old prac- 
 Med. and Surg. Journal. titioners or students, for we take it that the physician 
 
 Indited by one of the most accomplished writers should always be a student.— ^wericaw Lancet. 
 of our country, as well as by one who has long held | Prof. Dickson's work supplies, to a great extent, 
 a high position among teachers and practitioners of! a desideratum long felt in American medicine. — iV. 
 medicine, this ^vork is entitled to patronage and O. Med. and Surg. Journal. 
 
 careful study. The learned author has endeavored 
 to condense in this volume most of the practical 
 matter contained in his former productions, so as to 
 adapt it to the use of those who have not time to 
 devote to more extensive works. — Southern Med. and 
 Surg. Journal. 
 
 We can strongly recommend Dr. Dickson's work 
 to our readers as one of interest and practical utility. 
 
 Estimating this work according to the purpose for 
 which it is designed, we must think highly of its 
 merits, and we have no hesitation in predicting for 
 ita favorable reception by both studentsand teachers. 
 
 Not professing to be a complete and comprehensive 
 treatise, it will not be found full in detail, nor filled 
 with discussions of theories and opinions, but em- 
 bracing all that is essential in theory and practice, 
 
 ■well deserving of a place in their libraries as a book I it is admirably adapted to the\vants of the American 
 
 of referenc* ; and we especially commt-nd the first 
 part as presenting an admirable outline of the princi- 
 ples of medicine. — Dublin Quarterly Journal, Ftb. 
 1S50 
 
 This volume, while as its title denotes it is a 
 compendious view, is also a comprehensive system 
 of practice, perspicuously and pleasantly written, 
 and admirably suited to engage the interest, and in- 
 struct the reader. — Peninsular Journal of Medicine, 
 Jan. 1850. 
 
 This volume is designed as a text-book for teachers 
 and students; but its merits extend far beyond its 
 modest dedication ; It is a complete treatise upon me- 
 dicine, and one that will stand the test of years. The 
 arrangement is simple, a feature oflentimes obscured 
 in otherwise excellent works. This Treatise is a 
 valuableaddition to our medical literature, and in the | Lancet. 
 
 student. Avoiding all that is uncertain, it presents 
 more clearly to the mind of the reader that which is 
 established and verified by experience. The varied 
 and extensive reading of the author is conspicuously 
 apparent, and all the recent improvements and dis- 
 coveries in therapeutics and pathology are chroni- 
 cled in its pages. — Charleston Med. Jcyumal. 
 
 In the first part of the work the subject of gene- 
 ral pathology is presented in outline, giving a btau- 
 tiful picture of its distinsruishing features, and 
 throughout the succeeding cliapters we find that he 
 has kept scrupulously within the bounds of sound 
 reasoning and legitimate deduction. Upon the 
 whole, we do not hesitate to pronounce it a superior 
 work in its class, and that Dr. Dickson merits a 
 place in the first rank of American writers. — Western 
 
 DAY'S PRACTICAI- TREATISE ON THE DO- 
 .^lESTIC MANAGEMENT AND MORE IM- 
 PORTANT DISEASES OF ADVANCED LIFE. 
 One volume, octavo, cloth, 226 pages. SI 00. 
 
 DE JONGH ON COD-LIVER OIL, comparatively 
 considered, with its Chemical and Therapeutic 
 Properties. In one 12mo. vol., ex. cloth. 75 cents.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 11 
 
 DRUITT (ROBERT), M.R. C.S., &.c. 
 THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new 
 
 American, from the improved London edition. Edited by F. W. Sargent, M. D., author of 
 "Minor Surg-ery," &rc. Illustrated with one hundred and ninety-three wood-engravings. In 
 one very handsomely printed octavo volume, leather, of 576 large pages. $3 00. 
 
 Dr. Druitt's researches into the literature of his 
 subject have been not only extensive, but well di- 
 rected ; tlie most discordant authors are fairly and 
 impartially quoted, and, while due credit is given 
 to each, their respective merits are weighed with 
 an unprejudiced hand. The grain of wheat is pre- 
 served, and the chaff is unmercifully stripped off. 
 The arrangement is simple and philosophical, and 
 the style, though clear and interesting, ie so precise, 
 that the book contains more inform.ition condensed 
 into a few words than any other surgical \vork with 
 which we are acquainted. — London Medical Tinus 
 and Gazette. 
 
 No work, in our opinion, equals it in presenting 
 BO much valuable surgical matter in so small a 
 compass. — St. Louis Med. and Surgical Journal. 
 
 Druitt's Surgery is too well known to the Ameri- 
 can medical profession to require its announcement 
 anywhere. Prohnbly no work of the kind has ever 
 been more cordially received and extensively circu- 
 lated than this. The fact that it comprehends in a 
 comparatively small compass, all the essential ele- 
 ments of theoretical and practical Surgery — that it 
 ie found to contain reliable and authentic informa- 
 tion on the nature and treatment of nearly all surgi- 
 cal afTeetions — is a sufficient reason for the liberal 
 patronage it has obtained. The editor. Dr. F. W. 
 Sargent, has contributed much to enhance the value 
 of the work, by such American improvements as are 
 calculated more perfectly to adapt it to our own 
 views and practice in this country. It abounds 
 everywhere with spirited and life-like illustrrtions, 
 which to the young surgecm, especially, are of no 
 minor consideration. Every medical man frequently 
 needs just such a work as this, for immediate refer- 
 ence in moments of sudden emergency, when he has 
 not time to consult more elaborate treatises. — The 
 Ohio Medical and Surgical Journal. 
 
 The author has evidently ransacked every stand- 
 ard treatise of ancient and modern times, and all that 
 
 is really practically useful at the bedside will be 
 found in a form at once clear, distinct, and interest- 
 ing. — Edinburgh Monthly Medical Journal. 
 
 Druitt's work, condensed, systematic, lucid, and 
 practical as it is, beyond most works on Surgery 
 accessible to the American student, has had much 
 currency in this country, and under its present au- 
 spices promises to rise to yet higher favor. — Tht 
 Western Journal of Medicine and Surgery. 
 
 The most accurate and ample resume of the pre- 
 sent state of Surgery that we are acquainted with. — 
 Dublin Medical Journal. 
 
 A better book on the principles and practice of 
 Surgery as now understood in England and America, 
 has not been given to the profession. — Boston Medi- 
 cal and Surgical Journal. 
 
 An unsurpassable compendium, not only of Sur- 
 gical, but of Medical Practice. — London Medical 
 Gazette. 
 
 This ^vork merits our warmest commendations, 
 and we strongly recommend it to young surgeons as 
 an admirable digest of the principles and practice of 
 modern Surgery. — Medical Gazette. 
 
 It maybe said with truth that the work of Mr. 
 Druitt affords a complete, though brief and con- 
 densed view, of the entire field of modern surgery. 
 We know of no work on tlie same subject having the 
 appearance of a manual, which includes so many 
 topics of interest to the surgeon ; and the terse man- 
 ner in w^hicli each has been treated evinces a most 
 enviable quality of mind on the part of the author, 
 who seems to have an innate power of searching 
 out and grasping the leading facts and features of 
 the most elaborate productions of the pen. It is a 
 useful handbook for the practitioner, and we should 
 deem a teacher of surgery unpardonable wlio did not 
 recommend it to his pupils. In our own opinion, it 
 is admirably adapted to the wants of the student. — 
 Provincial Medical and Surgical Journal. 
 
 DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. 
 
 THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on 
 
 the Nature and Treatment of Disea.<es, Materia Medica, and Therapeutics, Diseases of Women 
 and Children, Medical Jurisprudence, Arc. ifec. In four large super-royal octavo volumes, of 
 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. 
 *jjf* This work contains no less than four hundred and eighteen distinct treatises, contributed by 
 sixty-eight distinguished physicians, rendering it a complete library of reference for the country 
 practitioner. 
 
 The most complete work on Practical Medicine I titioner. This estimate of it has not been formed 
 extant; or, at least, in* our language.— £«^'aio from a hasty examination, but after an intimate ac- 
 quaintance derived from frequent consultation of it 
 during the past nine or ten years. The editors are 
 practitioners of established reputation, and the list 
 of contributors embraces many of the most eminent 
 professors and teachers of London, Edinburgh, Dub- 
 lin, and Glasgow. It is, indeed, the great merit of 
 this work that the principal articles have been fur- 
 nished by practitioners who have not only ilevoted 
 especial attention to the diseases about \vhieh they 
 
 Medical and Surgical Journal. 
 
 For reference, it is above all price to every prac- 
 titioner. — Western Lancet. 
 
 One of the most valuable medical publications of 
 the day — as a work of reference it is invaluable. — 
 Western Journal of Medicine and Surgery. 
 
 It has been to us, both as learner and teacher, a 
 work for ready and frequent reference, (me in which 
 
 modern English medicine is exhibited in the most have written, but have also enjoyed opportunities 
 
 advantageous light. — Medical Examiner. 
 
 We rejoice that this work is to be placed within 
 the reach of the profession in this country, it being 
 unquestionably one of very great value to the prac- 
 
 for an extensive practical acquaintance with them, 
 and whose reputaticm carries the assurance of their 
 competency justly to appreciate the opinions of 
 others, while it stamps their own doctrines with 
 high and just authority. — American Medical Journ. 
 
 DEWEES'S COMPREHENSIVE- SYSTEM OF 
 MIDWIFERY. Illustrated by occasional cases 
 and many engravings. Twelfth edition, with the 
 author's last improvements and corrections In 
 one octavo volume, extra cloth, of 600 pages. S3'i(). 
 
 DEWEES'S TREATISE ON THE PHYSICAL 
 AND MEDICAL TREATAIENT OF CHILD- 
 REN. Tenth edition. In one volume, octavo, 
 extra cloth, 518 pages. $2 80. 
 
 DEWEES'S TREATISE ON THE DISEASES 
 OF FEMALES. Tenth edition. In one volume, 
 octavo, extra cloth, 532 pages, with plates. 8-3 00. 
 
 DANA ON ZOOPHYTES AND CORALS. In one 
 
 volume, imperial quarto, extra cloth, with wood- 
 cuts. SI5 00. Also, AN ATLAS, in one volume, 
 imperial fidio, with sixty-one magnificent colored 
 plates. Bound in half morocco. S:30 00. 
 
 DE LA BECHE'S GEOLOGICAL OBSERVER. 
 In one very l;irgeand handsome octavo volume, ex- 
 tra cloth, of 700 pages, with .300 wood-cuts. $-1 00. 
 
 FRICK ON RENAL AFFECTIONS; their Diag- 
 nosis and Pathology. With illustrations. One 
 volume, royal 12iuo., extra cloth. 75 cents.
 
 12 
 
 BLANGHARD & LEA'S MEDICAL 
 
 DUNGLISON (ROBLEY), M.D., 
 
 Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. 
 
 MEDICAL LEXICON; a Dictionary of IMcclical Science, containing a concise 
 
 Explanation of the various Subjects and Terms ot Physiology, Paiholosry, Hyo-iene, Therapeutics, 
 Pharniacolog-y, Obstetrics, Medical Jurisprudence, Arc. With the French and other Synonymes; 
 Notices ofClimate and of celebrated Mineral Waters; Formulae for various Ollicinal, Empirical, 
 and Dietetic Preparations, etc. Thirieenth edition, revi>ed. is now ready. In one very thick 
 octavo volume, of over nine hundred large double-columned pages, strongly bound in leather, 
 ■with raised bands. $4 00. 
 
 Every successive edition of this work bears the marks of the industry of the author, and of his 
 determination to keep it fully on a level with the most advanced state of medical science. Thus 
 nearly fifteen thoisand words have been added to it within the last tew years. As a complete 
 Medical Dictionary, therefore, embra6ing over FIFTY THOUSAND DEFINITIONS, in all the 
 branches of the science, it is presented as meriting a continuance of the great favor and popularity 
 which have carried it, within no very long space of time, to a thirteenth edition. 
 
 Every precaution has been taken in the preparation of the present volume, to render its mecha- 
 nical execution and typographical accuracy worthy of its extended reiintation and universal use. 
 The very extensive additions have been accommodated, without materially increasing the bulk ol 
 the volume by the employment of a small but exceedingly clear type, cast for this purpose. The 
 press has been watched with great care, and every effort used to insiue the verbal accuracy so ne- 
 cessary to a work of this nature. The whole is printed on fine while paper ; and, while thus exhi- 
 biting in every respect so great an improvement over former issues, it is presented at the original 
 exceedingly low price. 
 
 AVe welcome it cordi.THj'; it is an a(lniiral)le work, ! readers to its peculiar merits; and wre need do 
 and indispensable to all literary niediial men. The i little more tlian state, in reference to the present 
 labor which has been bestowed upon it is something reissue, that, notwithstandinsj the large additions 
 prodigious. The work, however, has now been I previously made to it, no fewer than four thou- 
 done, and we are. happy in the thought that no hu- j sand terms, not to be found in the preceding edi- 
 man beins will have again to undertake the same ! tion, are contained in the volume before us. — 
 
 gigantic task. Revised and corrected from time to 
 time, Dr. Dunglison's '■ Medical Lexicon" will last 
 for ctnturies.—BTitish and Foreign Med.-Chirurg. 
 Revieio. 
 
 The fact that this excellent and learned work has 
 passed through eight editions, and that a nintli is 
 rendered necessarj' by the demands of the publi*, 
 affords a sufficient evidence of tlie general apprecia- 
 tion of Dr. Dunglison's labors bythe medical pro- 
 fession in England and America. It is a book which 
 will be of great. service to the student, in teaching 
 him tlie meaning of all the technical terms used in 
 medicine, and will be of no less use to the practi- 
 tioner who desires to keep himself on a level with 
 the advance of medical science. — London Medical 
 Times and Gazette. 
 
 In taking leave of our author, we feel eompelled | perly appreciated by his own countrymen ; and we 
 to confess that his work bears evidence of almost can only confirm their judgment, by recommending 
 
 Whilst it is a wonderful monument of its author's 
 erudition and industry, it is also a work of great 
 practical utility, as we can testify from our own 
 experience; for we keep it constantly within oui 
 reach, and make very frequent reference to it, 
 nearly always finding in it the information we seek. 
 — British, and Foreign Med.-Chirurg. Revieio. 
 
 It has the rare merit that it certainly has no rival 
 in the English language for accuracy and extent 
 of references. The terms generally include short 
 physioliigjcal and pathological descriptions, so that, 
 as the author justly observes, the reader does not 
 possess in this work a mere dictionary, but a book, 
 which, while it instructs him in medieal etymo- 
 logy, furnishes him with a large amount of usefnl 
 information. The author's labors have been pro- 
 
 incredible labor having been bestowed upon its com 
 position. — Edinburgh Journal of Med. Science. 
 
 A miracle of labor and industry in one who has 
 written able and voluminous works on nearly every 
 branch of medical science. There couKI be no more 
 useful book to the student or practitioner, in the 
 present advancing age, than one in which would be 
 found, in addition to the ordinary meaning and deri- 
 vation of medical terms — so many of which are of 
 modern introduction — concise descriptions of their 
 
 this most usel'ul volume to the notice of our cisat- 
 lantic readers. Nomedical library will be complete 
 without it. — London Med. Gazette. 
 
 It is certainly more complete and comprehensive 
 than any with' which we are acquiiinted in the 
 English language. Few, in fact, could be found 
 belter qualified than Dr. Dunglison for the produc- 
 tion of such a work. Learned, industrious, per- 
 severing, and accurate, he brings to the task all 
 , , , . 1 11 .^1 • 1 ,1 the peculiar talents necessary for its successfuJ 
 
 explanation and einployment; andall this and much performance; while, at the same time, his fami- 
 more IS contained in the volume bef.ire us It is j Uj^^ity with the writings of the ancient and modern 
 
 therefore almostas indispensable to the other learned 
 professions as to our own. In fact, to all who may 
 have occasion to ascertain the meaning of any word 
 belonging to the many branches of medicine. From 
 a careful examination of the present edition, we can 
 vouch for its accuracy, and for its bein^ brought 
 quite up to the date of publication ; the autlior states 
 in his preface that hehasadded to it about four thou- 
 sand terms, which are not to be found in the prece- 
 ding <>ne. — Dublin Quarterly Journal of Medical 
 Sciences. 
 
 On the appearance of the last edition of this 
 valuable work, we directed the attention of our 
 
 " masters of our art," renders him skilful to note 
 the exact usage of the several terms of science, 
 and the various modificaticms which medical term- 
 inology has undergone with the change of theo- 
 ries or the progress of improvement. — American 
 Journal of the Medical Sciences. 
 
 One of the most complete and copious known to 
 the cultivators of medieal science. — Boston Med. 
 Journal. 
 
 The most comprehensive and best English Dic- 
 tionary of medical terms extant. — Buj/alo Medical 
 Journal . 
 
 BY THE SAME AUTHOR. 
 
 THE PRACTICE OF I^IEDICINE. A Treatise on Special Pathology and The- 
 
 rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. S6 25. 
 
 ferings of the race.— Boston Medical and Surgical 
 Journal. 
 
 Upon every topic embraced in the work the latest 
 information will be found carefully posted up. — 
 Medical Examiner. 
 
 The student of medicine will find, in these two 
 elegant volumes, a mine of facts, a gathering of 
 precepts and advice from the world of experience, 
 that will nerve him with courage, and faithfully 
 
 It is certainly the most complete treatiseof which 
 we have any knowledge. — Western Journal of Medi- 
 cine and Surgery. 
 
 One of the most elaborate treatises of the kind 
 
 direct him in his efforts to relieve the physical suf- ' we have. — Southern. Med. and Surg. JoumcU.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 13 
 
 DUNGLISON (ROBLEY), M. D., 
 
 Professor of Institutes of Medicine in tlie JeiTerson iMeilical College, Philadelphia. 
 
 HUMAN PHYSIOLOGY. Eiglith edition. Thoroughly revised and exten- 
 
 sively modified and enhuged, with five hundred and thirly-tvvo illustrations. In two larjre and 
 
 handsomely printed octavo volumes, leather, of about ISOO pag-es. (Just Ready, 185G.) $7 00. 
 
 In revi-ing this work for its eighth appearance, the author has spared no labor to render il worthy 
 u continuance of the very great favor which has been extended to it by the profession. The whole 
 contents have been rearranged, and to a great extent remodelled ; the" investigations which of late 
 years have been so numerous and so important, have been carefully examined and incoip )rated, 
 and the work in every respect has been brought up to a level with the present slate of the subject. 
 The object of the aullior has been to render it a concise but comprehensive treatise, containing the 
 \Vhole body of phy>iological science, to which the student and man of >cience can at all times refer 
 with the certainly of finding whatever they are in search of, fully presented in all its aspects; and 
 on no former edition has the author bestowed more labor to secure this re>ult. 
 
 A similar improvement will be found in the typographical execution of tlie volumes, which, in 
 this respect, are superior to their predecessors. A large number of additional wood-cuts have been 
 introduced, and the series of illustrations has been greatly modified by the substitution of many 
 new ones for such as were not deemed satisfactory. By an enlargement of the page, these very 
 considerai)le additions have been accommodated without increasing the size of the volumes to an 
 extent to render them unwieldy. 
 
 It has long since taken rank as one of the medi- 
 cal classics of our language. To say that it is by 
 far the best text-book of physiology ever pul)lisheJ 
 in this country, is but echoing the general testi- 
 mony of the profession. — N. Y. Journal of Medicine. 
 
 There is no single book we would recommend to 
 the student or physician, with greater confidence 
 than the present, because in it will be found a mir- 
 ror of almost every standard pliysiologieal work of 
 the day. We most cordially recommend the work 
 to every member of the profession, and no student 
 
 should be without it It is the completest work on 
 Physiology in the English language, and is highly 
 creditable to the author and publishers. — Canadian 
 Medical Journal. 
 
 The most complete and satisfactory system of 
 Physiology in the English language. — Amer. Med. 
 Journal. 
 
 The best work of the kind in the English lan- 
 guage. — Sillinian's Journal. 
 
 The most full and complete system of Physiology 
 in our language. — Western Lancet. 
 
 BY THE SAME AUTHOR. 
 
 GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a 
 
 Medical Text-book. Fit'lh edition, much improved. With one hundred and eighty-seven illus- 
 trations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $6 00. 
 
 Asa text-book for students, for whom it is par- 
 ticularly designed, we know of none superior to 
 it. — St. Louii Medical and Surgical Journal. 
 
 In this work of Dr. Dunglison,we recognize the 
 same untiring industry in the collection and em- 
 bodying of facts on the several subjects of which he 
 treats, that has heretofore distinguished him, and 
 we cheerfully point to these volumes, as two of the 
 most interesting that we know of. In noticing tlie 
 additions to this, the fourth edition, there is very 
 little in the periodical or annual literature of the 
 profession, published in the interval which has 
 elapsed since the issue of the first, that lias escaped 
 the careful search of the author. Asa book for 
 reference, it is invaluable Charleston Med. Jour- 
 nal and Review. 
 
 It may be said to be the work now upon the sub- 
 jects upon which it treats. — Western Lancet. 
 
 It purports to be a new edition, but it is rather 
 a new book, so greatly has it hern improved, both 
 in the amount and quality of the matter which it 
 contains. — N. O. Medical and Surgical Journal. 
 
 We bespeak for this editi(m, from the profession. 
 an increase of patronage over any of its former 
 ones, on account of its increased merit. — N. Y. 
 Journal of Medicine. 
 
 We consider this work unequalled. — Boston Med. 
 and Surg. Journal. 
 
 BY THE SAME AUTHOR, {A new 'Edition.) 
 
 NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND 
 
 ADMIXISTKATJON. Seventh edition, with extensive Additions. In one very large octavo 
 
 volume, leather, of 770 pages, {Just Ready, May, 185G.) §;.3 75. 
 
 Another edition of the " New Remedies" having been called for, the author has endeavored to 
 add everything of moment ihat has appeared since the publication of the la>t edition. 
 
 The chief remedial lueai.s which have obtained a place, for the first time, in this volume, either 
 owing to their having been recently introduced into pharmacology, or to their having received novel 
 applications — and which, con^equently, belong to the category of "New ILemedies" — are the fol- 
 lowing : — 
 
 ^ Apiol, Caffein, Carbazotic acid. Cauterization and cathet'-rism of the larynx and trachea, Cedron, 
 Cerium, Chloride of bromine. Chloride of iron. Chloride of sodium, Cinchonicine, Cod-liver olein. 
 Congelation, Eau de Pagiiari, Galvanic cautery, Hydriodic ether. Hyposulphite of soda and silver, 
 Inunction, Iodide of sodium. Nickel, Permanganate of potassa, Phosphate of lime, Pumpkin, Quinidia, 
 Rennet, Saccharine carbonate of iron and manganese. Santonin, Tellurium, and Trauinaticnie. 
 
 The articles treated of in the former edilions will be found to have undergone considerable ex- 
 pansion in this, in order that the author might be enabled to introduce, as far as practicable, the 
 results of the subsequent experience of others, as well as of his own observalion and relleclion; 
 and to make the w^ork still more deserving of the extended cireulatimi with which the preceding 
 editions have been favored by the profession. By an enlargement of the page, the numerous addi- 
 tions have been incorporated without greatly increasing the bulk of the volume. — Preface. 
 
 One of the most useful of the aiillior's works. — 
 Southern Medical and Surgical Journal. 
 
 This elaborate and useful volume should be 
 found in every medical library, for as a book of re 
 
 ference, for physii'ians, it is unsurpassed by any 
 other work in existence, and the double index for 
 diseases and for remedies, will be found greatly to 
 enhance its value. — ISew York Med. Gazette. 
 
 The great learning of the author, and his remark- 
 able industry in pushing his researches into every 
 source whence information is derivable, h;is enabled 
 him to throw together an extensive mass of facts 
 and statements, accompanied by full reference to 
 authorities; which last feature renders the work 
 practically valuable to investigators who desire to 
 examine the original papers. — The American Journal 
 of Pharmacy.
 
 14 
 
 BLANCHARD &; LEA'S MEDICAL 
 
 ERICHSEN (JOHN), 
 
 Professor of Surgery- in University Co3)ege, London, &e. 
 
 THE SCIENCE AND ART OF SURGERY; being a Treatise on Surgical 
 
 Injuries, Diseasks, and Operations. Edited by John H. Bkinton, M. D. Illustrated with 
 three luindred and eleven engravings on wood. In one large and handsome octavo Tolume, oi 
 over nine hundred closely printed pages, leather, raised band.s. §4 25. 
 
 It is, in our humb)e joHgment. decideilly llie best 1 rarely eneounter cases requiring surgieal raanage- 
 book of the kind in the English (ariguage. Strange meat. — Stethoscope. 
 
 that just such liooks are notoflener pro<laced by puh- Embracing, as will he pereeiv^-d. the whole sursi- 
 (ic leachp_rs_or_surgery in this _eouiiiry a»id^ Great | gal domain, and each division of itself almost coW>- 
 
 Brilain. Indeed, it is a malterof great astonishnnent. 
 hut no less true than astonishing, that oi the many 
 ■works on surgerj- repnblished in ihis cnontry wijhin 
 the last fifteen or twenty years as te.xtbooks for 
 
 medical students, this is the oi.ly one ihat even ap- i best single volume now exiam on the sul.je 
 proximaiesto ihe fiilnlinenl of the peeunar wants of | „.,,), „reai pleasure we add ii to our text b- 
 
 young men just entering upon the siiidy of this ti ranch 
 of the profession. — WtsiemJour .of Med. ani Surgery. 
 
 Its value is greatly enhanced by a very copious 
 well-arransed index. We regard this as one of the 
 most valuable contributions to modern surgery. To 
 one entering his tioviiiate of practice, we regard ii 
 ibemosi serviceable guide which he can consult. He 
 will find a iulnessof detail leadinghim through every 
 step of the operation, and not deserting him until the 
 final issue of the case is decided. For the same rea- 
 .?on we recommend it to those whose routine of prac- 
 tice lies ill such parts of ilie eouiitry that they must 
 
 plete and perfect, each chapter full and explicit, each 
 suhiect faithfully exhibited, we can on)y express our 
 esiimaie of it in the aggregate. "We consider it an 
 excellent contribution to surgery, as probably the 
 
 '?et, and 
 books. — 
 
 pie 
 NaskviUe Journal (^Medicine and Sur^ir^ 
 
 Prof. Eriehsen's worV, for its size, has not l>eea 
 surpassed; his nine hundred and eight pages, pro- 
 fusely illustraied. are rich in physiological, patholo- 
 gical, and operative suggestions, do'-trines, details, 
 and processes; and wi}/ prove a reliable resource 
 for information, both to physician and suraeon, in the 
 hour of peril —iV. 0. Med. and Surg Journal. 
 
 M'e are acQuainted with no other work whereia 
 so much good sense, sound principle, and prnctieai 
 inferences, stamp every page. — American Lancet. 
 
 ELLIS (BENJAMIN), M.D, 
 THE MEDICAL FORMULARY : beicg a Collection of PrescriptioDs, (5emed 
 
 from Ihe writings and practice of many of the most eminent physicians of America and Europe. 
 Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added 
 an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. Ti>8 
 whole accompanied with a few brief Pharmaceittic and Medical Observations. Tenth edition, 
 revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the 
 Philadelphia College of Pharmacy. h\ one neat octavo volume, extra eloth, of 29o pages. (Lately 
 Issued.) $1 75. 
 
 After an examination of the new matter and the 
 alterations, we believe the reputation of the work 
 built up by the author, and the late distinguished 
 editor, will continue to flourish under the auspices 
 of the present editor, who has the industry and accu- 
 racy, and, we would say, conscientiousness requi- 
 site for the lesponsjble task. — Am. Jour, of P harm. 
 
 It wi)l prove partie»>ar)y useful to students and 
 yot»ng prsictitioners, as the most important prescrip- 
 tions employetl in mo<iern practice, which lie scat- 
 tered through our medical literature, are here col- 
 lected and "conveniently arranged for refereaee. — 
 Charleston Med. Jo-Hmal axd Kevieie. 
 
 FOWNES (GEORGE), PH. D., &c. 
 ELE:MENTARY CHE:^IISTRY; Theoretical and Practical. With mimerom 
 
 iHnstrations. A new American, from the last and revised London edition. Edited, with Addi- 
 tions, by Robert Bridges, M. D. In one large royal 12mo. volume, of over 550 pages, whh ISl 
 wood-cuts. {Late/y Issued.) In leather, SI 00; extra cloth, $1 3-5. 
 "We know of no better text- lK)o)t, especinDy in the ) The v/ork of l>r. Powiies has losg been before 
 
 difhcult department of organic chemistry, upon 
 which it is particularly full and satisfactory. We 
 would recommend it to preceptors as a capital 
 " office book" for their students who are beginners 
 in Chemistry. It is copiously illustrated with ex- 
 
 the pubhe, and its merits have been fufly appreci- 
 ated as the best text-book on chemistry now in 
 existence. AVe do not, of course, piaee it in a rank 
 superior to tlie works of Brande, Graham, Turner, 
 Gregory, or Gmetin, but v/e say that, as a work 
 
 cellent wood-cuts, and alt<igether admirably "got for students, it is preferaWe to any of them. — Lom- 
 ap." — N. .1. Medical Rtporter. \ don Journal of Medicine. 
 
 A 8t:;nd.ird manual, which h.is long enjoyed the A work well adapted to the wants of the etndent. 
 reputation of embodying much knowledge in a small It is an excelient exposition of the chief doetrines 
 8pace. The author hasachieved the difficult task of and facts of modern chenijstry. Thesizeof the work, 
 condensation with masterly tact. His hook is con- ( and still more the condensed yet perspicnons style 
 cise without being dry, and brief without being too i in which it is written, abs(dve it from the charges 
 dogmatical or general. — Yirginia Med. a^d Surgical \ very properly urged against most manuals termed 
 JoMTttal. \ popular. — Edinburgh Journal of Medical Seienes. 
 
 FERGUSSON (WILLIAM), F. R. S., 
 
 Professor of Surgery in King's Coilege, London, Ac. 
 
 A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third 
 
 and enlarged London edilit>n. In one large and beautifully printed octavo volume, of about 700 
 
 pages, with 393 handsome illustrations, leather. S3 00. 
 
 The most iinportant subjects in connection with [ practitioner, and was more carefully arranged to 
 practical surge/y which have been more recentlv that single purpose than this. — if. Y. Med. Journal. 
 brought under the notice of, and discussed by, the T|,g .^jdition of many new pages makes this work 
 surgeons of Great Hntnin, are fully and dispassion- „„re than ever indispensable ro the student and prac- 
 ately considered by Mr. Ferg.isson, and that which ! tMonet.—Rartking's Abstract. 
 was before ^vantmg has now been suppiieo, so that i , , . 
 
 we can now look upon it as a work on practical sur- Among the numerous works upon surgery pub- 
 eerv instead of one on oiierative surgery alone, lished of late years, we know of none we value 
 Medical Times and Gazette. "»">■« highly than the one before us. It is perhaps 
 
 the very best we have for a text-book and for ordj- 
 
 No work was ever written which more nearly nary reference, being concise and eminent'.y practi- 
 compreheuded the necessities of the student and 1 cai. — Southern Med. and SMrg. Jo^moi.
 
 AND SCIENTIFIC PUBLICATIONS, 
 
 15 
 
 FLINT (AUSTIN), M. D., 
 
 Professor of the Theory and Practice of Medicine in the Uaiversity of Louisville, &c. 
 (All Important ]\'cto IVor/c.) 
 
 PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- 
 ING THE RESPIRATORY ORGANS. In oae large and handsome octavo volume, extra 
 cloth, 636 pages. (Now Ready.) $3 00. 
 
 The author has aimed in the present work to supply a vacanoy in medical literature, viz: "a 
 work limited to diseat^es affecting- the respiratory organs, treating iiiextenso and almost exeltisively 
 of the principles and practice of physical exploration, as applied to the diagnosis of those aflections." 
 The intricacy and importance of the subject demand a fuller and oiore detailed exoosition than has 
 been accorded to it in any volume as yet accessible to the American profession ; while the high re- 
 putation which the author has acqiiirHJ by his researches in kindred topics sulFiciently manifests his 
 ability to render the present work a text-book of great practical utility for the student, and a source 
 to which the praetitioner can at all times refer with certainty. 
 A very condensed summary of the contents is subjoined. 
 
 CONTENTS. 
 
 INTRODUCTION. 
 
 Section I. Preliminary points pertaining to the Ana- 
 tomy and Physioldonf of the Respiratory Appara- 
 tus. Section II. Topographical Divisioas of the 
 Chest. 
 
 PART I. 
 
 Physicai, Exploration of the Chest. 
 
 Chap. I. Definitions— Different Methods of Explora- 
 tions — General Remarks. Chap. IT. Percussion. 
 Chap. III. AiiseultJition. Chap. IV. Inspection. 
 Chap. V. Mensuration. Chap. VI. Palpation. 
 Chap. VII. Succussion. Chap. VIIl. Recapitu- 
 latory Enumeration of the Physical Si^ns fur- 
 nished by the several methods of Exploratioa. 
 Chap. IX. Correlation of Physical Signs. 
 
 PART 11. 
 
 Diagnosis of Diseases .\ffecting the Respiua- 
 TORV Organs. 
 
 Chap. I. Bronchitis, Pulmonary or Bronchial Ca- 
 tarrh. Chap. II. Dilatation and Contraction of 
 the Bronchial Tubes — Pertussis — Asthma. Chap. 
 III. Pneumonitis — Imperfect E.xpansii)n (Atelec- 
 tasis) and Collapse. Chap. IV. Emphysema. 
 Chap. V. Pulmonary Tuberculosis Bronchial 
 Phthisis. Chap. VI. Pulmonary Q3dema— Gan- 
 grene of the Lungs — Pulmonary Apople.'cj' — Can- 
 cer of the liUnss — Cancer in the Mediastinum. 
 Chap. VII. Acute Pleuritis — Clironic Pleuritis — 
 Empyema — Hydrothorax — Pneumothorax — Pneu- 
 mo-Uydrothorax--Pleuralgia-- Diaphragm a tic Her- 
 nia. Chap. VIll. Diseases affecting tiie Trachea 
 and Laryn.x — Poreiirn Bodies in the Air-passages. 
 Appendix. On the Pitch of the Whispering Souffle 
 over Puluioaary Excavations. 
 
 GRAHAM (THOMAS), F.R.S., 
 
 Professor of Chemistry in University College, London, &c. 
 
 THE ELEMENTS OF CHEMISTRY. Including the application of the Science 
 
 to the Arts. With numerous illustrations. With Notes and Additions, by Robert Bridges, 
 M. D., &c. &c. Second American, from the second and enlarged London edition. 
 
 PART I. (Lately Issued) large 8vo., 430 pages, 185 ilJustratioas. $1 50. 
 
 PART II. (Preparing) to match. 
 
 GRIFFITH (ROBERT E.), M. D., &c. 
 A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- 
 
 m' iiefering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- 
 j! t«. Second Edition, thoroughly revised, with numerous additions", by Robert P. Thomas, 
 J*. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one larg-e and 
 handsome octavo volume, extra cloth, of over 600 pages, double columns, (jicst Issued.) $3 00; 
 DC bound in sheep, $3 25. 
 
 It was a work requiring much perseverance, and j tioner can possihly have in his possession. — Mtdical 
 when piiblishe<l was iook-ed upon as by far the in^si Chronicle. 
 
 work of its kind that ha<t issued from the American 
 press. Prof Thoraai has certainly "improved." a? 
 well as added oihis Formulary, and has rendered it 
 additionally deserving of the confidence of pharraa- 
 aeutiste and physicians. — Am. Joumal of Pharmacy. 
 
 We are happy to announ<-e a new and improved 
 edition of this, one of the most valualtle and useful 
 works that have emanated from an Amf'rican pen. 
 It would do credit to any country, and will be found 
 of daily usefulness to practitioners of medicine; it is 
 better adapted to their purposes than the dispensato 
 ries. — Soul/iern Med. and Surg. Journal. 
 
 A new edition of this well-known work, edited by 
 R. P. Thomas, M D., affords occasion for renewinsj 
 our commendation of so useful a handbook, which 
 ought to be universally studied by medical men of 
 every class, ami made use of by way of reference by 
 office pupils, as a standard authority. It has Iveen 
 much enlariied, and now condenses a vast amount 
 
 The amountof useful, every-day matter, for a prac- 
 ticing physician, is really immense. — Boston. Med. 
 nnd Surg. Journal. 
 
 This is a work of six hundred and fifty one pa^es, 
 embracinf^ all on the subject of preparin<? and admi- 
 nistering medicines lh,-\tcan be desired l)y ihe physi- 
 cian and pharmaceutist — Western Lancet. 
 
 In short, it is a full and complete work of the kind 
 and should bo m ilie hands of every physician and 
 apothecary. O. Mtd. and Surg. Jnicmal 
 
 We predict a preat sale for this work, and we espe- 
 ciallv recommend it to all nudical teachers. — Rieh- 
 tnoHd Stethoscope. 
 
 Thiseditifmof Dr Griffith's work has been jrreatly 
 imiiroved l)y the revision and ample additions of Dr. 
 Thomas, and is now, we believf, one of Ihe most 
 complete works of its kind in any lanafiias^. The 
 adilitions amount to about seventy pnjes, and no 
 
 of needful and necessary knowledjre in small com- 1 effort ha<; heen spared to include in ihpui all the re- 
 
 pass. The more of such books the better for the pro- 
 lession and the public —N. Y. Med. Gazette. 
 
 It is one of the most useful books a country practi- 
 
 rent improvements which have been i>ublifhi-d in 
 medical journals, and systematic treatises. A work 
 of this kinrl appears to us indispensable to the physi- 
 cian, and ih^reis none we can more cordially recom- 
 ' mend.— JV. Y. Journal of Medicine. 
 
 BY THE SAME AUTHOR. 
 
 MEDICAL BOTANY; or, a Description of all the more important Plants used 
 
 iu Medicine, and of their Properties, Uses, and Modes of Administration. In one lar^e octavo 
 voiume, extra cloth, of 704 pages, handsomely printed, with nearly 350 illustrationsoa wood. $3 00.
 
 16 
 
 BLANCHARD & LEA'S MEDICAL. 
 
 GROSS (SAMUEL D.), M. D., 
 
 Professor of Surgery in the Jefferson Medical College of Piiiladelphia, fcc. 
 
 A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND 
 
 IMALFOKMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND, AND 
 THE URETHRA. Second Edition, revised and mnch enlarged, with one hundred and eigrhty- 
 foiir illustrations. In one large and very handsome octavo volume, of over nine hundred pages. 
 {Just Issued.) In leather, raised bands, $5 25; extra cloth, $4 75. 
 
 The author has availed himselfof the opportunity afforded by a call for a new edition of this 
 work, to thoroughly revise and render it in every respect worthy, so far as in his power, of the very 
 flattering reception whicM has been accorded to it by the profession. The new matter thus added 
 amounts to almost one-third of the original work, while the number of illustrations has been nearly 
 doubled. These additions pervade every portion of the work, which thus has rather the aspect of 
 a new treatise than a new edition. In its present improved form, therefore, it may confidently be 
 presented as a complete and reliable storehouse of information on this important class of diseases, 
 and as in every way fitted to maintain the position which it has acquired in Europe and in this 
 country, as the standard of authority on the subjects treated of. 
 A volume replete with truths and principles of the | provements, it ^vill probably remain one of the most 
 
 utmost value in the investigation of these diseases. — 
 American Medical Journal. 
 
 On the appearance of the first edition of this work, 
 the leading English medical review predicted that it 
 would have a " permanent place in the literature of 
 surgery ^vorthy to rank witii the best works of the 
 present a?e." This prediction has been amply ful- 
 filled. Dr. Gross's treatise has been found to sup- 
 ply completely the want which has been felt ever 
 since the elevation of surgery to the rank of a science, 
 of a good practical treatise on the diseases of the 
 bladder and its accessory organs. Philosiphical in 
 its design, methodical in its arrangement, ample and 
 .sound in its practical details, it may in truth be said 
 to leave scr.rcely any'hing to be desired on so im- 
 portant a subject, and with the additions and modi- 
 ficatiuns resulting from future discoveries and im- 
 
 valuable works on this subject so long as the science 
 of medicine shall exist. — Boston Med. and Surg. 
 Journal. 
 
 Dr. Gross has brought all his learning, experi- 
 ence, tact, and judgment to the task, and has pro- 
 duced a work worthy of his high reputation. AVe 
 feel perfectly safe in recommending it to our read- 
 ers as a monograph unequalled in interest and 
 practical value by any other on the subject in our 
 language. — Western Journal of Med. and Sicrg. 
 
 "Whoever ^vill peruse the vast amount of valuable 
 practical information it contains, and wliich we 
 have been unable even to notice, will, we think, 
 agree with us, that there is no work in the English 
 language \vhich can make any just pretensions to 
 be its equal. — N. Y. Journal of Medicine. 
 
 BY THE SAME AUTHOR. {Just Issued). 
 
 A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- 
 
 SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. S"2 75. 
 
 A very elaborate work. It is a complete summary conclude by recommending it to our readers, fully 
 of the whole subject, and will be a useful book of persuaded that its perusal wjll afford them much 
 reference. — British and Foreign Medico-Chirurg. practi'-al information well convej-ed, evidently de- 
 Revietv. rived from considerable experience and deduced from 
 
 A highly valuable book of reference on a most im- \ ^^ ample collection of facts. — Dutim Quarterly 
 portant subject in the practice of medicine. We i Journal, May, 1855. 
 
 BY THE SAME AUTHOR. (Preparijig.) 
 
 A SYSTEM OF SURGERY; Diagnostic, Pathological, Therapeutic, and Opera- 
 
 live. With very numerous engravings on wood. 
 
 BY THE SAME AUTHOR. 
 
 ELEMENTS OF PATHOLOGICAL ANATOMY; illustrated by colored En- 
 graving's, and two hundred and fifty wood-cuts. Second edition, thoroughly revised and greatly 
 enlarged. Jn one very large and handsome imperial octavo volume, leather, raised bands, pp. 
 82-2. 65 75. 
 
 GLUGE (GOTTLIEB), M . D., 
 
 Professor of Physiology and Pathological Anatomy in the University of Brussels, &c. 
 
 AN ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes 
 
 and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- 
 nia. In one volume, very large imperial quarto, extra cloth, with 320 figures, plain and colored, 
 on twelve copperplates. $5 00. 
 
 GARDNER'S .MEDICAL CHEMISTRY, for the 
 nse of Students and the Profession. In (me royal 
 Vimo. vol., ex. cloth, pp. 306, with illustrations. 
 SI 00. 
 
 HARRISON'S ESS.AY TOWARDS A CORRECT 
 THEORY OF THE NERVOUS SVSTE.M. la 
 one octavo volume, leather, 292 pages. SI 50. 
 
 HUGHES' CLINICAL INTRODUCTION TO 
 THE PRACTICE OF AUSCULTATION AxND 
 OTHER .AIODESOF PHYSICAL DIAGNOSIS, 
 IN DISE.ASES OF THE LUNGS AND HEART. 
 Sec<md American, from the second London edition. 
 1 vol. loyal 12mo., ex. cloth, pp. 304. SI 00. 
 
 HAMILTON (FRANK H.), M. D., 
 
 Professor of Surgerv, in Buffalo xMedical College. <fcc. 
 
 A TREATISE ON FRACTURES AND DISLOCATIONS. 
 
 In one handsome 
 
 octavo volume, with numerous illustrations. (Prepari/ig.) 
 
 The numerous improvements which this important branch of surgery has received from the skill 
 and ingenuity of American surgeons, renders particularly appropriate and valuable a complete and 
 systematic original vi'ork on the subject. The es-ays which Professor Hamilton has published on 
 kindred topics are already widely and favorably known, and give earnest that his forthcoming work 
 will prove indispensable, both as a text-book for llie student, aud as a guide for the practitioner.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 17 
 
 HOBLYN (RICHARD D.), M. D. 
 A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE 
 
 COLLATERAL SCIENCES. By Richard D. Hoblyn, A. M , &c A new American from 
 the last London edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of 
 the " Americsn Journal of the Medical Sciences." In one iarsre royal 12mo. volume, leather, 
 of over 500 double columned pages. (Noio Ready, 1856.) SI 50. 
 
 The preat care bestowed on the revision of this vi^ork, and the extensive additions made to it by the 
 editor, have caused the delay in its appearance. While careAillv excluding- obsolete words, it has 
 been his aim to render it a complete manual of definitions, in which the student of medicine or of 
 its allied sciences might feel assured of being able to find concise explanations of all terms occur- 
 ring in his course of reading. The amount of the additions thus made, may be estimated from the 
 fact that the present edition contains fully one-third more matter than the last, the number of pages 
 having been increased by over one hundred, notwithstanding an enlargement of the size of the page, 
 while at the same time it has been kept at the former exceedingly low price. 
 
 If the frequency with which we have rel'erred to | nor desire to procure a larger work. — American 
 this volume since its reception from the pul)" 
 
 two or three weeks ago, be any criterinn for the 
 future, the bin iing will soon have to be renewed, even 
 with careful hHutlling. We find that Dr. Hays has 
 done the profession great service by his careful and 
 industrious labors. The Dictionary has thus liecoine 
 eminently suited to our medical bretliren in this 
 country. The additions by Dr. Hays are in brackets, 
 and we believe there is not a single page but bears 
 tliese insignia; in every instance which we have thus 
 far noticed, the additinns are really needed and ex- 
 ceedingly valuable. We heartily commend the work 
 to all who wish to I)p au cnurnnt in medicul termi- 
 nology. — Boston Med. and Surg. Journal. 
 
 To both practitioner and student, we recommend 
 tills dictionary as being convenient in size, accurate 
 in definition, and sufficiently full and complete for 
 ordinary consultation. — Charleston Med. Journ. and 
 Review. 
 
 Admirably calculated to meet the \vant3 of the 
 practitioner or student, who has neither the means 
 
 Lancet. 
 
 Hoblyn has always been a favorite dictionary, and 
 in its present enlarged and improved form will give 
 greater satisl'action thiinever. The American editor, 
 Dr. Hays, has made many very valuable additions. 
 — N.J. Mid. Reporter. 
 
 To supply the want of the medical reader arising 
 from this cause, we know of no dictionary better 
 arranged and adapted than the one bearing the above 
 title. It is not encumbered with the obsolete terms 
 of a bygone age, but it contains all that are now in 
 use ; embracing every department of medical science 
 down to the very latest date. The volume is of a 
 convenient size to be used by the medical student, 
 and yet large enough to make a respectable appear- 
 ance in the library of a physician. — Western Lancet. 
 
 Hoblyn's Dictionary has long been a favorite with 
 us. It is the best book of definitions we have, and 
 ought always to be upon the student's table. — 
 Southern Med. and Surg. Journal. 
 
 HUNTER (JOHN). 
 TREATISE ON THE VENEREAL DISEASE. 
 
 Dr. Ph. Ricord, Surgeon to th« Venereal Hospital of Paris. 
 F. J. Btr.MSTEAD, M. D. In on« octavo volume, with plates. 
 Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c. 
 volimies, leather, with plates. 510 00. 
 
 With copious Additions, by 
 
 Edited, with additional Notes, by 
 $3 25. gy See Ricord. 
 
 In four neat octavo 
 
 HORNER (WILLIAM E.), M. D., 
 Professor of Anatomy in the University of Pennsylvania. 
 
 SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively 
 
 revised and modified. In two large octavo volumes, extra cloth, of more than one thousand 
 pages, handsomely printed, with over three hundred illustrations. $6 00. 
 
 This edition enjoyed a thorough and laborious revision on the part of the author shortly before 
 his death, with the view of bringing it fully up to the existing state of knowledge on the subject of 
 general and special anatomy. To adapt it more perfectly to the wants of the student, he introduced 
 a large number of additional wood-engravings, illustrative of the objects described, while the pub- 
 lishers have endeavored to render the mechanical execution of the work worthy of its extended 
 reputation. 
 
 JONES (T. WHARTON), F. R. S., 
 
 Professor of Ophthalmic Medicine and Surgery in University College, London, &c. 
 
 THE PRINCIPLES AND PRACTICE OP OPHTHALMIC MEDICINE 
 
 AND SURGERV. With one hundred and ten illustrations. Second American from the second 
 and revised London edition, with additions b/ Edward Hartshorne, M.D., Surgeon to Wills' 
 Hospital, cVc. In one large, handsome royal r2mo. volume, extra cloth, of 500 pages. {Now 
 Ready.) $1 ,50. 
 
 The thorough revisions which this work has undergone at the hands of both author and editor 
 have brought it thoroughly up to the present state of the subject, and have rendered it complete, 
 without detracting from its character as a manual, or deviating from its original object of affording 
 a digest of the present condition of ophthalmic science for study and reference by those whose 
 leisure does not admit of their perusing the larger works of Mackenzie or Lawrence. By an en- 
 largement of the size of the page, the numerous additions to this edition have been accommodated 
 without increasing the bulk of the volume, and at the very low price at which it is offered, a con- 
 tinuance of the favor which it has hitherto received is confidently expected. 
 
 We are confident that the reader will find, on 
 perusal, tlint the p.\ecution of the work amply fulfils 
 the promise of the preface, and sustains, in every 
 point, the already h gh reputation of the author as 
 an ophthalmic surgeon as well as a physiolocist 
 and pathologist. The book is evidently the result 
 of much laljor and research, .ind has been written 
 with the greatest care and attention; it possesses 
 that best quality which a general work, like a sys- 
 tem or manual can show, viz : the quality of having 
 all the materials whencesoever derived, so thorough- 
 
 ly wrought up, and digested m the author's mind, 
 as to come forth with the freshness and jmpressive- 
 ness of an original production. \Ve entertain little 
 doubt that this book will be<'ome \vliat its author 
 hoped it might become, a m:inu:il for daily reference 
 and consult:! tion by the student and the general prac- 
 titioner. The work IS m.nrkcd by that correctness, 
 clearness, and precision of style which distinguish 
 all the productions of the learned author. — British 
 and For. Med. Review.
 
 IS 
 
 JBLANCHAKD & LEA'S MEDICAL 
 
 JONES (C. HANDFIELD), F. R. S., &. EDWARO H. SIEVEKING, M.D., 
 
 Assistant Physicinns and Lecturers in St. Mary's Hospital, London. 
 
 A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, 
 
 Revised. Willi three himdred and ninety-seven handsome wood engravings. In one large and 
 beautiful octavo volume of nearly 750 pages, leather. (Lately Issued.) $3 73. 
 Asa concise te.ict-book, containing, in a condensed authors have not attempted to intrude new views on 
 form, a complete outline of what is known in the their professional brethren, but simply to lay before 
 domain of Pathological Anatomy, it is perhaps the them, what has long been wanted, an outline of the 
 best work in the English languaare. Its great merit present condition of pathological anatomy. In this 
 consists in its completeness and brevity, and in this they have been completely successful. The^vorkis 
 respect it supplies a great desideratum in our lite- one of the best compilations which we have ever 
 rature. Heretofore the student of pathology was perused. The opinions and discoveries of all the 
 obliged to glean from a great number of monographs, leading pathologists and physiologists are engrossed, 
 and the field was so e.xtensive that hut few cuftivated so that by reading any subject treated in the book 
 it with any degree of success. The authors of the you have a synopsis of the views of the most ap- 
 present work have sought to corrret this defect by proved authors. — Charleston Medical Journal and 
 placing before the reader a summary of ascertained Review. 
 
 facts, together with the opinions of the most eminent ^g j,ave no hesitation in recommending it as 
 
 worthy of careful and thorough study by every mem- 
 ber of the profession, old or young. — N. W. Med. 
 and Surg. Journal. 
 
 From the casual examination we have given we 
 are inclined to regard it as a text-book, plain, ra- 
 tional, and intelligible, such a book as the practical 
 man needs for daily reference. For this reason it 
 will be likely to be largely useful, as it suits itself 
 to those busy men who have little time for minute 
 investigation, and prefer a summary to an elaborate 
 
 pathok)gists both of the Old and New World. As a 
 simple work of reference, therefore, it is of great 
 value to the student of pathological anatomy, and 
 should be in every physician's library. — Western 
 Lancet. 
 
 We urge upon our readers and the profession a^ene- 
 rally the importance of informing themselves in re- 
 gard to modern views of pathology, and recommend 
 to them to procure the work before us as the best 
 means of obtaining this information. — Stethoscope. 
 
 In offering the above titled work to the public, the I Uea.tise.— Buffalo Medical Journal 
 
 KIRKES (WILLIAM SENHOUSE), M. D., 
 
 Demonstrator of Morbid Anatomy at St. Bartholomew's Hospital, &c.; and 
 
 JAMES PAGET, F. R. S., 
 
 Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital. 
 
 A MANUAL OF PHYSIOLOGY. Second American, from the second and 
 
 improved London edition. With one hundred and sixty-five illustrations. In one large and 
 
 handsome royal 12mo. volume, leather, pp. 550. $2 00. 
 
 In the present edition, the Manual of Physiology 
 has been brought up to the actual condition of the 
 science, and fully sustains the reputation which it 
 
 has already so deservedly attained. We consider 
 the work of MM. Kirkes and Paget to constitute one 
 of the very best handbooks of Physiology we possess 
 — presenting just such an outline of the science, com- 
 prising an accf>unt of its leading facts and generally 
 admitted principles, as the student requires during 
 his attendance upon a course of lectures, or for re- 
 ference whilst preparing for examination. — Am. 
 Medical Journal. 
 
 We need only say, that, without entering into dis- 
 cussions of unsettled questions, it contains all the 
 recent improvements in this department of medical 
 science. For the student beginning this study, and 
 
 the practitioner who hag but leisure to refresh his 
 memory, this book is invaluable, as it contains all 
 that it is important to know, without special details, 
 which are read with interest only by those who 
 would make a specialty, or desire to possess a criti- 
 cal knowledge of the subject. — Charleston Medical 
 Journal. 
 
 One of the best treatises that can be put into the 
 hands of the student. — London Medical Gazette. 
 
 Particularly adapted to those who desire to pos- 
 sess a concise digest of the facts of Human Physi- 
 ology. — British and Foreign Med.-Chirurg. Review. 
 
 We conscientiously recommend it as an admira- 
 ble " Handbook of Physiology." — London Journal 
 of Medicine. 
 
 KNAPP'S TECHNOLOGY; or. Chemistry applied 
 to tiie Arts and to Manufactures. Edited, with 
 numerous Notes and Additiims, by Dr. Edmund 
 RoxALDs and Dr. Thomas Richardson. First 
 American edition, w^ith Notes and Additions, by 
 Prof. Walter R. Jonxsox. In two handsome 
 octavo volumes, extra cloth, printed and illus- 
 trated in the highest style of art, with about 500 
 wood- engravings. SO 00. 
 
 LALLEMAND ON THE CAUSES, SYMPTOMS, 
 AND TREATMENT OF SPERMATORRHCEA. 
 Translated and edited by Hexry J. McDougal. 
 In one volume, octavo, extra cloth, 320 pages. 
 Second American edition. $X 75. 
 
 LUDLOW'S MANUAL OF EXAMINATIONS 
 
 upon Anatomy and Physiology, Surgery, Practice 
 of Medicine, Chemistry, Obstetrics, Materia Me- 
 dica. Pharmacy, and Therapeutics. Designed for 
 Studentsof Medicine throughout the Unittd States. 
 A new edition, revised and improved. In one la'ge 
 royal 12mo. volume, with several hundred illus- 
 trations. (Preparing.) 
 LEE'S CLINICAL MIDWIFERY. In one royal 
 l'2mo. volume, extra cloth, of 23S pages. 75 cents. 
 
 LISTONS LECTURES ON THE OPERATIONS 
 
 OF SURGERY. Edited, with numerous Addi- 
 tions and Alterations, by T. D. Mutter, M.D. 
 In one large and hnndsome octavo volume, leather, 
 of 566 pages, with '2J6 wood-cuts. $3 00. 
 
 HANDBOOKS 
 
 LARDNER (DIONYSIUS), D. C. L., &c. 
 
 OF NATURAL PHILOSOPHY AND ASTRONOMY. 
 
 Revised, with ntiinerous Additions, by the American editor. First Course, containing Mecha- 
 nics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics. In one large royal 12mo. 
 volume, of 750 pages, with 424 wood-cuts. SI 75. Second Course, containing Heat, Electricity, 
 Magnetism, and Galvanism, one volume, large royal r2mo., of 450 pages, with 2.50 illustrations. 
 
 51 25. Third Course (7iow ready), containing Meteorology and Astronomy, in one lar£re volume, 
 royal 12mo. of nearlj' eight hundred pages, with thirty-seven plates and two hundred wood-cuts. 
 
 52 00. The whole complete in three volumes, of about two thousand large pages, with over one 
 thousand figures on steel and wood. $5 00. Any volume sold separate, strongly bound in leather. 
 The various sciences treated in this work will be found brought thoroughly up to the latest period.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 19 
 
 LEHMANN (C. G.) 
 PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by 
 
 George E. Day, M. D., F. R. S., &:c., edited by R. E. Rogers, M. D., Professor of Chemistry 
 in the Medical Department of the University of Pennsylvania, with illustrations selected from 
 Funlce's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large 
 and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hmidred illus- 
 trations. (Noio Ready.) $6 00. 
 
 This great work, universallv acknowledged as the most complete and authoritative exposition of 
 the principles and details of Zoochemistry, in its passage through the press, has received from 
 Professor Rogers such care as was necessary to present it in a correct and reliable form. To such 
 a work additions were deemed superfluous, but several years having elapsed between the appear- 
 ance in Germany of the first and last volume, the latter contained a supplement, embodying nume- 
 rous corrections and additions resulting from the advance of the science. These have all been incor- 
 porated in the text in their appropriate places, while the subjects have been still furtner elucidated by 
 the insertion of illustrations from the Atlas of Dr. Otto Fun ke. With the view of supplying the student 
 with the means of convenient comparison, a large number of wood-cuts, from works on kindred 
 subjects, have also been added in the form of an Appendix of Plates. The work is, therefore, pre- 
 sented as in every way worthy the attention of all who desire to be familiar with the modern facts 
 and doctrines of Physiological Science. 
 
 Already well known and appreciated by the scien- 
 tific world, Professor Lehmanii's great work re- 
 quires no laudatory sentences, as, under a ne\vgarb, 
 it is now presented to us. The little space at ouf 
 command would ill suffice to set furlh even a small 
 portjim of its excellences. To all whose studies or 
 professional duties render tlie revelations of Physio- 
 logical Chemistry at once interesting and essential, 
 tliese volumes will be indispensable. Highly com- 
 plimented by European reviewers, sought fur with 
 avidity by sclinlars of every nation, and admirably 
 wrii ten throughout, it is sure to win a welcome and 
 to be thoroughly studied. — Boston Med. and Surg. 
 Journal, Dec. 1855. 
 
 The most important contribution as yet made to 
 Physiological Chemistry. — Am. Journal Med. Sct- 
 ences, Jan. 1S.56. 
 
 The present volumes belong to the small class of 
 medical literature which comprises elaborate works 
 of the highest orderof merit. — Montreal Med. Chron- 
 icle, Jan. 1S5G. 
 
 The ^v()rk of Lehmann stands unrivalled as the 
 most comprehensive boolc of reference and informa- 
 tion extant on every branch of the subject on which 
 it treats. — Edinburgh Monthly Journal of Medical 
 Science. 
 
 All teachers must possess it, and every intelligent 
 physici;in ouarht todo likewise. — Southern Med. and 
 Surg. Journal, Dec. 1^55. 
 
 BY THE SAME AUTHOR. {No7o Ready, 1856.) 
 
 MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, 
 
 with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital 
 Force, by Samuel Jackson, M. D., Professor of the Institutes of Medicine in the University of 
 Pennsylvania. With illustrations on wood. In one very handsome octavo volume, extra cloth, 
 of 336 pages. $2 25. 
 
 The original of this work, though but lately issued by its distinguished author, has already 
 assumed the highest position, as presenting in their latest development the modern doctrines and 
 discoveries in the chemistry of life. The numerous additions by the translator, and the Introduc- 
 tion by Professor Jacicson will render its physiological aspect more complete than designed by the 
 author, and will adapt it for use as a text-book of physiology, presenting more thorouglil)^ than has 
 yet been attempted, the modifications arising from the vast impulse which organic chemistry has 
 received within a few years past. 
 
 From Prof. Jacksoii's Introductory Essay. 
 In adopting the handbook of Dr Lehmann as a manual of Organic Chemistry for the use of the 
 students of the University, and in recommending his original work of Physiological Chemistry 
 for their more mature studies, the high value of his researches, and the great weigtit of his autho- 
 rity in that important department of medical science are fully recognized. 
 
 The present volume will be a very convenient one 
 for students, as offering a brief epitome of the more 
 elaborate work, and as containing, in a very con- 
 
 densed form, the positive facts of Physiological 
 Chemistry. — Ain. Journal Med. Sciences, April, 1856. 
 
 LAWRENCE (W.), F. R. S., &.C. 
 A TREATISE ON DISEASES OP THE EYE. A new edition, edited, 
 
 with numerous additions, and 2^3 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- 
 tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather 
 with raised bands. $5 00. 
 
 This work is so universally recognized as the standard authority on the subject, that the pub- 
 lishers in presenting this new edition have only to remark that in its preparation the editor has 
 carefully revised every portion, introducing additions and illustrations wherever the advance of 
 science has rendered them necessary or desirable, constituting it a complete and thorough 
 exponent of the most advanced state of the subject. 
 
 This admirable treatise— the safest guide and most \ octavo pages— has enabled both author and editor to 
 comprehensive work of reference, wliich is within do justice to all the details of this subject, and eon- 
 the reach of the profession. — Stethoscope. j dense iathis single volume the present state of our 
 
 ! knowledge of the whole science in this department, 
 
 This standard text-book on the department of whereby its practical value cannot be excelled. We 
 which it treats, has not been superseded, by any or ■ heartily commend it, especially as a book of refer- 
 all of the numerous publications on the subject i ence, indispensable in every medical library. The 
 heretofore issued. Nor with the multiplied improve- ; additions of the American editor very greatly en- 
 ments of Dr. Hays, the American editor, is it at all j hance the value of the work, exhibiting the learning 
 likely that this great work will cease to merit the and experience of Dr. Hays, in the light in which he 
 confidence and preference of students or practition- j ought to be held, as a standard authority on all sub- 
 erg. Its ample extent — nearly one thousand large | jects appertaining to this specialty .— iV. y'. illerf. Gaz.
 
 20 
 
 BLANCHARD & LEA'S MEDICAL 
 
 LA ROCHE (R.), M. D., &.c. 
 YELLOW FP^VER, considered in its Historical, Pathological, Etiological, and 
 
 Therapeutical Relations. Including a Sketch of the Disease as it has'occurred in Philadelphia 
 from Itiyyto 1854, with an examination of the connecIic)ri> between it and the fevers known undtr 
 tlie same name in other parts of temperate as well as in tropical regions In two large and 
 handsome octavo volumes of nearly 1500 pages, extra (;loth. (IVoiv Ready.) $7 00. 
 The publishers are happy in being able at length to present to the prolession this great work, 
 which they are assured will be regarded as an honor to the medical literature of the coiuitry. As 
 tlie result of many years of personal observation and study, as embodying an iniellisent rcs'/ime of 
 all that has been written regarding the disease, and as exhausting tlie subject in all its various 
 aspects, these volumes must at once take the position of the standard authority and work of refer- 
 ence on the many important questions brought into consideration. 
 
 From Profesfor S. H. Dickson, Charlestcn, S. C, 
 September 18, 1855. 
 
 A monument of intellisrent and well applied re- 
 search, iiUnost without example. It is, indeed, in 
 itself, a large iilirary, and is de.stined to constitute 
 tjie special resm-t as a book of reference, in the 
 subject of which it treats, to all future time. 
 
 We have not time at present, en<:aged as we are, 
 by day and by nisht, in the work of coml)ating this 
 very disease, now prevailm? in oui citv, to do more 
 than give this cursory notice of what'we consider 
 as undoubtedly the most able and erudite medical 
 publicali(m our country has yet produced But in 
 view of the startlin.- fact, that this, the most malig- 
 nant and unmanageable disease of modern times, 
 has for several years been prevailing in our country 
 to a greater extent than ever before; tliat it is no 
 longer confined to either large or small cities, but 
 penetrates country villages, plantations, and farm- 
 houses; that it is treated with scarcely better suc- 
 cess now than thirty or forty years ago; that there 
 is vast mischief done by ignorant pretenders to know- 
 ledge in regard to the disease, and in view of the pro- 
 bability that a majority of southern physicians will 
 be called upon to treat the disease, we trust that this 
 able and comprehensive treafise will We very gene- 
 rally read in the south.— Memphis Med, Recorder. 
 
 This is decidedly the great Americ.in medical work 
 of theday — a full, complete, and systematic treatise, 
 unequalled by any other upon the all-important sub- 
 
 erection of this towering monument to liis own fame, 
 and to the glory of the medical literature of liis own 
 country. It is destined to remain the great autho- 
 rity upon the subject of Yellow Fever The student 
 and physician will find in these volumes a r^sumi 
 ,of the sum total of the knowledge of the world upon 
 'the awful scourge which tliey so elaborately discuss. 
 The style is so soft and so pure as to refresh and in- 
 vigorate the mind while absorbing the Miouglits of 
 the gil"ted author, while the publishers have suc- 
 ceeded in bringing theextern.-ils into a most felicitous 
 harmony with the inspiration that dwells within. 
 Take it all in all, it is a bonk we nave often dreamed 
 of, but dreamed not that it would ever meet our 
 waking eye as a tangible reality. — Aashville Journal 
 of Medicine. 
 
 We deem it fortunate that the splendid work of 
 Dr. La Roche should have been issued from the press 
 at this particular time. The ^vant of a reliable di- 
 gest of all that is known in relation t . this frightful 
 malady has long been felt — a want very satisfactorily 
 met in the work before us. We def-m it but faint 
 praise to say that Dr. La Rtche has succeeded in 
 presenting the profession with an able and complete 
 monograph, one which will find its way into every 
 well ordered library. — Va. Stethoscope. 
 
 Although we have no doubt that controversial 
 treatises on the mode of origin and propagation of the 
 fever in question ■will, as heretofore, occasionally 
 appear, yet it must be some time befr>re another sys- 
 
 jeetof \ ellow Fever. The laborious, indefatigable, i tematic work can arise in the face of so admirable 
 and learned author has devoted to it many years of and carefully executed a one as the present. It is a 
 arduous research and careful study, and the result] mine of information, quite an encyclopa?dia of refer 
 
 is such as will reflect the highest' honor upon the 
 author and our country.— Sou/Aern Med. and Surg. 
 Journal. 
 
 The genius and scholarship of thisgreat physician 
 could not have been belter employed than in the 
 
 ences, and r£'.<w??jt' of knowledge relative to what has 
 been recorded upon the subject.— Lo)u/o» Lancet. 
 
 A miracle of industry and research, constituting 
 a complete library of reference on the disease of 
 which it treats. — Dublin Quarterly Journal. 
 
 BY THE SAME AUTHOR. 
 
 PNEU3I0XIA ; its Supposed Connection, Pathological and Etiological, with Au- 
 tumnal Fever>, including an Inquiry into the Existence an(rMorbid Agency of Malaria. la one 
 handsome octavo volume, extra cloth, of 500 pages. $.3 00. 
 
 A more simple, clear, and forcible exposition of I This work should be carefully studied by Southern 
 the groundless nature and dangerous tendency of | physicians, embodying as it does the reflections of 
 certain patliological and etiological heresies, has | an original thinker and close observer on a subject 
 seldom been presented to our notice.— A'. Y. Journal peculiarly their uwn.— Virginia Med. and Surgical 
 of Medicine and Collateral Science. I Journal. 
 
 MULLER (PROFESSOR J.), M. D. 
 PRINCIPLES OF PHYSICS AND METEOROLOGY. Edited, with Addi- 
 
 lions, by R. Eklesfeld Griffith, M. D. In one large and handsome octavo volume, extra 
 cloth, with 550 wood-cuts, and two colored plates, pp. 636. $3 50. 
 
 The Physics of MQUer is a work superb, complete, I tion to the scientific records of this country may be 
 unique : thegreatest want known to English Science | duly estimated by the fact that the cost of I'lie ori^i- 
 eould not have been better supplied. The work is I nal drawings and engravings alone has exceeded the 
 ol surpassing interest. The value of this contribu- | sum of £'2,000.— Lancet. 
 
 MAYNE'S DISPEXSATORY AND THERA- ! 
 PEUTICAL RE.ME.MHRaNCKR. Comprising ' 
 the entire lists of .Materia Medica. with every I 
 Practical Formula contained in the three "feritish 
 Pharmacopoeias. With relative Tables subjoined, ! 
 illustrating, by upwards of six hundred and sixty 
 examples, the Extemporaneous Forms and Com- 
 binations suitable for the diiTerent Medicines. 
 Edited, with the addition of the Formula of the 
 United States Pharmacopoeia, by R. Eglesfeld ' 
 Griffith, AI. D. In one 12mo volume, extra cloth, 
 of 300 large pages. 75 cents. 
 
 MATTEUCCrS LECTURES ON THE PHYSI- 
 CAL PHEXOVIENA OF LIVING BEINGS. 
 Edited by J. Pereira, M. D. In one neat royal 
 I'imo. volume, extra cloth, with cuts, .3dS pages. 
 $1 00. 
 
 MALGAIGNE'S OPERATIVE SURGERY, based 
 on Normal and Pathological Anatomy. Trans- 
 lated from the French by Frederick Brittan, 
 A. B., M. D. Withnumerousillustrationstmwood. 
 In one handsome octavo Volume, extra cloth, of 
 nearly six hundred pages. $2 25. 
 
 4
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 21 
 
 MEIGS (CHARLES D.), M. D., 
 
 Professor of Obstetrics, &c. in tlie Jefferson Medical College, Philadelphia. 
 
 OBSTETRICS: THE SCIENCE AND THE ART. Second edition, revised 
 
 and improved. With one hundred and thirty-one illustrations. In one beautifully printed octavo 
 volume, leather, of seven hundred and liity-two large pages. $3 75. 
 
 The rapid demand for a second etiition of thi.s work is a sufficient evidence that it has supplied 
 a desideratum of the profession, notwithstanding the numerous treatises on the same subject which 
 have appeared within the last few years. Adopting a system of his own, the author has combined 
 the leading principles of his interesting and dilficult subject, with a thorough exposition of its rules 
 o/' practice, presenting the results of long and extensive experience and of familiar acquaintance 
 with all the modern writers on this department of medicine. As an American Treatise on Mid- 
 wifery, which has at once assumed the position of a classic, it possesses peculiar claims to the at- 
 tention and study of the practitioner and student, while the numerous alterations and revisions 
 which it has undergone in the present edition are shown by the great enlargement ol the work, 
 which is not only increased as to the size of the page, but also in the number. 
 
 BY THE SAME AUTHOR. (^Lately Issued.) 
 
 WOMAN : HER DISEASES AND THEIR REMEDIES. A Series of Lee- 
 
 tures to his Class. Third and Improved edition. In oue large and beautifully printed octavo 
 volume, leather. pp. 672. $3 GO. 
 
 The gratifying appreciation of liis labors, as evinced by the exhaustion of two large impressions 
 of this work within a few years, has not been lost upon the author, who has endeavored in every 
 way to render it worthy of the favor with which it has been received. The opportunity thus 
 aflbrded for a second revision has been improved, and the work is now presented as in every way 
 superior to its predecessors, additions and alterations having been made whenever the advance of 
 science has rendered them desirable. The typographical execution of the work will also be found 
 to have undergone a similar improvement, and the work is now confidently presented as in every 
 way worthy the position it has acquired as the standard American text-book on the Diseases of 
 Females. 
 
 It contains a vast amount of practical knowledge, 
 by one who has accurately ol)served and retained 
 the experience of many years, and who tells tiie re- 
 sult in a free, familiar, and pleasant manner. — Dub- 
 lin Quarterly Journal. 
 
 There is an off-liand fervor, aglow, and a warm- 
 heartedness infecting the effort of Dr. Meigs, which 
 is entirely captivating, and which absolutely hur- 
 ries the re.iuler through from beginning to end. Be- 
 sides, the book teems with solid instruction, and 
 it shows the very highest evidence of ability, viz., 
 the clearness with which the information is pre- 
 sented. VVe know of no lietter test of one's under- 
 standing a sulijcct than the evidence of the power 
 of lucidly explaining it. The most elementary, as 
 well as tlie obscurcKt subjects, under the jiencil of 
 Prof. Meigs, are isolated and made to stand out in 
 
 BY THE SAME AUTHOR. (Lately Puhlished.) 
 
 ON THE NATURE, SIGNS, AND TREATxMENT OF CHILDBED 
 
 FEVER. In a Series of Letr?rs addressed to the Students of his Cliis. In one handsome 
 octavo volume, extra cloth, ol 365 pages. $2 50. 
 
 such bold relief, as to produce distinct impressions 
 upim the mind and memory of the reader. — Th« 
 Charleston Med. Journal. 
 
 Professor Meigs has enlarged and amended this 
 great work, for such it unquesti(mably is, having 
 passed the ordeal of criticism at home and abroad, 
 but been improved thereby ; for in tliis new edition 
 tlie author has introduced real improvements, and 
 increased the value and utility of the book im- 
 measuralily. It presents so many novel, bright, 
 and sparkling thoughts; such an exuberance of new 
 ideas on almost every page, that we confess our- 
 selves to have become enamored witli tlie book 
 and its author ; and cannot withhold our congratu- 
 lations from our Philadelphia confreres, that such a 
 teacher is in their service. — N. Y. Med. Gazette. 
 
 The instruct ive and interestin"; author of this 
 work, whose previous labors in the department of 
 medicine which he so sedulously cultivates, have 
 placed his countrymen under deep and aliiding obli- 
 gations, ;ig:iin challenges their admiration in the 
 fresh and vigorous, attractive and racy pages before 
 us. It is a delectable book. * * * Tliis treatise 
 upon child-lied fevers will have an extensive sale, 
 being destined, as it deserves, to find a place in the 
 library of every practitioner who scorns to lag in the 
 rear of his hret^iren. — Nashville Journal of Medi- 
 cine and Surgery. 
 
 This book will add more to his fame than either 
 of those which bear his name. Indeed we doubt 
 whether any material improvement will be made on 
 the teachings of this volume for a century to come, 
 since it is so eminently practical, and based on pro- 
 found knowledge of the science and consummate 
 skill in the ar« of healing, and ratified by an ample 
 and extensive experience, such as few men have the 
 industry or good fortune to acquire. — N. Y. Med. 
 Gazette. 
 
 BY THE SAME AUTHOR ; WITH" COLORED PLATES. (Lately Puhlished.) 
 
 A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK 
 
 OF THE UTEllUS. With numerous plates, drawn and colored from nature in the highest 
 style of art. In one handsome octavo volume, extra cloth. f4 50. 
 
 The object of the author in this work has been to present in a small compass the practical results 
 of his long experience in this important and distressing class of diseases. The great changes intro- 
 duced iiiio practice, and the accessions to our knowledge on the subject, within the last few years, 
 resulting from the use of the metroscope, brings within the ordinary practice of every physician 
 numerous cases which were formerly regarded as incurable, and renders of great value a work like 
 the pre.*ent combining practical directions for diagnosis and treatment with an ample series of illus- 
 trations, copied accurately from colored drawings made by the author, after nature. 
 
 BY THE SAME AUTHOR. 
 
 OBSERVATIONS ON CERTAIN OF THE DISEASES OF YOUNG 
 
 CHILDREN. In one handsome octavo volume, extra cloth, of 214 pages. $175
 
 22 
 
 BLANCHARD & LEA'S MEDICAL 
 
 MACLISE (JOSEPH), SURGEON, 
 SURGICAL ANx\TOMY. Forming one volume, very large imperial quarto. 
 
 With s^ixty-eig-ht large and splendid Plates, drawn in the hest style and beamifully colored. Con- 
 taining one hundred and ninety Figures, many of them the size of life. Together with copious 
 and explanatory letter-press. Strongly and handsomely bound in extra cloth, being one of the 
 cheapest and best executed Surgical works as yet issued in this country. $11 00. 
 *^* The size of this work prevents its transmission through the post-otlice as a whole, but those 
 
 who desire to have copies forwarded by mail, can receive them in five parts, done up m stout 
 
 wrappers. Price $9 00. 
 
 One of the greatest artistic triumplis of the age 
 in Surgical Anatomy. — British American Medical 
 Journal. 
 
 Too much cannot be said in its praise; indeed, 
 we have not language to do it justice. — Ohio Medi- 
 cal and Surgical Journal. 
 
 The most admirable surgical atlas we have seen. 
 To the practitioner deprived of demonstrative dis- 
 sections upon the human subject, it is an invaluable 
 companion. — N. J. Medical Reporter. 
 
 The most accurately engraved and beautifully 
 colored plates we have ever seen in an American 
 book — one of the best and cheapest surgical works 
 ever published. — Buffalo Medical Journal. 
 
 It is very rare that so elegantly printed, so well 
 illustrated, and so useful a work, is offered at so 
 moderate a price. — Charleston Medical Journal. 
 
 Its plates can boast a superiority which places 
 them almost beyond the reach of competition. — Medi- 
 cal Examiner. 
 
 Every practitioner, we think, should have a -work 
 of this kind within reach. — Southern Medical and 
 Surgical Journal. 
 
 No such lithographic illustrations of surgical re- 
 gions have hitherto, we think, been given. — Boston 
 Medical and Surgical Journal. 
 
 As a surgical anatomist, Mr. Maclise has proba- 
 bly no superior. — British and Foreign Medico-Chi- 
 rurgical Review. 
 
 Of great value to the student engaged in dissect- 
 ing, and to the surgeon at a distance from the means 
 
 of keeping up his anatomical knowledge. — Medical 
 Times. 
 
 The mechanical execution cannot be excelled. — 
 Transylvania Medical Journal. 
 
 A work which has no parallel in point of accu- 
 racy and cheapness in the English language. — N. Y. 
 Journal of Medicine. 
 
 To all engaged in the study or practice of their 
 profession, such a work is almost indispensable. — 
 Dublin Quarterly Medical Journal. 
 
 No practitioner whose means will admit should 
 fail to possess it. — Banking's Abstract. 
 
 Country practitioners will find these plates of im- 
 mense value. — N. Y. Medical Gazette. 
 
 We are extremely gratified to announce to the 
 profession the completion of this truly magnificent 
 work, which, as a whole, certainly stands unri- 
 valled, both for accuracy of drawinaf, heauty of 
 coloring, and all the requisite explanations of the 
 subject in hand. — The New Orleans Medical and 
 Surgical Journal. 
 
 This is by far the ablest work on Surgical Ana- 
 tomy that has come under our observation. We 
 know of no other work that would justify a stu- 
 dent, in any degree, for neglect of actual dissec- 
 tion. Ju those sudden emergencies that so often 
 arise, and which require the instantaneous command 
 of minute anatomical knowledge, a work of this kind 
 keeps the dettiils of the dissecting-room perpetually 
 fresh in the memory. — The Western Journal of Medi- 
 cine and Surgery. 
 
 The very low price at which this work is furnished, and the beauty of its execution, 
 requii-e an extended sale to compensate the publishers for the heavy expenses incurred. 
 
 MOHR (FRANCIS) PH. D., AND REDWOOD (TH EOPH I LUS). 
 PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and 
 
 Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, 
 by Prof. William Procter, ot the Philadelphia College of Pharmacy. In one handsomely 
 printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. $2 75. 
 
 MACKENZIE (W.), M.D., 
 
 Surgeon Oculist in Scotland in ordinary to Her Majesty, &c. &c. 
 
 A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE 
 
 EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section ol 
 the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- 
 larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to 
 Wills Hospital, &:c. ice. Inone very large and handsome octavo volume, leather, raised bands, with 
 plates and numerous wood-cuts. (_I\'ow Ready.) $5 25. 
 
 The treatise of Dr. Mackenzie indisputably holds i accordance with the advances in the science which 
 the first place, and forms, in respect of learning and have been made of late years. Nothing worthy of 
 
 repetition upon any branch of the subject appears to 
 have escaped the author's notice. We consider it 
 the duty of every one who has the love of his profes- 
 sion and the welfare of his patient at heart, to make 
 himself familiar with this the most complete work 
 in the En2;lish language upon the diseases of the eye. 
 — Med. Times and Gazette. 
 
 The fourth edition of this standard work will no 
 doubt be as fully appreciated as the three former edi- 
 
 researcli, an FIncyclopoEdia unequalled in extent by 
 any other work of the kind, either English or foreign. 
 — Dixon on Diseases of the Eye. 
 
 Few modern books on any department of medicine 
 or surgery have met with such extended circulation, 
 or have procured for their authors a like amount of 
 European celebrity. The immense research which 
 it displayed, the thorough acquaintance with the 
 subject, practically as well as theoretically, and the 
 
 able manner in which the author's stores of learning '>""s. It is unnecessary to say aword in its praise, 
 and experience were rendered available for general; f'"" tlie verdict has already been passed upon it by 
 use, at once procured for the first edition, as well on ' "'^ most competent judges, and " Mackenzie on the 
 
 the continent as in this country, that high positicm 
 as a standard work which each successive edition 
 has more firmly established, in spite of the attrac- 
 tions of several rivals of no mean ability. This, the 
 fourth edition, has been in a great measure re-writ- 
 ten ; new matter, to tlie extent of one hundred and 
 fifty pages, has been added, and in several instances 
 formerly expressed opinions have been modified in 
 
 the most competent judges, and ' 
 Eye" has justly obtained a reputation which it is 
 no figure of speech to call world-wide. — British and 
 Foreign Medico-Chirurgical Review. 
 
 This new edition of Dr. Mackenzie's celebrated 
 treatise on diseases of the eye, is truly a miracle of 
 industry and learning. We need scarcely say that 
 he has entirely exhausted the subject of his specialty. 
 — Dublin Quarterly Journal.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 23 
 
 MILLER (JAMES), F. R. S. E., 
 
 Professor of Surgery in the University of Edinburgh, &c. 
 
 PRINCIPLES OF SURGERY. Fourth American, from the third and revised 
 
 Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two 
 
 hundred and forty exquisite illustrations on wood. (Noiv Ready, 1856.) $3 75. 
 
 The extended reputation enjoyed by this work will be fully maintained by the present edition. 
 Thoroughljf revised by the author, it will be found a clear aiad compendious exposition of surgical 
 science in its most advanced condition. 
 
 In connection with the recently issued third edition of the author's " Practice of Surgery," it 
 forms a very complete system of Surgery in all its branches. 
 
 The work of Mr. Miller is ton well and too favor- 
 ably known anions: us, as one of our best text-books, 
 to render any further notice of it necessary than the 
 announcement of a new edition, the fovrth in our 
 
 country, a proof of its extensive circulation amon: 
 us. As a concise and reliable exposition of the sci- 
 ence of modern surgery, it stands deservedly high — 
 we know not its superior. — Boston Med. and Surg. 
 Journal, May, 1856. 
 
 The works of Professor Miller are so well known 
 to the profession, that it is unnecessary for us say 
 anything in relation to their general merits. The 
 present edition of his "Principles," however, de- 
 serves a s)iecial notice, from the number, variety, 
 and faithfulness of its illustrations. The \vood-cuts 
 are beautifully executed, and many of them are new 
 and exceedingly iristructive, particularly those illus- 
 trating mortifieation, <liseased and fractured bones, 
 and the varieties of aneurism. — WesternLancet, May, 
 1856. 
 
 This edition is far superior, both in the abundance 
 and quality of its material, to any of the preceding. 
 We hope it will be extensively read, and the sound 
 principles which are herein taught treasured up for 
 future application. The work takes rank with 
 
 BY THE SAME AUTHOR. (Lately Published.) 
 
 THE PRACTICE OF SURGERY. Third American from the second Edin- 
 burgh edition. Edited, with Additions, by F. W. Sargent, M. D , one of the Surgeons to Will's 
 Hospital, &c. Illustrated by three hundred and nineteen engravings on wood. In one large 
 octavo volume, leather, of over 700 pages. $3 75. 
 
 No encomium of ours could add to the popularity I his works, both on the principles and practice of 
 of Miller's Surgery. Its reputation in this country I surgery have been assigned the highest rank. If we 
 is unsurpassed by that of any other work, and, when were limited to but one work on sursery. that one 
 
 Watson's Practice of Physic; it certainly does not 
 fall behind that great work in soundness of princi- 
 ple or depth of reas<ining and research. No physi- 
 cian who values his reputation, or seeks the interests 
 of his clients, can acquit himself before his God and 
 the world without making himself familiar with the 
 sound and philos<iphical views developed in the fore- 
 going book. — New Orleans Med. and Surg. Journal. 
 
 Without doubt the ablest exposition of the prin- 
 ciples of that branch of the he;iling art in any lan- 
 guage. This opinion, deliberately formed after a 
 careful study of the first edition, we have had no 
 cause to change on examining the second. This 
 edition has undergone thorough revision by the au- 
 thor; many expressions have been modified, and a 
 mass of new matter introduced. The hook is got up 
 in the finest style, and is an evidence of the progress 
 of typography in our country. — Charleston Medical 
 Journal and Revieio. 
 
 We recommend it to both student and practitioner, 
 feeling assured that as it now comes to us, it pre- 
 sents the most satisfactory exposition of the modern 
 doctrines of the principles of surgery to be found in 
 any volume in any language. — N. Y. Journal of 
 Medicine. 
 
 taken in connection with the author's Princijiles of 
 Surgery, constitutes a whole, without reference to 
 which no conscientious surgeon would be willing 
 to practice his art. The additions, by Dr. Sargent, 
 have materially enhanced the value of the work. — 
 Southern Medical and Surgical Journal. 
 
 It is seldom that two volumes have ever made so 
 profound an impression in so short a time as the 
 " Principles" and the " Practice" of Surgery by 
 Mr. Miller — or so richly merited the reputation they 
 have acquired. The author is an eminently sensi- 
 ble, practical, and well-informed man, who knows 
 exactly what he is talking about and exactly how to 
 talk it. — Kentucky Medical Recorder. 
 
 By the almost unanimous voice of the profession, 
 
 should be Aliller's, as we regard it as superior to all 
 others. — St. Louis Med. and Surg. Journal. 
 
 The author, distinguished alike as a practitioner 
 and writer, has in tliisand his " Principles," pre- 
 sented to the profession <ine of the most complete and 
 reliable systems of Surgery extant. His style of 
 writing is original, impressive, and engaging, ener- 
 getic, concise, and lucid. Few have the faculty of 
 condensing so much in small space, and at the same 
 time so persistently holding the attention; indeed, 
 he appears to make the very process of condensation 
 a means of eliminating attractions. Whether as a 
 text-book for students or a book of reference for 
 practitioners, it cannot be too strongly recommend- 
 ed. — Southern Journal of Med. and Phys. Sciences. 
 
 NEILL (JOHN), M. D., 
 
 Professor of Surgery in the Pennsylvania Medical College, &c. 
 
 OUTLINES OF THE ARTERIES. With short Descriptions. Designed for 
 
 the Use of Medical Students. With handsome colored plates. Second and improved edition. 
 In one octavo volume, extra cloth. $1 25. 
 
 OUTLINES OF THE NERVES. With short Descriptions. Designed for the 
 
 Use of Medical StuderUs. With handsome plates. Second and improved edition. In one octavo 
 volume, extra cloth, f 1 25. 
 
 OUTLINES OF THE VEINS AND LYMPHATICS. With short Descrip- 
 
 tions. Designed for the Use of Medical Students. With handsome colored plates. In one octavo 
 volume, extra cloth. $1 25. 
 ALSO — The three works done up in one handsome volume, half bound, with numerous plates, pre- 
 senting a complete view of the Circulatory, Nervous, and Lymphatic Systems. $3 25. 
 
 and the reading of larger works. — N. Y. Journal of 
 Medicine. 
 
 This book should be in the hand of every medical 
 student. It is cheap, portable, and precisely the 
 thing needed in studying an important, though diffi- 
 cult part of Anatomy. — Boston Med. and Surg. 
 Journal. 
 
 We recommend every student of medicine to pur- 
 chase a copy of this work, as a labor-saving ma- 
 chine, admirably adapted to refresh the memory, 
 with knowledge gained by lectures, dissections, 
 
 This work is from the pen of a Philadelphia ana- 
 tomist, whose familiar knowledge of the subject has 
 been aided by the press, the result of which is a vo- 
 lume of great beauty and excellence. Its fine exe- 
 cution commends it to the student of Anatcuny. It 
 requires no other recommendations. — Western Joum. 
 of Medicine and Surgery.
 
 S4 
 
 BLANCHARD & LEA'S MEDICAL 
 
 NEILL (JOHN), M. D., 
 
 Surgeon to the Pennsylvania Hospital, &c.; and 
 
 FRANCIS GURNEY SMITH, M.D., 
 
 Professor of Institutes of Medicine in the Pennsylvania INIedical College. 
 
 AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES 
 
 OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised 
 
 and improved. In one very large and handsomely printed roj-al l"2mo. volume, of about one 
 
 thousand pages, with three hundred and seventy-four illustrations on wood. Strongly bound in 
 
 leather, with raised bands. {Now Ready, 1856.) $3 00. 
 
 The very flattering reception which has been accorded to this work, and the high estimate placed 
 upon it by the profession, as evinced by the constant and increasing demand which has rapidly ex- 
 hausted two large editions, have stimulated the authors to render the volume in its present revision 
 more worthy of the success which has attended it. It has accordingly been thoroughly examined, 
 and such errors as had on former occasions escaped observation have been corrected, and whatever 
 additions were necessary to maintain it on a level with the advance of science have been introduced. 
 The extended series of illustrations has been still further increased and much improved, while, by 
 a slight enlargement of the page, these various additions have been incorporated without increasing 
 the buUc of the volume. 
 
 The work is, therefore, again presentedaseminently worthy of the favor with which it has hitherto 
 been received. As a book for daily reference by the student requiring a guide to his more elaborate 
 text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate 
 examination, or as a soiu'ce from which the practitioners of older date may easily and cheaply acquire 
 a knowledge of the changes and improvement in professional science, its reputation is permanently 
 established. 
 
 In the rapid course of lectures, where work for ; what it \vas when they left it olT. — The. Stethoscope 
 the students is heavy, and review necessary for an | ^ve recommend it to our readers as the best work 
 
 f^^^™"?.!!!'": ^.•.''r"!'.l!".U^ "'ri,i'"iL\"i"".I !;„ "' ' "^ t'>e l^-inJ with which we are acquainted.— Med. 
 ,^„„t „ ,.«,., „..„ ««„ ,= «„<. ,„ ,„..> >,„ .,, J^xatniner, April, 1850. 
 
 it is almost a sine qua non. The one before us 
 in most of the divisions, tlie most unexceptionable 
 of all books of the kind that we know of. The 
 newest and soundest doctrines and the latest im- 
 provements and discoveries are explicitly, tbouo^h 
 concisely, laid before the student. Of course it is 
 useless for us to recommend it to all last course 
 students, but there is a class to whom we very 
 sincerely commend this cheap book as worth its 
 weight in silver — that class is the graduates in 
 medicine of more than ten years' standing, who 
 have not studied medicine since. They will perhaps 
 find out from it that the science is not exactly now 
 
 j Having made free use of this volume in our ex- 
 aminatidns of pupils, we can speak from experi- 
 ence in recommending it as an admirable compend 
 i for students, and as especially useful to preceptors 
 ' who examine their pupils. It will save the teacher 
 j much labor by enabling him readily to recall all of 
 the points upon which his pupils should be ex- 
 amined. A work of tills sort should be in the hands 
 of every one who takes pupils into his office witli a 
 view of examining them; and this is unquestionably 
 the best of its class. — Transylvania Med. Journal. 
 
 NELIGAN (J. MOpRE), M. D., M. R. I. A., &.c. 
 
 (A sjjiendid icork. Notv Ready.) 
 
 ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra 
 
 cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of 
 
 disease. $4 50. 
 
 This beautiful volume is intended as a complete and accurate representation of all the varieties 
 of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has 
 especial reference to the author's " Treatise on Diseases of the Skin," so favorably received by the 
 profession some years since. The publishers feel justified in saying that no more beautifully exe- 
 cuted plates have ever been presented to the profession of this country. 
 
 The diagnosis of eruptive disease, however, under ; placed within its reach and at a moderate cost a most 
 all circumstances, is very difficult. Nevertheless I accurate and well delineated series of plates illus- 
 Dr. Neligan has certainly, "as far as possible," j trating tlie eruptive disorders. These plates are all 
 given a faithful and accurate representation of this drawn from the life, and in many of them the daguer- 
 class of diseases, and there can be no doubt that reotype has been employed ^vith great success. Such 
 
 these plates will be of great use to the student and 
 practitiimer in drawing a diagnosis as to the class, 
 order, and species to which the particular case may 
 belong. While looking over the " Atlas" we have 
 been induced to examine also the " Practical Trea- 
 tise." This was published in 1852, and we are in- 
 clined to consider it a very superior work, combin- 
 ing accurate verbal description, with sound views 
 of the pathcdogy and treatment of eruptive diseases. 
 — Glasgow Medical Journal. 
 
 The profession owes its thanks to the publishers of 
 Neligan's Atlas of Cutaneous Diseases, for they have 
 
 BY THE SAME AUTHOR. 
 
 A PRACTICAL TREATISE ON DISEASES OP THE SKIN. 
 
 neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. 
 
 works as these are especially useful to country prac- 
 titioners, who have not an opportunity of seeing the 
 rarer forms of cutaneous disease, and hence need the 
 aid of illustrations to give them the requisite infor- 
 mation on the subject. With tliese plates at hand, 
 the inexperienced practitioner is enabled to discri- 
 minate with much accuracy, and he is thus, com- 
 paratively speaking, put on an equal footing with 
 those who have had the opportunity of visiting the 
 large hospitals of Europe and America. — Va. Med. 
 Journal, June, 1856. 
 
 In one 
 
 We must say he bears off the palm for clearness, 
 conciseness, and rigid plainness of expression. This 
 style enables him to compress much in a single sen- 
 tence, without in any degree injuring the sense, but, 
 on the contrary, making it more comprehensive and 
 impressive. By far the largest proportion of the 
 volume is devoted to therapeutic considerations. 
 Not merely are I'ull details of treatment and formulae 
 given at the close of each section, but an entire 
 
 chapter is devoted to " those general points in thera- 
 peutics which are specially applicable to this class 
 of affections." The present work forms a favorable 
 contrast to the voluminous and disputed details of 
 many of its predecessors, and will, ^ve feel assured, 
 be admirably conducive to facilitating the study of 
 the student, and improving the practice of the prac- 
 titioner. — Dublin Quarterly Journ. of Med. Science. 
 
 S!^ The two volumes will be sent by mail on receipt of Five Dollars. 
 
 OWEN ON THE DIFFERENT FORMS OF 
 THE SKELETON, AND OF THE TEETH. 
 
 One vol. royal 12mo., extra cloth, with numerous 
 illustrations. (Just Issued.) $1 25.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 25 
 
 {Now Comjdete.) 
 
 PEREIRA (JONATHAN), M . D., F. R. S., AND L. S. 
 
 THE ELEMENTS OF MxVTERIA MEDIGA AND THEllAPEUTICS. 
 
 Third American edition, enlarged and improved by the author; including Notices of most of the 
 Medicinal Substanceis in use in the civilized world, and forming an Encyclopaedia of Materia 
 Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and 
 Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, 
 on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with 
 raised bands. $9 00. 
 
 Gentltjmen who have the first volume are recommended to complete their copies without delay. 
 The first volume will no longer be sold separate. Price of Vol. 11. $5 00. 
 
 Wlien we rememlier that Philology, Natural His- 
 tory, Botany, Chemistry, Physics, and the Micro- 
 scope, are all brought forward to elucidate the sub- 
 ject, one cannot fail to see that the reader has here 
 a work wortliy of the name of an eneyclopsedia of 
 Materia JFcdica. Our ow^n opinion of its merits is 
 that of its editors, and also that of the whole profes- 
 sion, both of this and foreign countries— namely, 
 " tliat in copiousness of details, in extent, variety, 
 and accuracy of information, and in lucid explana- 
 tion of difficult and recondite subjects, it surpasses 
 all other works on Materia Medica hitherto pub- 
 lished." VVe cannot close this notice without allud- 
 ing to the special additions of tlie American editor, 
 which pertain to the prominent vegetable produc- 
 tions of this country, and to the directions of the 
 United States Pliarmacopoeia, in connection with all 
 the articles contained in the volume which are re- 
 ferred toby it. The illustrations have been increased, 
 and this edition by Dr. Carson cannot well be re- 
 garded in any other light than that of a treasure 
 which should be found in the library of every physi- 
 cian. — Neiv York Journal of Medical and Collateral 
 Science. 
 
 The third edition of his "Elements of Materia 
 Medica, although completed under the supervision of 
 others, is by far the most elaborate treatise in the 
 English language, and will, while medical literature 
 is cherished, continue a monument alike honorable 
 to his genius, as to his learning and industry. — 
 American Journal of Phartnucy. 
 
 The work, in its present shape, forms the most 
 comprehensive and C(nnplete treatise on materia 
 medica extant in the English language. — Dr. 
 Pereira has been at great pains to introduce into 
 his work, not only all the information on the 
 natural, chemical, and commercial history of njedi- 
 cines, 'vvhich might be serviceable to the physician 
 and surgeon, but whatever might enable his read- 
 ers to understand thoroughly the mode of prepar- 
 ing and manufacturing various articles employed 
 either for preparing medicines, or for certain pur- 
 poses in the arts connected with materia medica 
 and the practice of medicine. The accounts of the 
 physiological and therapeutic effects of remedies are 
 given with great clearness and accuracy, and in a 
 manner calculated to interest as well as instruct the 
 reader. — Edinburgh Medical and Surgical Journal. 
 
 PEASELEE (E. R.), M . D., 
 Professor of Anatomy and Physiology in Dartmouth College, &c. 
 
 HUMAN HISTOLOGY, in its application,g to Physiology and G-eneral Pathology; 
 
 designed as a Text-Book for Medical Students. With numerous illustrations. In one handsome 
 
 royal r2nio. volume. (Prepariiig.) 
 
 The sul>jeet of this work is one, the growing importance of which, as the basis of Anatomy and 
 Physiology, demands for it a separate volume. The book will thereibre supply an acknowledged 
 deficiency in medical text-books, while the naine of the author, and his experience as a teacher lor 
 the last thirteen years, is a guarantee that it will be thoroughly adapted to the use of the student. 
 
 PIRRIE (WILLIAM), F. R. S. E., 
 
 Professor of Surgery in the University of Aberdeen. 
 
 THE PPJNCIPLES AND PRACTICE OP SURGERY. Edited by John 
 
 Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania 
 Hospital, ifcc. In one very handsome octavo volume, leather, oi'7S0 pages, with 316 illustrations. 
 $3 75. 
 
 We know of no other surgical work of a reason- 
 able size, wherein there is so much theory and prac- 
 tice, or where subjects are more soundly or clearly 
 taught. — The Stethoscope. 
 
 There is scarcely a disease of the bones or soft 
 parts, fracture, or dislocation, that is not illustrated 
 by accurate wood-engravings. Then, again, every 
 instrument employed by the surgeon is thus repre- 
 sented. These engravings are not only correct, but 
 really beautiful, showing the ast<inishing degree of 
 perfection to which the art of wood-engraving has 
 
 arrived. Prof. Pirrie, in the work before us, has 
 elaborately discussed the principles of surgery, and 
 a safe and effectual practice predicated upon them. 
 Perhaps no work upon this subject heretofore issued 
 is so full upon the science of the art of surgery. — 
 Nashville Journal of Medicine and Surgery. 
 
 One of the best treatises on surgery in the English 
 language. — Canada Med. Journal. 
 
 Our impression is, that, as a manual for students, 
 Pirrie's is the best work extant. — Western Med. and 
 Surg. Journal. 
 
 PANCOAST (J.), M. D., 
 
 Professor of Anatomy in the Jefferson Medical College, Philadelphia, &e. 
 
 OPERATIVE SURGERY; or, A Description and Demonstration of the various 
 
 Processes of the Art; including all the New Operations, and exhibiting the State of Surgical 
 Science in its present advanced condition. Complete in one royal 4to. volume, extra clolh, of 
 380 pages of letter-press description and eighty large 4to. plates, comprising 486 illustrations. 
 Second edition, improved. $10 00. 
 This excellent work is constructed on the model 
 
 of the French Surgical Works by Velpeau and Mal- 
 
 t^aigne; and, so far as the English language is con- 
 
 cerned, we are proud as an American to say that, 
 
 OF ITS KIND IT HAS NO SUPKRIOK.— iV. Y. Joumal of 
 
 Medicine. 
 
 PARKER (LANGSTON), 
 
 Surgeon to the Queen's Hospital, Birmingham. 
 
 THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- 
 MARY AND SECONDARY; comprisingtheTreatment of Constitutional and Confirmed Syphi- 
 lis, by a safe and successful method. With numerous Cases, Formulee, and Clinical Observa- 
 tions. From the Third and entirely rewritten London edition. la one neat octavo volume, 
 extra cloth, of 316 pages. {Just Issued.) $175.
 
 26 
 
 BLANCHARD & LEA'S MEDICAL 
 
 PARRISH (EDWARD), 
 
 Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c. 
 
 AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- 
 Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many For- 
 mulae and Prescriptions. In one handsome octavo volume, extra cloth, of 550 pages, with 243 
 Illustrations. {Now Ready, 1856.) $2 75. 
 
 This work, while necessary to the educated pharmaceutist, will also be found of the greatest 
 importance to those practitioners who, residing at a distance from apothecaries, are called upon to 
 dispen^e as vi'ell as to prescribe. The author has not only given a thorough outline of the principles 
 of pharmacy and its general processes, but has also presented their special applications in the details 
 of preparing all the dillerent classes of medicines, illustrated with numerous engravings of apparatus 
 and implements, which, in all cases, are of the simplest description. Under the diflerent heads 
 are contained many tables and syllabi of classes of medicines, presenting the remedies of the 
 United States Pharmacopoeia, together with many new ones, so arranged as to render their relations 
 of easy comprehension, and embodying all the more important formulae of the Pharmacopoeia, as 
 well as many others Irom the practice of distinguished physicians, not hitherto in print. Especial 
 notice has been taken of the numerous important remedies recently obtained from our indigenous 
 flora, and their composition and preparation pointed out. 
 
 The long experience of the author as a teacher of pharmacy has rendered him familiar with the 
 wants of students, and entirely competent to supply them. He has acct)rdingly descended to those 
 minutiae which so often interpose difficulties in the way of the young practitioner, who has hitherto 
 had no practical guide to point out the modes of overcoming them. 
 
 A careful examination of this work enables us to, Medica ; it familiarizes him with the compounding 
 
 speak of it in the highest terms, as being the best 
 treatise on practical pharmacy with which we are 
 acquainted, and an invaluable vade-mecum, not only 
 to the apothecary and to those practitioners who are 
 accustomed to prepare their own medicines, but to 
 every nietiical man and medical student. Througli- 
 out the work are interspersed valuable tables, useful 
 formula;, and practical hints, and the whole is illus- 
 trated by a large number of excellent wood-engrav- 
 ings. — Boston Med. and Surg. Journal. 
 
 This is altogether one of the most useful books we 
 have seen. It is just what we have long felt to be 
 needed by apothecaries, students, and practitioners 
 of medicine, most of Avhom in this country have to 
 put up their own prescriptions. It bears, upon every 
 page, the impress of practical knowledge, conveyed 
 in a plain common sense manner, and adapted to the 
 comprehension of all who may read it. No detail 
 has been omitted, however trivial it may seem, al- 
 though really important to the dispenser of medicine. 
 — Southern Med. and Surg. Journal. 
 
 To both the country practitioner and the city apo- 
 thecary this work of Mr. Parrish is a godsend. A 
 careful study of its contents will give the young 
 graduate a familiarity ^vith the value and mode of 
 administering his prescriptions, which will be of as 
 much use to his patient as to himself. — Fa. Med. 
 Journal. 
 
 Mr. Parrish has rendered a very acceptable service 
 to the practitioner and student, by furnishing thi 
 
 [ drugs, and supplies those minutiae which but few 
 practitioners can impart. The junior practitioner 
 ■will, also, find this volume replete with instruction. 
 — Charleston Med. Journal and Review, Mar. 1656. 
 
 There is no useful information in the details of the 
 apothecary's or country physician's office conducted 
 according to science that is omitted. The young 
 physician will find it an encyclopedia of indispensa- 
 ble medical knowledge, from the purchase of a spa- 
 tula to the compounding of the most learned pre- 
 scriptions. The work is by theablest pharmaceutist 
 in the United States, and must meet with an im- 
 mense sale. — Nashville Journal of Medicine, April. 
 1856. 
 
 We are glad to receive this excellent w^ork. It 
 \vill supply a want long felt by the profession, and 
 especially by the student of Pharmacy. A large 
 majority of physicians are obliged to compound 
 their own medicines, and to them a work of this 
 kind is indispensable. — JV. O. Medical and Surgical 
 Journal. 
 
 We cannot say but that this volume is one of the 
 most welcome and appropriate which has for a long 
 time been issued from the press. It is a work which 
 we doubt not will at once secure an extensive cir- 
 culation, as it is designed not only for the druggist 
 and pharmaceutist, but also for tlie great body of 
 practitioners tliroughout the country, who not only 
 have to prescribe medicines, but in the majority of 
 instances have to rely upon their own resources- 
 
 book, which contains the leading facts and principles whatever these may be— not only to compound, but 
 
 of the science of Pharmacy, conveniently arranged 
 for study, and with special reference to those features 
 of the subject which possess an especial practical in- 
 terest to the physician. It furnishes the student, at 
 the commencement of his studies, vi^ith that infor- 
 mation which is of the greatest importance in ini- 
 
 tiating him intothedomainof Chemistry and Materia ' Lancet, March 24, 1856. 
 
 also to manufacture the remedies they are called 
 upon to administer. The author has not mistaken 
 tlie idea in writing this volume, as it is alike useful 
 and invaluable to those engaged in the active pur- 
 suits of the profession, and to those preparing to en- 
 ter upon the field of professional labors. — American 
 
 RICORD ( 
 A TREATISE ON THE VENEREAL 
 
 With copious Additions, by Ph. Ricord, M. D. 
 M. D. In one handsome octavo volume, extra 
 Every one will recognize the attractiveness and 
 value which this work derives from thus presenting 
 the opinions of these two masters side by side. But, 
 it must be admitted, what has made the fortune of 
 the book, is the fact that it contains the '-most com- 
 plete embodiment of the veritable doctrines of the 
 Hopital du Midi," which has ever been made public. 
 The doctrinal ideas of M. Ricord. ideas which, if not 
 universally adopted, are iiicoiiiesiably dominant, have 
 heretofore only been interpreted by more or less skilful 
 
 P.), M. D., 
 
 DISE ASE. By John Hunter, F. R. S. 
 
 . Edited, with Notes, bv Freeman J. Bumstead, 
 cloth, of 520 pages, with plates. $3 25. 
 
 I secretaries, sometimes accredited and sometimes not. 
 
 I In the notes to Hunter, the master substitutes him- 
 self forhis interpreters, and gives hisoriginal thoughts 
 to the world in a lucid and perfectly iiilelligible man- 
 ner. In conclusion we can say that this is iucon- 
 lestably the best treatise on syphilis with which we 
 are acquainted, and, as we do not often employ the 
 phrase, we may be excused for expressing the hope 
 lliat it may find a place in the library of every phy- 
 sician. — Virginia Med. and Surg. Journal. 
 
 BY THE SAME AUTHOR. 
 
 ILLUSTRATIONS OF SYPHILITIC DISEASE. 
 Translated by Thomas F. Bettox, M. D. With 
 fifty large quarto colored plates. In one large 
 quarto volume, extra cloth. S15 00. 
 
 LETTERS ON SYPHILIS, addressed to the Chiet 
 Editor of the Union Medicale. Translated by W. 
 P. Lattimore, M.D. In one neat octavo vol- 
 ume, of 270 pages, extra cloth. S2 00.
 
 AND SCIENTIFIC PUBLICATIONS. 
 
 27 
 
 RAMSBOTHAM (FRANCIS H.), M.D. 
 THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND 
 
 SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly 
 revised liy the Author. With Additions by W. V. Keating, M. D. In one large and handsome 
 imperial octavo volume, of 6-50 pages, strongly bound in leather, with raised bands; with sixty- 
 four beamifiil Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred 
 large and beautiful figures. (Lately Issued, 18-56.) §-5 00. 
 
 In calling the attention of the profession to the new edition of this standard work, the publishers 
 would remark that no eflbrts have been spared to secure for it a continuance and extension of the 
 remarkable favor with which it has been received. The last London issue, which was considera- 
 bly enlarged, has received a further revision from the author, especially for tliis country. Its pas- 
 sage through the press here has been supervised by Dr. Keating, who has made numerous addi- 
 tions with a view of presenting more fully whatever was necessary to adapt it thoroughly to 
 American modes of practice. In its mechanical execution, n like superioritj- over former editions 
 will be found. 
 
 From Prof. Hodge, of the University of Pa. 
 To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being 
 the best authorized exponent of British Midwifery. Its circulation will, 1 trust, be extensive throughout 
 our country. 
 
 The publishers have shown their appreciation of : cine and Surgery to our library, and confidently 
 the merits of this \vork and secured its success by recommend it to our readers, with the assurance 
 the truly elegant style in which they have brought that it will not disappoint their most sanguine ex- 
 it out, excelling themselves in its production, espe- | pectations. — Western Lancet. 
 
 cinlly in its plates. It is dedicated to Prof. Meigs, | jj jg unnecessary to say anything in regard to the 
 and has tlie emphatic endorsement of Prof. Hodge, i utility of this work. It is already appreciated in our 
 as the best exponent of British Midwit^ery. \\ e • country for the value of the matter the clearness of 
 know of no text-book which deserves in all respects I jtg style, and the fulness of its ilhistrath.ns. To the 
 to be m..re highly recommended to students, and we physician's library it is indispensable, while to the 
 could wish to see It in the handsof every practitioner, i student as a text-book, from which to extract the 
 
 for they will find it invaluable for reference. — Med 
 Gazette. 
 
 But once in a long time some brilliant genius rears 
 his head above the horizon of science, and illumi- 
 nates and purifies every department that he investi- 
 gates ; and his works become types, by wliich innu- 
 merable JmiL.itors model tlieir feeble productions 
 
 material for laying the foundation of an education on 
 obstetrical science, it has no superior. — Ohio Med. 
 and Surg. Journal. 
 
 ■\Ve will only add that the student will learn from 
 it all he need to know, and the practitioner will find 
 it, as a book of reference, surpassed by none other. — 
 
 ucli a genius we find in the younger Ramsbotham, 1 Stethoscope 
 and such a type we find in the work now before us. ! The character and merits of Dr. Ramsbotham's 
 The binding, paper, type, the engravings anil wood- i work are so well known and thoroughly established, 
 cuts are all so excellent as to make this book one of , tliat comment is unnecessary and praise superfluous, 
 the finest specimens of the art of printing that have I The illustrations, which are numerous and accurate, 
 given such a world-wide reputation to its enter- ! are executed in the highest style of art. We cannot 
 
 prising and liberal publishers. We welcome Rams- I too highly recommend the work to our readers. St. 
 
 botham's Principles and Practice of Obstetric Medi- I Louis Med. and Surg. Journal. 
 
 ROKITANSKY (CARL), M.D., 
 
 Curator of the Imperial Pathological Museum, and Prolessor at the University of Vienna, &c 
 
 A MANUAL OF PATHOLOGICAL ANAT03IY. Four volumes, octavo, 
 
 bound in two, extra cloth, of about 1200 pages. (Now Ready.) $-5 50 
 Vol. I. — Manual of General Pathological Anatomy. Translated by W. E. Swaine. 
 Vol. II. — Pathological Anatomy of the Abdominal Viscera. Translated by Edward Sieveking, 
 M.D. ' 
 
 Vol. III. — Pathological Anatomy of the Bones, Cartilages, Muscles, and Skin, Cellular and Fibrous 
 
 Tissue, Serous and Mucous Membrane, and Nervous System. Translated by C. H. Moore. 
 Vol. IV. — Pathological Anatomy of the Organs of Respiration and Circulation. Translated bv G 
 
 E. Day. 
 To render this large and important work more easy of reference, and at the same time less cum- 
 brous and costly, the four volumes have been arranged in two, retaining, however, the separate 
 paging, &rc. 
 
 The publishers feel much pleasure in presenting to the profession of the United States the great 
 work of Prof Rokitansky, which is universally referred to as the standard of authority by the pa- 
 thologists of all nations. Under the auspices of the Sydenham Society of London, the combined 
 lal>or of four translators has at length overcome the almost insuperable ditliculties which have so 
 long prevented the appearance of the work in an English dress, while the additions made from 
 various papers and essays of the author present his views on all the topics embraced, in their latest 
 published form. To a work so widely known, eulogy is unnecessary, and the publishers would 
 merely state that it is said to contain the results of not less than thirty thousand i)ost-mortem 
 examioations made by the author, diligently compared, generalized, and wrought into one com- 
 plete and harmonious system. 
 
 The profession is too well acquainted with the re- 
 pu^tion of Rokitansky's work to need our assur- 
 ance that this is one of the most profound, thorough, 
 and valiKilde books ever*issued from the medical 
 press. It is sui generis, and has no standard of c(un- 
 jiarison. It is only necessary to announce that it is 
 issued in a form as cheap as is compatible with its 
 size and preservation, and its sale follows as a 
 matter of course. No library can be called com- 
 plete without it. — Buffalo Med. Journal. 
 
 An attempt to give our readers any adequate idea 
 of the vast amount of instruction accumulated in 
 these volumes, would be feeble and hopeless. The 
 effort of the distinguished author to concentrate 
 in a small space his great fund of knowledge, has 
 
 so charged his text with valuable truths, that any 
 attempt of a reviewer to epitomize is at once para- 
 lyzed, and must end in a failure. — Weitfn Lancet. 
 
 As this is the highest source of knowledge upon 
 the important subject of which it treats, ^no real 
 student can alford to be without it. The American 
 liublishers have entitled themselves to tlie thanks of 
 the profession of their country, for tliis timeous and 
 beautiful edition. — Nashville Journal of Medicine. 
 
 As a book of reference, therefore, this work must 
 prove of inestimable value, and we cannot too highly 
 recommend it to the profession.— CAar/eiion Med. 
 Journal and Review, Jan. 1856. 
 
 This book is a necessity to every practitioner. — 
 Am. Med. Monthly.
 
 30 
 
 BLANCHARD & LEA'S MEDICAL 
 
 TAYLOR (ALFRED S.), M. D., F. R. S., 
 
 Lecturer on Medical Jurisprutlence and Chemistry in Guy's Hospital. 
 
 MEDICAID JURISPRUDENCE. Fourth American, from the fifth improved and 
 
 enlarged English Edition. Willi Notes and References to American Decisions, by Edward 
 
 Hartshorne, M. D. In one large octavo volume, leather, of over seven hundred pages. (Just 
 
 Ready, June, 1S56.) $3 00. 
 
 Thi-; standard work has lately received a very thorough revision at the hands of the author, who 
 has introduced whatever was necessary to render it complete and satisfactory in carrying out the 
 objects in view. Tne editor has likewise used every exertion to make it equally thorough with 
 regard to all matters relating to the practice of this country. In doing this, he has carefully ex- 
 amined all that has appeared on the subject since the publication of the last edition, and has incorpo- 
 rated all the new information thus presented. The work has thus been considerably increased ui 
 size, notwithstanding which, it has been kept at its former very moderate price, and in every resp)ect 
 it w'\.\\ be found worthy of a continuance of the remarkable favor which has carried it through so 
 many editions on both sides of the Atlantic. A few notices of the former editions are appended. 
 
 We know of no work on Medical Jurisprudence 
 which contains in tiic same space anything like the 
 same amount of valuable matter. — lY. Y. Journal of 
 Medicine. 
 
 No work upon the subject can be put into the 
 hands of students either of law or medicine which 
 will engage them more closely or profitably ; and 
 none could be offered to the busy jiractitioner of 
 either calling, for the purpose of casual or hasty 
 reference, that would be more likely to afford the aid 
 desired. We therefore recommend it as the best and 
 safest manual for daily a.se.-^American Journal oj 
 Medical Sciences. 
 
 So well is this work known to the members both 
 of the medical and legal professions, and so highly 
 is it appreciated by them, that it cannot be necessary 
 for us to say a word in its commendation j its having 
 already reached a fourth edition being the best pos- 
 s'ble testimony in its favor. -The autlior has ob- 
 viously subjected the entire work to a very careful 
 revision. — Brit, and Foreign Med. Chirurg. Review. 
 
 This work of Dr. Taylor's is generally acknow- 
 ledged to lie one of the ablest extant on the subject 
 of medical jurisprudence. It is certainly one of the 
 
 most attractive books that, we have met with; sup- 
 plying so much both to interest and instruct, that 
 we do not hesitate to affirm that after having once 
 commenced its perusal, few could be prevailed upoa 
 to desist before completing it. In the last London 
 edition, all the newly observed and accurately re- 
 corded facts have been inserted, including much that 
 is recent of Chemical, Microscopical, and Patholo- 
 gical research, besides papers on numerous subjects 
 never before published .-CAorZe«2o« Medical Journal 
 and Review. 
 
 It is not excess of praise to say that the volume 
 before us is the very best treatise extant on Medical 
 Jurisprudence. In saying this, we do not wish to 
 be understood as detracting from the merits of the 
 excellent works of Beck, Ryan, Traill, Guy, and 
 others; but in interest and value we think it must 
 be conceded that Taylor is superior to anything that 
 has preceded it. Tlie author is already well known 
 to the profession by his valuable treatise on Poisons ; 
 and the present volume will add materially to his 
 high reputation for accurate and extensive know- 
 ledge and discriminating judgment. — N. W. Medical 
 and Surgical Journal. 
 
 BY THE SAME AUTHOR. 
 
 ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND 
 
 MEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo 
 volume, leather, of 6S8 pages. $3 00 
 
 TODD (R. B.), M. D., AND BOWMAN (WILLIAM), F. R. S. 
 PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With 
 
 numerous handsome wood-cuts. Parts I, II, and III, in one octavo volume, 552 pages. $2 50. 
 Part IV will complete the work. 
 
 The first portion of Part IV, with numerous original illustrations, was published in the Medical 
 News and Library for 1853, and the completion will be issued immediately on its appearance in 
 London. Those who have subscribed since the appearance of the preceding portion of the work 
 can have the three parts by mail, on remittance of $2 50 to the publishers. 
 
 WATSON (THOMAS), M. D., Sec. 
 LECTURES ON THE PRINCIPLES AND PRACTICE OF PPIYSIC. 
 
 Third American edition, revised, with Addit 
 "Treatise on the Diseases of Children," tzc. 
 large pages, strongly bound with raised bands. 
 
 To say that it is the very best work on tlie sub- 
 ject now extant, is but to echo the sentiment of the 
 medical press throughout the country. — iV. O. 
 Medical Journal. 
 
 Of the text-books recently republished Watson is 
 very justly the principal favorite. — Holmes^s Rep. 
 to Nat. Med. Assoc. 
 
 By universal consent the work ranks among the 
 very best text-books in our language. — Illinois and 
 Indiana M^d. Journal. 
 
 Resrarded on all hands as one of the very best, if 
 not the very best, systematic treatise on practical 
 medicine extant. — St. Louis Med. Journal. 
 
 ions, by D. Francis Condie, M.D., author of a 
 In one octavo volume, of nearly eleven hundred 
 
 §3 25. 
 
 Confessedly one of the very best works on the 
 principles and practice of physic in the Knglish or 
 any other language. — Med. Examiner. 
 
 Asa text-book it has no equal; as a compendium 
 of pathology and practice no superior. — New York 
 Annalist. 
 
 We know of no work better calculated for being 
 placed in the hands of the student, and for a text- 
 book ; on every important point the author seems 
 to have posted up his knowledge to the day. — 
 Amer. Med. Journal. 
 
 One of the most practically useful books that 
 ever was presented to the student. — N. Y. Med. 
 Journal. 
 
 V/HAT TO OBSERVE 
 AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. 
 
 Published under the authority of the London Society for Medical Observation. A new American, 
 from the second and revised London edition. In one very handsome volume, royal 12mo., extra 
 cloth. {Just Issued.) $1 00. 
 
 To the observer who prefers accuracy to blunders 
 and precision to carelessness, this little book is in- 
 valuable. — N. H. Journal of Medicine . 
 
 One of the finest aids tea young practitioner we 
 have ever seen. — Peninsular Journal of Medicint.
 
 It offers to the student all the assistance that can 
 be expected from such a work. — Medical Examiner. 
 
 The most complete and convenient manual for the 
 student we possess. — American Journal of Medical 
 Science. 
 
 In every respect, this work as an anatomical 
 o;uide for the student and practitioner, merits our 
 warmest and most decided praise. — London Medical 
 Gazette. 
 
 AND SCIENTIFIC PUBLICATIONS. 31 
 
 WILSON (ERASMUS), M.D., F. R. S., 
 
 Lecturer on Anatomy, London. 
 
 A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- 
 
 can, from the last English edition. Edited by Paul B. Goddard, A. JM., M. D. Wilh two hun- 
 dred and filly illustrations. Beautifully printed, in one large octavo volume, leather, of nearly 
 six hundred pages. $3 00. 
 In many, if not all the Colleges of the Union, it 
 
 has become a standard text-book. This, of itself, 
 
 is sufficiently expressive of its value. A work very 
 
 desirable to the student; one, the possession of 
 
 which will greatly facilitate his progress in the 
 
 Btudy of Practical Anatomy. — New York Journal of 
 
 Medicine. 
 
 Its author ranks with the highest on Anatomy. — 
 Southern Medical and Surgical Journal. 
 
 BY THE SAME AUTHOR. (Now Ready.) 
 
 THE DISSECTOR'S MANUAL; or. Practical and Surgical Anatomy. Third 
 
 American, from the last revised and enlarged Englii-h edition. Modified and rearranged, by 
 "William Hunt, M. D., Demonstrator of Anatomy in the University of Pcnn>ylvania. In one 
 large and handsome royal 12mo. volume, leather, of 5S2 pages, with 154 illustrations. $2 00. 
 The modifications and additions which this work has received in passing recently through the 
 author's hands, is sufficiently indicated by the fact that it is enlarged by more than one hundred 
 pages, notwithstanding that it is printed m smaller type, and with a greatly enlarged page. So com- 
 plete has the author rendered it, that the editor has found but little to do, except in rearranging 
 it to suit the mode of dissection practised in this country, and in introducing a large number of 
 additional illustrations. Of these, many new ones have been engraved expressly tor the work, 
 and the series throughout will be found greatly enhanced in value. The typographical execulicsu 
 of the volume has undergone a like improvement, and in everyrespect the work is presented as merit- 
 ing an increase of the favor which it has hitherto enjoyed as a sound practical guide to the study oi 
 anatomy. 
 
 It remains only to add, that after a careful exami- I ing very superior claims, well calculated to facilitate 
 nation, we have no hesitation in recommending this") their studies, and render their labor less irksome, by 
 work to the notice of those for whom it has been I constantly keeping before them definite objects of 
 expressly written — the students — as a guide possess- | interest. — The Lancet. 
 
 BY THE SAME AUTHOR. 
 
 ON DISEASES OF THE SKIN. Third American, from the third London 
 
 edition. In one neat octavo volume, of about five hundred pages, extra cloth. $1 75. 
 
 The " Diseases of the Skin," by Mr. Erasmus I in that department of medical literature. — Medico- 
 Wilson, may now be regarded as the standard work | Chirurgical Review. 
 
 BY THE SAME AUTHOR. 
 
 ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON 
 
 SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with 
 four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions, f 2 25. 
 
 BY THE SAME AUTHOR. {Just IssUed.) 
 
 HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- 
 tion and Management. Second American, from the fourth London edition. One neat volume, 
 royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. $1 00 ; paper cover, 
 75 cents. 
 
 WHITEHEAD (JAMES), F. R. C. S., &c. 
 
 THE CAUSES AND TREATMENT OP ABORTION AND STERILITY; 
 
 being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions 
 J of the Uterus. Second American Edition. In one volume, octavo, extra cloth, pp. 36S. $175. 
 
 WALSHE (W. H.), M. D., 
 
 Professor of the Principles and Practice of Medicine in University College, London. 
 
 DISEASES OF THE HEART, LUNGS, AND APPENDAGES; their 
 
 Symptoms and Treatment. In one handsome volume, extra cloth, large royal 12mo., 512 pages. 
 
 ft 50. 
 
 We consider this as the .ablest work in the En- I the author being the first stethoscopist of the day — 
 glish language, on the subject of which it treats; | Charleston Medical Journal. 
 
 WILDE (W. R.), 
 
 Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. 
 
 AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- 
 EASES OF THE EAR. In one handsome octavo volume, extra cloth, of 476 pages, with 
 illustrations. $2 80. 
 
 This work certainly contains more information on laws, and amenable to the same general methods of 
 the subject to which it is devoted than any other treatment as other morbid proces.ses. The work is 
 with which we are acquainted. We feel grateful to not written to supply the cravings of popular patroii- 
 the author for his manful effort to rescue this depart- age, but it is wholly addres.sed to the profession, and 
 ment of surgery from the hands of the empirics who bears on every page the impress of the reflections 
 nearly monopolize it. We think he has successfully of a sagacious and practical surgeon.— Ta. Surg, and 
 shown lliat aural diseases are not beyond the re- Med. Journal. 
 sources of art; that they are governed by the same
 
 32 BLANCHARD & LEA'S SCI E N TIF IC PUBLICAT 1 ONS. 
 
 WEST (CHARLES), M. D., 
 
 Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for 
 
 Sick Children, ice. 
 
 LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. 
 
 Second American, from the Second and Enlarged London edition. In one volume, octavo, 
 extra cloth, ol nearly five hundred pages. (Just Issued.) $2 00. 
 
 We take leave of Dr. West with great respect for 
 his attainments, a due appreciation of his acute 
 powers of observation, and a deep sense of obliga- 
 tion for this valuable contribution to our profes- 
 sional literature. His book is undoubtedly in many 
 respects the best we possess on diseases of children. 
 Dublin Quarterly Journal of Medical Science. 
 
 Dr. West has placed the profession under deep ob- 
 
 ligation by this able, thorough, and finished work 
 upon a subject which almost daily taxes to the ut- 
 most the skill of the general practitioner. He has 
 with singular felicity threaded his way through all 
 tlie tortuous labyrinths of the difhcult subjecthe has 
 undertaken to elucidate, and has in many of the 
 darkest corners left a light, which will never be 
 extinguished. — Nashville Medical Journal. 
 
 BY THE SAME AUTHOR. {Nearly Ready.) 
 Puhli-^hing i7i the '■'Medical News and Library^'''' for 1S56. 
 
 LECTURES ON THE DISEASES OF WOMEN. In two parts. 
 
 Part I. 8vo. of about 300 pages, comprising the Diseases of the Uterus. 
 
 Part I[. {Pre/paring)., will contain Diseases of the Ovaries, and of ail the parts connected 
 
 Willi the Uterus ; of the Bladder, Vagi.na, a.nd External Organs. 
 The object of the author in this work is to present a complete but succinct treatise on Female 
 Di»etl^^es, embodying the results of his experience during the last ten years at St. Bartholomew's 
 and the Midwilery Hospitals, as well as m private practice. The characteristics which have se- 
 cured to his former works so favorable a reception, cannot fail to render the present volume a 
 -standard authority on its important subject. To show the general scope of the work, an outline ol 
 the Contents of Part I. is subjoined. 
 
 Lectures J, II. — Introductory — Symptoms — Examination of Symptoms — Modes of Examina- 
 tions. Lectures ///., IV , V — Disorders of Menstruation, Amenorrhoea, Menorrhagia, Dys- 
 menorrhosa. Lectures VI., VII., VIII. — Inflammation of the Uterus, Hypertrophy, Acute 
 Inflammation, Chronic Inflammation, Ulceration of the Os Uteri, Cervical Leucorrhoea. Lectures 
 IX , X., XL, XII , XIII. — Misplacement of the Uterus, Prolapsus, Anleversion, Retrover- 
 sion, Inversion. Lectures XIV., XV., XVI. , XVII. — Uterine Tu.mors and Outgrowths, 
 Mucous, Fibro-cellular, and Glandular Polypi, Mucous Cysts, Fibrinous Polypi, Fibrous Tumors, 
 Fibrous Polypi, Fatty Tumors, Tubercular Diseases. Lectures XVII1.,'XIX., XX. — Cancer 
 OF the Uterus. 
 Part IL will receive an equally extended treatment, rendering the whole an admirable text-book 
 for the student, and a reliable work for reference by the practitioner. 
 
 BY the same author. {Just Issued) 
 
 AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- 
 ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. 
 
 WILLIAMS (C. J. B.), M. D., F. R. S., 
 
 Professor of Clinical Medicine in University College, London, &c. 
 
 PRINCIPLES OF MEDICINE; comprising General Pathology and Therapeu- 
 
 tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and 
 Hygienics. Edited, with Additions, by Meredith Clymer, M. D. Fourth American, from the 
 last and enlarged Loudon edition. In one octavo volume, leather, of 476 pages. $2 50. 
 
 The best exposition in our language, or, we be- I Few books have proved more useful, or met with 
 lieve, in any language, of rational medicine, in its | a more ready sale than this, and no practitioner 
 present improved and rapidly improving state. — I should regard his library as complete without it. 
 British and Foreign Medico-C hirurg . Revieio. \ — Ohio Med. and Surg. Journal. 
 
 YOUATT (WILLIAM), V. S. 
 
 THE HORSE. A new edition, with numerous illustrations; together with a 
 
 general history of the Horse; a Dissertation on the American Trotting Horse ; how Trained and 
 
 Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and the Mule. 
 
 By J. S. Skinner, formerly Assistant Postmaster-General, and Editor of the Turf Register. 
 
 One large octavo volume, extra cloth. $1 50. 
 
 The attention of all who keep horses is requested to this handsome and complete edition of a 
 work which is recognized as the standard authority on all matters connected with veterinary medi- 
 cine. The very low price at which it is now ottered, free by mail, places it within the reach ol 
 every one. 
 
 BY the same author. 
 
 THE DOG. Edited by E. J. Lewis, M. D. With numerous and beautiful 
 illustrations. In one very handsome volume, crown Svc, crimson cloth, gilt. $1 25. 
 
 ILLUSTRATED MEDICAL CATALOGUE. 
 
 BLANCHARD & LEA have lately issued a Catalogue of their Medical, Surgical, and Sci- 
 entific Publications, containing descriptions of the works, with Notices of the Press, and 
 specimens of the Illustrations, making a very handsome pamphlet of sixty-foiu* large octavo 
 pages. Copies will be sent by mail, and the postage paid, on application to the Publishers, 
 by inclosing six cents in postage stamps.
 
 UNIVERSITY OF CALIFORNIA AT LOS ANGELES 
 
 THE UNIVERSITY LIBRARY 
 This book is DUE on the last date stamped below 
 
 I 9 r969j ^^^^^^ 
 
 '87 
 
 AUG 1 5 RECD 
 AUG 1 2 RBffl 
 
 BIOMED M 2 74 
 
 JANISREC'O 
 biomeW 
 FEB 8 RECO 
 
 BlOMEOBIOME&iid^^d 
 
 AUG 3 RECO 
 
 SEP ^^^^^ 
 
 RECD 
 
 Form L-9-15))i-7.'35 
 
 SEP 8 1987 
 
 UNIVEKi 
 
 .1 CALIFORNIA 
 
 LOS ANGELES 
 LIBRARY
 
 I 
 
 \ 
 
 #